Full Charge!

This morning, we distributed the first batch of solar panels from G24 Innovations. I was also able to reconnect with CHWs I hadn't seen in a while. Everyone was extremely happy - I'll let the pictures tell the story.

Of course, Alex ran the session. The instructions were quick and easy, and everyone was rather celebratory:


To close the meeting, the CHWs sang a song for me that they had prepared - I'm not sure what the lyrics were, but "phones" and "messages" were included! Afterward, I traveled with Dickson Mtanga and Mary Kamakoko to their villages - it took a good two hours on a bicycle. We spent another 3 hours biking around and seeing patients, before I started back to the hospital. Dickson and Mary, using their new panels:

SMS for Patient Care, in its Truest Form

I sat down with Alex today, to discuss the FrontlineSMS and its impact on the Home-Based Care (HBC) program at St. Gabriel's. Essentially, he's a one-man, mobile care unit - focusing on chronically ill patients and those who simply cannot travel to the hospital. The backpack, pictured above, is full of medical supplies.

The SMS network has brought Alex to the homes of 130 patients who would not have otherwise received care. That's about five responses, per week, to requests for remote medical attention.

Before the SMS program, Alex was visiting around thirty patients a week, rotating through the HBC roster. He now follows up on five patients per week, usually checking in on those who have been recently discharged from the hospital. The CHWs take care of the rest - since the program started, approximately 520 HBC patient updates have reached the hospital via SMS.

The difference in Alex's HBC activities amounts to about 500 hours and over $1,000 in fuel saved. He has responded to ~40 requests for healthcare supplies (usually dressing materials for wounds and cervical cancer patients). With FrontlineSMS blasting automated responses to drug inquiries and Alex responding to questions regarding basic care, the central SMS hub truly serves the CHWs and their patients.

Alex, who is a highly capable nurse, also holds full shifts in the male ward at the hospital, and is one of two staff members coordinating antiretroviral treatment (ART) for the catchment area. His multitude of responsibilities make time saved in managing the Home-Based Care program extremely valuable.

The first batch of solar panels from G24 Innovations (www.g24i.com) arrived today - I tested one of the products and it quickly charged my phone, to completion, amidst a thunderstorm. More on this later - we are gearing up for training and distribution on Monday.

Tuberculosis, Meet FrontlineSMS

On Christmas morning, Silia stopped by the guest house to talk about the SMS program. He's responsible for testing, drug provision, and follow-ups for TB patients. He described how he's using FrontlineSMS and the network of cellphone-wielding CHWs. Almost all of what follows developed in my absence.


Some sputum-positive patients don't turn up to receive their medication. It's Silia's job to track these patients and get them back on their drug regimens. Before the SMS program, he was visiting an average of 17 patients per week - this took him three trips on his motorbike. Each trip would take ~9 hours. That's 27 hours per week spent tracking patients in various villages.

The SMS network has allowed Silia to share his workload with the CHWs. He now tracks an average of 20 patients per week via SMS. He simply texts CHWs nearby patients that haven't turned up. As Silia says, the CHWs provide "immediate feedback."

The program has been running for roughly 26 weeks. With the shift to SMS-based patient tracking, Silia had an additional 700 hours to utilize. Not surprisingly, he's been using FrontlineSMS to supplement other areas of his work.

He now visits an average of 4 patients per week, for different reasons. Some messages from the CHWs tell of patients who are too ill to travel to the hospital. Silia will respond by bringing a new supply of drugs. Other messages relay symptoms of community members - e.g. "A man has a chronic cough, and we suspect TB." Silia will visit the patients, and collect a sputum sample. He'll return to the hospital to do testing and send the results, by SMS, back to the CHW.

Finally, when patients at the hospital test positive for TB, they're told which CHWs near their home have cell phones.

Some numbers from the TB program for the last 6 months:

700 hours of follow-up time saved
450 follow-ups via SMS
(At least) $2000 in motorbike fuel saved
100 new patients enrolled in TB treatment program

Coming up: Impact on Home-Based Care, PMTCT, Public Health, and HIV/AIDS programs

The Real Story

Here's the truth - this project involves people, rich in character and experience. It's not only about the technology. If I'm interested in the tech fulfilling its potential, I've got to pay attention to the people.

Case in point:

I spent yesterday mulling over text messages sent through FrontlineSMS over the last four months, noting which CHWs had communicated least. I put together a list of a few CHWs I suspected might be having signal issues. Looking at the map, three of six CHWs on this list were clumped together - clearly, they must not have good reception.

