It’s convenient to frame this as a Third World problem. And while it is, it’s also a problem within and between developed countries. For example, people from one area of Glasgow (in Scotland) live a decade longer than people residing in another area of the same city, in spite of (theoretically) having access to precisely the same medical expertise.

A most basic analysis of Great Britain (and much of the developed world) reveals an organizational chasm, which most people are not prepared to cross: For example, medical services and social care provision are completely different activities – separate funding, differing structures, responsibilities, professional bodies. Even though individual “patients” shift seamlessly between them. It’s an organisational situation made worse by the difficulty both groups seem to have integrating with anything – in my experience (largely failing to integrate public transport into health and social services), a combination of:

• The intrinsic (internal) complexity of the service itself, which leaves little mental capacity for also dealing with “external” factors.
• The tendency to be staffed by those with people-orientated skills, who are often less able to think strategically or in abstract.
• The dominance of the government, with a natural tendency towards bureaucracy and politicized (irrational) decision making.

Complexity is the biggest problem, because it keeps getting worse: More (medical) conditions and treatments to know about, higher public expectations, greater interdependence between different cultures and areas of the world. Inability to manage growing complexity ultimately threatens modern civilization – it will probably be one of the defining problems of the current age. So adding even further complexity in the form of understanding about “fringe issues” is far from straightforward.

Beyond these practicalities lurk difficult moral debates – literally, buying life. Public policy doesn’t come much harder than this.

Into this arena steps Nigel Crisp. Former holder of various senior positions within health administration, now a member of the UK’s House of Lords. Lord Crisp’s ideas try to “kill 2 birds with one stone”: For the developed world to adopt some of the simple, but more holistic approaches to health/society found in the less developed world, rather than merely exporting the less-than-perfect approach developed in countries like Britain.

To understand Crisp’s argument requires several sacred cows to be scarified: That institutions like the National Health Service (which in Britain is increasingly synonymous with nationhood, and so beyond criticism) are not perfect. That places like Africa aren’t solely populated by people that “need aid” (the unfortunate, but popular image that emerged from the famines of the 1980s). That the highest level of training and attainment isn’t necessarily the optimum solution (counter to most capitalist cultures). If you’ve managed to get that far, the political and organisational changes implied are still genuinely revolutionary: To paraphrase one commenter, “government simply doesn’t turn itself upside down”.

While it is very easy to decry Nigel Crisp’s approach as idealistic, even naively impractical, he is addressing a serious contemporary problem. And his broad thinking exposes a lot of unpleasant truths. This article is based on a lecture Crisp gave to a (mostly) medical audience at the University of Edinburgh. And the response of his audience. The lecture was based on his book, Turning the World Upside Down: the search for global health in the 21st Century (which I have not read).

Problem, What Problem?

In the last century, Western medicine did rather well – dramatically increasing life expectancy. So it isn’t immediately clear that the system which delivered this needs to be changed. In practice, the demands placed on the system are changing, as is the wider environment in which the system functions. For example:

• Greater global interdependence – diseases travel rapidly between continents, staff and knowledge move (fairly) freely between countries.
• Lower tendency for (especially educated) patients to follow medical instructions, coupled with the reluctance of the medical profession to accept such an exercise of free will.

The (medical) service was built to provide treatment, but the need is also for supporting social care. The basic model of provision is becoming the problem.

While Crisp expects to see solutions emerge from many areas (like pioneering individuals, disability groups, or other industries), he focused on “global health”: Using insight from other countries.

Global Health

Sub-Saharan Africa has 10% of the world’s population, 25% of the diseases, 3% of the resources, and 1% of the medical staff. It isn’t hard to start identifying problems. Fundamentally, there aren’t enough medical staff being trained: For example, Ethiopia trains a hundred doctors each year, while the United Kingdom trains thousands. Both countries have similar population sizes.

However, places like Africa have advantages:

• They provide space to innovate: Developing world solutions are often simpler and cheaper than First World solutions, yet can be just as effective. Both treatments and policies have transferred from developing, to developed markets.
• Traditions often accentuate the role of family and community in activities. The result is that issues like health, education and economic activity are naturally linked. Health isn’t seen as remote from “other things”, in the way it often is in developed countries.
• People are trained for a job, not a profession: Individual skills tend to be more specific, and consequently much cheaper and quicker to train. In contrast, Western medics tend to be highly (and expensively) trained in a broad range of procedures, and then spend much of their working lives not using most of their skills.

