Turning the Health World Upside Down

There’s a growing acceptance of the links between health, wealth and wider society. Not just the impact of wealth inequalities on measures like life expectancy. But the importance of fixing the underlying social causes of medical problems, rather than just administering the medicine and wondering why the patient doesn’t get better.

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). Read More

Virtual Worlds, Serious Work, and Collaboration for DKP

Byron Reeves (Stanford University) spoke to the Media X conference about how experiences from virtual worlds could be transferred into working life. This article summarises his talk, and contains personal analysis of the potential for using DKP (Dragon Kill Point) systems to measure contribution to collaborative activity.

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.

Michael Malone on The Protean Corporation

Michael S. Malone is perhaps best known for his work defining the “Virtual Corporation” in the early 1990s. At Stanford’s Media X conference he proposed the next iteration of organisational development – the Protean Corporation. The topic forms the basis of Malone’s next book. This article is based on his talk.

Trends

The total number of consumers is growing exponentially. Wireless broadband covers an ever-increasing amount of territory. The US may become the first truly “entrepreneurial society”, with skill-based work that never last more than a few years, where people never plan to do the same work forever: A mixture of creativity and volatility. The increasing size of the customer base will lead to larger organisations. Simultaneously, competitive threats can appear from anywhere, particularly in fast-moving technology sectors.

The result is two contradictory forces:

  1. Centrifugal: Technology enables workers to be spread out.
  2. Centripetal: Humans still need a sense of legacy and wider purpose; and are inherently social creatures. The “fatal flaw” of the Virtual Corporation was that once everything has been pulled apart, nothing is left.

Throughout history, from pre-corporations (such as early modern trading companies and guilds), through Taylorism to the virtual/adaptive/wired organisations, two trends can be seen:

  • Increased autonomy of employees, with greater communication between them.
  • Reduced management control.

The Protean Corporation

The paradox is simple: How to build an enterprise that lasts, while still being flexible and adaptive?

Michael used the Quantum atom to demonstrate the shape of things to come: An organic form, in constant flux, which retains its core. The design attempts to recreate the structures within Hewlett Packard, where a group of long-term employees remained at the core, with the traditional enterprise formed around them.

The Protean Corporation has three parts:

  1. Core
  2. Inner Ring
  3. Cloud

The Core are the permanent staff – people that have been with the business since as long as anyone can remember – “the immortals”. Their role is to protect the culture of the company, which they do somewhat informally. For example, they might be highly regarded by other employees for their experience or ability to get a result out of the organisation. Largely unseen, they are the people that make the organisation run smoothly. They may not be immediately apparent to the senior management, and as such they need to be protected from a new CEO – they are likely to be accidentally culled along with the rest of the workforce.

The Inner Ring are the traditional full time employees. They manage and operate the business. Their job is to recruit the Cloud.

The Cloud are 90% of the organisation. Their employment might last a matter of hours or days. They might work remotely, never having met their employer. The cloud is so transient that they might make errors before they have time to learn. It is critical that the Core is able to watch over the Cloud, and maintain the company’s culture and standards.

The role of the company’s board is merely to adjudicate and not to manage – to act like the company’s Supreme Court.

Competence Aggregator

The Protean Corporation will be fixed in perpetual motion. The most important role in such a corporation will be “competence aggregators”. These people pull individuals together for specific projects, much like creating start-up companies within the corporation. Competence Aggregators exist within the Cloud, but are still governed by the Core. The Competence Aggregators will be the new superstars of the economy.

Private and Public

The shape-shifting Protean Corporation can exist in both public and private sectors of the economy. To achieve this is the zenith of the concept.

A key problem remains: There is no way to accurately value the Protean Corporation. Its assets are intangible, and not reflected in conventional accountancy-based corporate market valuation. It is a similar issue to that which limits social entrepreneurs – there is no way to measure the performance of non-profit organisations. The ultimate limitation on the whole process is the lack of a market for intellectual capital.

The Protean Corporation in Practice

Wikipedia was cited as an example of a protean-like corporation.

I personally recognise the existence of both the Core, Inner Ring and Cloud from the Open Directory Project. The Core was part-formalised as “Editalls” – floating editors that had no fixed role, but which were always trusted and experienced veterans of the project. The Inner Ring consisted of “Meta” editors (and later Admins), who appointed everyone else, and took the formal leadership role. However, neither group entirely matched these roles. The Cloud, the regular editors, were just as described by Malone: The majority of the organisation, often with very limited ties to the project, many moving on after a short period of work.

The Core is also commonly found within British local government: In most long-established authorities there are a handful of people who both provide a sense of stability, and can simply get things done that nobody else can (usually through some combination of contacts and experience). Without these people I suspect that much of local government would be rendered totally dysfunctional (as close to collapse as a public body can become).

It was noted that Intel had originally shunned the concept of the Virtual Organisation, yet had subsequently developed into one “by walking backwards into it”. For example, only 20% of its “employees” are now traditional permanent staff. Far more contribute “virtually” or as suppliers. Yet all need access to company data and systems, so have to be trusted. A fifth have never met their boss face-to-face, and half of those never expect to: Such an organisation is logically already facing the challenges that the Protean Corporation seeks to answer.

Michael S. Malone’s book is called The Future Arrived Yesterday: The Rise of the Protean Corporation and What It Means for You.