I told Alex about my findings, this morning. He took a look at the names and said, "Well, Bernadeta took her phone with her to Zambia, we've discovered that Chrissy is not able to write her own name, and Jereman's phone battery was stolen while it was charging at the local barber shop." My time away from the hospital almost made me forget the multitude of stories swirling around these phones and the hospital they're linked to. With 100 phones in the field, three random problems are to be expected.

Whether or not everyone agrees, I think personal stories convey a project's successes, as well as their failures. Silia, a hospital attendant who runs the hospital's TB program, said yesterday, "The SMS project is very, very good - I can get much more work done, instead of driving the motorbike everywhere. It's very simple - we can expect feedback about patients immediately." I met the new hospital administrator today, and his second sentence was, "You know, it's not only beneficial for communication. The volunteers are now committed to their work, and more will follow."

I'm letting stories from patients, CHWs, and the medical staff at St. Gabriel's drive my exploration into this project's value. I turned to people for the direction of the initiative, and I'm turning back to them to measure part of its impact.

The first batch of solar panels arrives tomorrow.

Back on the (Wet) Ground

I'm back in my old room at the hospital's guest house, and it's pouring rain. I arrived just in time for the last Home-Based Care course - 21 new, volunteer CHWs were reviewing referral procedures, patient rights, the contents of their drug kits, etc. The group, seen above, is copying acronyms into their notebooks. Here's a snapshot of what they're writing:




At the end of the session, the CHWs were asked to turn in a piece of paper describing the location of their home. Most of their responses were paragraphs long - some included extensive maps.


Joanna, who is running PointCare's CD4-count outreach program, relayed an interesting conversation with one of the CHWs a week ago. She traveled to their farthest site - a good 100 mile drive - and ran into Zakeyo, who said, "You know, Josh is coming on the 19th." I checked FrontlineSMS, and Alex hadn't warned him. It's exciting to know that the next time I see him, I'll pass along a solar panel accompanied by a solar-powered light.


Tomorrow, I'm going to spend some quality time with FrontlineSMS - working through the communication over the last four months.


Please comment freely, or shoot me an e-mail, with any questions. I have just two weeks before I return to Stanford, and I'm trying to make the most of it! As always, thanks for reading.

CNN - "Texting to save lives"

That's the headline the CNN Technology site is using to pull visitors to a story covering the project. Here's the link:

Text service provides more than a Band-Aid for rural health service by Steve Mollman

It's amazing to see Alex and Grace on the site, and I think Steve wrote a wonderful article. I'm headed back to the hospital for Christmas break, and I'll be updating the blog regularly - starting now. Here's a (very) quick 30-second video, as a re-introduction to the project and a few of the people involved.

Busy October

Here's some information on conferences and events I'm set to attend in the next month:

October 9th - Stanford Undergraduate Research and Public Service Symposium

October 11th - BarCamp Africa @ Google

October 12-14th - Alex Ngalande from St. Gabriel's Hospital will be speaking at MobileActive08

October 14-15th - Institute For The Future's 'Reinventing Health Care in a Mobile World'

October 22nd - Stanford Community Health and Public Service Fall Forum

October 23rd, 9AM - Health 2.0 Conference

Frequently Asked Questions

Building an SMS Network into a Rural Healthcare System

This guide provides an inexpensive way to create an SMS communications network to enable healthcare field workers as they serve communities and their patients. The steps are purposefully simple – the system is easy to set up, use and maintain.

Contents

1. Who might benefit from a text-based communications network?

2. What are the benefits for my hospital, clinic or organization and the people it serves?

3. What technology do I need?

4. Do I need an internet connection?

5. How expensive is an SMS network?

6. How do I distribute communication credit?

7. How much staff training is required?

8. How much time does it take, per day, to manage the SMS network?

9. How do I conduct SMS training?

10. What is the best power source for the cell phones?

11. Do the CHWs communicate with each other?

12. Where can I find more information on FrontlineSMS?


FAQ #1: Who might benefit from a text-based communications network?

In the summer of 2008, an SMS network was implemented at St. Gabriel’s Hospital in rural Malawi. The hospital serves ¼ million people, spread throughout a catchment area 100 miles in radius. St. Gabriel’s recruited 600 community health workers (CHWs) to serve as volunteer healthcare representatives in their villages. Disconnected from hospital services and resources, the CHWs’ ability to help patients was limited.

Hospitals, clinics, and organizations faced with the defining challenges of rural healthcare – namely, distance and the isolation it breeds – are set to benefit from a low-cost SMS network. Given specific steps and tools to connect individuals, SMS (“short message service”) can provide the missing link – between a hospital and its field worker, patients, support group members, or CHWs in their respective villages.

Ultimately, the aim is for benefits to fall upon those served by the health network. See FAQ #2 for an outline of the benefits derived from a newly implemented SMS program that is providing connectivity for a rural healthcare network.


