Here in Part Two of our interview with Design that Matters, Tim Prestero and Malory Johnson sound off on the pitfalls of designing for social impact, how to assess user feedback, what it's like working with design newbies, the future of their current project, and what young designers seeking long careers should consider.

Tim Prestero and Malory Johnson

If you missed Part One of our interview, it's here.

Core77: Let's talk about the importance of partnerships.

Tim: When an organization talks about what they're doing, is there rigor? One of the ways in which we see a lack of rigor is organizations that talk about different, better, and good as though they're synonymous.

Like, "We're going to provide a different way of filtering water." Well, the fascists came up with a different way to run the government. Different is value neutral.

"Better." "We've got a better way of providing prenatal care." Is it a good way? It can be better than what exists and it can still suck. Unfortunately, that is the history of appropriate technology, international development, et cetera. Kevin Kelley talks about how most technologies change the problem. That's not my objective, to kick the can down the road.

Then what does "good" look like? This is the kind of design research that we do, talking to stakeholders, figuring this out, and understanding that human-centered design is a simplistic term for a complex process that involves dozens of stakeholders. There isn't some human, some user that we can satisfy. There's regulators, financial people, manufacturers, all this stuff. That's how we understand what good is or what great is. The joke is that the number one thing you learn at MIT is how to get the lowest A in the class. We're aiming a little higher than that.

I think the third part of it is given that all of us are dependent on partners, one of the themes across social impact design is how nobody delivers the service. MASS builds hospitals; Partners in Health operates them. We design medical devices; our partner MTTS in Vietnam manufactures them; our partner Firetree distributes them. Every other story looks like that. Partnership is critical.

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How do you find good partners?

Tim: We talk about, how do you look for rigor in partnership? We break it up into two parts. One is, is it a partnership in name or in deed? If this organization is our partner, are they around, when was the last time we saw them?

Then two, when something has been handed off for the partners, you want to look for evidence of what happens once that artificial stimulus of foreign, outside money is removed.

Here's an example. With Firefly, we spent a long time trying to get it perfect, but you always miss stuff. And we missed something in the transition to manufacturing. There's always some common dimensions or common step where, if you're outside of that, it gets much more expensive.

So one of our PCBs (printed circuit boards) was very long. It turns out there's just one-tenth as many vendors in China who can make a PCB that long. Our manufacturing partner independently did a design revision and broke it up into smaller panels. We didn't pay them to do it, we didn't tell them to do it; they just did it. It was partly value engineering for them, like they wanted to cut their costs, but they were also having a high reject rate because this piece was so big.

For us, that was success, the fact that they're invested in this enough to continue to refine the design. So I think every organization should ask themselves "How does our partner demonstrate intellectual ownership, or is it that they only do things because we're thrashing them and pushing them?"

I would guess that manufacturer was an anomaly.

Tim: I do think we chose well. Some of that is just the strategy of, it's better to work with the hungry number three than the super number one. Because they're as hungry as you are, whereas if you're just initiative number 20, well….

What are some of the pitfalls of designing for social impact in general?

Tim: I think that when you look at the field of social impact design, unfortunately there's a lot of value engineering. Where people think "Well, cost-to-buy must be the limiting variable, so let's make it cheap."

But think about the cost of ownership. For example with Firefly, the hospital cost of treating a newborn for jaundice over five years is 15 times the purchase price of the device. If our device can reduce the treatment time by 10%, we've already recovered the whole purchase price of the device. If all I'm doing is trying to make the device less expensive, I'm sort of missing the point on the opportunity.

What you need to look at is "What is the total cost of the outcome?" This is not some academic, feel good exercise where all we want to do is win design awards. Those are nice but in the end, if we're not saving lives, I should go get another job.

The other part of our intake criteria is in the world of needs, which is great. There are many, many needs. What are the ones where design alone can transform someone from sick to healthy, from suffering to the absence of suffering. I think those opportunities exist, but they're hard to find.

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Is it hard for you to chart the connection between design and the total outcome?

Tim: It's—I don't know if you realize that Tolstoy's a humorist, but there's a great joke in "War and Peace" where he talks about the different kinds of happiness. He said the British people are happy because they've got a great government. French people are happy because they've got a wonderful culture. Italians are happy because they get excited and they forget what they're doing. Russians are happy because they don't know anything and they know they never will. I was like, "I've got Russian happiness." That's me. I'm totally ignorant and I'm learning nothing, and I never will. Reality is unknowable.

