Author: Sandra Caballero

Positive Deviance Wisdom Series, Number 5, pp. 1-10.   Boston, Tufts University: Positive Deviance Initiative

In a remote mountainous community in Haripur District of Pakistan’s North West Frontier Province (NWFP), a few dozen miles north of the ruins of the ancient Buddhist educational township of Taxila, 19-year old Rahima felt a sharp, painful twitch in her abdomen. Eight months pregnant, Rahima wondered if the labor pains for her first child had begun–four weeks prematurely! As the cold wind blew outside her sparse two-room home in Bagra village, Rahima’s anxiety climbed steeply, much like the full moon gleaming in the sky. Did the full moon represent a good omen? Rahima would accept any kind of assurance, celestial included, for she knew that of the last eight births in Bagra village, two newborns did not make it past the first 40 days. Would her firstborn beat the one-in-four odds of survival in this harsh physical environment that had the dubious distinction of harboring one of the highest rates of infant mortality in the world? The odds for Rahima’s firstborn to face pregnancy complications were stacked high.

She had received no ante-natal care leading up to her impending delivery, no iron or vitamin supplements, and no tetanus toxoid vaccination. Her workload was heavy, and she tired easily cooking, cleaning, and caring for her in-laws, her husband, and his three younger unmarried brothers. While Rahima’s body needed more food and nutrients for the growing fetus, her mother-in-law limited her food portions so that the newborn would not be too big and thus be easily delivered. Rahima’s husband, Mushtaq, a small-time subsistence wheat farmer, was looking forward to becoming a father, wishing for the birth of a male child who could carry on the family name. Although a conscientious husband, Mushtaq, like most other husbands in Bagra village, was not involved in his wife’s pregnancy and ante-natal care. His preoccupation were his wheat fields and providing for the extended family. Mushtaq had no cash savings and made no preparation for any emergencies or pregnancy-related complications for Rahima.

As per Bagra’s social norms, pregnancy, delivery, and child care were exclusively in the women’s domain. Mushtaq’s mother, Shakila Bano, who with her experience of birthing 13 children (10 of whom survived), was Rahima’s primary resource for maternal and newborn care. With the midnight hour approaching and blistery mountainous winds howling, calling the dai, the traditional birth attendant, from a neighboring village was not possible. Shakila would help Rahima deliver the baby with the help of a neighboring aunt. Knowing the messiness of delivering a baby, Shakila spread some jute bags on the cold floor of the animal shed where Rahima would squat holding on to a charpoy, a four legged bed, for support. Writhing in pain, Rahima pushed and pushed until her firstborn—a daughter—was delivered. Shakila sawed the umbilical cord with a bamboo stick and tied a traditional thread around it to stop the bleeding. A dressing of desi ghee (clarified butter) was applied to keep the cord moist and lubricated. The aunt laid the premature newborn girl on the cold floor as Shakila delivered Rahima’s placenta. Mushtaq brought in a bucket of tepid water heated in haste over a wood stove and the aunt bathed the shivering newborn in an attempt to remove the vermix. The baby was then wrapped in a rag blanket and handed to Shakila so she could administer the child gutti, a homemade pre-lacteal concoction made from green tea, buffalo milk, ghee, and sugar. The prevailing belief is that the person who administers the gutti transfers their characteristics (intelligence, disposition, or charm) to the newborn. The thick colostrum, keer, flowing out of Rahima’s breasts,

full of antibodies to boost a newborn’s immunity, was discarded, deemed unfit for the newborn’s consumption. For the first hours, the gutti would suffice. With the newborn washed, wrapped, and fed, Mushtaq’s father, the elder male, was summoned to whisper azan, a prayer from the Holy Quran, in the newborn’s ear on the threshold of the room where Rahima delivered. Rahima prayed silently that her tiny premature baby girl would survive, if not thrive, against overwhelming odds.

Between January 2001 and October 2004, the Positive Deviance approach was implemented in a phased manner in eight villages of Haripur District in Pakistan’s North West Frontier Province to deliver better health outcomes for the likes of Rahimas and their newborns. Positive Deviance (PD) is based on the observation that in every community there are certain individuals or groups whose uncommon behaviors and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges. In essence, among the thousands of Rahimas, Shakilas, and Mushtaqs of Haripur District, were there a handful of individuals whose uncommon practices resulted in better health outcomes for the mothers and their newborns? Initiated by Save the Children as part of their Saving Newborn Lives (SNL) Initiative in Pakistan, the project represented the first application of the PD approach to address maternal and newborn care issues.