FAQ #2: What are the benefits for my hospital, clinic or organization and the people it serves?

Implemented at a hospital in rural Malawi in the summer of 2008, a text-based communications network is making a significant impact on hospital operations and patient care. Here is a list of the current functions of the SMS network:

• Requests for remote patient care

CHWs text the hospital staff when immediate care is needed, and the Home-Based Care mobile unit subsequently visits the patient. Patient location and health status are communicated, allowing the mobile team to bring needed drug supplies. According to Dickson Mtanga, a CHW in the pilot program, “When I have a problem with my patient, I just send a message to the hospital, at once. If they are helped and assisted, I feel so much better.”

• Patient tracking

The hospital is now able to track patients in their distant communities. According to Mr. Ngalande, “Each and every department is free to use FrontlineSMS. We have ART, Home-Based Care, TB, PMTCT (Prevention of Mother to Child Transmission). For example, TB patients who are not coming for their appointments, we use FrontlineSMS to text volunteers close to the patient’s village. It’s easy to get feedback from the community.”

• Checking drug dosages

CHWs in the field have been given basic drug supplies (e.g. Panadol, Ferrous Sulfate, eye ointments) for primary care. The CHWs now check drug dosages and uses within seconds. When FrontlineSMS receives an SMS with a drug name, it automatically responds to the health worker with that drug’s information.

• Patient updates

CHWs regularly update the hospital staff with regards to patient status, including reporting patient deaths. These messages have created a post-discharge connection to patients’ well being.

• Coordinating Home-Based Care visits

In addition to responding to medical emergencies in the communities, the Home-Based Care (HBC) unit also follows a schedule of home visits – sometimes checking on patients have been discharged recently. Other patients are enrolled in the hospital’s palliative care program. Before traveling to the patients’ villages, the mobile unit text messages CHWs in close proximity to the clients they plan to visit. Any response by the CHW (e.g. “Patient is not at home.”) is forwarded to the mobile team’s phone, allowing medical staff to maximize their productivity by visiting available patients.

• CHW-to-CHW communication and group mobilization

CHWs are now communicating and collaborating. All texts are shuttled through the hospital, and FrontlineSMS commonly relays messages and requests between CHWs. This has been an important function in setting meeting dates for Village AIDS Committees and linking HIV/AIDS support groups. Hospital activities throughout the catchment area (including microfinance and Positive Living programming) are organized using the SMS network. Baxter Lupiya, a CHW in TA Kalolo, notes, “We used to travel a long distance. Now, we have easy communication with others. The program must be continued, because it is so good!”

• Integrating connectivity into HIV counseling

HIV Counseling and Testing (HCT) at the hospital has been augmented because of the SMS network. If a client tests positive, he or she is paired with to an HIV-positive CHW with a phone – these volunteers act as models for Positive Living and provide comfortable, relatable links to the hospital.


Other benefits:

• CHW status

The connection to hospital services has solidified the CHWs’ role as legitimate healthcare representatives in their villages. The patients and their communities, according to the program’s participants, have noticed the phones, each one clearly marked with the hospital’s logo.

• Incentives and accountability

The phones provided very concrete incentives for the volunteer work done by the CHWs. The SMS network created, for the first time, a way to track the CHWs’ activities, paving the way for more informed decisions regarding allocation of resources (e.g. which CHWs should receive bicycle ambulances).

The listed benefits developed organically from a particular hospital’s needs. Undoubtedly, future demands will uncover new functionalities. For example, the hospital in Malawi is exploring the use of FrontlineSMS’s ‘Forms’ function to collect structured data regarding the status of palliative care patients – information that can quickly be exported to donors and organizations supporting those patients.


FAQ #3: What technology do I need?

Here is a quick list of the equipment used in Malawi:

- 75 Motorola V195 cell phones, purchased at $15/phone from a recycling company
- 15 Nokia 6210 cell phones, $40/phone
- 10 Nokia 6100 cell phones, $50/phone
- 1 Falcom SAMBA75 GSM modem, $200
- 1 donated Compaq Presario laptop
- 100 cell phone chargers + Malawian adapters

Software:

- FrontlineSMS version 1.4.7, free software downloaded at www.frontlinesms.com/download
- FrontlineSMS is running on a Windows Vista operating system

A few notes on hardware and software:

• As long as the cell phones get service and function on your local network – they can send/receive text messages – they will work with FrontlineSMS. Motorola V195 phones were chosen for the program in Malawi because of their low cost and ease of use. The Nokia phones were chosen for similar reasons – teaching texting using the Nokia models (6100 and 6210) was straightforward. The steps for sending an SMS with the Motorola V195 were slightly more complex.

