Chapter 2

Christopher Charles and the Groundbreaking Research

CHRISTOPHER CHARLES WAS an undergraduate student at the University of Guelph in Canada when he came to a life-changing realization: he vastly preferred research to standard classwork and exams. Now an anesthesiologist based in Barrie, Ontario, Charles always found joy in unearthing the unknown and solving problems to help others, characteristics that would serve him well as he ventured into rural Cambodia in 2008. It was a trip of discovery and, ultimately, the initial stages in the evolution of Lucky Iron Fish.

From the relative comfort of Guelph, Charles was thrust into a new world. He was living in a traditional Cambodian hut called a Phteah Keung, with local scientist couple Nary and Tharith, who were tasked with helping him identify health issues experienced by people in the area. There was no running water or electricity, and Charles would bathe by the river. He was a new, distinct face in a place that had never had a westerner as a resident before. Nary and Tharith would translate for him as he tried to adjust to a very different life than he was accustomed to.

“It was a learning opportunity for all of us,” says Charles.

“Their English was elementary at the start and my Cambodian was non-existent. We reached a point where their English and my Cambodian got better, and we were able to communicate effectively as time went on.

“I spent the first month or two going around to different communities that surrounded the village I was living in. I would talk to families, mostly women, about their health, concerns that they were able to self-identify, and how they were managing.”

Charles had spent the previous couple years of his bachelor’s degree in the lab, sprinkling in some fascinating summer jobs that enabled him to travel the world and work in an area of personal interest, the field of global health. As he neared the end of undergrad, Charles was in search of a way to combine that passion for research and health work.

“I always thought I would go into medicine,” he adds.

On his path to med school, however, Charles was first contemplating doing a master’s degree. He began applying for government funding and was successful in landing federal money to work in Cambodia. Charles connected with Heather Murphy, a Ph.D. engineering candidate at the time who was completing work on water and sanitation in the Asian country. She had directed him to a reputable water and sanitation-centric NGO named Resource Development International — Cambodia. He began to research the issues facing the Cambodian population and found that helminth (parasitic worms) infections were pervasive. Hookworm infections, as they are more commonly known, were a result of poor water conditions and caused both malnutrition and anemia. Another cause of anemia is iron deficiency.

Charles planned to go to Cambodia for three months after he had completed his bachelor’s degree and before his master’s. But the project soon grew bigger when he realized the extent of the problems in the region. The best national estimates at the time suggested that anemia affected 50 to 60 percent of the population, which Charles recognized as a staggering number. After carefully designing some studies, he was finding that closer to 92 to 95 percent of the population was testing anemic.

“There was no government intervention,” notes Charles. “It was tough to see. To go out and collect these narratives from people and to have conversations about how they felt, their energy levels, and how they were going to get through their day was difficult. They were literally ticking off every single sign and symptom of anemia that you would find in a textbook. That was the reality for these people. Their quality of life was so impacted by anemia. It was a big challenge.”

When he was out and about, Charles would visit pharmacies, or at least what passed as pharmacies, always on the lookout for iron pills to assess the supply, the cost, and so forth. His sobering discovery was that iron pills were unattainable for families. In almost all cases, households would bring in perhaps a dollar or two a day, while a one-month supply of the pills could range from $2.50 to $7.50, and that was just for one person. So the pills were simply out of reach for families with several children and other adults in the household.

“My initial work was to try to quantify the prevalence of anemia in those communities. At the end of the three-month period, I realized that I had collected this huge swath of data and uncovered a massive problem. I was going to hand the project off and maybe it would sit on someone’s desk and perhaps that would be the end of it.”

Charles was in a psychological and moral crisis. He had a decision to make. Ultimately, he called his adviser at the University of Guelph, Dr. Alastair Summerlee, who was also serving as the school’s president at the time, and expressed his concern that he couldn’t just walk away from these Cambodian people in need. He wanted to delay his master’s to do more work overseas. Summerlee, whom Charles describes as a “big thinker, flexible, and an intellectual powerhouse,” got back to his future graduate student with a proposal — stay in Cambodia and focus the master’s on global health rather than lab-bench research.

“That seemed to tick a lot of boxes,” says Charles. “Pretty quickly, things changed course.”

