Alexander is the Head of Research at the King’s Centre for Global Health, King’s College London, Deputy Director of the INDOX research network at Oxford University and the CEO of MedicineAfrica Ltd. He has previously held positions as a researcher at The Mayo Clinic with Dr Bryan McIver, a Kennedy Scholar at Harvard in systems biology and genetics, a junior doctor in London and an Academic Clinical Fellow in Cancer Medicine at Oxford University.
Tell me about Medicine Africa. What do you do and what are the main aims of the organisation?
MedicineAfrica is an attempt to address the mismatch between the global burden of disease and the global clustering of healthcare expertise. I draw some analogy between 1947 Britain, where a Londoner wasn’t necessarily all that interested in the health of an Aberdonian, and the situation globally today. Truly global health for me represents something akin to the national transformation in the UK in the middle of the last century. I am certainly not advocating the creation of trans-national health services but I do think we are on the cusp of the world becoming accountable for the health of all of its citizens. This may not seem like a new thing, but imagine this, comprehensive healthcare free at the point of access to everyone, globally. Tantalising. To get to there from the world we have today, will require passion, action and a huge amount of pragmatism.
At the level of vision our slogan is ‘Bringing the world to the bedside’ so we are trying to create an environment in which, regardless of a healthcare worker or patient’s location on earth, there is a conduit through which they can access the collective medical expertise of the globe. On a more practical level that means providing real-time mentoring, tutoring and clinical support to isolated healthcare workers in low and middle income countries, specifically Somaliland, Ghana, Palestine, Tanzania, and we hope soon Rwanada, Uganda, Sierra Leone, Zambia and Zimbabwe. So rather than flying five doctors from a single hospital for one week a year to ‘capacity build’, we want to connect up whole hospital campuses in different parts of the world.
How did the idea first come about and how have things changed from your initial vision to the present reality?
I first started a project called academicswithoutborders.com (acawibo), in the U.S., with Moira Smith and Felix Greaves. We had an excellent team but a quick google search will show you how far that project got! I was studying Genetics and Systems Biology on a Kennedy Scholarship at Harvard at the time I remember the excitement with which I shared my ideas with the Late Senator Edward Kennedy over a lobster at his house in Hynanisport, Cape Cod. The next thing I knew, I was in the American Senate being introduced to science advisors and catching glimpses of the upcoming Black Senator from Illinois, who now occupies the White House. Edward Kennedy was, for all the controversies surrounding him, an incredible man. However, while we had the makings of an idea, it became clear that we still had much detailed work to do to turn it into a business.
It was not until travelling to Somaliland with Mr Andy Leather (Director of the King’s Centre for Global Health and Former Director of Surgery at King’s College Hospital), Simon Little and Nathalie Cronin (Max-Facs Trainee, London), during my house jobs that I saw the opportunity to use the potential of scaleable internet architecture to improve global healthcare provision and education. Andy Leather, who established the King’s THET Somaliland Partnership, has been a great mentor to me and supporter of MedicineAfrica since the outset.
How did you choose a team?
I have relied heavily on friends and contacts who have been incredibly supportive. Bringing people into a shared vision is one thing but creating systems to allow them to operate independently yet cohesively and in a way which they enjoy is a constant challenge.
I initially started and trialed MedicineAfrica with my close friend and colleague Simon Little (Neurology, Oxford / London). Dr Jordan Bowen (Geriatrics, Reading) then played a critical role in directing the first few terms of tutoring with the Somali doctors and medical students. We then brought on Oliver Johnson (All Party Parliamentary Group on Global Health and Head of Programmes at the King’s Centre for Global Health) who has an enormous capacity for effective administration, organisation and strategy. More recently we have brought in Nada Al – Hadithy (Plastics, London / Edinburgh) who has added to our team dynamic.
Finding the right team is key to any successful venture, yet it can be one of the trickiest factors to get right. What advice do you have for others about forming a team, based on your experiences?
If people are asking you difficult questions and you feel uncomfortable they might be just the perfect person for the job. Platitudes are easy. My supervisor at Harvard, Phil Leder who was the person who cracked the genetic code, said to my parents when they came to visit me in Cambridge, Massachusetts, that one should keep asking the difficult questions. When those questions started to come from elsewhere I originally felt intimidated, and to some extent I still am. However, we have a culture of open debate and a willingness to accept improvements which we have found to be really rewarding.
As a medic, how have you coped with running the business side of things?
Trial and error. Error, and being able to accept and learn from mistakes and failure, are a vital part of the process.
Have you or any of your team had any formal business education?
No but, my family has been incredibly supportive. In particular, my dad has been a really big source of inspiration. He is a commercial lawyer based in Edinburgh so I have always been surrounded by talk of business, of wealth creation, of job creation and of entrepreneurship. Formal training is something which I definitely lack. Thankfully, Felix has an MBA and we have been able to call on a massive amount of good will from friends and family to help advise us.
Do you think business skills should be taught to medics during their training?
With healthcare budgets everywhere coming under increasing pressure, it is important that doctors should understand the financial consequences of the decisions that they make and the extent to which business skills can help them to be more efficient. I am conscious that I still have much to learn about business. For doctors who are interested in business, Emma Stanton and Claire Lemer’s ‘MBA for Medics‘ course is a very worthwhile starting point. From there it is open to each individual to decide whether to get more detailed business training.
What have been the best aspects of setting up and running the business?