• Each distributed phone was labeled with the hospital logo. This was important for ownership and accountability, along with community transparency and health worker status.

• I had the Malawian Department of Surveys print a map of the hospital’s catchment area. On this map, color-coded pins were placed, showing where distributed phones are located (along with each CHW’s program type, e.g. Home-Based Care or ART Monitoring).

• When selecting phones for your network (if you are purchasing new or used phones), keep a few things in mind:

1. Consider the experience of the user. In most situations, simpler is better – sending and receiving an SMS is meant to be easy.
2. Check to see which bands (e.g. GSM 900 band) work with your local network, and make sure the phone supports that band. Here is a site with GSM coverage maps for a number of countries: http://www.gsmworld.com/roaming/gsminfo/index.shtml

• The new versions of FrontlineSMS are configured to run on a number of operating systems. You can find comprehensive information on Windows, Mac and Linux compatibilities here: http://www.frontlinesms.com/download/requirements.php

• Although the SAMBA75 GSM modem is being used in Malawi, a number of modems and cell phones may be connected to the computer running FrontlineSMS. For a list of phones and modems that work well, see the following link: http://www.frontlinesms.com/download/requirements.php

FAQ #4: Do I need an internet connection?

All that is necessary is a cellular network signal on your modem or phone – no internet connection is needed. If you can send and receive text messages in your area, FrontlineSMS will work. Check the GSM coverage map link for more information on your local network: http://www.gsmworld.com/roaming/gsminfo/index.shtml

FAQ #5: How expensive is an SMS network?

The cost of your network will largely depend on the scale (e.g. the number of phones and the volume of text messages processed per day). Here are the numbers in Malawi:

• The pilot network includes 75 community health workers (CHWs) and 10 members of the hospital staff.
• During the final weeks of the implementation period (weeks 7 and 8), an average of 10 messages were received from the hospital per day. The number of responses by the hospital (along with new patient tracking requests) varied.
• Once the phones are distributed, the only running cost is the rate per SMS. Given that one SMS costs 10 cents, and they are free to receive, the program is running on just over $1/day. So, $4,000 will fund the SMS network for a little over 10 years.


FAQ #6: How do I distribute communication credit?

There are a few options here. Your distribution method will depend on the structure of your healthcare delivery teams and/or volunteer organization. This is how we tackled this logistical issue in Malawi:

• Celtel, the local network provider, has a ‘Me2U’ service that allows a user to send communication credit (“units”) from one phone to another via text message.
• Every phone that we distributed had a 2-digit identification number engraved on its case, specific to that phone and SIM card.
• Using the keyword and auto-forward functions in FrontlineSMS, we automated the entire top-up process, allowing the CHWs to request automatic unit refills.
• For example, the owner of phone #11 sends a message to the hospital, “11 units” which is recognized by FrontlineSMS. FrontlineSMS then sends a message to Celtel’s Me2U service, requesting that phone #11 receive another dollar of credit.

Other options include passing large quantities of units to trusted individuals, such as CHW leaders, coordinators, or other staff who have regular contact with those receiving phones. The key to maintaining accountability is making it clear that FrontlineSMS documents every message received by the hospital. Be sure it is understood that the communication credit given to your contacts should be used to communicate with your hospital, clinic, or organization.



FAQ #7: How much staff training is required?

No technical experience is required for implementing or sustaining an SMS network. The nurse in Malawi managing day-to-day communication, using FrontlineSMS on the hospital laptop, had never used a computer before the SMS program was introduced.

Within the first week, the hospital staff understood the functionalities of FrontlineSMS – for this reason, the uses of the SMS network developed organically, shaped by the needs of the hospital, the CHWs, and the patients they serve.

After a 1-hour training session on operating FrontlineSMS, the nurse and ART coordinator were left with a simple, step-by-step operation guide. The guide, available to anyone who requests it, uses images of FrontlineSMS, showing how to:

1. Send a message
2. Check for new messages
3. Add/delete a contact or group
4. Copy and paste text (a useful explanation, for first-time computer users)
5. Ensure that FrontlineSMS is communicating with the attached modem (or phone)
6. View a specific contact’s message history

FrontlineSMS also has a built-in Help guide, which explains in detail each function, including forms, e-mail, and keywords. The keywords and their respective automated action (e.g. auto-forward, auto-reply) were all created on the ground, and I have absolutely no technical background.

The program, along with the SMS data collected, is purposefully uncomplicated. According to Alex Ngalande, the nurse running FrontlineSMS for the pilot program, “[Setting up FrontlineSMS] was very quick. And, people didn’t know that this thing could work here – because, it’s our first time to have this kind of system whereby people can directly communicate with the hospital… It’s simple and straightforward.”


