Issue #2 - High Tech Health - Global Health Magazine

making money online from personal tragedy to action 10 rwandan women raise children of rape 06

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Issue 02 SPRING 2009 $4.95 U.S.

HIGH TECH HEALTH www.globalhealthmagazine.com —

innovating to save lives

Join Us! At the Global Health Conference for a panel discussion and reception The panel “35 Years—Learning, Teaching, Innovating” will present a retrospective of Jhpiego’s growth and an exploration of new innovations in maternal and newborn health, infectious disease prevention and reproductive health.

May 27, 2009, 5:30–8:30 p.m.

RSVP to 35years@jhpiego.net Please visit our booth in the conference exhibit hall.

celebrating 35 years

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issue 02

contents —

In this issue:

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14 does your credit card know more than your doctor?

18 is the cell phone leading the mhealth revolution?

COVER STORY: high tech health

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21 Open source: access to the people

Disease surveillance with the internet 20 years of mobile technologies low-tech, high impact for safer childbirth health hotlines

also in this issue: 6 making money online 8 from personal tragedy to action 10 rwandan women raise children of rape screenshots —

04 youth and tobacco 05 population in 2050 05 Where are the skilled health workers?

Cover: Shawn Braley

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stories online

www.globalhealthmagazine.com

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Issue 02

Global Health

letter

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from the editor

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Executive Editor

Annmarie Christensen Managing Editor

Tina Flores Web

Winnie Mutch Liza Nanni Graphic Design

Shawn Braley

to dream the virtual dream When people are hobbled in their daily lives by the dearth of food, water and shelter along with a lack of access to health care, it may seem a lofty idea to speak of the importance of technology in their lives. In countries where there are no roads, electrical grids or land lines for telephones, what purpose can technology serve when basic necessities are not covered?

As with many innovations, however, skepticism eventually yields to experience; resistance gives way to adoption. Rapidly advancing technology is the reality and hallmark of this new millennium, and has the potential to transform the lives of those we serve.

In this issue of GLOBAL HEALTH, we highlight the “leapfrogging” effects of innovation, with cell phones and other mobile technologies transcending the lack of infrastructure in the field. We look at the potential benefits of a system of standards and interoperability for health reporting; and we become more familiar with the concept of “open source” systems, giving developers and users a low-cost way to share, adapt and reuse technology.

There are also stories from a Nigerian doctor who writes about his drive to eradicate malaria in his rural village.

(And, as a bracing reality check, we note that he had to travel 300 kilometers to send his story via the Internet.)

We provide the success story of a million-dollar email; and also the moving account of a photographer who returned to Rwanda to document the brave women who raised the children born from their rape.

Please remember, this print edition is a bridge to www. globalhealthmagazine.com, where the discussion continues through additional stories, blogs, and most certainly, your feedback.

The Editors ISSUE 02 spring 2009

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E-mail:

magazine@globalhealth.org Global Health Council Board of Directors

Susan Dentzer, chair, William Foege, MD, MPH,

chair-emeritus Rogaia Mustafa Abusharaf, PhD Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Haile T. Debas, MD Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Joel Lamstein, SM Joy Phumaphi Reeta Roy

Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members.

Learn more about the Council at www.globalhealth.org

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issue 02

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online exclusives

go to www.globalhealthmagazine.com for further reading

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C cover stories

online

Low-Tech Solution Saves Lives A non-pneumatic, anti-shock garment saves women from postpartum hemorrhage morbidity in low-resource settings.

C The Blog

From the first email in Africa Global mHealth pioneer AEDSatellife on 20 years of experience with mobile technology.

C Hot Escapes

Slovenia: Join Jennifer Hyman as she discovers dragons and other delights while dawdling in Ljubljana.

Photo credit: Photo courtesy of AED

Catching Disease Online Kumanan Wilson and John S. Brownstein on using the Internet for disease surveillance.

Photo credit: Dawn Shapiro

Southern Sudan – A Crisis Worse than Darfur Joanne Offer from the IRC on the worsening conditions for people in southern Sudan.

Phone Consultations A toll-free phone service connects health-care workers in Ethiopia with doctors who can give them quick, accurate and up-to-date answers on HIV/AIDS care and treatment.

Photo credit: Jennifer Hyman

C Dim Sum

A collection of film picks, book reviews and other cultural forays.

C Going Viral Photo credit: Joanne Offer/IRC

Do you have a blog? Contact magazine@globalhealth.org.

What’s the buzz on YouTube, Facebook, LinkedIn and other places online

www.globalhealthmagazine.com

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Global health statistics

screenshots —

youth and smoking % female % male

ISSUE 02 spring 2009

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mexico

colombia

brazil

malaysia

indonesia

india

malawi

turkey

romania

russian federation

bosnia and herzogovenia

pakistan

lebanon

% exposed to smoke at home

Source: WHO Report on the Global Tobacco Epidemic, 2008 Youth: 13–15 years old

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skilled health workers Doctors, nurses or midwives per 10,000 people

who regions europe

the americas

western pacific

nurses and midwives physicians

eastern mediterranian south-east asia

africa Source: World Health Organization, World Health Statistics 2008

World population by 2050: F Top 10 Gainers and Losers

% projected change

F

F

F

F

germany

F

F

F

F

What will your country look like in 2050? Go to www.PRB.org

poland

F

ukraine

Dem. rep of congo pakistan

china

south korea

F

russia

united states

indonesia

romania

F

japan

nigeria

uganda

taiwan

F

F india

F

F

ethiopia

bulgaria

F

F

F

F

bangledesh

spain

F

F

Source: PRB 2008 World Population Data Sheet 2008-2050

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By shannon raybold

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Photo courtesy of UN Foundation

The Million Dollar Email

Raising $1 million with one email message with stories from the field? Hard to believe, but Nothing But Nets, a grassroots campaign to save lives by preventing malaria, has raised more than $25 million by keeping it simple.

Keep it simple, find compelling ways to tell your story, give people a myriad of ways to get involved, and report back to them their success – these are key components to a successful online strategy.