I think that trying to do something with a positive social impact but also having a way to modify this based on what you learn is incredibly exciting. I think what I am saying is that feeling that you can be responsive is really rewarding rather than feeling that you are constrained by too many external factors.
And the worst?
Being confronted with seemingly intractable problems, we have one right now, but there is always a solution somewhere.
What have been the greatest challenges?
Getting the right balance between flexibility and accountability and between empirical innovation and orthodoxy have been the greatest challenges. Being lean is critical when starting out with very little cash but it is also important to establish appropriate processes and procedures. When you are doing something that has not been done before, that needs a lot of detailed thought. But integrating that into the existing healthcare available in a responsible and sustainable way is where the challenge lies for me. I would not for one moment claim we were close to mastering the “magic” although we can see the enormous opportunity which information technology presents to achieve broader access to good care globally a reality.
We are probably in the throes of our greatest challenge to date in that we are just about to rebuild MedicineAfrica from scratch to a higher spec and with more robust organisational structures.
What one achievement are you most proud of?
Somaliland is a fledgling democracy with big dreams and passionate people. Despite this many patients with mental ill-health are shackled and chained to the floor of their houses or institutions. This is a country without a single psychiatrist in the public sector. Think about that. Close your eyes and try to experience the suffering of a patient with psychotic depression, anxious in ways that very few of us have ever experienced, teetering on the edge of taking their own life, ostracised from their community and chained to the floor. Through excellent leadership from Dr Susie Whitwell at the Institute of Psychiatry we are able to offer a UK based psychiatrist mentor to every graduating doctor in Somaliland so that they can discuss their difficult psychiatric cases and problems on a weekly or monthly basis. It is a bit like a consultant ward round but the consultant just happens to be 6,000 miles away. It is not perfect and the consultant cannot touch the patients, but given the alternative, it seems to me to be a positive start.
Would you do anything differently if you were starting out now?
I guess a challenge when you are doing something relatively new but which segways into a world as established as healthcare is that there is a period at the start where logic, passion, action and good intention are the drivers. At some point good intentions are no longer good enough. At this point rigorous evaluation and impact assessment are absolutely critical. Working out the point at which a good idea is trumped by a lack of evidence can be a challenge. You can only hope the evidence gets there first.
Working out the point at which the good idea requires confirmatory evidence can be a challenge. We are constantly trying to think both of the direct effect but also of the indirect impact. Assessing our responsiveness, sustainability and avoiding negative indirect effects such as dependency are really important. We have several people working on this now including Molly Fyfe, a PhD student from the University of California, San Francisco and MedicineAfrica’s own evaluation team lead by Felix Greaves (Public Health, Imperial) and Rosamund Southgate (Public Health, Oxford). We also always appreciate other people’s input in this process because it is clearly not always possible to have seen every eventuality from the start.
Has it been challenging starting a business alongside clinical training?
Gosh – yes. Trying to play a tiny part in capacity building in the health sector of low resource countries is incredibly challenging. There are political uncertainties, economic insecurities, technical challenges, educational hurdles in addition to the infrastructure and personnel issues and the lack of consensus about the right way to do things. We are all working on a voluntary basis to build MedicineAfrica as well as doing our day jobs. I am on an OOPE right now. I would say if you feel like the system is getting you down fight hard to demonstrate to the system what you can do for it and if you cannot, go back to barracks, regroup and then try again.
What would be your top 3 tips for medics who have entrepreneurial aspirations?
1. Try to do your day job well.
2. Remember your home constituency is health, and you signed up to alleviate at least some of the suffering, inequity and ill-health so a business which does ‘good’ somewhere in the healthcare value chain seems like a good place to exhibit any potential entrepreneurial flare.
3. Go placidly amid the noise and haste……..
There is currently an increasing recognition amongst leaders in the NHS that we need to encourage innovation within our healthcare service. What do you think needs to happen to ensure more medics are able to get involved in such innovation and take their ideas forward?
I like google’s ‘20% rule’ – A Google Doc: 4 days a week working at the coalface and 1 day turning their frustrations into solutions, and then implementing and evaluating them and, if successful, scaling them up.
Doctors have positive values. Doctors see problems. Doctors have solutions to problems. Those solutions take different forms, not all of which fit neatly into a 6 week audit. As a profession we are going through a phase of looking back nostalgically at the things we used to do that other professionals can now do as well. The time is ripe for asking what it is that we, doctors, can be doing to improve all aspects of healthcare delivery. We need to bridge the ‘know-do’ divide. The Dartmouth Centre for Healthcare Delivery Science would be a great place to start looking.
What does the future hold for you and for Medicine Africa?
I am currently on OOPE, with a job as Head of Research at the King’s Centre for Global Health, a research team for a project called Information and Communication Technology in Global Health (ICT4GH) and a job as the Deputy Director of INDOX, a research capacity building group in Oxford. These positions have enabled me to free up time to work on MedicineAfrica. I have been incredibly fortunate to have had so much support and encouragement from friends and colleagues.
I think MedicineAfrica will continue to throw up many challenges such as we the one we have now rebuilding to deal with increased capacity and increased responsibility. I hope that we will be able to work together to overcome them. Whilst we do I think we can learn a lot and hopefully continue to deliver useful medical support to fragile states.
Follow Medicine Africa and Alexander on twitter:
This week saw an article about Medicine Africa published in the Lancet – well worth taking a look: http://www.thelancet.com/