With a new life plan, Charles was energized to do the important work in Cambodia and take steps to help resolve some of the health issues of these people whom he was getting to know and care for. He did weeks of research and found a series of anthropological studies from the 1970s set in sub-Saharan Africa and Brazil that examined the use of iron cooking vessels in anemia prevention. Initial findings usually suggested that using iron cookware on a regular basis had a positive effect.

“The concept is that if you’re cooking in an iron pot, some of that iron will leach from the pot, go into the food, and enrich it,” notes Charles. “Even if you’re eating an iron-deficient diet, you’re able to provide that little bit of supplementation at the household level.

“But the problem with iron cookware is that it’s not widely used in the developing world. It’s very costly and heavy. Families will leave food in cooking pots and if leftovers sit overnight, the food absorbs more iron, altering the taste and colour. “I ran with the idea and thought, ‘What if there was a way to add iron to the cooking pot, then take it out later?’ We began thinking of adding a hunk of iron or iron ingots. I was working with a great group of people who were really motivated and well-connected.”

Charles began communicating with iron ore smelting factories among Cambodia’s larger manufacturing industries. The idea was to create an iron ore ingot that could be added to cooking pots. The first concept was an iron block about the size of a deck of cards. They were distributed to people in the area and Charles asked the women of the households to cook with them. It proved to be a challenge. There was resistance. But the Cambodian people knew Charles was a Canadian health care worker trying to help. He had started to gain their trust.

An even bigger challenge was the language and knowledge barrier. Most of the research subjects in the initial study had low levels of education, high rates of illiteracy, and a poor understanding of health in general.

“Anemia was an unknown concept,” notes Charles. “They felt the way they felt — dizzy, tired, low energy. They didn’t know that it might be related to their diets. I had some pretty rudimentary materials that I used, photos and basic PowerPoint graphics, to show ‘This is how you feel today, this is the problem. And it’s called anemia.’ The way to treat it was to add more iron to their diets. It wasn’t just a matter of handing out these iron blocks, but it was about getting people to understand why this is a problem that they should be concerned about and why I thought the iron block might be helpful.”

It was the most sensible solution, it seemed, given how expensive iron pills were. Charles began to emphasize how using the iron blocks could benefit an entire family, noting anemic mothers give birth to underweight and anemic babies, continuing a harmful cycle that is difficult to break.

“That was a really important concept and an area that ultimately helped lead to the success of Lucky Iron Fish,” Charles says.

He left the iron ingots in the communities for approximately three months then returned to interview the women and take blood samples to see if hemoglobin and iron levels had changed. That’s when Charles experienced his first major research setback — a “complete and utter failure,” as he describes it. The Cambodians had understood what he wanted them to do but it was such a foreign concept to add this piece of iron to their cooking pots. Charles gathered a collection of photos that showed what the people did think the iron was good for: propping up broken tables, using it as a doorstop or paperweight, among other uses.

“Kids were using them as toys, painting and drawing on them,” Charles says. “Very few families were actually using them to cook. I heard from many people that the appearance was really quite discouraging. Cambodia is very much a food culture. A lot of your social life revolves around gathering as a group, gathering as a family, and eating food together, whether it’s a plain bowl of rice or something special. People really do come together and value that ability to share a meal with one another.

“If you’ve got this ugly piece of iron and you’re mixing that in with something that you’ve saved a lot of money to purchase … it’s a struggle.”

It was a massive learning experience for Charles. In addition to the poor visual appeal of the iron, he recognized that he had to do a better job explaining just how important it was to address anemia. He was frustrated that a few months of work was rendered essentially useless. Complicating matters was that he lived in a rural Cambodian house with no running water or electricity, but he somehow had to test blood samples. That hurdle required some ingenuity to overcome. When Charles first arrived in Cambodia, he attended an auction for equipment from a Russian-owned hospital that was closing down. He purchased a centrifuge that was approximately fifty years old and ran on car batteries. It wasn’t possible to send the samples to the city to be tested, given the time it would take to get there, so Charles, Nary, and Tharith would run the tests at night at the house and try to make their own diagnoses.

Charles continued to communicate with the village elders and women in the study to address the concerns about the ingots and discuss what could be done to make the product more palatable, in addition to building on the education component. Charles found that the villagers thought the ingot would damage the cooking pot, and there was the issue of its lack of visual appeal. He focused on the latter point. He went through a couple of iterations of shapes, changing from a block with sharp corners to a simple disk. Then came a design that mimicked the lotus flower, a plant that is familiar to Cambodians, particularly in rice fields. The flower is also associated with good fortune, which seemed to be a good path to Charles.