The Nothing But Nets campaign grew from a Sports Illustrated column by Rick Reilly about malaria, challenging each of his readers to donate at least $10 for the purchase of anti-malaria bednets and the subsequent

Nothing But Nets stats Jan 2007-today • $ raised: 26 million (on and offline) • Avg contribution: $53 • Page views: 2,215,497 • Avg time on Site: 2:15 • Online fundraising teams: 4,821

response from thousands of Americans across the country.

To date, the UN Foundation has raised more than $25 million, delivered more than 2.5 million life-saving bednets, and created a “buzz” around malaria that has led to the involvement of faith groups, sports teams, local mayors, governors and everyday citizens in this battle to eliminate this preventable, infectious disease.

How did we do it?

We made it simple for people to understand the problem and how they can help.

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The concept of the bednet is so easy, we were able to break it down to six words: Send a Net. Save a Life. This tag line is the heart of the campaign, both online and off.

This simplicity was reinforced on the website, NothingButNets.net, the true home of the Nothing But Nets campaign. It contains all the tools of the digital age – blogs, multi-media, Flash, etc. They pave the way for the actions we want people to take upon visiting the site – donate, involve their community through the Netraiser tool, and share their story with one another. No matter where they go on the website, visitors are prompted to take those three actions.

More than 1 million people have visited the site in the last two years, and the average donation is approximately $53. The site has hundreds of stories from around the country about how Americans are helping send bednets to Africa. A common theme is that they didn’t understand how easy or cheap it is to save a life – until finding Nothing But Nets.

Telling the Story An important component of the website and the campaign is to tell the story of how malaria impacts the lives of women and children in Africa. The main section, or Flash feature, of the homepage, is used to illustrate the problem of malaria for new supporters through the life of a young refugee in Uganda. This rotating feature contains compelling photographs and short copy, explaining the current goal of the campaign.

Right now, the focus is the immediate need to send more than 275,000 bed nets to refugees in four African countries. In the “storycube,” there is a compelling slide show of how malaria is affecting the refugees in each country, an explanation about the urgent need for nets, and an immediate link to the donate page. Again, it makes it simple to understand and easy for the audience to act.

Involving the Community Another main feature of the website is its bustling blog, showcasing individuals and their involvement in the fight against malaria, along with touching stories from the field

Shannon Raybold is the Internet director at the United Nations Foundation.

Learn more at NothingButNets.net

about those who receive the bednets. Many organizations feel they don’t have the internal resources to maintain or monitor a blog. The UN Foundation had that same concern, but the blog is worth the effort. It’s not only a prominent place to acknowledge donors’ work, but it also helps drive people to the website. Individuals who share their stories often share the link – and the cause – with others. This means the campaign is constantly being introduced to new audiences – for once it is posted on the homepage, the individual(s) who have written the post share the link with their friends and family.

The campaign also gives people other ways to engage their friends and family. Upon signing up for the campaign, they have the option of getting monthly text message updates. They can create their own fundraising teams online; share videos, toolkits, web banners, and links to buy Nothing But Nets gear; or play a bed net delivery game. They can also join us on the social networking sites Facebook, MySpace, YouTube and Flickr – now even more important with the new Facebook design, which has increased access to supporters’ feeds and enables us to reach all their friends through status updates.

Reporting Back – The $1 Million Email Reporting back to our community is a key part of the overall communications strategy. In 2008, the executive director of Nothing But Nets sent a message to the campaign’s email list about a net distribution in Mali. It focused on thanking supporters for their contribution, encouraging more ways for them to help protect children, and continuing to educate about malaria. This email, which featured stories and pictures from the ground, raised $1 million and is the UN Foundation’s single most successful email, ever.

Nothing But Nets is just one of the many initiatives the United Nations Foundation has developed to tackle global problems, but the lessons learned from this effort have informed all of its online (and overall communications) strategies. Eliminating malaria by 2015 is a daunting goal, but at the UN Foundation, we believe we’ve found a platform to engage individuals and get them on board with helping to solve this global challenge. GH —

www.globalhealthmagazine.com

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By Chukwumuanya Igboekwu

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Personal Tragedy with Malaria Breeds Action

As a young boy, I remember coming back from school one day and hearing wailing. I hurried closer to discover that the wailing was actually coming from our house. Many women were crying, shouting at the top of their voices as they screamed the name of my 2-year-old brother, Tobechukwu. When I entered our house, I found my mother wailing, with several other women surrounding and consoling her. My father was speechless as he struggled to control his emotions. He is a man, and this is Africa – men are not supposed to cry even when tragedies like this occur. “Your younger brother has passed away,” whispered one elderly man to me. The news was very devastating. I immediately broke down and wept, and wept, and wept. Our home became a house of mourning.

About four days before my brother’s death, he developed a fever. He was initially treated at home, but Tobechukwu’s situation did not improve. My parents later decided to take him to the hospital in town, but by the time they got there, it was too late. He had become very ill and died shortly after the doctor had administered treatment. My brother died of malaria.

Like my mother, thousands of women in sub-Saharan Africa have lost their children to malaria. The onslaught of malaria on Africa’s youngest citizens has brought untold misery and grief to thousands of homes across the continent. In Nigeria, thousands of children do not live to witness their fifth birthday because of its devastating impact. In rural Mashegu, where I currently work and live as a community physician, one out of every three deaths among children younger than five is attributed to malaria. About 80 percent of our entire pediatric outpatient load at the rural hospital is due to malaria.

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June to November, 2007, was a particularly distressing time as I witnessed the death of dozens of children claimed by malaria during the peak of rainy season.

Their parents could not afford $2 worth of anti-malarial medicines. There was the heartbreaking case of 18-month-old Zainab who died just as her mother stepped into our clinic. Her parents had walked nearly two hours to the facility. Her father tearfully conveyed that she had developed a fever a week earlier. With no health facilities in their village, they had to resort to traditional medicines. Unfortunately, her clinical condition continued to deteriorate, leading to convulsions the morning of the day she died.

