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Where There Is No Ambulance There's Text

By Daniel J. Gerstle | HELO Magazine | March 4, 2010

CREDIT: The Reboot (CC).

Since 2008, Nadim Mahmud and Frontline SMS: Medic have been attempting to revolutionize rural medicine in Africa and Asia by deploying text-messaging platforms which link Frontline health workers with doctors at faraway hospitals. The platforms have dramatically reduced the time it takes for many rural sick to receive care. And what's especially curious is that once the agency sets up the system, unlike most aid programs, they hand the platform over completely to the local community. How's that for post-colonial technology transfer?

HELO: Where are you from and what made you want to get involved in medicine and technology? What got you wanting to bring this work into the sphere of development overseas with Frontline SMS: Medic?

Nadim Mahmud: I was born in Danville, Pennsylvania, a small farming village, nothing terribly exciting. Both of my parents are from Bangladesh so I'm entirely Bengali. My Dad is a radiologist and he works at the hospital in Danville, which is pretty progressive. This is the kind of environment I grew up in, this bizarre clash between farming village and large hospital. I spent a lot of time in the hospital with my Dad, shadowing him, seeing how the hospital worked. I've always been interested in medicine and healthcare.

When I was in college I did a lot of volunteering at the ER in the hospital in New Haven. Then I had the opportunity to go abroad to Bangladesh. That's when I really started to understand the disparity in healthcare. Healthcare works completely differently in the developing world. Just in terms of resources it's very limited. People die in throngs from diseases which are entirely preventable.

It's a terrible tragedy to see people passing away from things that we know how to prevent. That's how I got to wanting to work abroad and make an impact in that sense. I was working in Bangladesh at the International Center for Diarrheal Disease Research (ICDDR). They handle a lot of cholera cases. During the monsoon season they admit more than a thousand patients a day, which is unthinkable. They have patients spilling out into parking lots, under these canvas canopies. But they provide exquisitely good care, which is amazing.

The majority of the patients are coming from rural areas, a lot of distance to travel. I saw firsthand that there was a terrible communication barrier between the physicians at this clinic and the patients they were trying to serve. It was to the point that many people are not even aware that this kind of care is available in the capital. When there is a case of a patient getting sick in the village it's hard to get a consultation. Should they be going to the capital to get treatment? There's a huge disconnect between the health workers.

I had this idea when I came to Stanford Medical School that there was this sort of communications barrier around the world. There were two others at Stanford. Josh Nesbit was one of them, and another med school friend. Josh had been working in Malawi and saw firsthand how in rural Malawi St. Gabriel's Hospital had been trying to provide care for 250,000 people who lived sometimes more than 100 miles away from the hospital. When there's no reliable transport then you need to send a healthcare worker on foot 100 miles just to keep contact.

Using technology is an intelligent solution to bridge that gap. Josh had been on Stanford campus and met Ken Banks who was writing code for SMS software use and had the idea to use cell phones to bridge that gap. We wanted to disseminate this as much as possible. I took it back to Bangladesh and worked with a few organizations there to see how the SMS network could benefit healthcare workers and we went from there.

H: Many of our readers and contributors are aid workers. The big thing is water and sanitation, preventing diseases like cholera. Most of the time, it's just hygiene and water issues. Prior to what you're doing, why do you think the millions of dollars going into sanitation aid have been unable to sustainably change the population?

NM: A lot of what I was doing in Bangladesh was working with mothers to try to get them to breastfeed more often. They're supposed to be exclusively breastfeeding until their infant is six months old. When you see cases like cholera or shigella in infants, you normally wouldn't expect that if they were breastfed.

There are enormous corporate pressures from organizations like Nestle that produce instant formulas. They're pervasively advertised in places like Bangladesh. If a mother works in the rice paddies every day, it's exhausting. So if a cheap alternative is available, you just add water and feed your child, then that's a great alternative. You don't need to feed your child for hours a day, which is exhausting. The problem is they mix it with dirty water. And they basically formula-feed their children life-threatening diarrheal diseases.

In India and Bangladesh, it's particularly difficult because you're being rained down on with a new strain of cholera every day. It's hard to find an appropriate water source.

H: Seems like the breastfeeding would also be better than the artificial because the mother is transferring some of her antibodies to the child? But also if the woman is not good with hygiene couldn't she be transferring infection from her hands even while breastfeeding?

NM: Yes, when the mother breastfeeds, she transfers antibodies to her child. Whatever resistance the mother has, the child has at that time, and there is some risk of transmitting these diseases by unhygienic practices with breastfeeding. But to my knowledge breast milk is a privileged fluid.

H: How are Kiwanja, Frontline SMS, and Frontline SMS: Medic related and working together on bringing new communications to rural healthcare?

NM: Kiwanja is Ken Banks's foundation. He wrote the program for You can download the software on the site and there are user forums where people have been talking about how you can use it. Frontline SMS: Medic is a separate entity that Josh and I started last February. It's specifically using Frontline SMS software in the context of healthcare, not only implementing it in clinics but also building software modules for each user. There's a piece of software being released soon called Patient View. It's basically an electronic medical records system that can be updated remotely on cell phones by workers in the field linked to unique patient records.

H: The premise is that even in really rural areas people may not have everything they need in terms of health and development, but people on their own prioritize their cell phone.

NM: It's an interesting situation where these areas stricken with astronomical proportions of tuberculosis or HIV or malaria are the same areas well covered by cell phone service. Internet is not developed for the most part, it's not reliable, but they have very good coverage for cell phones. There are a lot of people where their cell phone number becomes part of their identity. It's their address. It's very vital to who they are. Outside their shacks or huts, they'll write their number. [But] it depends on where you're talking about. In Malawi, a lot of these people haven't even seen cell phones before. It's still highly variable.