Then on a walk through a marketplace, there was a light-bulb moment.

“I saw a gentleman whittling a piece of wood into a fish,” said Charles. “Fish are absolutely the lifeblood of the Cambodian people. I thought, ‘Well, that’s an interesting idea.’” Cambodia is mostly landlocked, with the Mekong River running through it. Communities rely heavily on fish, and it is the predominant protein source in the Cambodian diet. The wood carving was about the size of the ingot needed in the cooking pots. The fish was also an image seen everywhere in the country, a food source with which all Cambodians were familiar.

Charles took the idea and had a prototype made out of wood. It looked like a catfish and in focus groups it was a success. He remembers someone suggesting that the design should be based on a particular species of fish called try kantrop, which is considered lucky.

“It’s a fish that they only eat when they’re having a celebration,” explains Charles. “One time a year perhaps, people get together and have it.”

Charles now had the right shape and size, a good weight, and a flat design that maximized surface area, all while resembling a species of fish that the people cherished. It was a better product. About 150 were produced with the intent of repeating the initial study.

The next challenge for Charles was to address the anthropological aspect and see if he could change the behaviour related to using the fish. He sat down with the families in the study and started from square one, requesting that they use it for three months. Charles made sure to break down the information better. He explained that iron was a micronutrient and pointed out what could happen to people when they don’t get enough of it and how that would impact the whole family.

“When I first moved to Cambodia, I began working with an NGO called Resource Development International — Cambodia, an organization that does a lot of work in water and sanitation, but they also had a small village health program,” he explains. That’s how he teamed up with the pair of individuals we introduced earlier, Nary, a pharmacist, and Tharith, a medical student who would go to school on the weekends.

That meant Tharith was available during weekdays, so the bulk of their work was conducted then and he would travel to Phnom Penh to study on weekends, which he did for five years.

“As I mentioned, both of them spoke only rudimentary English when we started working together and I spoke no Cambodian. But after I arrived in Cambodia, it wouldn’t have been more than five or six days before the three of us moved into this hot, tiny village, Preak Russei.”

Charles said that moving to the village was a culture shock for Nary and Tharith.

“They were doing village health work, but they weren’t living in the villages that they were working in,” he says. “They would go out for day trips and they would try to do small health interventions. They would help with building wells and things like that in communities that were funded by this NGO. But this was an experience, I think, for them to see what a different level of poverty looked like.”

Charles benefitted from the fact the pair were health practitioners, but they had never done any research projects at this level before. It meant Charles had to engage in a certain amount of education, such as explaining how they were going approach the project, or how they would actually assess whether the iron fish was going to be effective or not. Another issue was how to build trust in the community.

“I had to learn a ton from them,” Charles notes, pointing to the frustration and debilitating effects of the initial failed test. “I would say it was very much a collaboration to try to figure out how can we make this a successful project. I was incredibly intimidated. When they suggested that the first thing we had to do was to sit down with the village elders, I had no idea what that type of a meeting would even look like, or how to go about requesting it or what the proper protocol was, and how do you demonstrate respect to these elders in a way that is authentic.”

The team of three had to figure out how to make the points that they needed to get across to folks who maybe didn’t even understand the reasons they were there.

“That initial meeting was very challenging, and I remember being very worried about how that would go,” Charles recalls. “Thankfully, in the end, it went very well. It was a bit of a dance, and they didn’t know what to make of me and I didn’t know what to make of them. You have to be willing in those circumstances to just put in the time and to make yourself a little humble and accept the fact that you’re not going to be the one leading the charge.”

The primary goal was to work with the community at large rather than singling out individuals. In the village in this case, there were an estimated eighty to ninety households and each would consist of roughly five to ten people. The goal was to work with the full community, with a focus primarily on impacting women’s health.

“The first people that we had to reach out to were village elders, to get their buy-in, and specifically focusing on those village elders who were women themselves, who could help to sway the others to try to encourage them to look at this as something that’s really important, not just for women, but for whole families,” Charles explains. “That involved sitting down, having tea and spending hours in some cases, just talking through who we were, what we were there to do, what they could expect during our time in the village.