The tragedy of Zainab’s death brought back painful memories of my younger brother’s death. And from that moment, I decided it was time to fight back malaria. With donations made through the GlobalGiving Foundation, and financial support from my friend Uzodinma and his mother, Ngozi Okonjo Iweala (now managing director at the World Bank), Physicians for Social Justice (PSJ) was created. PSJ’s malaria project took off in early 2008. It is an ambitious task that aims to provide 20,000 children and their families in rural Mashegu with malaria prevention education, life-saving medicines and insecticide treated nets (ITNs), with the overall goal to significantly reduce malaria-related deaths among children and pregnant women. Providing families and children with ITNs is the most important component of the project. Our target is to distribute 50,000 ITNs by the end of 2009. This is because bednets have been proven to be an effective lowtechnology tool that can be successfully deployed even in rural areas to significantly reduce malaria mortality and morbidity. Documented evidence from UNICEF shows that the use of ITNs alone can reduce malaria mortality by as much as 30 percent.

Dr. Chukwumuanya Igboekwu is a community physician working in rural Mashegu in northern Nigeria. He travelled about 300 kilometers get Internet access to send this story. He can be reached at drmuanya@yahoo.com or www.globalgiving.org/1886.

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About 80 percent of our entire pediatric outpatient load at the rural hospital is due to malaria.

With a team of trained community volunteers, we set out to conquer malaria in rural Mashegu. Our strategy has been to conduct community-based malaria prevention outreach in rural communities. In collaboration with community stakeholders, the malaria team rotates from one village to another to deliver basic packages of interventions.

A typical malaria outreach to a rural community or village usually entails a full day of activities for the community physician, a nurse and two community health extension workers, which comprises the malaria project team, as it conducts community education sessions focusing on malaria prevention. Community members are educated on how malaria is transmitted, early clinical features, the role of mosquitoes in malaria transmission, the need for early diagnosis and treatment – especially for children – and how malaria can be controlled through environmental sanitation. This aspect of health education is very important because many women delay bringing their children in for medical care because of misconceptions, such as associating fever in children with teething or attainment of developmental milestones.

Other key components are free distribution of ITNs to children and nursing mothers, including demonstrations on how to set up, use and maintain ITNs. All children under five with suspected cases of malaria are treated by the community physician in the mobile clinic tent. In some cases, the mobile malaria team also administers targeted anti-malarial prophylaxis to pregnant women and children, especially during the peak months of malaria transmission.

Successes So Far...

The outreach has become so successful that some women travel several kilometers from their own villages to a neighboring community to access PSJ’s mobile malaria services. For example, during one of our outreach activities in one of the villages, I encountered a mother who had traveled about 10 kilometers on foot from a neighboring village to present her 9-month-old baby for treatment, after hearing about PSJ’s visit from a friend. The mobile team treated her sick child and gave her an insecticide treated net, neither of which she could afford.

malaria Statistics • Malaria comes from the medieval Italian words mala aria or “bad air.”

Photo credit: Mark Tuschman

To date, the malaria project has reached about 7,000 families with malaria prevention services. The project has distributed more than 4,500 insecticide-treated nets to children and pregnant women in seven rural villages in Mashegu. Through the mobile malaria clinic outreach component, the project has also administered antimalarial medicines to more than 3,000 children in hardto-reach, remote villages.

Preliminary findings point to some positive results.

In Sahon-rami village, for instance, where the project distributed about 900 ITNs to women and children, and conducted two malaria prevention outreach activities, a clinic-based study conducted at Rural Hospital Sahonrami revealed a nearly 10 percent decline in new cases of malaria among children under five within 12 months of the project’s implementation, compared to the previous year.

For most children in rural Mashegu, malaria is the most important single cause of frequent school absenteeism, anemia and poor growth. Their constant battle with malaria is that of survival or death.

Child mortality resulting from malaria is both preventable and curable. The deaths of these children is an injustice and a gross violation of their right to life, right to safe childhood, right to health and right to development as enshrined in the United Nations Convention on the Right of the Child. Saving vulnerable children from further death due to malaria is, therefore, one of the most urgent obligations of our time. The fight against malaria in Africa needs to go beyond the rhetoric to ensuring that families can prevent and treat the disease. GH —

• One person dies about every 30 seconds.

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Intended Conseqences: Rwanda’s Living Legacy of Violence and Healing photos and story

By Jonathan Torgovnik

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A WORD FROM THE PHOTOGRAPHER April 7, 2009, marked the 15th anniversary of the Rwandan genocide. On this date in 1994, Rwandan Armed Forces and Hutu militia began one of the most intensive killing campaigns in human history with the mass slaughter of more than 800,000 Rwandan Tutsis and moderate Hutus. Forced to witness the annihilation of their families, many women were then subjected to unconscionable forms of sexual violence – gang rape, rape with sharpened objects, sexual mutilation. In the aftermath of the destruction, many female survivors learned that they had been impregnated by their captors, contracted HIV/AIDS, or both.

I first traveled to Rwanda in February 2006 on assignment for Newsweek magazine with then-health editor, Geoffrey Cowley, to work on a story about HIV/AIDS on the 25th anniversary of the disease’s identification. It was then that I met Odette, a woman who had been brutally raped multiple times during the genocide. She described how her entire family had been killed and recounted the abuse she experienced, in detail. The ordeal resulted in a pregnancy – a baby boy – and HIV/AIDS. It was the most powerful and saddest interview I had ever witnessed.

Odette’s horrific story led me to return to Rwanda to document her story and those of others like her.

Local nongovernmental organizations estimate 20,000 children were born from rapes committed during the genocide. Over the last three years, I returned to Rwanda several times, uncovering more details of the heinous crimes committed against the mothers of these children.

The photographs and stories I collected comprise the book and exhibition, Intended Consequences: Rwandan Children Born of Rape.

