This year, people in Charleston, S.C., taught young children to read. In Las Cruces, N.M., others cured hepatitis C. And still others treated depression in the slums of Kampala, Uganda.

On the surface, these people have nothing in common — except for being featured in Fixes columns this year. But they are all cousins, in a sense. They all owe their success to one particular strategy.

This year in the Fixes column, we’ve looked at 60 or so ways that people are trying to change the world. Some of these projects are successful, some partially successful, some are failing in ways we can learn from, and some are intriguing ideas that have yet to compile a track record.

The initiatives we’ve covered are — quite literally — all over the map. But there are ideas that unite them, a few strategies that show up over and over again. By connecting the dots we can get a sense of what can work in various contexts to solve many different types of problems. These, then, are Fixes’ nominations for the big ideas in social change of 2014.

DOWNSHIFT JOBS

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Dr. Naomi Clancy, a primary care physician who collaborates with specialists through Project ECHO, with a patient at Hidalgo Medical Services-Bayard Community Health Center in Bayard, N.M.. Credit Catherine Karnow, Courtesy the Robert Wood Johnson Foundation

Reading Partners in Charleston, Project ECHO in New Mexico, and Strong Minds in Kampala all rely on task shifting: taking jobs normally restricted to specialized professionals and turning them over to people with far less training in order to reach underserved groups.

At face value, task shifting sounds dangerous. After all, we have professional qualifications for a reason. It takes training and experience to be a good teacher, hepatologist or psychologist. People in those professions have learned things they need to know.

What’s next, having amateurs take over the operating room? It’s already happening. Zambia, a country the size of Texas, has only six surgeons in its rural areas. So it offers clinical officers a three-year surgery course, during which they learn to do the most commonly needed operations, such as C-sections, hysterectomies, appendectomies and bowel obstruction surgery.

Personally, I’d prefer a surgeon. But in rural Zambia, a surgeon isn’t the alternative. Death is. Task shifting matters because it brings good things like health care and education to people who otherwise wouldn’t get them at all.

And not just in Africa. Project ECHO began training rural doctors by video because when it started, in 2003, only 5 percent of New Mexico’s 34,000 chronic hepatitis C patients were getting treatment. It uses regular case-based training, and specialists work remotely with the front-line doctors and nurses.

Another example is dental therapists, who have two or four years of graduate training. They are treating patients in Alaska and Minnesota (and soon, Maine) who live in areas with limited access to dental services.

Task-shifting doesn’t necessarily mean second-class care, and sometimes it produces better results than the specialists do. The patients with hepatitis C in rural New Mexico seen by local nonspecialists do better than those seen at the specialist clinic in Albuquerque, possibly because health workers from the same community do better at getting patients to stick to their care plans, and can interact regularly and catch problems early.

In India, the nongovernmental group Pratham devised one-page tests for basic reading and math. Volunteers with very little training go door-to-door to test children. Because of their simplicity and portability, these tests have allowed Indian parents for the first time to grasp the true failure of the country’s educational system — and mobilize to do something about it.

Especially when care involves behavioral change, less training can be an asset, not a liability. Who’s better at getting people to improve their eating and exercise habits? A doctor — an authority figure who can spend only 15 minutes and generally learns little about a patient’s life — or a health worker from the patient’s own community, with the same problems, who can visit the patient at home and has the luxury of spending time? Experience indicates it’s the latter.

Task-shifting can be an alternative any time resources are short and people can learn to do a specific activity without the full training specialists receive. Reading Partners succeeds, for example, because it isolated the key components of helping children learn to read, and found a way to teach them clearly and quickly to community volunteers.

Like other forms of task-shifting, this is a money-saver, as volunteers or low-paid workers are stretching the efforts of higher-paid professionals. Such programs also allow people to get access to preventive services, which almost always result in huge savings later. The advantages of task shifting can be summed up in the aphorism: “Don’t let the perfect be the enemy of the good.”

FOCUS ON PEOPLE’S STRENGTHS, NOT THEIR NEEDS

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#039;s Pre-K program at Wissahickon Charter School helped his son make predictions during reading." width="480" height="319" />

A father in Springboard's Pre-K program at Wissahickon Charter School helped his son make predictions during reading. Credit Jessie Fox

This idea is related to task-shifting — in fact, it’s the main reason task-shifting is effective: we often underestimate what ordinary people can accomplish and succumb to stereotypes about low-income people or minorities. Look at the Springboard Collaborative, a summer reading program in Philadelphia, for example. Springboard uses the public school system’s most underemployed resource: low income, predominately African-American or Latino parents, a group usually falsely written off as unable or unwilling to help their children.

Alejandro Gac-Artigas, Springboard’s founder, wondered whether low-income parents didn’t get as involved with their children’s education as more affluent parents because they didn’t believe they had much to offer. So Springboard’s system gives parents an easy-to-use curriculum that mainly involves asking questions of the child before, during and after reading — even parents who can’t read can use it. Parents average over 90 percent attendance at the weekly training sessions — and instead of falling back several months over the summer, which is standard for low-income kids, their children gain more than three months in reading. “In our experience, people want to do things they’re good at and avoid things they’re bad at,” said Gac-Artigas.

