What one truck taught me about scale
Field notes from growing a single mammography truck into a national mobile screening network, and the unglamorous lessons collected on the way.
In 2023 we put one mammography truck on the road. Today the network has reached more than 300 communities and screened more than 22 000 women. Written in one sentence it sounds like a smooth curve. It was a series of hard corrections, and the lessons that survived them are worth recording, if only so I stop relearning them.
The truck is the least of it
Visitors always want to see the truck. Fair enough: it is photogenic, and a mammography unit on wheels still surprises people. But the truck was never the hard part. The hard part is everything around it. The roster that gets a radiographer to a mine gate at 06:30. The booking system that works for a woman who shares a phone with her household. The result that arrives in days rather than months, and the follow-up call that actually happens when something needs attention.
A screening service that finds a cancer and then loses the patient has provided anxiety rather than healthcare. Most of our engineering effort, and almost all of our redesigns, have gone into the unglamorous machinery of follow-through. If I could audit any health programme on one question only, it would be this one: what happens after the abnormal result?
Trust is operational
In the communities we serve, trust is won by turning up on the day you said you would, at the time you said you would, with the same staff the community met last time. Branding plays a far smaller part than anyone in marketing would like. The first visit to a new site is always slow. The second is busier. By the third, the queue forms before the truck arrives, because word has moved through churches, stokvels and WhatsApp groups that the service is real and the people are kind.
That word-of-mouth machine runs on reliability, which means trust is an operations problem. Every breakdown, every cancelled visit, every result that takes too long spends trust that took months to earn. We learnt to treat a missed site visit with the seriousness a hospital would give a cancelled theatre list.
Data decides where we go
Early on, we chose sites by instinct and invitation. Some days the team screened a handful of women in a parking area while a community twenty minutes away went without. The fix was to let the data lead. Every screen produces a record of where demand actually is, who is coming forward, and who is missing. Utilisation tells you where the next truck should go far more honestly than any committee.
This sounds obvious. It is also surprisingly rare. Plenty of outreach work is planned the way ours once was, by goodwill and geography. Measurement scales in a way goodwill alone never can.
Hard environments are design inputs
Our units work through power cuts because we assumed from day one that the grid would fail us, and fitted solar. They handle dust and corrugated roads because we assumed the roads would be bad. All of this is ordinary discipline: treating difficult conditions as specifications rather than excuses. A system designed for the environment it actually operates in will outperform a more sophisticated system designed for the environment its planners wished for.
Scale is repetition done honestly
The most useful thing I have learnt is the least exciting. Scale is repetition. Identical truck layouts, identical checklists, identical reporting workflows, so that a radiographer can move between units without retraining and a fault in one can be fixed in all. The temptation as you grow is to let each new site become its own small invention. Resist it. Creativity belongs in the design phase; in the field, sameness is a form of safety.
There were months when the numbers were thin, when financing was harder than medicine, and when the distance between the mission and the bank balance felt very wide. Building infrastructure is mostly that: unglamorous, repetitive, occasionally frightening. Then you stand at a site at sunset, watching the last patient of the day step down from the unit, and the point of the whole machine becomes a single person who got her scan close to home. That is the unit of progress. Everything else is logistics.