ISSUE 02 spring 2009

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Even though I knew what their stories might contain, it was impossible to prepare myself for what I was going to hear. Most of the women had not revealed their experiences to their children and communities; yet each woman shared the most intimate details of her suffering and the daily challenges that continue as a direct result of the brutality. They knew why I was there, and they wanted to tell their stories to the world.

It is hard for me to understand how a mother can say, “I do not love my child.” In one of the interviews, the mother put her hand on me and said, “I know what you are asking me. I understand your question very well. I know it is terrible saying this as a mother, but this is what I feel now. Maybe one, day it will change.”

On the other hand, several mothers told me that their children are their hope, that without them they would not feel the will to survive. All of the women I photographed and interviewed demonstrated that they cared for their children. They had accepted the responsibility of motherhood despite the violent circumstances in which their children were conceived and, in many cases, despite knowing that the fathers of their children were responsible for killing their families. The mothers in this project have lived through the most severe torture any human can endure, and in the aftermath they continue to struggle against multiple levels of trauma. I admire their resilience and courage. They are undoubtedly the strongest human beings I have ever encountered.

On Sept. 2, 1998, the International Criminal Tribunal for Rwanda made history by issuing the first conviction for genocide in an international court, as well as the first conviction for sexual violence in a civil war. It also was the first time that an international court held that rape IS an act of genocide when it is committed to destroying a target ethnic group.

Jonathan Torgovnik is an award-winning photographer, whose work has been featured in publications such as Newsweek, The Sunday Times Magazine, Smithsonian and Paris Match, as well as in exhibitions around the U.S. and Europe.

Considering that rape was not included in the 1948 United Nations Genocide Convention, this case was a landmark decision, and an overdue revision to international law. For the first time, it was recognized that genocide could be accomplished through rape.

Rwandans have continued making significant strides in healing the genocidal rape and devastation that nearly destroyed them. In 2003, the constitution was rewritten so that 30 percent of parliamentary and cabinet seats are reserved for women. In September 2008, Rwanda’s parliament became the first in the world where women hold 56 percent of the seats. Although they are healing, Rwanda’s wounds are still very open and fresh and the daily reality of the female survivors of genocidal rape is complicated as many women bore a child of rape, contracted HIV, or both. These women continue to suffer in silence 15 years post-genocide.

When I asked them how they viewed their future and that of their children, a question with which I closed all of the interviews, they would often look at me and say, “I don’t even know what’s going to happen to me tomorrow.”

When pushed further and asked what future they would envision if they had the means, nearly every mother talked about education for her children and how vital it is that these children, in particular, acquire the skills to provide for themselves should their mothers not survive.

More than half of the women I met are HIV positive. I was deeply moved by this repeated appeal and affected by

To learn more about Torgovnik’s work, visit www.foundationrwanda.org View Intended Consequences: Rwandan Children Born of Rape at www.globalhealthmagazine.com

the incredible challenges these women and children face daily. For the first time in my career, I felt compelled to do something beyond documenting stories. Inspired to act, I co-founded a nonprofit organization, Foundation Rwanda, to improve the lives of children born of rape committed during the genocide. Foundation Rwanda provides funding for secondary school education for these children and links their mothers to existing psychological and medical services. It also helps raise awareness about the consequences of genocide and sexual violence through photography and new media. Many of the same Hutu militiamen who killed, raped and maimed in Rwanda, escaped to Congo and neighboring countries. These militiamen are continuing the cycle of violence and raping young girls and women on a massive scale in Congo today.

Many of the women we spoke to took more than a decade to start the healing process and tell their stories.

For some, these interviews were the very first time they spoke about what had happened to them. Unfortunately, victims of sexual violence in Congo, Darfur and around the world are facing challenges similar to the women in Rwanda. My greatest hope is that, in reading these stories and seeing the images of the women and children in this book, people will be inspired to act and work toward ensuring that similar acts of violence never happen again and that these families can have a brighter future. GH —

www.globalhealthmagazine.com

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Technology is a tool that lets people help themselves, be it finding today’s prices for their fish or crops, reminding them to take their medicine, or surveying the epicenter of the latest outbreak of disease. Never before in history has so much information been available to so many people in the most remote corners of the globe.

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To think that this revolution is merely in its infancy is astounding. But with it comes challenges to do it right, to be flexible enough for change, and to harness the technology to do what we need it to do, and not what it dictates to us. These are the challenges but the opportunities are boundless.

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By Karl Brown, Dave A. Ross and David Lubinski

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Does Your Credit Card Know More About You Than Your Doctor?

One of the biggest challenges facing health systems around the world might come as a surprise, because it’s not about doctors, drugs or money. From Boston to Beijing to Bamako, governments and health systems face an information challenge — specifically the lack of information.

been greater. This is thanks to advances in lowcost computing, widespread access to broadband Internet connections, the incredible growth of mobile phones and wireless connectivity, as well as 30 years’ experience in health informatics in the industrialized world.

In a world where business is transacted at the speed of light, where supplies can be ordered, inventories managed, and production quotas established on a daily basis, many countries, including highly developed economies, struggle to know basic facts about births, deaths, emerging threats to health or even the status of changing health systems.

A simple story will demonstrate the incredible disparity in how information is used in two of the world’s largest industries: health and finance. Let’s imagine you’re on vacation in Las Vegas. You go to the casino, approach the banker, hand him your credit card, and shortly thereafter, he agrees to loan you $5,000. Within a matter of seconds, from a piece of plastic in your pocket, the banker knows your name, date of birth, address, and has access to your up-to-date bank account balance, credit line, credit history, risk rating, and so on – everything he needs to decide how much money to

The scope of information needs is immense, but the opportunity to revolutionize the use of information in health, especially in developing countries, has never

Karl Brown is associate director at the Rockefeller Foundation and focal point for eHealth.

David Ross is executive director of the Public Health Informatics Institute.

David Lubinski is a consultant for PATH, and was previously the chief technology officer for the Health Metrics Network.

All three helped organize the “Making the eHealth Connection” conference and are signatories to the Bellagio call to action.