A world away, nine million women in villages in Mali and some 40 other African countries are living better by using savings groups. Women make small deposits at each meeting, and members can borrow from the pool of funds.

It’s sort of like microcredit — except there’s no money from outside and no bank, just a locked box. No outsiders at all, in fact, except to facilitate spreading the word and getting things started, and not always then. These groups go on for years and years with no intervention.

The advantages are obvious: women who live too far away from anything to be served by a bank or traditional microcredit can benefit, which means they are less likely to experience food shortages during the year. After the initial training, these groups cost nothing to run. And they last. Projects NGOs bring in from outside often fall apart when the NGO pulls out. Not savings groups, because they truly belong to the women themselves. (The Family Independence Institute in the United States uses a similar model of self-organized problem-solving led by families, and has also produced surprising results.

We usually define “helping people” as doing things for them. But often, it should mean asking them to do things for others. People like to feel competent, useful, needed — they benefit greatly from that feeling. That’s the insight behind the work of The Mission Continues, which asks veterans — a highly service-oriented group — to continue serving at home, working with chronically homeless veterans, building playgrounds or mentoring young people.

Another example is the Homeless World Cup, a series of local, national and international soccer leagues for homeless people. If you listed what homeless people need, a soccer league probably wouldn’t figure high on that list. And yet it can be a catalyst, a painless way to for a homeless person to build the confidence, trust and relational skills to be able to go after all the other things they need.

It can also work for depression, the world’s second most burdensome disease — for women, it’s first. In Kampala, Strong Minds is testing cost-effective ways to treat depression, with the goal of eventually getting to self-sustaining peer groups. Peer support groups do successfully treat depression. They can be doubly effective, in fact, because people get more out of helping others than being helped. Helping others reinforces their own behaviors, and being useful is in itself a depression-fighter. In Alcoholics Anonymous, the very model of a self-sustaining peer group, research shows that sponsors benefit more than the people they sponsor. But it’s best to do both — and in peer support groups, people do.

TARGET THE “SOCIAL DETERMINANTS”

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A Trauma Smart therapist talked about feelings with a child at a school in Kansas City, Kan. Credit Tyrone Turner for The Robert Wood Johnson Foundation

A medical mystery: A child lands in the hospital with asthma. The doctor prescribes medicines. The child uses them — properly. Yet two months later, she is back in the hospital.

Maybe the problem is that the child lives alongside mold, insects and rats. That child doesn’t need a doctor — she needs a lawyer, who can persuade, or threaten, the landlord to clean it up. And at more than 230 medical clinics around the country, lawyers are on hand to help.

Health isn’t just a medical problem. Health is undercut by substandard housing, air pollution, food deserts, dangerous streets, trauma and toxic stress — the social determinants of health. Being poor can make you sick, and doctors can’t always help.

Education, too, has social determinants. “Zero tolerance” has become the fashion in American schools — kids who act up are suspended and then expelled, even in preschool, and sometimes arrested.

This policy succeeds only in sabotaging the education of the children who need it most — mostly low-income African-American or Hispanic boys, many of whom have already faced daunting, often overwhelming, problems. When a 6-year old is aggressive, uncontrollable or violent in class, the question shouldn’t be “What’s wrong with him?” but “What happened to him?” The answer, too often, is that he experienced homelessness, divorce, family violence, incarceration, drug use, neighborhood violence, sudden separation or loss — or typically a combination of the above. Researchers now call these things ACEs or “adverse childhood experiences.” Increasingly, they are measuring them and discovering how drastically they can decrease the chances of a successful life if parents, educators or doctors fail to recognize them and respond. But parents and teachers can learn new, and better ways of helping these children — far more effective than reflexive punishment — and the kids themselves can learn ways to calm themselves and manage their strong emotions.

Social determinants follow students all the way through their educations. Community colleges have become the colleges of the poor in this country. And six years after enrolling, only one-third have completed a degree or transferred to a four-year college.

Why do students drop out? Overwhelmingly, it’s that they can’t afford school, and can’t afford to take time off from work to study.

One response is Single Stop, which has offices now spreading through community colleges that help people find out if they qualify for benefits such as food stamps, child care subsidies, federal financial aid or the earned-income tax credit — and if so, Single Stop helps clients to get them.

Looking for the social determinants is not the same as looking for root causes, which can sometimes become an excuse for inaction — the idea that you have to solve everything before you can solve anything. Both concepts recognize that poverty causes interlocking problems. But targeting social determinants is specific and practical. A medical clinic doesn’t have to lift a child out of poverty to treat her asthma. But it must get the landlord to do mold abatement. Schools can’t reduce adverse childhood experiences. But they can manage their impact.

You don’t have to solve everything to make progress on social problems. But what needs to be solved may be hidden from view. Finding it, attacking it and measuring the results — that’s a big idea in social change, this year and every year.

Read more: http://opinionator.blogs.nytimes.com/2014/12/11/big-ideas-in-social-change-2014/?_r=1

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