Our struggle is doing what's right rather than what's easy. I think that in evaluating outcomes, it is really, really hard but all important and good stuff is hard. Saying it's hard so we didn't do it again, well…particularly in the social field, I think there's sometimes a feeling that "Well, our intentions are correct," and that that's good enough.

It's also a sentimental field, right? When donors and the international aid community look at different outcomes, they look at Playpumps. I'm sure you've seen the sad story of Playpumps where kids push a merry go round that drives a water pump and water comes shooting out and it's amazing. Well, go back a year later. The kids are sick of playing on it and you've got an old lady pushing the merry go round, or the stupid thing is broken. Again, resisting the comfort of ignorance and the warm bath of Russian happiness, it's a challenge.

What does the next six months to a year look like for you guys?

Tim: We have to—first off let me say, Firefly's awesome. We love it and we're really proud of it. I think it makes a really strong statement about our philosophy as designers and agents of change. It's now in 21 countries and we've treated tens of thousands of kids. I read Geoff Moore's "Crossing the Chasm" and he talks about the difference between early adopters and the early majority. Early adopters are willing to take an incomplete product and build everything else they need around it to get the outcome that they want. The early majority wants a whole product.

We realized that Firefly's not a whole product. There are two things that we're trying to fix, or two gaps that we're trying to solve for the next year with Firefly. First is warming. We've got to take the newborns' clothes off to treat them effectively for jaundice. But then it's like, "Hey, welcome to the hypothermia lottery."

We see within warming an opportunity to make a very strong statement about design and about the limitations of international standards of care. There are two existing devices to solve the warming problem, incubators and radiant warmers, and they're both terrible fits for rural hospitals:

Incubators are boxes that you keep warm, that you thermoregulate. We interviewed the biomedical technicians at Boston Children's Hospital, and they said it takes them 45 minutes to properly clean an incubator between patients. That's never going to happen in a developing country.

If it doesn't get cleaned, well, now you have a warm box that's incubating everything, including germs. And hospital-acquired infections is one of the number one killers of kids. That's not acceptable.

Radiant warmers require a skin temperature probe, a sticker that goes on the baby's skin and that's hooked up to the temperature control. That sticker is $5, it's a consumable. You're supposed to use a new one with every patient. Where do you buy those in rural wherever? They don't. Either they're using old ones, or they're not using them at all. So, bad fit.

Our goal is to use conductive warming. This is a warm surface. Our hypothesis is that we can do it without a skin temperature probe. It's a seamless bassinet that you could just wipe out with alcohol between babies. I'm sure we said this in other forms, but our philosophy is making medical devices that are hard to use wrong in the context of a developing country. We need to design a match for this rural context.

What's the second thing you're trying to fix?

Tim: The second thing gets into that statistic from the WHO, that only 20% of equipment donations are ever turned on. Firefly has a use meter in it. Whenever it's on, it's logging hours of use. That's amazing. On research trips it's not uncommon for me to find machines that should be being used but are covered in cobwebs, but the use meter can tell you whether it's being used and for how long.

So our question is, "How might we remotely monitor equipment?" If I can remotely monitor a soda machine, why can't I remotely monitor a piece of medical equipment? There's three outcomes that we want:

1. Someone's using it all the time. Send them more equipment.

2. Somebody's never using the equipment. Send them more training.

3. The equipment is sending an error message. So we know our equipment is broken. If our equipment is broken, there's probably a bunch of other broken equipment, due to a power surge or something else. Send them a technician.

Data sensing is not a hard, it's not a design problem. Transmission is a little bit tricky but again, that's not the problem. The design problem in this, and this is a new area for us, is how do you protect the most vulnerable?

What do you mean?

Tim: Well, we already get accused of being spies wherever we go. I go to a rural hospital in North Vietnam, I'm taking pictures of everything and they're like "Why are you here?" Well, I'm the baby spy. In the Peace Corps, they're like "Why are you really building these latrines?" and I'm like "Yeah, I'm going to steal your poo, that's why I'm here. I'm a poop stealer."

So they're going to open up a Firefly, and there's going to be a cell phone in it that we've rigged up to transmit. And they're going to be like "Oh, we knew it."

So there's two aspects to the design problem of data monitoring. One is the client asking "What's in it for me?" For example, I'm happy to trade everything about my life to Google because it got me to this meeting on time and we're able to email with each other. I know what's in it for me, I can see the benefits.

So we have to figure out how to answer "What's in it for a hospital?" Maybe resource scheduling, we're thinking. If you're at capacity, does a neighboring hospital have spare capacity? You could refer a patient there. That's what's in it for you.