Beginning with an experimental PD process in two villages—Bagra and Banda Muneer Khan, followed by a pilot phase in Kaag and Chanjiala villages, where various PD processes, tools, and strategies were further refined, a larger four-village intervention was implemented in Garamthone, Nilorepaeen, Bhaira, and Chambapind villages. Baseline and end-line data were collected in these four interventional villages and in four comparison control villages to rigorously assess the effects of the PD intervention.

The use of the PD approach in these eight communities of Haripur District followed an iterative, well-defined process in two phases. In Phase one, activities were initiated to foster community dialogue about the problem of newborn mortality and morbidity among community members (separately between male and female groups) in order to identify PD newborns and their families, discover what were their demonstrably successful strategies (through a PD inquiry), and develop a plan of action. Phase two was dedicated to community action via community-designed neighborhood activities undertaken by both male and female groups.

The PD process, designed to build strong rapport with the community members, helped the intervention team learn about the local contexts of understanding with respect to maternal and newborn care. For instance, the concept of “newborn” was extended to babies under 40 days to match the cultural mindset in which babies have a special moniker for up to 40 days. Because in the NWFP of Pakistan, safe motherhood, pregnancy, and delivery are highly taboo subjects, a step by step approach was employed with various participatory activities such as transect walks, focus group discussions, social network maps, newborn mapping, and in-depth interviews. During the community orientation and feedback sessions, facts and figures about newborn and maternal care were shared, including powerful, emotive testimonies from family members who had lost a newborn or a wife, daughter-in-law, or niece during labor and delivery.

A baseline about newborns in the community was established working with both women and men’s groups. A newborn mapping activity was conducted by both groups to determine how many babies had been born the year before, how many had been stillborn or died immediately after birth, after 7 days, after 28 days and within 40 days. Concurrently, explorations of common practices with women’s groups around pregnancy, delivery, and immediate and subsequent post-partum care were explored using stuffed dolls as props. The dolls provided a visual representation of how the newborn was handled during the delivery process and post-delivery.

A baseline about newborns in the community was established working with both women and men’s groups. A newborn mapping activity was conducted by both groups to determine how many babies had been born the year before, how many had been stillborn or died immediately after birth, after 7 days, after 28 days and within 40 days. Concurrently, explorations of common practices with women’s groups around pregnancy, delivery, and immediate and subsequent post-partum care were explored using stuffed dolls as props. The dolls provided a visual representation of how the newborn was handled during the delivery process and post-delivery.

Besides the newborn, family members related to the newborn were identified as PD persons, such as a father who saved money in case of obstetric emergency at delivery, a mother-in-law who prepared a delivery kit for the arriving newborn, a dai who successfully resuscitated newborns who were not breathing and practiced clean cord cutting and appropriate cord care.

The inquiry also helped discern household behaviors that increased the chances of newborn survival, including tetanus toxoidd vaccination and antenatal care for the mother, delivery preparedness on part of mothers-in-law and dais, emergency-preparedness on part of husbands, the use of clean surface for delivery, clean hands while delivering, clean cutting of umbilical cord, thermal care of newborns, exclusive breastfeeding, timely care-seeking for premature or sick babies, paternal involvement in spouse and childcare, increase in postpartum maternal diet, and others.

The PD inquiry also yielded rich insights on messaging strategies used by the misali kirdars. For example, a religious leader noted: “we don’t need to bathe the baby for azan as when we listen to azan (a prayer from the Holy Quran) five times a day, we are not clean most of the time, so in the same way newborns need not be bathed before saying azan in their ears.” This religious leader, and his message about delaying the bathing rituals of a newborn, was then given play in mohallah (neighborhood) sessions and in community Healthy Baby Fairs, thus multiplying its effects.

To advocate for paternal involvement in maternal health pre and post delivery, a father noted: “Giving panjiri, a nutritionally-rich protein bar, to the pregnant woman can lead to a healthy baby and also keep mother’s life out of danger. If we provide food for the mother, it will ensure the health of the baby.” A mother-in-law explained the benefits of exclusive breastfeeding for her daughters-in-law: “The baby has no disease in the mother’s womb. If breast milk were dangerous, the baby would become ill in the womb. So mother’s milk is safe for the baby because it comes from the mother’s body.” Different channels of communication were used to repeat and reinforce the PD messages through different media, including religious and secular leaders and popular, culturally appropriate tools, such as street theatre to validate the messages given by the PD volunteers. However, the PD methodology focuses not just on the message delivery but also creates an enabling environment at the household level by involving husbands, mothers-in-law, the village health committee members, and members of the Village Action Team (VAT), who collectively facilitate and support the process of behavior change.