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Just as many African nations moved directly to fiber and wireless communications instead of laying down copper wire, the possibility for many countries to leapfrog to bestof-class integrated health information systems is quite real.

lend you. The casino’s informed decision – and indeed, its business – is based on rapid and secure access to reliable financial information.

So how is health information handled? Money in hand, you head to the roulette wheel and put down $5,000 on black. Unfortunately, the ball lands on red, your world starts spinning, and you collapse, clutching your heart. The ambulance arrives. Your life is now on the line – the decisions taken over the next few minutes are critical. Like the banker, the paramedics need rapid and secure access to reliable information: Are you on any medication? Do you have a history of heart disease?

Have you had any recent surgery?

Unfortunately, this information is not available; there is no card they can scan, no database they can consult.

The medical records that might save your life are confined to the filing cabinets among your doctors’ offices a thousand miles away. Aside from an insurance card to identify who will be paying for your care, the paramedics know absolutely nothing about you or your health history.

The financial services industry has figured out how to solve the problem of distributed access to information.

Every day, financial institutions rapidly and securely move massive amounts of information, research and money, around the country and around the world, using information and communication technologies (ICTs).

Networks (mechanisms for transporting information) and standards (common formats for representing information) are at the core of how the financial world manages its information. Unfortunately, health is a different story.

Despite the potential for ICT’s impact on health, the health industry has lagged behind many other industries

in the adoption of information technology. For example, a recent study found that fewer than 8 percent of hospitals in the U.S. have electronic health records (EHRs) in place for even one department, and only 1.5 percent have an electronic system in place for all departments.

When we look at health information exchanges (the ability to move EHRs from one place to another), the picture is even worse, even among advanced institutions. A few years ago, two of the hospitals voted “most wired in the U.S.” were in New York City, only a few blocks apart. But the only way to get patient records from one “wired” hospital to another was to print them out and carry them on foot! So why have banks digitized all of their records, but the hospitals have not?

There are many explanations for the slow adoption of ICT in health. Health information is complex and needs standardized vocabularies and coding structures.

Patients have legitimate concerns about privacy that must be met with satisfactory legal frameworks.

Health IT systems are expensive to procure and support. In third-party payer systems like the U.S., perverse financial incentives can actually discourage more integrated approaches to care, thereby limiting the impact information systems can have. And, the collective failure to articulate commonly held requirements for how information systems must support health care and community health protection leave those in need of help wondering which systems to buy and what to expect out of an ICT investment.

Nonetheless, there is a growing global movement to leverage eHealth, or the use of information technology in health, through systematically defined standards, expanded collaboration to share treatment and prevention knowledge, and a more unified global

U.S. Health Care Industry Moves Slowly Onto the Internet http://bits.blogs.nytimes.com/2009/04/05/health-care-industry-moves-slowly-onto-the-internet/?emc=eta1

www.globalhealthmagazine.com

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approach to strengthening health systems through integrated, accurate and timely information. The global eHealth arena promises innovations around every aspect of personal care, population health, and environmental risk-factor management.

During the Rockefeller Foundation’s “Making the eHealth Connection” conference held in July 2008, health and technology leaders from all over the world declared a vision for reshaping health through a coordinated and collaborative approach to stimulating and sharing ehealth solutions to the most pressing problems.

Building upon information architecture standards evolving through global standards organizations, like the International Organization for Standardization (ISO) and Health Level 7 (HL7), these leaders envision a new generation of integrated health information systems capable of directing resources where they are needed, informing individual care, and intervening in the complex web of social and environmental influences that impact health outcomes.

This is not an unrealistic vision, and developing countries will likely achieve it faster, and at lower cost, than richer nations. This is because legacy (i.e. old) information systems, which have bedeviled efforts for integration in the wealthy countries, are much less entrenched in the emerging economies. Just as many African nations moved directly to fiber and wireless communications instead of laying down copper wire, the possibility for many countries to leapfrog to best-ofclass integrated health information systems is quite real.

There are already examples, like Belize, which recently installed a fully-integrated nationwide health information system, or the city of Sao Paolo, Brazil, which has developed an integrated system connecting all of the health posts in a city of 14 million people.

From silos to systems In the past, information systems were often developed

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to address narrowly defined vertical disease treatments or health programs – resulting in what are called data silos. Because such systems were designed for a single purpose within a single context, they have built-in limitations to the use and accessibility of the data. What is worse, due to the lack of coordination, these efforts often recreate the common building blocks of a health information system, such as patient identification, storage, security, authentication, and backup. All around the world, health information systems are fragmented and more expensive than they need to be, and do not easily share data. For example, in 1993 during a hantavirus outbreak in the U.S., officers from the Centers for Disease Control and Prevention had to compare information from several public health databases by hand.

Integrating requests for data and creating information that informs action on a range of problems have been barriers to better use of resources and to patient care.

As the power of computing devices increases, there is the potential to leapfrog today’s integration barriers, and open a world of information to even the remotest locations.

The power of integrating multiple streams of data is witnessed daily by anyone who uses Google Earth to zoom into an address or by those who view a weather forecast that combines satellite data with ground monitoring data to warn of advancing weather events.

Similarly, information systems that accurately predict epidemic trends or spot environmental threats will influence the health of every society in the future. As a hint of things to come, Google recently released a tool that is able to detect flu outbreaks weeks before official reporting systems, based on search keyword analysis.

We believe that moving from silos of data to integrated information systems (which combine multiple streams of official and unofficial data) will fundamentally transform the practice of health.

http://www.who.int/healthmetrics/en/

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What would a future health system, supported by timely and accurate information, look like? Here is one possible scenario: imagine that the South African minister of health has a dashboard that shows her, on a daily basis, the number of patients receiving antiretroviral (ARV) treatment, how predicted future needs map to existing stock levels of ARVs, the number of new cases of HIV, TB, malaria, and other major infectious diseases detected (and where those cases are), case reports on new and emerging infections, statistics on chronic diseases, the number of doctors and nurses per capita on a per-district basis, how many doctors and nurses are currently in the training pipeline, the latest statistics on births and deaths, the latest environmental monitoring trends, and so on.

