15The Cardinal Rule of Behavior ChangeIn the late 1990s, a public health worker named Stephen Luby left his hometown of Omaha, Nebraska, and bought a one-way ticket to Karachi, Pakistan.Karachi was one of the most populous cities in the world.By 1998, over nine million people called it home.It was the economic center of Pakistan and a transportation hub, with some of the most active airports and seaports in the region.In the commercial parts of town, you could find all of the standard urban amenities and bustling downtown streets.But Karachi was also one of the least livable cities in the world.Over 60 percent of Karachi’s residents lived in squatter settlements and slums.These densely packed neighborhoods were filled with makeshift houses cobbled together from old boards, cinder blocks, and other discarded materials.There was no waste removal system, no electricity grid, no clean water supply.When dry, the streets were a combination of dust and trash.When wet, they became a muddy pit of sewage.Mosquito colonies thrived in pools of stagnant water, and children played among the garbage.