FROM INQUIRY TO CREATIVE IMPLEMENTATION OF A COMMUNITY-DESIGNED ACTION PLAN 

The PD practices that were discovered were openly shared with community members in community-wide meetings, albeit separately, because of cultural mores, with male and female members. Here the community members had an opportunity to discuss the PD behaviors, seeing their relevance, usefulness, and practicality. Moreover, this community meeting served as a springboard for action and the development of a community led initiative. 

The action plan was developed with the consensus of the whole community and displayed in a common social place to ensure transparency of roles and responsibilities to achieve the objectives. This basic plan was further developed or modified by the community-identified activists in the VAT workshop. The VAT was formed to manage the project and members were asked how they could measure the impact of the initiative (e.g. survival of newborns, adoption of new PD behaviors, lasting change, and others) and how they would monitor the progress of the program. These village health activists developed a six month plan, deciding that in cooperation with the community members, a plethora of activities would be undertaken at the neighborhood level with regular bi-monthly group interaction mohallah (neighborhood) sessions. 

These meetings were facilitated by local social activists, who volunteered to carry out the community action plan. Each bi-monthly session was focused on a newborn and maternal care topic and highlighted certain specific PD behaviors and strategies that had been discovered during the recent PD inquiries. One of the fun activities in the male mohallah sessions was to set up a mock bazaar where men were asked to buy what they considered a clean delivery kit for pregnant women. Discussion on each participant’s purchase followed and resulted in men declaring, some anonymously, that a new razor blade was the best tool for cutting the umbilical cord. The community’s respect and open support for the men’s contributions and decisions helped enhance their self and collective efficacy, leading to the emergence of a new and innovative leadership. Scores of new male volunteers signed up to run the mohallah sessions. Similarly, in the female mohallah sessions, community volunteers set up a bazaar, laying out several objects on a table and asking pregnant mothers, mothers-in-law, and dais, to select the five or six objects (e.g. soap bar, clean blade, clean plastic sheet, etc.) that were essential for a clean delivery kit. The selection of each object, essential or non-essential, sparked a healthy discussion about the object’s relevance in delivery preparedness. New leadership emerged from these sessions to serve as volunteers and activists in improving the quality of lives of newborns and their mothers.

MEN TAKE CHARGE 

The initial community dialogue in intervention villages unequivocally revealed that male involvement in maternal and newborn care was minimal. In this dominant Pashtun culture of patriarchy, male bonding with infants or caring for one’s wife is perceived as not being “manly.” A popular local folktale emphasizes this norm of paternal-detachment: Once upon a time a father who was going for work in another village directed his wife not to pick-up the newborn baby too often and advised her to hold a hen instead. When he came back after a few weeks, he saw that the hen had become weak and the baby was thriving!” The PD processes employed several interactive games and simulated role plays to help the local Pashtun men to become more involved in the care of their wives and newborn children. One of the games used to pass on responsibility to the male Village Action team was the balloons-as-newborn game. Men blew air into balloons and floated them over their heads. They were told that newborns are happy and alive as long as they are floating, but if they fall to the ground that means they are sick and may die. So, what could they do individually, as well as collectively, to minimize newborn deaths? By floating balloons, and keeping them in the air, they were “acting” on their communal, parental and spousal responsibilities: if they stayed together as a team and continue their PD work the newborn would survive and be safe; if they discontinued their collective effort the newborn would be endangered.

The PD project in Haripur District used a variety of interactive exhibits and artifacts to improve delivery preparedness and newborn care. In addition to the objects (e.g. new razor blade, soap bar, etc.) used during the mohallah bazaars, a big hit were homemade dolls, filled with rice or sand, and with detachable umbilical cord and placenta. These dolls were used to elicit accurate information from female community members on current practices regarding how the cord was cut, how the placenta was delivered, where the newborn is laid down, how the newborn was handled, and how he or she was resuscitated. The stuffed dolls were used to train female community volunteers in appropriate delivery and post-delivery practices, including the learning of new, improved newborn life saving behaviors. The dolls allowed mothers, mothers-in-law, fathers, and dais (the traditional birth attendants) to engage in learning by doing. 