When the minister of health makes a decision, it is based on live data instead of reports from 3 months or 1 year ago, and she can now watch the results of her decisions as they unfold, and adjust her interventions in real-time. In addition, just as your bank is alerted immediately when strange spending behavior occurs, public health officials are alerted when unusual health conditions occur – odd patterns of drug prescription, increases in emergency room visits, an outbreak of an unknown disease, and so on.

One could also imagine that a subset of this information, targeted at the local needs, is available to district health managers, hospital directors, community health workers, and the public. The vision we should aim for is that every person who makes decisions in the health system, whether the minister of health, a surgeon, a rural community worker, or a patient, has access to all of the information he or she needs in order to make an informed decision.

The Way Forward The health and technology leaders convened at the “Making the eHealth Connection” conference all agreed

http://ehealth-connection.org/content/bellagio-ehealth-call-action

that we need to move from silos of health information to more coordinated and aligned eHealth systems. The promotion of standards, which are sorely lacking in many health information systems, was underlined as a particular need.

The Rockefeller Foundation, International Development Research Centre, and others will be supporting processes to develop reusable national blueprints and architectures for health information systems, foster agreement on common standards for exchange of health information, develop human capacities to design and manage eHealth systems, and deploy eHealth systems to low-income countries.

Through funding from the Bill & Melinda Gates Foundation and other donors, the World Health Organization supports the Health Metrics Network, an international network devoted to giving developing countries a framework for how health information systems can inform better health resource allocation, improve patient services, and impact community health.

This effort has led a global movement among more than 100 countries that have adopted the HMN Framework to guide improving national health information systems.

Many countries are already developing plans and strategies for integrating their information systems, and some have advanced considerably towards implementation.

The conditions are ripe for suppliers of health information technologies, the countries that require these systems, and donors and supporting agencies to align in support of health information systems that are supportive of the health system as a whole (and not just a priority disease or program), affordable and sustainable. Most importantly, this must be done quickly, before today’s pilot projects become tomorrow’s isolated data silos. GH —

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Cell Phones Leapfrog Computers

By Nellie Bristol

Health workers are tapping into mobile phones in the developing world as use of the portable handhelds leapfrogs exponentionally over landlines and lagging Internet access.

In fact, cell phone use in developing countries is driving a whole new industry in health-related electronic applications for programs in the most remote areas that range from diagnosis and health worker education to social marketing and the flow of emergency food rations.

Global health and technology experts cite dozens of projects using electronic methods (known as “eHealth”) that are increasing data collection opportunities and leveraging meager health-care work forces.

But the technology explosion is facing many of the same problems as in developed countries: lack of interoperability, funding shortfalls and scant solid evidence of outcomes improvement. It also faces hurdles unique to global health – sustainability, inability to scale, and hardware and infrastructure challenges.

Promising new technologies are being developed, including low-energy use computers that are functional in challenging environments, and solar-generated power sources. But the biggest boon to extending the technology revolution to remote rural areas is coming from an unexpected source and, in something unusual in global health, being driven by the private sector:

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the explosion of cell phones in the developing world, particularly in Africa.

“I think it took a lot of people by surprise because the cell phone spread so quickly and immediately connected all of these people who were not able to be connected through other ehealth programs,” said Karl Brown, associate director of applied technology for the Rockefeller Foundation. Spurred by low-cost handsets and pay-as-you-go airtime purchasing, estimates indicate that 64 percent of all mobile phone users are in the developing world and that a majority of Africans have access to a phone.

“A whole set of technical interactions can be mediated so much better by cell phones than by websites,” says Peter Benjamin, general manager of Cell-Life, an HIVcare technology project in South Africa. He notes that 18 percent of clinics in South Africa have connected computers while 96 percent have a least one cell phone.

Phones often are connected to a central computer or server, which acts as the hub for the system. In this way, mobile technology “is really a way to strengthen broader eHealth initiatives and to connect what’s happening in the field to what’s happening in the cities where there is a platform for eHealth infrastructure,” said Katrin Verclas, editor and coordinator for MobileActive.org, a group that advocates mobile phone use for social change.

Nellie Bristol is a freelance journalist specializing in health policy.

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18 percent of clinics in South Africa have connected computers while 96 percent have at least one cell phone.

Photo credit: nthabiseng@flickr.com

Examples of new cell phone developments include:  ClickDiagnostics, a Boston-based group that uses smart phones with high-resolution photography to snap photos of skin problems. The image is transmitted to a computer and downloaded on a website accessible by pass code. Participating dermatologists can access the site from anywhere in the world and make a diagnosis.

After starting in Egypt, Ghana, Botswana, Bangladesh and Haiti, the group is now conducting projects in a number of other countries and is struggling to keep up with demand for services.  Cellphones 4 HIV, developed by Cell-Life, offers remote patient monitoring that tracks vital signs and drug adherence. It also is establishing patient support networks and helps build organizational capacity for HIV groups.  EpiSurveyor, open source software that allows data collection in remote areas largely with PDAs, is taking a major step forward this year with a web-based

History of the web

http://www.boston.com/business/technology/specials/webtimeline/

version that will use cell phones as collection devices.

Improvements to the system, developed by Washington, D.C.-based DataDyne, will allow surveys to be collected and transmitted in real time to a central administrator.

While enthusiasm is high for the new devices, there are challenges. Among those are financing constraints, lack of connectivity among various systems and devices, and securing local buy-in. Another issue listed as a major barrier by WHO’s Global Observatory for eHealth (GOe): lack of language variability. GOe’s 2006 study found multi-lingualism and cultural diversity to be “the least developed area of any examined.” It adds: “It appears that these issues which directly impact citizen access to information are not high on the current agenda of many governments.”