“We knew that we were not going to be able to work with all of the households in the village, we knew that there wouldn’t be buy-in from all of them. But the idea was to essentially get a critical mass where there’s enough people who are engaged in this, there’s enough people who kind of understand and have the ability and time to cook meals on their own and to start using the iron fish. And we knew that word would spread to others. And so, as we continued, we would constantly get women coming to us and say, ‘I am not part of your study, but I really want an iron fish. I go over to my neighbour, and I see it, I see how they’re cooking with it. And I think I can do the same thing. How can I get one?’”

One of the challenges of any research study is that a stepwise approach is required to build that evidence base, to work with the community and see if over time the solution, the iron implement in this case, is going to be effective.

“Then at the end of that time, if we were successful, if the evidence was positive, and we showed that we could have an impact, we wanted to make sure that the iron fish was available to anyone else in the village who wasn’t a part of the study,” Charles says. “I think that built a lot of goodwill in that community. And I have no doubt that that goodwill spread, people talked about us. It was amazing, because we would go to neighbouring villages, on the way back to the NGO where we were now based, which was about a half-day trip, including two different ferries, and you’re driving through a number of different villages and people come and say, ‘Oh, you’re the iron fish people. Come to our village because we want to be part of this, too.’ And that was something that was really amazing. You could see that even before the research study had finished.”

The word was spreading that this was a basic tool that was effective and easy to use.

“We weren’t seeking people out and trying to twist their arms to be involved. They were reaching out to us,” Charles says.

Success would require gaining a high enough level of trust from people who had been burned, despite good intentions, in the past. In the late 1980s and early 1990s, UNICEF initiated a program to get Cambodian villagers to change their drinking water habits because their current ones were making them sick. At the time, people were drinking from the river, where animals were bathed, where people bathed. The water was a muddy brown colour and teeming with bacteria. UNICEF went around to those communities and in each drilled two wells down into the groundwater and the communities changed their source of drinking water. What wasn’t known at the time was that those two wells contained incredibly toxic levels of arsenic.

“They were telling communities that this was a safe source of drinking water, and they got the entire community on board,” Charles says. “Then years later people started falling ill with arsenicosis, or arsenic poisoning. Folks would have cancers or really awful skin conditions, toughening and blistering of the hands and the feet. So it was very clear, especially to those who were a little bit older and had been drinking that water for longer, that they were really suffering from this and dying. As a result, there was a lot of lingering distrust about working with NGOs and folks from the outside. We were battling against that distrust.”

Ultimately, UNICEF returned and capped the wells. Some of the work of the NGO that Charles had partnered with involved bringing water filters into the community. The ceramic water filters required no movable parts and villagers could use them to purify the river water.

“And then in addition to trying to regain trust, blood is seen as something that’s sacred, as something that you don’t spill,” Charles says. “It’s seen as part of their essence. So even though we were using it right there in the moment, running our lab tests, it had people worried, wondering what we were doing with that blood. “We were outsiders, and Nary and Tharith were outsiders just as I was, even though they’re Cambodian, because they weren’t from that area. They were educated. It was apparent to people that they had more money, and we drove a car into this village that didn’t have any cars. There was a lot of hesitation around that. It surprised me that it would be such a hurdle to get over and how important it was to demonstrate to people that this is something that’s safe.”

In that village and surrounding communities there were no doctors, and the nearest hospital was many kilometres away. As a result, villagers could not access the hospital, so they were not familiar with having blood taken.

“There is a lot of research looking at iron deficiency and income generation,” says Charles. “We know that families that are iron deficient generate less income. The children do poorer in school. And there are greater rates of maternal anemia and hemorrhage in childbirth. The research shows why it’s important to tackle the issue.” Those conditions would eventually serve as a motivator for villagers once they recognized and identified the problem.

After developing trust and gaining the willingness of people to have their blood taken, the team still always had to get villagers to use the fish regularly. Charles and his partners had a strategy. They targeted some of the households where the “social butterflies” of the community lived. People would come to see the foreigners and groups would gather for cooking demonstrations. Nary, whom Charles describes as a “fantastic cook,” showed how the fish was used. She would discuss recipes and how the iron fish could help. There is research showing that the acidity level of food is important in helping the iron to be absorbed. Using lemon when boiling water with the iron fish helps add acidity.

The team also returned on a monthly basis for blood samples and to remind the Cambodians in the study that they had not gone anywhere. Charles emphasized that they were there to answer questions and help in any way needed. This new plan proved to be much more effective.

