We often hear about the lack of access to drugs and other medical treatments in the developing world. However, for many people in underserved areas, the problem is not lack of expensive drugs but the lack of access to basic medical knowledge that causes needless suffering, pain, and death. All the drugs and treatments in the world won’t help cure diseases without the knowledge of when and how to use them.
Recognizing this fact more than 35 years ago, Hesperian published a small book called Where There Is No Doctor. It immediately became a “cult classic” for Peace Corps volunteers, international aid workers, and community health workers. Translated into 70+ languages, this practical and down to earth guide has saved countless lives and greatly reduced suffering around the world from headaches to broken ankles, worms, the common cold, and everything in between.
Last year the Bill and Melinda Gates Foundation asked Hesperian to update this wonderful little livesaver for the 21st century. First and foremost this means reworking the content (HIV/AIDS did not exist when version 1.0 was published). It also means using new technologies, such as mobile phones and the Internet, to develop and distribute the material.
As Hesperian’s technology partner on this project, we face the daunting task of helping them figure out what it means to deliver safe and effective healthcare information via mobile phones. Last year Hesperian did a few experiments with SMS text messaging. They quickly determined that 160 characters was just enough information to be dangerous. Sure that pain in your tummy could be just indigestion which can be cured with antacids. On the other hand, it could be appendicitis which requires immediate surgery. 160 characters just isn’t enough to safely distinguish between cases like these and provide appropriate information.
Fortunately, many other groups are working hard to figure out what “mHealth” (mobile health) means and how best to create good systems of care. For example, some projects have tried using interactive voice response systems, recorded messages sent in response to an SMS, in order to deliver healthcare information. We’re still investigating these but to date nothing has emerged as a clear winner. (For a good overview of mHealth efforts, see the recent UNF / Vodafone report prepared by VitalWave consulting.)
Today, most of the money and attention has been going towards collecting data from the field rather than delivering knowledge to the point of care. For example, the EpiSurveyor product from Datadyne has been used by the WHO in 13 countries in sub-Saharan Africa to collect epidemiologic data from mobile phones and PDA’s. It’s easy to understand why the WHO, policymakers, other aid organizations, and national officials might to collect the data on illness in order to allocate resources effectively. However, data collection does little or nothing to help a person with an illness. They simply become another data point used to generate statistics and plead for more funding.
The real promise of mHealth rides on a two-way system where knowledge about diseases and treatments flows down to the individual point of care while epidemiologic data flows up to the regional and national care centers. That promise comes down to the details of the interaction between a health-care worker and a patient. How can we use technology to inform that interaction with timely, relevant, and accurate knowledge?
The first version of Where There Is No Doctor succeeded because it took a narrative approach to healthcare knowledge. Instead of listing diseases and treatments, it provides a context for the dialogue between patients and healthcare providers. It ties healthcare information into the local communities with home remedies (gargling with salt water instead of buying cough drops) and explain how environmental factors, like clean water, affect health. Each interaction was illustrated with a series of simple diagrams that supported readers with low levels of literacy. How can we take that contextual information and recreate meaningful dialogues on the limited screen of a mobile phone? Finding an answer will take lots of work in the field. Going together with partners to health workers in real-life communities, getting their thoughts on what works and what doesn’t work, asking them to try early prototypes, and continually improving interaction in response to their voices. All this means that the content development effort becomes substantially harder. Instead of creating pages of printed information, the Hesperian staff has to create the equivalent of short stories or scripts for each topic. Chunks of information that can be packaged and delivered to field workers in conjunction with partners. If you have experience or ideas on what works, please contact us. We’re actively looking for partners on this project.
Community health workers will continue to serve as the eyes, ears, and hands of the national and international health organizations for the foreseeable future. Mobile technologies promise to empower those workers by informing them with the most effective tools and treatments available. Now the question is how to deliver on that promise. We believe that Hesperian’s strong reputation for working with underserved communities to provide practical, useful, and accessible information gives this project a good shot at delivering on that promise of better health for all.