FAQ #8: How much time does it take, per day, to manage the SMS network?

Towards the end of the pilot period (weeks 7 and 8) in Malawi, two members of the hospital staff were spending 15 minutes every morning and 15 minutes at the end of the workday managing incoming and outgoing SMS data.

This management time (an average of 30 minutes per day) included reading new messages, responding to urgent requests, forwarding CHW-to-CHW messages, passing on patient updates to relevant hospital staff, sending out patient tracking requests, and processing other outgoing texts.


FAQ #9: How do I conduct SMS training?

The success of the SMS program relies on the users being able to operate their phones. For this reason, patient training and a slow rollout are recommended. In Malawi, we trained 10-15 community health workers (CHWs) per week for 6 weeks (75 CHWs in all) – each session lasted about three hours. A few tips, especially applicable if your contacts are first time cell phone users:

1. Start with the basics. The first step displayed on our training posters? Open the phone.
2. Keep the training groups small.
3. Take simple steps to make your instructions outstandingly clear – we made posters showing which buttons to press.
4. After each ‘lesson,’ have a member of the group lead the others through what they learned (e.g. after teaching the group how to check for new text messages in the phone’s inbox, have a participant repeat the steps).
5. Poll the group to find out how many have used a cell phone before. Have the experienced participants guide others through the SMS steps.
6. Have the group practice texting something simple (e.g. “Malawi”), then something more difficult (e.g. their full name and birth date).
7. Have expectations for the group prepared (e.g. what will be communicated, and when they are expected to communicate).
8. The most committed volunteers received the first phones. This distribution method contributed to the success of the pilot program.

The training in Malawi was conducted in Chichewa by hospital staff. The staff running the training sessions knew the CHWs, and were used to speaking to groups.


FAQ #10: What is the best power source for the cell phones?

Depending on your area of operation, electricity may or may not be widely available or affordable. The pilot in Malawi looked at a few options:

• When asked, “Who has access to electricity?” every CHW said they could charge the phones on their own. This turned out to be a half-truth – they had to pay a small fee to charge the phones at a local barbershop, as an example of a local solution.
• We created a local charging station, next to the hospital, where the CHWs could charge their phones free of charge.
• I brought hand-powered chargers, which simply did not work.
• As a short-term solution, CHWs in the most remote locations were given battery-powered phone chargers (which provide 2-3 full charges per AA battery).
• For sustainable, remote, off-the-grid charging, individualized solar panels may be the best option. Solar panels will power the SMS network for the pilot program in Malawi.


FAQ #11: Do the CHWs communicate with each other?

Absolutely. This was one of the first questions raised by the CHWs in the pilot group in Malawi. CHW-to-CHW communication is vital for group mobilization, and has a large impact on day-to-day CHW activities. It’s important to realize, however, that FrontlineSMS will not track messages between phones in the field. If one CHW wants to contact his colleague many miles away, they are asked to send a message to the hospital – along with directions to forward the message: e.g. “Send to John: The support group will meet this Saturday, at 10 o’clock in the morning. From Dickson.” This system ensures that all messages are accounted for.


FAQ #12: Where can I find more information on FrontlineSMS?

Visit www.frontlinesms.com for more information on the free, open-source program. The site includes a detailed description of the software, demo, map of current users, and download request form.

The following is an interview with Alex Ngalande, the Home-Based Care nurse in Malawi who is currently running FrontlineSMS on setting up and using the program:

http://www.youtube.com/watch?v=Go09UxPEW7k

Here is an interview with a community health workers involved in the pilot program. She speaks on volunteer activities, as well as the impact the SMS-based network has on patient care:

Verona Kapagawani: http://www.youtube.com/watch?v=kHXP5S0HkIQ&feature=related

In Writing - What's Happened

Healthcare challenges

In 2008, FrontlineSMS was implemented as a central SMS hub for a rural hospital in Namitete, Malawi. Located 60 km from Lilongwe, St. Gabriel’s Hospital serves 250,000 Malawians spread over a catchment area 100 miles in radius. The vast majority of the people the hospital serves are subsistence farmers, living on under $1 a day.

• The catchment area has an HIV prevalence rate of 15% combined with widespread malnutrition, diarrhea, Multi-Drug-Resistant Tuberculosis (MDR TB), Pneumocystis pneumonia (PCP) and other opportunistic infections. Three medical officers are employed at St. Gabriel’s – creating a physician-to-patient ratio of 1:80,000.

• The hospital has enrolled over 600 volunteers to act as community health workers (CHWs) in their respective villages. Many of the volunteers are active members of the HIV-positive community, and were recruited through the hospital’s antiretroviral therapy (ART) program.