H: Much of our audience has worked in these areas or is curious about them. What comes to mind is Somalia or Sudan. You go so far out and you wonder whether an aid program should prioritize cell phone services over food and water and medicine. It would be strange. But people themselves make those choices because they think that communication is the key to everything else. Could you walk us through it? What does it look like from the rural family's point of view using SMS Medic?

NM: I should clear up how it works. The rural families aren't necessarily the ones using cell phones. We tend to give them to community health workers. These are workers recruited in the communities being catered to by the hospitals. If we have a hospital trying to treat people in 10 villages, we might have an employee or volunteer from each of those 10 villages. If you're a rural family, say in Malawi, and somebody gets sick, you'll go down the street and find the village where your local community health worker lives. He or she will use a cell phone to contact the clinic, so they're the intermediary.

This [service we've put together] is enormously convenient to them. Often times, [the sick person will] have no choice but to be escorted by the health worker all the way to the clinic, but if the health worker is able to text the hospital to request care for a specific injury, the hospital can send one of their personnel out on motorbike to triage that case.

It makes the life of the patient simpler in terms of the expediency and quality of care. Even if there's just a question, a patient's query, they can get a response the same day by asking their community health worker to relay that question to a physician.

One of the most convenient uses is acute care. There is an example where a patient had a seizure and fell in a fire and burned his leg badly. He wasn't able to walk. The community health worker and his patient were more than 50 miles to the clinic. This clinic in Malawi has one home-based worker who has a motorbike. Before we implemented this system he would bike basically from one village to the next just to see if he was needed.

Once we implemented this system, he would receive specific text messages saying, "Your help is needed. A patient has been burned and cannot come to the clinic. Come to village C as soon as you can." And he would take his motorbike, his gauze, his antibiotics, and bike directly to that village to provide care to this patient. Being able to respond to an emergency was a novel concept in this environment.

H: Can you talk about any surprises or unexpected barriers to applying this technology? Do you need permits from the local government? Do you have people who resist this service?

NM: When I was working in Bangladesh—this might be a statement about working in development in general—I think there's a strong culture of dependency in some of these organizations. They see people bringing aid from abroad and they expect these people to bring all the answers with them. We would hold focus groups with the community health workers explaining how the technology worked and then we'd ask them for their input.

"Given how the system works, how do you think we can use it? How could it be useful for you?" The first time I asked that question there were no answers. We sat in silence. Then somebody spoke up and said, "Shouldn't you be telling us?" Eventually, we got them thinking about what the barriers were in their daily routine. They came up with some pretty amazing ideas, actually.

One health worker came up with this great referral system where they would receive text messages based on whether their patients had gone to appointments at clinics, so they wouldn't have to follow up with these patients with all they were currently doing. They had been spending hours in a day following up with patients just to find that they did go to the clinic. The clinic would send texts [only] when patients did not show up, so that saved them hours and hours of time.

H: Is there ever any friction between the global health coming through this system and the local traditional healers?

NM: I haven't experienced any friction because we work in a system in which they already trust the community health workers and that system of care, so really we're just giving them a tool to make that structure more efficient.

H: You work like an NGO where you apply for funding to perform this service, or if someone wants to get involved in this thing how would people connect to what you do and reproduce it?

NM: [Frontline SMS: Medic] is still pretty young. We've been around just about a year, so up to the present day we don't have a ton of funding. Everything we've done so far has been funded by individual fellowships or small grants. It's all been completely free for the clinics. We made a point for there to be as few barriers to entry as possible. People who've wanted to help out just contact us directly. We have clinics contacting us to use the system. The only thing we're lacking is implementers. We have a list of clinics just waiting to use the system. I don't work on salary, but just as a volunteer to advance SMS Medic.

We want to give local clinics complete ownership of everything. That's why we've done every site personally. We send somebody to the clinic to help set up the system, deliver cell phones, to conduct trainings sessions with the health workers and teach them how to use the [free open source] software. But the way they use it is entirely up to them.

We don't come in and say, "You should be using this system to track the tuberculosis patient experience" or "You should use this to create a triage system." We show them what's possible with the technology, describe to them what to do, and then we ask them to generate the usage cases, which makes this much more organic and lets them take ownership of the program. Once they're all set up, we're gone, and they run everything. That's really important for us. We don't want to be that typical aid organization that creates a culture of dependency. The long-term goal is to make the program entirely self-implementable.

H: Is there a role for this kind of work back in Danville, Pennsylvania?

NM: There's definitely a role for it in domestic, especially rural settings. The biggest market for this is really the developing world. But there are definitely still places [in the U.S.] that still suffer gaps in communication between patients and physicians.

H: What's your family think about all this? On a personal level how does this reflect?

NM: My family, they like what I'm doing. They can definitely see the merit in it. I had a discussion with my dad, and I assume he's kidding—he left [Bangladesh] during the war for independence. Getting out of the country and coming to the United States was a big deal for him.

When I voluntarily go back to Bangladesh, he always wonders, "I work so hard to bring us to the United States and you just want to go back to Bangladesh." I think he's kidding. He's appreciative, and he appreciates the fact that I go a lot to Bangladesh specifically. I see the value of what we do in Africa and all over the place, but for me there's some attachment for doing work in Bangladesh.

© 2010 HELO Magazine. Republished with kind permission.

Read More: Business, Communication, Development, Health, Technology, Bangladesh, Malawi, Africa, Asia

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