“At the end of that three-month study, we were able to show that about ninety-five percent of our participants were still using the fish on a daily basis,” says Charles. “That was a tremendous success given the disappointing outcomes with the iron ingots previously.”

Charles and the team were certainly on the right track. But concerns remained. They wanted the products to be as pure as possible and it was difficult to get consistent, high-quality sources of iron. An underlying principle of the work was to “do no harm” and that thought was always front of mind for Charles. They worked very hard to source pure iron and, after about six attempts, found one source they were certain was good quality and free of contaminants.

The next step was to increase the scale of the project from both a production and a scientific perspective. In Canada, a test for anemia would assess about five to ten different lab values. When the team ran samples on the old centrifuge, they looked at one single lab value, hematocrit levels, which reveal how much of the blood is made up of red blood cells. More information was needed. Charles was confident in the results of the pilot study, but he knew he needed to be able to replicate the findings in a larger study, with potentially four to five hundred people. For the next year and a half, Charles focused on producing a bigger, more formalized, randomized control trial, tackling the logistics of increasing the scale.

The team had already expanded to six, a few new members having been added to help with the community relations aspect of the work. But getting around and transporting blood to labs was still a hurdle. Motos, or small motorcycles, are the main method of transportation in Cambodia, a hot country with limited refrigeration facilities which meant blood samples had to be sent quickly for testing rather than stored. The team began using a crew of moto drivers, who would strap the blood samples on their backs and deliver them to labs a few hours away. Around 6:00 a.m. the team would collect blood samples for the first half of the day before sending them off with the moto drivers.

Charles expanded the study population and fine-tuned the educational materials so that as he introduced the iron fish to different communities, everything was done the same way. Everyone had to be on the same page regarding how the messages were delivered. Trust, as always, was essential.

“One of the scourges of international development in Cambodia is that it’s a country that suffered a great genocide and has had tremendous sadness in its political history,” says Charles. “After the genocide, there was a large number of NGOs that went into Cambodia to try to help rebuild, I think almost as a penance for not having done more during the genocide itself. It led to a significant NGO presence, with some less than rigorous work being done.

“Very early on, I realized that if I was going to be successful in this work, I needed to think past my lab-bench mentality. I couldn’t just be a scientist.”

Charles embraced the idea that he needed to build an understanding of anthropology and culture and how to effectively communicate. His master’s in biomedical science quickly transformed into a much more interdisciplinary project that required different levels of expertise.

More time passed for Charles in Cambodia. His initial three months turned into a year, then two. Ultimately, he would spend close to seven years with the people who had grown close to his heart. In about the second year of the journey, the Cambodian government saw value in the work, and a partnership was formed. Samples could now be tested at a lab in the capital city of Phnom Penh. Then it was time for a randomized control trial where one group used the iron fish, and one group didn’t. The goal was to compare the health outcomes over time. Charles also developed a questionnaire that addressed quality of life outcomes, energy levels, headaches, and dizziness, and looked at signs and symptoms of anemia. He had come quite a long way since measuring a single lab value back in the old centrifuge days.

Also in that second year, a North American team was assembled, with people in British Columbia, Guelph, and the United States. By years three and four of the project, an anthropologist, an epidemiologist, a nutritionist, and a biomedical scientist joined in the interdisciplinary work. Charles’s master’s eventually turned into a Ph.D., which he completed at Guelph.

Throughout his years in Cambodia, Charles faced an internal struggle. He did not have a formal medical background but because he was discussing health and nutrition with the local people, many assumed he was a doctor. It was true he had a great amount of health knowledge, but there were challenges working in the communities.

“Someone brought their grandfather, who had had a machete accident, to see me,” recalls Charles. “He had part of his foot chopped off. Or someone who had a stroke. I was constantly encountering these situations where people were asking me for help. I didn’t have that medical training. I felt like I was asking so much of them, but I wasn’t able to give them all that they needed in return. I became a bit of a self-taught, self-trained first responder. I was able to provide some help to these folks. But I wanted to make sure that if I was going to do this for the rest of my life, that I would have that high-quality skill set so that I could help as much as I possibly could.

“It was a privilege to be able to develop relationships with people who had such different lives from my own. I spent a lot of time in two particular communities where I lived. I started to develop a bit of a routine. I would encounter people every day and we would share stories. That was really positive from a personal perspective because sometimes I was just on my own. You need those human connections, while also trying to maintain that scientific approach and not wanting to influence things too much.”

