M&Ms and slow ideas, or what a simple check can do

Making a list, checking it twice: BRAC’s oral rehydration program in the 1980s

I was psyched to read about David Lee Roth and his famous brown M&Ms in Atul Gawande’s The Checklist Manifesto over the weekend. It’s a favorite story of mine, as I’ve often considered it a metaphor for Great and Meaningful Things.

By way of background: Last summer, when Gawande’s article “Slow Ideas” appeared in The New Yorker, I decided to dip into the rest of his writings. In that article, the surgeon and ideas man used the scaling up BRAC’s oral rehydration therapy program in the 1980s as a proof point for why some ideas spread quickly and others slowly. Some ideas, like oral rehydration, can be made to spread quickly even despite the apparent disadvantage of addressing a problem that’s huge, like children’s diarrhea, with a solution that works invisibly, like oral rehydration solution.

Yes, it’s a nuanced and complex argument, but it’s worth reading. He makes it better than I do. 

Easier to grok is David Lee Roth’s insistence on brown M&Ms being barred from backstage when he was the frontman for Van Halen, an American rock and roll band, in the 1980s.

In The Checklist Manifesto, Gawande goes checklist crazy. He hops around from operating room to construction site to the kitchens of great restaurants. In every arena, wherever he sees amazing feats being performed, he sees the power not of great ideas or great women and men, but great checklists.

So one day he’s listening to the radio, and he hears the story of David Lee Roth’s notorious insistence in that a bowl of M&Ms be provided for Van Halen backstage at every concert, but with every single brown M&M removed. This line in the contract was cited for years as the ultimate proof of rock star vanity.

Actually, it served a really useful purpose. As Roth writes in his autobiography, Van Halen was venturing into markets where rock bands of that size (that is, with such ridiculous amounts of gear, staging and lights) seldom played. The technical requirements were enormous, far beyond anything most local promoters were used to. Lots could go wrong. Perhaps the platform couldn’t support the staging or the voltage requirements for the amps exceeded the capacity of the venue. A sloppy set-up by technicians who hadn’t read the requirements could mean a life-threatening situation.

Therefore, upon pain of cancellation of the show, with full compensation to the band, there would be no brown M&Ms backstage, according to article 126 of a very long contract stipulating the complex technical requirements of the show.

If the band walked backstage and found brown M&Ms, it meant somebody hadn’t read the details. There were sure to be problems. So they’d line check everything.

You could say the brown M&Ms were a canary in the coalmine, to use another metaphor for Great and Meaningful things, except in this case the poor canary wouldn’t have to die.

Or as Atul Gawande shouted at the radio when he heard this story, “David Lee Roth had a checklist!”

Coming back to oral rehydration solution. It was a simple innovation that saved millions of lives, but one that had to be delivered effectively and at a massive scale for it to really solve the problem of children’s death from diarrhea. And for that, checklists were required. Checklists upon checklists:

In 1979, BRAC wanted to see if it was possible to teach Bangladeshis with limited literacy how to make their own oral rehydration solution using exact proportions of sugar, salt and water. So it launched a pilot and paid the trainers based on retention of correct knowledge. A month after the training, a monitor would visit and quiz the housewives to ascertain if the recipe had been remembered properly.

It worked — to a degree. The problem was how to monitor the monitors — how to be sure the monitors weren’t simply filling out the forms at a tea stall, rather than making their required rounds. With lives at stake, it was a real concern.

The answer lay with the children of the household. When the trainer first visited, he or she would record the first name of the youngest born. The name was kept from the monitor — a field left blank on his form, to be filled on the follow-up. When the forms came back, sometimes the names matched, which meant the monitor had visited the right household. Sometimes they didn’t. “We had to sack many of the monitors,” Abed recalls.

Ruthlessly efficient? More like ruthlessly compassionate.

Sometimes a simple check is all that’s needed to make sure complex systems are working.

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