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Better: A Surgeon's Notes on Governance Reform

Naniette Coleman's picture

Better: A Surgeon’s Notes on Performance” by Atul Gawande seems an unlikely place to find governance reform ideas and development inspiration but I found both therein last week.  The book was recommended by a dear colleague who knows of my interest in organizational change.   An accomplished non-fiction writer "Atul Gawande, a 2006 MacArthur Fellow, is a general surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and an associate professor at Harvard Medical School and the Harvard School of Public Health.”    He tackles the “universal struggle to perform well” through the eyes of a surgeon.  Along the way we are introduced to countless examples of organizational seizure, organizational change and the people at the center of these operations. 

One story in particular might resonate with reform minded readers.  Gawande references an anti-starvation program headed up by a nutritionist at Tufts University and his struggles to maintain momentum in Vietnam

“The antistarvation (sic) program, run by Tufts University nutritionist Jerry Sternin and his wife, Monique, had given up on bringing outside solutions to villages with malnourished children.  Over and over, that strategy had failed.  Although the know-how to reduce malnutrition was long established – methods to raise more nourishing foods and more effectively feed hungry children –most people proved reluctant to change such fundamental matters as what they fed their children and when just because outsiders said so.  The Sternins therefore focused on finding solutions from insiders.  They asked small groups of poor villagers to identify who among them had the best-nourished children – who among them had demonstrated what the Sternins termed a “positive deviance” from the norm.  The villagers then visited those mothers at home to see exactly what they were doing.  Just that was revolutionary.  The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways – feeding their children even when they had diarrhea, for example; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children’s rice despite its being considered a low-class food.  And the ideas began to spread.  They took hold.  The program measured the results and posted them in the villages for all to see.  In two years, malnutrition dropped 65-85 percent in every village the Sternins had been too.”

A number of takeaways stood out for me after reading this story and reviewing Gawande’s book, the most memorable being: 

  • incorporate what he calls “positive deviance,” such as holding a series of small, group guided discussions where people at every level are appreciated for their ability to contribute to solving organizational problems. 
  • meetings should not be bogged down with so called “directives, charts or suggestions by experts.”  The age old term is brainstorming, a period of time when every option can and should be raised no matter how creative. 
  • although ideas raised may not be “terribly new” it is important to allow people the chance to be heard and valued, possibly for the first time in their work environment, especially in situations where power dynamics might discourage individuals from speaking up.  The process creates ownership and levels the playing field.
  • publicize ideas, small victories and the people who champion them so process participants can put a face to innovation and change.
  • collect detailed surveillance of the process and outputs.  If you can do nothing else in the beginning this will raise awareness and help you amass data to support your proposed changes. 


In essence, you want to respect and “build on capabilities people already have rather than telling them how they should change.”  This process allows for greater creativity, a topic I will cover in next week’s blog post.  Creativity is something the authors of “An upside down view of governance,” the good folks at the Centre for the Future State and the Institute of Development Studies, would appreciate.

Photo courtesy of Flickr user ALA The American Library Association 
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