It was painful for Charles to see the poverty and lack of privilege compared to what he was fortunate to have. The Cambodians frequently suffered serious injuries or got infections, and in their environment, that could mean a death sentence. Those thoughts weighed heavily on him.

“It was really challenging to see what they were encountering day in, day out,” he says. “I was rightfully focused on one area, anemia and nutrition, but it was at the expense of having to look past all of the other struggles I could see. That was tough.”

The emotional toll aside, the work ultimately went well. His studies showed the iron fish worked and a great solution had been discovered. It made sense culturally, anthropologically, and scientifically. The next phase would be to scale it up, working in different areas of Cambodia, and other countries as well.

Personally, Charles had not intended to do a Ph.D., but his time in Cambodia took him down that path. He still had medicine in the back of his mind, too. He spent months considering whether to pursue more training in medicine or work on commercializing the iron fish.

“My interest from day one in this project was working with the people on the ground, getting to share stories, and see the impact of the work,” explains Charles. “I had less interest in sitting in boardrooms, developing budgets, research proposals, and business plans. At that point, I considered bringing on someone who had more business experience to develop the next phase of the project.

“That allowed me to take a look and say, ‘Now is the time to pursue additional training in medicine so that I can fulfill that skill set I thought was missing.’”

Charles had an incredible passion for the Lucky Iron Fish project. He wanted to see it move forward and be in good hands, with a team-based approach. He put out a call for applications. He knew a manufacturing acumen would be key, as would opting for the social business venture route, as opposed to working with NGOs.

“I think after we’d collected all this evidence to show that the iron fish could have great results, people were willing to use it, it was effective,” Charles explains. “From an anecdotal perspective, people identified that their symptoms of anemia had gone away.” The team had demonstrated that the fish could be produced on a small scale and distributed.

“Step one, you have a successful public health intervention, then the next step is scaling up, and scaling up is a huge logistical challenge,” he explains. “You need to find a manufacturer; you need to figure out how to get things from point A to point B. And you need to figure out how to market and how to keep your budget balanced when it’s no longer a research project. And then if this is something that’s going to continue in perpetuity, how are you actually going to make it work?”

It was those challenges that took Charles’s thinking away from the public health side of things and much more into the business side, which he didn’t see as his personal forte. And, all the while, a career in medicine continued to be on his mind.

“I grew up, I think as many doctors do, thinking that I wanted to be a doctor without really understanding what that meant,” Charles says. “I don’t come from a family of doctors at all and I’m the first in my family to work in health care. So I didn’t really have much exposure, but it was always something that I wanted to do. I always really liked science and math and I liked helping people. So medicine seemed like the obvious path.”

His undergraduate degree and then graduate school had reinforced a great interest in research. At the same time, reinforced by his experience working in Cambodian villages, he believed he was lacking a skill set. “That was the medicine background,” he says.

“There were many instances when I was following up with women who had an iron fish to take a blood sample or to talk to them about their usage, and they would start talking to me about their relative who was sick. They would ask if there was anything that we could do to help them. Or they would say their baby’s not eating, or that they cut themselves really badly and it doesn’t look good. And now there’s pus seeping from the wound.”

Charles points to one of the most striking examples that led to his interest in medicine. He went into a household to visit a woman, and he could hear a baby screaming.

“It was coming from the backyard,” he recalls. “In villages there are lots of babies, but in this instance, we discovered a mother in great distress and were unsure what to do. In Cambodia, people in rural areas cook over an open fire, and her toddler — I imagine about two years old — had fallen into the fire and burned both hands quite badly. They had no idea what to do, and I’m talking fingers down to stubs and a very, very bad burn.

“They had gone to the local health centre, which was staffed by folks that you would hope were doctors and nurses but are often not that. They’re often someone with a little bit of extra training who can maybe give out bandages and things of that nature.

“In this case the child’s hands were wrapped up and they were sent home after being told there was nothing else that they could do. We arrived a couple of days after the accident had occurred, and the mother was overwhelmed and distraught because obviously something bad had happened. And she doesn’t know how to access health care for her baby. She can’t afford it. She can’t get onto the back of a moto and drive to Phnom Penh and go to a children’s hospital.