Nigel Crisp’s logic is that knowledge and methods should transfer from the developing world to the developed world. Part of a much more genuine, mutually beneficial trade than currently exists: Co-development, not international development.

Mutually beneficial, because this allows ideas to move around globally, experience to be shared, individual minds to be opened. And, of course, it neatly addresses issues in both the developed, and developing medical systems.

Perspective

In subsequent debate, a member of audience referred to the “profoundly disabling” impact of First World medicine. The tendency for Western populations to be maintained on a cocktail of drugs and treatments, that often limit patients’ ability to live full lives. Also evident in perceptions of “illness” between countries – very few 40-year olds in the developed world consider themselves ill, in contrast to the United States (in particular), where almost the entire older-adult population seems to be being treated for something. It triggered the kind of audience reaction video doesn’t record: The slow realization that, actually, Western medicine might not have it all right.

It’s a sentiment echoed in the tendency of high income countries to ignore the work of bodies like the World Health Organization. By cynics like me, who see organisations like the (UK) National Health Service as national institutions, more than services. By the population, who appear to be rapidly losing trust in the wider medical profession. Or even in the ultimate utilitarian criticism – the perpetuation of life for the purpose of expending further medical resources on the perpetuation of life.

That the medical profession might have something radically new to learn, could be [sorry] a tough pill to swallow. That they might have something to learn from primordial Africa, could be quite a revelation. Yet the bigger problem is likely to be us, because the wider population also has to accept the benefits of an inherently global approach. And we may be far more reluctant.

De-Complexity

Equally fascinating was the audience’s apparent reluctance to accept reduced technical training for most medics. It would be easy to dismiss this as job protection – doctors clearly prize their status in wider society, which diminishes once most have been relegated to specialist nurses or social workers – even if the current profession is too “top heavy”, with large numbers of people that are over-qualified for the work they actually do. Rather, I suspect it goes to the core of a society that strives to “be better”. That values more training, better experience – and so is reluctant to accept second best, even when second best may be entirely adequate.

Yet less extensive training appears to be a requirement for individuals to broadened their experience into other areas. Wider social issues, practice in Zambia, whatever. Less complexity in an individual’s core trained skill creates mental space to consider other complex elements. The implication is that an element of de-skilling is required to handle greater complexity. And logically – since few (if any) individuals retain a full range of skills – there is then far greater requirement for team, community, society based methods of operating. The risk, of course, is that this simply narrows the “silos” (focus) of job-orientated professionals even further, and/or requires greater management.

I’m reluctant to dismiss the notion of learning from developing world, because there clearly are things that can be learnt. However, I’m unconvinced that more simple approaches can be transferred into the developed world, while still maintaining the benefits of the complex structures already found here. There may not be an equilibrium where the “best of both worlds” can co-exist. Rather, the adoption of less complicated methods might result in a less complicated overall society: One that does not support the types of scientific advances that have historically emerged from places like Europe, and generally haven’t emerged from places like Africa.

This isn’t a simple problem, yet I continually encounter it…

Playing Puzzle Pirates at Work

Take a dull job such as that of a call centre worker. Now take the online game, Puzzle Pirates. Strip out the puzzling part, and add in the dull job. What do we get?

• Metrics about the performance of yourself and others – highly detailed feedback loops that are largely missing from most regular jobs.
• Through these metrics, a way to identify issues with team performance, giving…
• An easy way to notice and resolve human issues within the team.
• A way to make money that relates directly to performance within the game.

Why Might This Work?

Some possible reasons:

1. Worlds are popular. People like playing them! Reeves was unusual among academics in acknowledging the huge popularity of teen-orientated worlds like Habbo Hotel, and down-playing relatively unpopular titles like Second Life.
2. A new “gamer generation” is emerging. Even without the online component of games, these features aspects of competition, failure, risk and feedback. It is reasonable that this generation will come to expect to work using collaboration tools with features that match.
3. Well understood recipe for creating a great game.
4. Emotional involvement. Byron Reeves showed how heart rate increased by the value of 10 [presumably beats per minute] when playing with another human-controlled avatar, rather than a computer-controlled agent. This implies a performance gain when human collaboration is present.
5. Technology: Worlds are easier to build, and “better”.
6. Painful long-standing problems in enterprises might be solved. For example, large proportions of workers are “out of the office”; have limited employee feedback; do fundamentally dull work; and require emotional contact with other humans to innovate.