EVIDENCE OF OVERCOMING ODDS

A pre-post, interventional control research design pointed to significant gains in maternal and newborn care indicators. In comparison to control villages where the gains were insignificant, in the intervention villages:

The percentage of mothers giving home made pre-lactal feeds in the first 3 days decreased significantly from 70% to 25%

The percentage of mothers giving home made pre-lactal feeds in the first 3 days decreased significantly from 70% to 25%

The percentage of newborns whose cords did not receive unhygenic homemade remedies increased significantly from 7% to 19%

The percentage of fathers who saved money and arranged for transport to tackle pregancy emergencies increased significantly from 45% to 62%  

The percentage of families that used a new blade to cut the baby’s cord increased significantly from19% to 33% 

The percentage of families that delayed bathing the newborn for the first 24 hours increased significantly from 18% to 32% 

It is useful to highlight that, in contrast to adopting the relatively simple behavior of using a new blade for cord cutting, the delayed bathing of a newborn represents a far more complex behavioral change, given its religious and cultural significance. Post-delivery bathing of a newborn is undertaken in most communities of Haripur District within minutes of delivery; an azan (a Quranic prayer) is whispered by a male elder in the ear of the newborn, and the child needs to be “clean” for this purpose. However, early bathing causes hypothermia—a major killer of newborns. The PD approach also helped in changing certain social norms in the intervention villages. In the North West Frontier Province, a highly conservative part of Pakistan, communication about maternal and newborn health is virtually absent. Infant and maternal mortality are couched in fatalistic terms—“as God’s will.” Women, by tradition, are not allowed to participate in health education meetings. However, the introduction of the PD approach, which began by building trust with the community’s male elders, led to more open household, neighborhood, and community discussions on such “taboo” topics between men and women. The Positive Deviants identified by the community (mothers, mothers-in-law, dais, husbands, religious leaders, and others) found a forum to advocate their uncommon yet effective behavioral practices at community levels. The odds of survival for the yet-to-be-born in Rahima’s village have gone up significantly since the PD approach to maternal and newborn care was implemented.

Positive Deviance Wisdom Series, Number 1, pp. 1-8.   Boston, Tufts University: Positive Deviance Initiative

Positive Deviance Grows Roots in Vietnam¹ in the Land of a Thousand Rice Fields Combating Malnutrition by Arvind Singhal, Jerry Sternin, & Lucía Durá Positive Deviance Wisdom Series, Number 1, 2009 www.positivedeviance.org Rice farming in Vietnam photo: Modified from original by Chris Feser @ flickr.com CC POS IT IVE DEVIANCE I N I T I A T I V E 

“Sternin, you have six months to show results,” noted Mr. Nuu, a high-ranking official in the Vietnamese Ministry of Foreign Affairs. “What? Six months? Six months to demonstrate impact?”

Jerry Sternin could not believe his ears. “Yes, Sternin, six months to show impact, or else, I will not be able to extend your visa.” malnutrition would not yield quick and sustainable results, the Sternins wondered if the construct of Positive Deviance, coined a few years previously by Tufts University nutrition professor Marian Zeitlin,¹ might hold promise. Zeitlin broached the notion of PD as she tried to understand why children in some poor households, without access to any special resources, were better nourished than children in other households. What were the parents of these children doing? Perhaps combating malnutrition called for an assets-based approach: that is, identifying what’s going right in a community and finding ways to amplify it, as opposed to the more traditional deficit-based approach of focusing on what’s going wrong in a community and fixing it from the outside. PD sounded good in theory. But no one, to date, had operationalized the construct to actually design a field-based nutrition intervention. Might it work in a community-setting? How? The Sternins had no road maps or blueprints to consult. Where to begin? Beginning close to Hanoi, their home base, made sense. Childhood malnutrition rates were high in Quang Xuong In December 1990, Jerry Sternin, accompanied by his wife Monique and ten-year old son Sam, arrived in Hanoi to open an office for Save the Children, a U.S.-based NGO. His mission: To implement a large scale program to combat childhood malnutrition in a country where two thirds of all children under the age of five suffered from malnutrition. The Vietnamese government had learned from experience that results achieved by traditional supplemental feeding programs were not sustainable. When the programs ended, the gains usually tapered off. The Sternins had to come up with an approach that enabled the community, without much outside help, to take control of their nutritional status. And quickly! Mr. Nuu had given the Sternins six months! 

CRISIS OR OPPORTUNITY 

From years of studying Mandarin, Jerry knew that the Chinese characters for “crisis” were represented by two ideograms: danger and opportunity. Perhaps there was an opportunity to try something new in Vietnam. Necessity is the mother of invention. If old methods of combating Crisis Danger Opportunity 1 