Building scale also is a problem. Warren Kaplan of the Boston University Center for International Health & Development, in a review of mobile health technologies in 2007, found there are a number of pilot projects that involve less than 40 people. “There’s a million of these,”

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Mobile phones reach further into developing countries than other technology and health infrastructures.

Figure 1. Technology and health-related statistics for developing countries (millions).

5,300

5,000 4,000 3,000 2,293 2,000 1,000 0

305

11 hospital beds

he said. “The question is can you create a business model and can you adequately scale this stuff up so that it works.”

Cell-Life’s Benjamin agrees: “There’s currently a lot of hype and baskets full of anecdotes and exciting little projects but almost nothing that actually show its use at any sort of scale.”

Neal Lesh, strategic director for Dimagi, a Massachusetts-based developing world technology group, describes the current global health technology field as “a thousand flowers blooming.” He compares it to early U.S. car development when dozens of models were advanced before the market settled on the few that actually functioned and sold well.

There are efforts to bring some standardization and coordination to the field so that devices and systems can talk to each other and provide a common data set of individual, community and country health information. The UN Foundation, the Vodaphone Foundation, and the Rockefeller Foundation announced in February the launch of a Mobile Health Alliance to join the disparate elements of the growing movement, including manufacturers and operators, NGOs, global governance groups and donors. The alliance aims to limit fragmentation and duplication while building scale and sustainability.

But consultant David Lubinski, formerly with Microsoft and WHO’s Health Metrics Network and now working with PATH, warns that while integration is important to advancing electronic technology, the real barrier

computers

mobile phones

population

to larger scale projects is a lack of systems expertise among those involved in the field in that they know only their own projects but not how to develop systems.

Applications are developed by narrow programs for their specific purposes but run into the same “silo” driven mindset that afflicts other aspects of global health.

Further, he said, many applications are developed starting from the viewpoint of the end user, not the worker in the field.

“Before we worry about plugging all these things together, have we done good design, have we understood the work of a community health worker, have we understood the work of a facility nurse, have we understood the work of a warehouse manager?”

Lubinski asked. Without that understanding and with continued focus on vertical programming, new applications could simply transfer current inefficient, donor-driven paper systems onto high tech devices.

“It would be a sad day if, in fact, you saw community health workers carrying two or three different phones because they were designed to work for different ways of collecting health information,” he said.

Despite the obstacles, the potential of electronic technologies, particularly the cell phone, has many in the global health community excited. With hopes for better systems, more local expertise and more efficacy research, global health practitioners are aiming for a common goal. “We’re trying to see what is the potential for using technology to empower people with information, communication and interactive service to take better care of their health and improve the lives of the people they love,” Peter Benjamin said. GH —

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Chart source: Vital Wave Consulting, Business Monitor International (BMI), International Telecommunications Union, World Bank’s World Development Indicators and the United Nations

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By dykki settle

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Open Source for Global Health

Everywhere you turn these days, it seems that global health is going digital. New terms like eHealth, mHealth, and telehealth have sprung into common usage in meetings, email lists, communities of practice and journals alike. A concept frequently used, misused and generally debated in all of these forums is Open Source.

What exactly is Open Source? You’ll hear it’s Linux vs.

Windows, OpenOffice vs. Microsoft Office, Firefox vs.

Internet Explorer, but what makes it different? What makes it useful? What makes it valuable for global health?

Open Source is most clearly defined as a kind of license governing how software, once created, can be shared, adapted and reused. The Open Source Initiative (www. opensource.org) maintains the (largely) communityrecognized definition of Open Source. According to the initiative, software is Open Source if it can be legally and freely: • Shared: Distributed without cost or restriction • Adapted: Easily and legally modified by other developers (usually from the software’s source code: the form of the software that is written and changed during development) • Reused: new works may be built from it, in whole or in part.

There are fine hairs to be split here, but that’s the spirit.

It doesn’t take long to see that this concept can also apply to other kinds of creative work. Open Source

software, along with written works, music, art and other media licensed ‘openly’ are frequently referred to as Open Content. Education using Open Content and equally open course materials is known as Open Education, and so on. More information on how to legally open or restrict these kinds of creations and innovations can be found at the Creative Commons (www.creativecommons.org).

The ability to freely and easily share, adapt and reuse Open Content and Open Source technology is a powerful opportunity for the developing world. Not having to incur debt and dependence on the innovations of the global North means that countries can focus on building their own capacity to learn from, build on and adapt software and information to meet their specific needs.

This opportunity is not acknowledged by everyone.

A lively debate continues around the advantages and disadvantages of Open Source and proprietary models.

Champions of proprietary technology argue that real innovation only occurs with investment, and investment takes place only when there is a clear opportunity for financial return on that investment. Proprietary licensing and copyright protection are designed to ensure that return.

Global health activities, for the most part, are using different measures for their return on investment. Many projects around the world are using the power of open licensing to ensure a return measured by the utility and sustainability of their global health solutions. Here are just a few:

Dykki Settle is director of health informatics for the Capacity Project at IntraHealth International, where he supports open source health worker informatics. Settle began his career as the first webmaster for the SunSITE project (now www.ibiblio.org), one of the earliest, largest and longest-running online libraries of open resources.

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The ability to freely and easily share, adapt and reuse Open Content and Open Source technology is a powerful opportunity for the developing world.

Photo Courtesy of IntraHealth

• The Open Source Medical Records System, OpenMRS (www.openmrs.org), is pioneering a unique multiinstitutional and multi-country community of developers and implementers building and adapting a tool for managing and tracking clinical encounters. OpenMRS is being implemented by a diverse team in more than 14 sites in 10 countries. Other Open Source clinical encounter systems include WorldVistA (www.worldvista. org) and openEHR (www.openehr.org).

• The District Health Information System developed by the Health Information Systems Programme is an early and growing effort to help countries develop a disease surveillance and service statistic monitoring system built on Open Source technology.

• The OpenROSA Consortium (www.openrosa.org) is working to reduce duplication of effort in mHealth (mobile health applications), fostering Open Source, standards-based tools for mobile data collection, aggregation, analysis and reporting. Their JavaROSA Open Source platform is being developed for a wide range of uses ranging from disease surveillance to supporting community health workers.