• When one ART monitor, Benedict Mgabe, was asked why he started volunteering, he replied, “I began when I saw my relatives and friends who were suffering from HIV and AIDS. I took it very personally; I knew I must get involved in curbing this epidemic.”


A need for a true community health network

Distance presents an often-insurmountable obstacle for patients seeking care at St. Gabriel’s. Many patients walk up to 100 miles to the hospital; those with more resources ride bicycles or oxcarts. In order to report patient adherence, ask for medical advice, or request medical care for remote clients, CHWs had to travel similar distances to the hospital’s doors.

The most motivated of the CHWs kept their own patient records, and journeyed to the hospital every few months. Their activities effectively isolated by distance, the impact of the volunteers’ work was restricted to their communities and disconnected from the centralized medical resources at the hospital – their potential role delivering healthcare stifled by disjunction.


Implementing the project

During the summer of 2008, I traveled to St. Gabriel’s with 100 recycled cell phones and a copy of FrontlineSMS – a free program developed by Ken Banks to act as a central text-message hub. My plan was to implement a text-based communications network for the hospital and the CHWs.

In groups of 10-15, CHWs were brought to the hospital, given cell phones, and trained in text messaging. The volunteers’ locations were mapped, and the phones were disseminated throughout the catchment area.

Stationed at the hospital, a laptop running FrontlineSMS coordinates the health network’s activities. The day-to-day program operations were handed over to hospital staff within two weeks. FrontlineSMS is operated by Alexander Ngalande, a nurse who heads the hospital’s Home-Based Care program.

Mr. Ngalande, on setting up and running FrontlineSMS:

“It was very quick. And, people didn’t know that this thing could work here – because, it’s our first time to have this kind of system whereby people can directly communicate with the hospital using FrontlineSMS. It’s simple and straightforward.”


Impact on patient care and hospital operations

The SMS network has enabled the following:

• Requests for remote patient care

• CHWs text the hospital staff when immediate care is needed, and the patient is subsequently visited by the Home-Based Care mobile unit. Patient location and health status are communicated, allowing the mobile team to bring needed drug supplies. According to Dickson Mtanga, a CHW in the pilot program, “When I have a problem with my patient, I just send a message to the hospital, at once. If they are helped and assisted, I feel so much better.”

• Patient tracking

• The hospital is now able to track patients in their distant communities. According to Mr. Ngalande, “Each and every department is free to use FrontlineSMS. We have ART, Home-Based Care, TB, PMTCT (Prevention of Mother to Child Transmission). For example, TB patients who are not coming for their appointments, we use FrontlineSMS to text volunteers close to the patient’s village. It’s easy to get feedback from the community.”

• Checking drug dosages

• CHWs in the field have been given basic drug supplies (e.g. Panadol, Ferrous Sulfate, eye ointments) for primary care. The CHWs now check drug dosages and uses within seconds. When FrontlineSMS receives an SMS with a drug name, it automatically responds to the health worker with that drug’s information.

• Patient updates

• CHWs regularly update the hospital staff with regards to patient status, including reporting patient deaths. These messages have created a post-discharge connection to patients’ well being.

• Coordinating Home-Based Care visits

• In addition to responding to medical emergencies in the communities, the Home-Based Care (HBC) unit also follows a schedule of home visits – sometimes checking on patients have been discharged recently. Other patients are enrolled in the hospital’s palliative care program. Before traveling to the patients’ villages, the mobile unit text messages CHWs in close proximity to the clients they plan to visit. Any response by the CHW (e.g. “Patient is not at home.”) is forwarded to the mobile team’s phone, allowing medical staff to maximize their productivity by visiting available patients.

• CHW-to-CHW communication and group mobilization

• CHWs are now communicating and collaborating. All texts are shuttled through the hospital, and FrontlineSMS commonly relays messages and requests between CHWs. This has been an important function in setting meeting dates for Village AIDS Committees and linking HIV/AIDS support groups. Hospital activities throughout the catchment area (including microfinance and Positive Living programming) are organized using the SMS network. Baxter Lupiya, a CHW in TA Kalolo, notes, “We used to travel a long distance. Now, we have easy communication with others. The program must be continued, because it is so good!”

• Integrating connectivity into HIV counseling

• HIV Counseling and Testing (HCT) at the hospital has been augmented because of the SMS network. If a client tests positive, he or she is paired with to an HIV-positive CHW with a phone – these volunteers act as models for Positive Living and provide comfortable, relatable links to the hospital.

Other benefits:

• CHW status

• The connection to hospital services has solidified the CHWs’ role as legitimate healthcare representatives in their villages. The patients and their communities, according to the program’s participants, have noticed the phones, each one clearly marked with the hospital’s logo.