POSITIVE DEVIANCE enables communities to discover the wisdom they already have, and then to act on it. district in Thanh Hóa province, south of Hanoi. After a four-hour ride on Highway One in a Russian car the Sternins arrived on locale. The Ho Chi Minh trail, the major supply route for the Vietcong guerillas during U.S. hostilities in Vietnam, snaked through Quang Xuong, so suspicion of Americans, was noticeably high. The Sternins’ first task was to build trust with all stakeholders. The rest would follow. After several days of consultation with local officials, four village communities were selected for a nutrition baseline survey. Armed with six weighing scales and bicycles, health volunteers weighed some 2,000 children under the age of three in four villages in a record 3.5 days. A very, very poor families who are healthy!” These poor families in Thanh Hóa who had managed to avoid malnutrition without access to any special resources represented the Positive Deviants. things right, and “Deviants” because they engaged in behaviors that most others did not. What behaviors were these PD families engaging in that others were not? To answer this question, community members decided to visit with six of the poorest families with well-nourished children in each of the four villages. The Sternins believed that if the community self-discovered the solution, they were more likely to implement it. photo: PDI Women weighing children in an interventional village growth card for each child, with a plot of their age and weight, was compiled. Some 64% of the weighed children were found to be malnourished. No sooner was the data tallied, with abated breath the Sternins asked, “Are there any well-nourished children who come from very, very poor families?” The response: “Yes, yes, there are some children from Palpable excitement bathed the community hall. The self-discovery process yielded the following key PD practices among poor households with well-nourished children: Family members added greens of sweet potato plants to their children’s meals. These greens are rich in beta carotene, the miracle vitamin, and other essential micro nutrients e.g. iron and calcium. 2 POSITIVE DEVIANCE is based on the premise that if the community self-discovers the solution, they are more likely to implement it. “Positive” because they were doing (powered by a noisy tractor engine), Family members collected tiny shrimps and crabs from paddy fields adding them to their children’s meals. These foods are rich in protein and minerals. Family members and villagers did not have this nutritional scientific knowledge, but that wasn’t important. Interestingly, these foods were accessible to everyone, but most community members believed they were inappropriate for young children. Further, besides feeding their children uncommon food, PD caregivers were feeding their children three to four times a day, rather than the customary two meals; PD caregivers were actively feeding their children, making sure there was no food wasted; and PD caregivers washed the hands of the children before and after they ate. 

DOING NOT TELLING 

With the “truth” discovered, the natural urge was to go out and tell the people what to do. Various ideas for posters, educational sessions, and others. However, from previous field-based experience in other countries, the Sternins knew that old habits die hard; new ones, even when they hold obvious advantages, are hard to cultivate. Their experience suggested that such “best practice” solutions almost always engendered resistance from the people. The Sternins coined a phrase for it, the “natural human immune system rejection” response to being told what to do by others. As the brainstorming wound down, a skeptical village elder volunteered quietly: “A thousand hearings isn’t worth one seeing, and a thousand seeings isn’t worth one doing.” 3 Shrimps and crabs for the taking in Vietnamese rice paddies “A thousand hearings isn’t worth one seeing, and a thousand seeings isn’t worth one doing.” PD emphasizes “doing.” “telling” were brainstormed: household visits, attractive photo: Modified from orig. by Intl. Rice Research Inst., CC On the car ride back to Hanoi, the Sternins talked about the wisdom inherent in the elder’s remark. Could they help design a nutrition program which emphasized “doing” more than “seeing” or “hearing?” A two-week nutrition program was designed in each of the four intervention villages. Mothers, other family members, or caregivers whose children were malnourished, were asked to forage for shrimps, crabs, and sweet potato greens. The focus was on action. Armed with small nets and containers, mothers waded the paddy fields picking up tiny shrimps and crabs. Caregivers learned how to cook new recipes using the foraged ingredients. Again, the emphasis was on “doing.” Before the caregivers sat down to feed the children, they weighed their children, and plotted the data points on their growth chart. The children’s hands were washed, and the caregivers actively fed the children, ensuring no food was wasted. Some caregivers noted how their children seemed to eat more in the company of other children. When returning home, mothers were encouraged to break the traditional two-meal-a-day practice into three or four smaller portions. Such feeding and monitoring continued for two weeks. Caregivers could visibly see the children becoming healthier. The scales were tipping! After the pilot project, which lasted two years, malnutrition had decreased by an amazing 85 percent in the communities where the PD approach was implemented. 4 photo: PDI Children’s weight was plotted on charts to map their growth THE POSITIVE DEVIANCE approach is informed by and bathed in data. Data is collected at every step and openly posted for the community to monitor the progress. Data informs where problems and solutions lie. 5 attitude, practice) framework on its head. As opposed to subscribing to the notion that increased knowledge changes attitudes, and attitudinal changes influence practice, PD believes in changing practice. PD believes that people change when that change is distilled from concrete action steps. Second, the PD approach questions the traditional role of outside expertise, believing that the wisdom to solve the problem lies inside. While social change experts usually make a living discerning community deficits and then implementing outside solutions to change them, in the PD approach, the role of experts is framed differently. The community members are the experts. The facilitator’s role is to help the community find the Positive Deviants, identify their uncommon but effective practices, and then design a community intervention to make those practices accessible to everyone. Over the next several years, the PD intervention became a nationwide program in Vietnam, helping over 2.2 million people, including over 50,000 children improve their nutritional status. Born out of necessity, this pioneering PD operationalization experience in Vietnam, with all its struggles and learnings, yielded several key insights. First, the PD approach turns the dominant A cooking session in progress in an intervention village Third, in the PD approach, the change is led by internal change agents who present the social proof to their peers. As the PD behaviors are already in practice, the solutions can be implemented without delay or access to outside resources. Further, the benefits can be sustained, since the solution resides locally. Six months after the Sternins’ arrival in Vietnam, a beaming Mr. Nuu from the Vietnamese Ministry of Foreign Affairs handed them their renewed visa. They photo: PDI “transmission” interventional KAP (knowledge, In the PD approach, the change is led by internal change agents who present the social proof to their peers. would end up living in Vietnam for six years. The PD approach had found Vietnam to be a fertile ground to grow roots. Now the saplings could travel places, finding nurturance in other soils. ¹This pioneering Vietnam story draws upon numerous conversations and audiotaped interviews with both Monique and the late Jerry Sternin. To learn more read (1) Pascale, R.T., and Sternin, J. (2005). Your company’s secret change agents. Harvard Business Review. May, 1-11; (2) Sternin J. and Choo R. (2000).The power of Positive Deviance. Harvard Business Review, January-February: 14-15; and (3) Zeitlin, M., Ghassemi, H., and Mansour, M. 1990. Positive deviance in child nutrition. New York: UN University Press. 6 photo: PDI Monique Sternin listening to a discussion on nutrition Research shows that many younger siblings born several years after the project were able to avoid malnutrition altogether – a clear demonstration that the change in behavior had stuck with family members and caregivers. Design Team: Arvind Singhal, Lucía Durá, Robert Gutierrez, and Sarah Ontiveros Department of Communication The University of Texas at El Paso Email: [email protected] The Positive Deviance Initiative Tufts University 150 Harrison Avenue, Room 135 Boston, MA 02111 tel (617) 636-2195 fax (617) 636-3781 www.positivedeviance.org POS IT IVE DEVIANCE I N I T I A T I V E