Two, for the consumers of the information, how might we present the information to get the right outcome? How do you make data that's hard to use wrong? In a world with runaway data, and definitely the overpromise of data science, it's hard. Those are the two big pieces that we're trying to assemble.

What are the steps in assessing feedback?

Tim: We have a hierarchy of evidence going back to that "How do you know that you're doing a good job." The lowest level of evidence for us is the person who says something, having seen it for the first time. Next is what somebody says after they've used it. After that is data. What can we measure about their use? What is a statistically significant sample about use?

We actually discovered a [new signifier]. We sent one of the donors for this program to visit a hospital inVietnam, to see Firefly in place because he was planning to dramatically increase his funding for the program. They got to the hospital and Firefly was…gone.

For us, this is our worst nightmare. Most medical equipment isn't used. Every hospital has this graveyard of junk behind it, and we thought "Oh no, that's what's happened." But the hospital staff were saying "Oh it was here yesterday, we don't know what happened."

Fortunately Luciano, our field partner talked to the staff, took someone around the corner and started twisting their arm. "All right, where is it, really?" It turns out the director of the hospital took it home to treat his sister's son. I was like "That is awesome! He liked Firefly enough to steal it—would he do a commercial?"

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What else is in Design that Matters' future?

Tim: Right now there's such demand and interest in the social enterprise field. We put out a posting for industrial design interns for the summer team. We got like 300 applications for two industrial designer positions. We get four or five resumes a week. So I feel like now, part of our mission is shifting towards education and just trying to give back more.

There's a lot of TED talks about "How I climbed Mount Everest." But the most interesting TED talk is "How anybody can climb Mount Everest." The more the we can do the latter, the more we can get feedback about the ways that we could be more generous about sharing what we've learned, the better.

Malory: There's also this notion about what it means to be a non-profit, like there's a connotation of if you work at a non-profit, you kind of surrendered a little bit. Like maybe you're altruistic to a fault, a little soft in the head or you couldn't hack it at a "real job."

I think [correcting that perception] could be another important message. Working for a nonprofit is not just surrendering on your goals. It can be something a lot bigger and impactful.

Speaking of which, transitioning from design school to the real world often calls for some adjustments. Do you guys ever run into issues working with freshly-minted design school grads?

Tim: One of the first things we have to do with a lot of the industrial designers we've hired is, there's a minute where you have to cure them of their "My work speaks for itself" feeling. There's this kind of intellectual purity, particularly in industrial designers because I think of the overlap with art school that "I'm not a prostitute. I'm not a huckster. I make good, simple things. I have a beard and all this stuff."

I feel like one of the things we have to do is help people de-mythologize design and designers. We'd particularly like to inspire the young designer who thinks "Well, I wasn't born Steve Jobs." Steve Jobs wasn't born Steve Jobs. I really want to puncture the myth of exceptionalism that I think makes it hard for people to get started. The only way I started Design that Matters is I didn't know what I was doing. I was just like "This is really fun. What do I have to do next?" They're like "Well, you need money." "Great. How do I get money?" "Well you have to incorporate." "What does that mean?" And so forth.

Now we're here. And then there's the future. For me, what's exciting is looking at the future of manufacturing in poor countries. Poverty is isolation. Let's take shipping: Cambodia, maybe someday, will have shipping at the airport. Laos never will. Laos will always be poor under the current market economic structure that [limits] access to international shipping lines. There's this great book called "The Box," a history of shipping. It talks about that's real poverty now.

But what happens when, and we're already seeing this, we can email a file to one of our partners, and then it's a thing and they're holding it up for us to see on Skype? What happens when that's a medical device manufacturer in Rwanda and we email them Firefly version 2, and they can print the 100 units that their country needs? And then they print 100 kinkajous to solve the literacy problem?

If supply chains have changed the world, if just-in-time manufacturing has changed the world, this is also going to change the world. It's happening in our lifetime. I feel like we just have to aim it so that it's not just…how can I say it…sometimes Kickstarter breaks my heart because there's so much garbage on there. Do you really need to track your yoga session?

We talk about a poverty of imagination. If you look at, say, the ancient Greeks, they took rigor and morality and social justice and treated those like Olympic events. They competed to be the most just, to be the most generous. What are we competing for now, the most "likes?" —Okay, now I sound like Father Time, "You kids get off my lawn."

The bottom line is that design clearly has the potential to make enormous benefits to life. For young designers who want to go a long way in their career, the action is with the people who need it most.

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