Dragon Kill Points as a Measure of Contribution

Dragon Kill Points (DKP) might be used as a way to value contributions to collaborative environments such as wikis. DKP is a way of resolving how to share finite loot among a group – originally from killing dragons in Everquest, now from any encounter that requires a group to complete.

The application of DKP to other collaborative environments was not fully developed. So let me try.

Loot is the primary reward from most collaborative activity in an game such as World of Warcraft (probably where DKP is currently most used). At the most advanced stages of the game a hostile creature might require 10 or 25 people to kill, yet only yield 2 or 3 items of loot. An equitable method of distributing loot is critical to long-term motivation of players.

Pragmatic random distribution of loot is one method: Players those avatars would benefit from the loot are invited to roll a virtual 100-sided dice, and the highest score wins the loot. The process is not entirely without social mediation. For example, one player might pass (forfeit their roll) to allow another to win loot that the first player knows they particularly need. Likewise rolling on loot that the rest of the group perceive the player doesn’t really need is likely to cause a social backlash. Pragmatic random distribution of loot is easy to administer and well suited to small groups comprising players that might not regularly play together.

However, pragmatic random distribution does not account for long-term contributions: One player might attend one session, gain a rare loot, and stop contributing to further sessions. Meanwhile another player might attend multiple sessions and gain nothing.

DKP is an alternative method. It creates a tally of points based on contribution to group activity. Loot is then distributed based on the volume of points a player has banked (and is prepared to spend) from earlier contributions. DKP is generally used where:

• Groups are composed of many people, typically 10 or more.
• Groups are formed out of a limited set of people that often play together.
• A low volume of loot is generated relative to the time commitment required to generate it.
• Groups routinely split play sessions between activities which generate different amounts of loot. For example, learning/practice (“progression”) vs gathering loot from already familiar activities (“farming”).

If DKP sounds simple, it isn’t: A DKP system is a complex construct, with different ways to measure contribution and balance the flow of loot to players. Agreeing that balance is a highly social activity, and failure to get the balance right can break-up long-established groups.

Group stress (“drama”) caused by the requirement for a complex DKP system may be one of the reasons for the growing importance of tokens in World of Warcraft. Group activity yields tokens, rather than loot. The tokens can still be traded for loot within the game. However tokenization removes some of the requirement for groups to balance the value of different items of loot.

DKP as a Currency

Edward Castronova and Joshua Fairfield have already mused on some of the economic aspects of DKP. But there are some interesting tangents that have not obviously been explored.

DKP is a meta-currency where the value of the currency is based on the values players place on one another’s contribution. Oddly this makes DKP far more like a modern physical-world currency than the formal in-game currencies created and balanced by game designers. Most modern currencies are valued on nothing more than trust – even if most users of currency never realise.

DKP systems effectively create many different currencies, each balanced and exchanged between a tiny number of people. The economy this creates is so devoid of complex economic mechanisms, and so obviously balanced by social interaction, that it might be mistaken for barter; but it isn’t.

Applying DKP Elsewhere

The value of DKP is in the ability of a group to allocate their own collective set of values to the results of collaborative activity. The value of the currency is a reflection on the group itself.

Applying DKP to a wiki-type collaborative environment is problematic: Contributions are not equally balanced within the group – the classic 1%-9%-90% pattern, where most contribute nothing, and few contribute a lot. While DKP might seem an ideal way to resolve this imbalance, and give the 1% the credit they deserve, we must remember that the DKP system’s balance is a social construct: The system will naturally be primarily designed by the 1%, and so will be biased to reflect their needs or perceptions of value. So DKP resolves nothing.

Administering DKP tends to be complex and time-consuming. DKP is not just technically complex (which might be eased through better software tools): Its value-system is an ever-changing function of the group itself.

That all assumes DKP will always be established through negotiation between those involved. We could theorise that eventually standard approaches will develop, that later generations of players will come to recognise and accept a standard approach. But standardisation would merely create another traditional currency system. Such a currency would be less arbitrary than some formal in-game currencies, since its value would genuinely reflect the work of players, and would not have to be carefully balanced by those designing the world.

It is not clear that DKP can be applied to any collaborative situation. However it may form a currency that better reflects players’ effort than one designed by those operating the virtual world. Consequently it does have a lot of potential for further development.