Positive Deviance Wisdom Series, Number 2, pp. 1-8.   Boston, Tufts University: Positive Deviance Initiative

While all 24 students in Ramón’s first grade class await their birthdays, they are unaware of how bleak their future might be. Within two years, by the time they are in third grade, it is likely that 5 out of the 24 will have stopped going to school. By the sixth grade, another 7 out of the remaining 20 will have dropped out.1 In 2000, a first grader in San Pedro and, more generally, in Argentina’s rural province of Misiones would have had a 3 in 4 chance of getting to third grade and a 1 in 2 chance of making it past the sixth grade. Ramón’s entering class of 24 would have become a class of 12 students by seventh grade. Ramón’s entering class of 24 would have become a class of 12 students by seventh grade.

What explains this sharp drop in school enrollment rates in Misiones? Why do so many Ramóns drop out of school, missing out on learning basic literacy and numeracy skills? The answers, in part, lie in the traditional roles that young children in Misiones play in subsistence agriculture. For instance, Ramón may drop out of school:

To help his parents plant cassava branches, a staple food in Northeastern Argentina.

To help with the tobacco harvest. Children like Ramón are well equipped to pick tobacco leaves
as one has to squat low in order to pluck them from the bottom, keeping the upper ones intact.

To help with weeding, a non-complex task which children carry out with relative ease. Weeding, much like tobacco harvesting, requires long hours of squatting in the fields.

In essence, young children in Misiones play a key role in generating family livelihoods.For them, and their parents, school attendance is a relatively low priority. Survival takes precedence over education. However, not every elementary school in Misiones has high dropout rates. Some schools do better.

Consider Mr. García’s school. Mr. García is a teacher in
a school in Misiones which has higher student retention rates. After school hours, Mr. García can often be seen at his students’ home sipping a cup of mate, a local beverage made of herbs. He may ask parents about the well-being of the family pig that appears to be pregnant and about the tobacco harvest: “How much are they selling it for per kilo?” Mr. García may encourage Manuel and Lydia, the parents of Sylvia whom he knows on a first name basis, to continue sending their child to school. “Education is a great equalizer,” he emphasizes. “Sylvia is a good student and has a bright future ahead.”

The boys and girls in Mr. García’s class, as well as their parents, know that Mr. García believes in their potential and will go the extra mile to encourage their continued presence in school, even when they are absent.

In Misiones, teachers like Mr. García are beacons of hope for the Ramóns and Sylvias, who otherwise would not make it past third grade.