• Incentives and accountability

• The phones provided very concrete incentives for the volunteer work done by the CHWs. The SMS network created, for the first time, a way to track the CHWs’ activities, paving the way for more informed decisions regarding allocation of resources (e.g. which CHWs should receive bicycle ambulances).

A whole-hearted thanks goes out to everyone who has been reading these posts. I'd be thrilled to hear from you. In the next few days, I'll put up a post that will (attempt to) cover the various, exciting ways this project is moving forward. In the next week or so, I'll also be developing a DIY guide, based on a series of FAQs - much more on this later.

Verona Kapagawani; Community AIDS Committee Chair

As promised, here is an interview with one of the Community Health Workers involved with the pilot in Malawi. Verona speaks on why she started volunteering, how the SMS program has changed her ability to care for patients, and what it means to be a healthcare volunteer.



Here are a few of the messages sent to the hospital by Verona, in the first weeks of the pilot:

AK has a problem of CCF; his medicine is finished, and he is getting a bit better.

AJ is on TB treatment, he is taking the drugs following instructions. He is improving. AM had swollen thighs but she is improving. She is taking drugs following instructions - the guardian is strict.

Adherence: TN is alright. He is taking the drugs following the instructions, he did not miss any day.

PT is very fine, working hard in the garden. He did not miss any day.

Straight from the User

After a few days of traveling, I'm back at Stanford. It was difficult to leave Namitete, but there's plenty to be done in the US.

Below, I've uploaded an interview with Alexander Ngalande, the hospital's Home-Based Care nurse, regarding his experience with FrontlineSMS. Please excuse the poor quality - my equipment was limited to a small, digital camera.

Need-Stressing Couched in Gratefulness*

I promise I'll explain the title - in a bit. First, here's a re-cap of some of the week's developments:

Above, I've provided a snapshot of today's activities in the Home-Based Care (HBC) office, the new home of FrontlineSMS and the CHW maps. From left to right - Neggie, a nurse in labor ward; Grace, the hospital's ART coordinator; Alex, the HBC nurse. Neggie showed up at the office with a list of mothers - they were enrolled in the hospital's PMTCT program, but they've failed to report for their 6-week follow up (when blood samples are taken in order to determine the child's HIV status by DNA PCR). Alex is locating the mothers' villages, and reading off the ID numbers of CHWs in their vicinity.

These days, the majority of the patient visits made by the mobile team are responses to SMS requests for immediate medical attention. Still, certain visits are scheduled follow-ups after patients have been discharged. Traveling with Alex, I realized that, at least half the time, the patient is nowhere to be found. Alex now sends a few quick messages to the CHWs overseeing the patients he's planning on visiting, letting them know he'll be stopping by. While he's out in the field, any response from the CHWs is forwarded to his cell phone. This assures that he sees patients who are available - and avoids 40-mile journeys to discover a patient is away, selling maize in Mozambique.

A CD4 outreach initiative funded by the World Bank starts up later this week. They will use the CHW communications network to inform villagers of testing sites and dates - aiming to increase client turnout, thereby bolstering access to the free testing services.

This past Saturday, we gathered the first 30 CHWs for a refresher course - explaining the automatic unit top-ups and the drug keywords (we've already had BB Paint, TEO, Panadol, and Multivitamin info requests). After the session, I video-interviewed four of the CHWs, in English.

I'm leaving Malawi this coming Friday, and when I'm back at Stanford I will be uploading the videos. I'm planning to embed them in individual posts - so you can hear the stories of care from those who have lived them. Their general attitude might be described as thankful, yet realistic about the pressing needs of their families and friends - hence, the title of this post. Malawians are said to spend roughly 10 percent of their waking hours at funerals. The statistic does reflect troubling times - but it also demonstrates the blurred boundaries between family and fellowship. Villages are full of brothers, sisters, and mothers - some share heredity, but all share circumstances. Every text message sent by the CHWs has invited me to appreciate the true meaning and function of community.



*title credit: Maggie Chen

Caught Smoking

A baker's dozen left St. Gabriel's Hospital on Thursday with cell phones, trained and ready to communicate. Below, a CHW practices texting "Malawi." He's the Home-Based Care provider in his village, and runs an orphan care center.


Text messages are notorious for being concise, hence the Short Message Service (SMS) protocol and its 160 character/message cap. Most of the messages to and from the hospital are brief, and to the point. Some CHWs, however, send stories - sometimes, five messages in length. A few examples (translated from Chichewa):

PF is refusing to use the condoms in his family which has made his wife to be pregnant of three months and he also drinks alcohol much, and also likes women. In so doing I advised him not to stop using condoms and also to stop drinking because they are putting his life in danger. And his wife should start going to her doctor visits, like at St. Gabriel's.