“So we see this baby and she’s got these horrific wounds and filthy bandages,” Charles says. “You can just see this is not going to go well. And in instances like that, as a researcher in public health, you can’t go in and have an agenda. You don’t want to speak to the woman about how she’s using the iron fish. Even as a non-physician, you know that you need clean bandages, and you need to keep the wounds clean. There are basics that need to happen.”

In the end Charles says he always felt that if he were to have an impact on global health, “I had to have that background of medicine in order to be able to help the folks that I’d encounter along the way. So it was a combination of those things. One, sort of that childhood dream of being a doctor, and then, that realization in the moment as you’re working, doing this research, that okay, both of these things would be useful and helpful to have together.”

He points to his sense of helplessness and being overwhelmed by the heat, smells, and noise. Charles describes it as sensory overload, coupled with witnessing what true poverty looks like. “It’s overwhelming,” he says, “yet you’re pulled in different directions. You’re trying to focus on the iron fish as well, but I couldn’t at the same time turn a blind eye to suffering.”

In the case of the burned little girl, Charles and his colleagues dropped what they were doing and took the child and her mom in the backseat of the car and drove them to the children’s hospital. Then through the help of the NGO and other donors they scraped together enough money to pay for her care.

“You can’t turn a blind eye to something like that, right?” he says. “You’d never be able to sleep; it would be something that would haunt you. Sure, you’ve got an agenda. You want to try to impact people’s nutrition, but you can’t do that in a vacuum. You have to take into account the other things that person or that family is experiencing at that time.”

Charles said he and his partners didn’t see the child again but were told she stayed in the children’s hospital in Phnom Penh for several weeks where they gave regular dressing changes, pain medication, and extended help for the little girl.

“It’s sad, though, because I know that that kid likely ended up back in a household that was very, very poor,” he adds, noting the unlikelihood that her family could escape that poverty any time soon.

The gut-wrenching experiences, the persistent drive toward medicine to try to make a difference, and the recognition that he had a limited skill set when it came to the business side of Lucky Iron Fish were all conspiring to point Charles on a new course.

“I think one thing that we often see from international development is we have really great content experts, people who are experts in public health, people who are experts in nutrition, or water and sanitation,” he says. “But we don’t often engage with private industry and with folks who are great at business and all of those logistics to make large-scale intervention successful. I do think there’s a value in bringing in people that have specific skill sets that aren’t your own.

“I think that there was an interest level for me in whether this could be effective and whether we could change people’s lives. But when it came to the next steps, I saw that as something that was going to pull me away from the engagement that I was able to have with folks living in villages, and instead having to take a step back, work more remotely, manage budgets and supply chains and things of that nature. It was a very, very difficult challenge.”

Charles recognized what his interests and limitations were and wondered if there could be someone who could have an impact.

“The goal was always to have the biggest impact that we could possibly have and show that this was going to be useful,” he says. “We wanted to make sure that we could help as many people as possible to have a fish in their home. I felt that the goal was going to be more quickly achieved by someone, or a team of people, who had a different skill set than what I had.”

The time had come to try to find an individual or team that could grow that dream. Among the proposals, one applicant seemed to stand out. Gavin Armstrong displayed the characteristics being sought — a business education background and an interest in global health and social justice.

“It was rare,” notes Charles. “You often see people who are either business or development inclined, but to bridge those two worlds was harder to find.” Armstrong had that unique ability, and the stage was set for the next phase in the evolution of Lucky Iron Fish.

“Gavin connected with Chris when he was in university,” Linda Armstrong, Gavin’s mother, recalls. “As I understand it, Chris had other interests and that is how Gavin became involved with Lucky Iron Fish. He started with just doing a thesis based on work in Cambodia, and as he was working on getting his Ph.D., he recognized the concept could be developed as a business. I was so happy that Gavin went this way. He was thinking of working at a bank or whatever; he wanted to be rich. But he went a different way.”

In the meantime, Charles went on to complete medical school at McMaster University in Hamilton, Ontario. Today he remains a part of the Lucky Iron Fish board. His analytical nature and genuine love of research were critical to the project’s success, especially after those early, dark moments of failure when Charles still chose to persevere.

“The story of the Lucky Iron Fish is that after that initial three month study, I could have looked at it and said, ‘Ah, no one is interested in putting these iron ingots in their cooking pots. Let’s move on.’

“But I forced myself to look at what worked and what didn’t. I tried to be humble and lay it out to those around me. Having that collaborative approach is one of the most important aspects of overcoming failures.”