DEFIANT WELCOME

“Señor, Argentina no es Vietnam (Sir, Argentina is not Vietnam). Your Positive Deviance approach that may have worked in Vietnam will not work here in Misiones! We, the teachers, haven’t been paid in months. The parents of these children who drop-out are worthless and disinterested. And you Señor, you know nothing of our situation or problems,” noted a senior female teacher. Other teachers, with crossed arms and defiant looks, nodded in agreement.

“Señora, lo que usted dice es absolutamente la verdad!” (Madam, what you say is absolutely true), replied Jerry

Sternin, co-founder of the Positive Deviance Initiative. “It is also true that some of you, sitting in this room at

this very moment, have been able to retain over 85% of your students. So, yes, I know nothing about your situation. But I do know that the solution to your problem already lurks in this room.”2

After a long pause, an elder teacher noted, “Yes, Señor, that is correct.” She added, “but we are so often blamed for student drop-outs by both the parents and school administrators.”

“Is that the case every time?” asked Jerry. “At every school?” There was a long pause. Some teachers leaned in. Some appeared to drop their frowns. Some seemed to be smiling.

“PD is not a magic bullet,” Jerry noted with humility, “but by looking at elementary schools in Misiones that
are able to retain and graduate more students without access to any special resources, we might get somewhere.”

More folded arms began to open and Jerry’s suggestions received affirmation…

Positive Deviance Wisdom Series, Number 3, pp. 1-8.   Boston, Tufts University: Positive Deviance Initiative.

A tragedy of such appalling magnitude unfolds itself daily in U.S. hospitals. On average, hospital acquired infections (HAIs) kill about 275 patients in U.S. hospitals a day. This is largely because their doctors, nurses, therapists, ambulance drivers, and other health care workers did not follow hand hygiene protocols, were too busy to properly gown and glove, or were, simply, in a hurry. 

A leading bacterial source of HAIs is Methicillin Resistant Staphylococcus Aureus (MRSA), a deadly pathogen resistant to most commonly-used antibiotics, that can live up to six weeks on environmental surfaces and transmits easily through contact. MRSA infections have increased 32-fold in the U.S. in the past three decades. Amidst this alarming reality, a handful of U.S. hospitals have shown sharp declines in MRSA infections. At Billings Clinic, a multi-specialty physician practice in Billings, Montana, healthcare-associated MRSA infections have dropped by a whopping 84% in the past 2.5 half years.

What is Billings Clinic doing differently? As opposed to the traditional approach of focusing on what does not work, and rewarding or punishing employees to practice safety, Billings Clinic’s approach to MRSA prevention focuses on what works, believing that among its vast pool of employees, doctors, nursing staff, housekeepers, therapists, technicians, pastors, and social workers, there are individuals who practice certain simple yet uncommon behaviors that prevent MRSA transmission. For instance: A physician purposely sees his MRSA patients last during rounds, a simple practice that greatly reduces the risk of transmitting MRSA. An ICU nurse disinfects a patient’s side rails several times during her shift to keep MRSA from being picked up and spread. A nurse places a clean sheet between herself and a MRSA patient to avoid direct microbial transfer. 

 A physician stops wearing his tie, his white coat, and long sleeves, all vectors for the spread of MRSA infections. Many others adopt his practice.

These individuals, and dozens of others like them, at Billings Clinic are Positive Deviants. They are “Deviants” because their behaviors are not the norm and “Positive” as they model the desirable MRSA-prevention behaviors. As more people discover how to practice safety, the norm across the institution begins to shift.

TRACKING INTRACTABLE BEHAVIORAL PROBLEMS In the summer of 2004, Billings Clinic CEO Nick Wolter, MD attended a workshop in Durham, NH, where Jerry Sternin, co-founder of the Positive Deviance Initiative at Tufts University, made an impromptu 15 minute presentation on the topic. Sternin emphasized that the Positive Deviance (PD) approach was especially suited to address intractable social and behavioral problems.

Following basic hand hygiene protocols, Wolter knew, was an intractable behavioral problem in U.S. hospitals, including his own. Adherence to hand hygiene protocols for every patient encounter in U.S. hospitals ranged from 29 to 48 percent. This meant that, more than likely, the interaction between a health care worker and a patient carried the risk of infection transfer. This figure was highly problematic as patients expect hospitals to be safe environments, not transmission vectors of deadly pathogens. As a physician, Wolter knew that if he washed his hands before examining a patient, it would be cumbersome to wash them again just because he answered his pager during the process. When one’s hands feel clean, the behavioral tendency is to resume interrupted work, not fully grasping the implications for infection transfer…

Positive Deviance Wisdom Series, Number 4, pp. 1-8.   Boston, Tufts University: Positive Deviance Initiative.