• The USAID-funded Capacity Project has developed the iHRIS suite of Open Source tools (http://www. capacityproject.org/hris) to strengthen the availability, quality and use of information on health workers.

The project’s human resources information system (HRIS) strengthening program based on this software is supporting health workers, their supervisors and qualifying authorities in 10 countries throughout subSaharan Africa.

In the spirit of Open Source, each of these software

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packages, and everything needed to use and build on them, is freely available to everyone in the world. More importantly than cost, however, these applications are adaptable in a way that more restrictive software can’t be. These packages have the ability to be transformed, improved, and even combined as needed to meet country needs, both now and into the future.

It’s no longer just about deploying a software package to meet an eHealth need. Outdated and unsupported software programs and computers can be found in ministry of health closets around the world. It is now about building the capacity of a health system to identify, adapt and create solutions from an entire library of technology options and opportunities.

Until now this capacity has been built in a siloed and haphazard way by individual Open Source projects. With the emergence of convening groups such as RHINO and the Health Metrics Network in the last few years, these projects have begun to find each other and explore ways to join efforts.

Community is essential to the adaptability and sustainable capacity building critical to Open endeavors.

Since these efforts are not proprietary or closed, they can be highly collaborative without fear or restriction.

Each of the activities listed above works because it involves a community effort. In-country developers and implementers work hand-in-hand with others from around the world. If the OpenMRS implementation in Eldoret, Kenya, is having trouble with their software they can join online forums and collaborate with other OpenMRS projects. If they develop something new (for example, integration with the iHRIS software) this development can be shared so that Haiti, Sierra Leone,

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or any of the other OpenMRS projects can use it. The effort isn’t about protecting what you have done, but sharing it so that all may benefit, with the knowledge your work will also benefit from what is shared in return.

strengthening, and to build the tools needed to stay on top of emerging health issues. A health system able to provide better and more equitable health care for everyone it serves.

Ultimately, what can result from such an emphasis on collaboration, local capacity building and system strengthening is a new kind of national health system.

A strong, dynamic and adaptable health system that has the power to discover and know its own problems, to prioritize its own needs for development and

If this sounds good to you, go online and read about the Creative Commons and the Open Source Initiative. Think of how you can make your own work more ‘Open’, and jump right in. The opportunities for global health, and for all of us committed to it, are tremendous. GH

IntraHealth OPEN IntraHealth OPEN is a new initiative that engages African technology leaders and health workers to develop and sustain Open Source software applications tailored to meet urgent health care needs.

As IntraHealth CEO Pape Gaye explains, “The OPEN Initiative will foster a new generation of technology professionals, eHealth workers and national leaders who understand, use and support Open technologies to build capacity and improve health.”

To raise funds and visibility for the initiative, IntraHealth recently launched a campaign in partnership with Grammy Awardwinning artist Youssou N’Dour and musicians from around the world who are donating remixes of N’Dour’s song “Wake Up.” IntraHealth has also created an OPEN Council made up of leaders in the fields of public health,

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technology and entertainment to guide and support the project.

“Open Source technologies let us address health challenges collaboratively with African developers in the lead,” says N’Dour. “If we invest in Open Source development training in Africa we will be supporting selfsufficient health professionals able to use technology and customize programs to address their critical health challenges.”

The OPEN Remix campaign involved donations of services pro-bono from artists, engineers, studios, mastering companies, producers, labels, distributors, advertisers and graphic and website designers.

“It’s a noble cause and something that not only interests me on a technological level but also an effort I can totally get behind on a humanitarian level,” notes Michael Donaldson, better known as Q-Burns Abstract Message, who contributed a remix.

Free downloads of the songs are available with a suggested donation through distribution partners including Rhapsody, iLike, Amazon MP3, and at IntraHealth’s website www.intrahealth.org/open.

Youssou N'Dour

“Youssou is one of Africa’s greatest artists,” adds Toubab Krewe percussionist Luke Quaranta, “and it’s a privilege to be part of this project. We love to work with other musicians, and here collaboration can help save African lives.”

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High Tech health

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C

online exclusives

By andrew sideman —

C AED-Satellife 20 years later Sometime in the recent past – no one is exactly sure when – a milestone was passed which marked a paradigm shift to which the international health community has failed to respond.

Photo Courtesy of AED

Sometime in 2007 or 2008, the number of mobile phones in the world passed the halfway point: the number of cell phones in use is now well more than half the number of people in the world.

everywhere else. So, even if we allow that some people tote more than one phone, where is this new growth coming from?

In case you hadn’t noticed, most of the developed world is already connected. As are the wealthy and elite

Go to www.globalhealthmagazine.com to read the full story.

By Kathryn Utan

By jennifer wilder

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C Phone Consultations for

C Low-tech solution

Ethiopia is home to an estimated 980,000 people living with HIV or AIDS, including some 75,000 pregnant women. Currently, some 3,500 health-care workers at nearly 420 separate facilities spanning the country are providing combination antiretroviral treatment to more than 180,447 patients. The vast majority of these are receiving first-line therapy.

Like many Nigerian women, Jamila delivered her first baby at home, with the help of a traditional birth attendant. But following the birth, her uterus failed to contract and she began to bleed heavily.

The birth attendant failed to recognize the severity of blood loss, and by the time Jamila reached the nearest primary health center, she was in shock and her life was in jeopardy.

Ethiopian Health-Care Workers

To fill this void, the National AIDS Resource Center in Addis Ababa has established the Fitun Warmline, a tollfree telephone service designed to provide health-care professionals across Ethiopia with quick, accurate and up-to-date answers to their questions about HIV/AIDS care and treatment.

Go to www.globalhealthmagazine.com to read the full story.

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saves lives

Luckily, the health worker at the primary health center had been trained to use the nonpneumatic anti-shock garment to halt postpartum hemorrhage and reverse shock.

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