“When you’re given to an LRA (Lord’s Resistance Army) commander, you are his forced wife. You are expected to take care of all his needs. Everything! I returned from the bush a few days ago but am still haunted by frightful dreams. I hear children crying. We are being attacked, or fighting, walking for days in the hot desert without food or water.” “I’m happy to be back, but I have no hope of returning to school. I don’t know what the future holds for me.” – Cecilia, a returned abductee in Northern Uganda²

Seventeen-year old Cecilia, abducted from her home in Gulu district of Northern Uganda and held in captivity for five years, is one of the lucky survivors of the brutal civil conflict that has ravaged the Northern Ugandan landscape since 1986. For over two decades, the Lord’s Resistance Army (LRA), in the name of the local Acholi people, has engaged in guerrilla warfare against the Ugandan government, avowing to establish a theocratic state based on the Ten Commandments. The conflict has claimed tens of thousands of innocent lives, displaced over a million people, and led to the abduction and enslavement of over 50,000 children, including the likes of Cecilia. Accused of widespread human rights violations, the LRA’s crimes against humanity include murder, abduction, mutilation, sexual enslavement of women and children, and forced soldiering. 

“They (the LRA) take an axe and split your head with it. They don’t waste any bullets on you,” recounted Cecilia. POSITIVE DEVIANCE is an approach that is uniquely effective in addressing intractable and highly complex social problems. What could be more complex than the reintegration of unwelcome abductees like Cecilia? Instead of being welcomed home, returned abductees like Cecilia are often treated by their community members as pariahs. After all, the abducted children were forced to side with the rebel army, killing and ravaging their own people. Physically scarred and emotionally-traumatized, some returned abductees also bear the burden of mothering an enemy’s child: “My eldest is Elma Alimo, meaning ‘difficult moment.’ I named him that because I was just 13 when I had him,” noted Cecilia. Unwelcomed and having no education or skills, many girls like Cecilia resorted to transactional sex, that is, sex in exchange for food, clothing, or even a place to sleep. How might these young vulnerable girls take more control of their lives?

LIFE AFTER THE LRA In March of 2007, Save the Children launched a pilot project to assist in the empowerment and reintegration process of vulnerable girls in northern Uganda’s Pader district using the Positive Deviance approach. The PD project targeted 500 young mothers and vulnerable girl survivors as well as 50 adult mentors who provide communitybased guidance, farming and financial advice, and general psychosocial support. One of the participating young mothers in this PD pilot is Hélène, a Positive Deviant among her cohort, whose daily practices led her to not just survive, but rather to thrive Anyira, lagam me pekowa, tye botwa… Girls, the answers to our problems lie within us… 

Much like a sunflower reaches toward the sun, Hélène’s garden grows nurtured by her dreams and aspirations. In the same soil, with the same amount of water and sunlight, a few sunflowers still find ways to plant their roots more firmly and reach higher. Some tower high over Hélène.

“I mixed all of my seeds, sunflower, cucumber, and others, in one basket and spread them in the field. These plants grow well together. I learned this skill from my father, he was a good farmer. He taught me about intercropping.”

Positive Deviance is rooted in the belief that the answers to a community’s problems lie in existing local wisdom. Bed lanyut maber Be exemplary The role of local and outside experts in PD is to act as listeners and facilitators. They can facilitate communitywide PD Inquiry, which allows community members to self discover the existing demonstrably successful strategies used by some to solve or prevent a particular problem. A PD Inquiry can help identify people in the community who, without any extra resources, address the problem more effectively. The idea is to make the PD behaviors visible and actionable so that others can replicate the uncommon but effective practices.

Similar to the sunflower plant that sinks its roots deeper to reach higher, Hélène, despite the hardships of abduction, early pregnancy, and motherhood, engages in certain practices which make her a valuable and integrated citizen in her returned community. Through her PD practices, Hélène presents social proof to her peers that overcoming the odds is possible. If she can do it, so can they. And since Hélène’s behaviors are already in action, others can begin immediately, without extra resources. Tii pi kwoni Work for your life Hélène’s practice of intercropping produces a healthy harvest. She has access to the same resources as other girls in her community, yet Hélène maximizes her harvest by practicing the wisdom passed down by her father. Her intercropping method is a rich source of local scientific wisdom. With guidance from Anna, her abayo (aunt and mentor), she will hire others to help with the harvest and will be able to sow more for the next season. From a mentor’s perspective, Anna is very proud. As she builds the capacity of children, she builds her own capacity…

Performance, 2(3): 78-83.

Journal of Creative Communication, 4(1): 1-17.