I found TJ smoking, and he is on TB medication. He failed his first treatment in 2006, and this is his second treatment. AJ is on TB treatment, he is taking the drugs following instructions. He is improving. AM had swollen thighs but she is improving. She is taking drugs following instructions - the guardian is strict.

Both of these CHWs texted for the first time a little over a week ago.

I'm planning to video-interview a few of the CHWs this Tuesday and Wednesday. Any questions for them?

Web of Positive Living

At the weekly ART meeting, the "Prevention of Mother-To-Child Transmission" (PMTCT) staff reported on the number of children from their program who have been confirmed HIV-positive.

Mothers are given a single dose of nevirapine, to be taken during labor (whether they deliver at home or in the hospital), and children born at the hospital to HIV-positive mothers receive short-course AZT, in an attempt to deter transmission of the virus. Each case that the PMTCT staff reported had a story. Some examples:

• Mothers enrolled in the program for their first birth, but neglected to contact the hospital during a subsequent pregnancy
• Faced with substantial travel costs, some mothers played their (rather, their children's) chances - delivering without PMTCT ARVs
  
• Mothers from a certain village failed to deliver at the hospital, afraid the care-seeking behavior would reveal their status
  

These mothers might bring in their children for testing after 18 months, or only if symptoms present. This delay in determining HIV-seropositivity dramatically decreases the child's chances of survival. Because the drugs (single-dose at birth, followed by a one-week course) are so effective in halting vertical transmission of HIV, every child born HIV-positive to women enrolled in the PMTCT program is deeply troubling.

After talking with hospital staff, we're going to integrate the new SMS network into the hospital's Voluntary Counseling and Testing (VCT) services. As part of their post-test counseling, every client who tests positive will be paired with an HIV-positive CHW with a cell phone. Many of the CHWs we have trained to text are committed members of the HIV-positive community - leaders of support groups, impressively drug-adherent, and people who spread a 'Positive Living' message.

These CHWs, along with their mobiles, will provide HIV-positive individuals a link to hospital services, a way to privately ask questions, and someone to look over their health. It will also provide a means by which to track pregnancies for HIV-positive patients, and follow deliveries for mothers in the PMTCT program.

Above - the fourth group of CHWs. After the training session, Alex and I situated each CHW's ID pin on the map of the catchment area. As promised, new colors appeared - youth counselors and reproductive health volunteers are now connected to the hospital.
At the week's medical meeting, a new category was reported - "SMS Follow-Ups" - for the TB and ART programs.

Virtues of FrontlineSMS

Over the last week, there's been a cascade of communication. A few examples, of many:

- A man missed his appointment with a TB officer. A CHW was texted, who reported the man had gone to Zambia for a funeral. The hospital will be notified upon his return.

- An HIV support group met, and decided on new member guidelines. Via SMS, the group leader asked the hospital to print copies for the lot.

- A CHW asked about ferrous sulfate dosages, so he could administer the proper amount to an anemic child.

I'm at the halfway point of my trip, and after five weeks on the ground, a discussion of the tools is in order. Ken Banks, the creator of FrontlineSMS, recently wrote an article about the emerging social power of mobiles for BBC News:

http://news.bbc.co.uk/2/hi/technology/7502474.stm

Ken is building a community of implementers. Interested parties should visit two of the group's sites: www.kiwanja.net and www.frontlinesms.com.

It is precisely due to FrontlineSMS's smart simplicity that the project has developed organically - first and foremost, to meet the hospital's needs as it serves its catchment area. The quick uptake of the project was fueled, in no small part, by how user-friendly FrontlineSMS is, as a central communications hub.

It also has provided solutions to some potentially tricky questions. A quick example:

Text messages cost 10 cents. Units can be sent from one phone to another via Celtel's Me2U service, but managing the units of 100+ phones manually is near impossible. So, I had to find a way to both monitor each phone's unit level and top up (replenish depleted reserves) automatically.

Before leaving Stanford, I engraved each phone's faceplate with a two-digit ID number. Using FrontlineSMS's auto-forward function, I've set up a system to automatically top CHWs up. When they are running low on units, CHWs can text "(ID number) Units" to FrontlineSMS. Subsequently, a message is sent to Celtel, with instructions to top up that particular CHW. System abuse is unlikely and avoidable - the volunteers know that FrontlineSMS records every message received, sandwiched by unit requests.

We're starting to explore additional functionalities of FrontlineSMS. Each CHW is given a kit of basic medications - a portion of the questions we're fielding involve those drugs. We'll set up an auto-reply system so that any message containing a given drug name returns a summary - function, dosages, etc. - for that drug.

Putting Technology to Work

Above - another happy group of health workers, the program's newest inductees. By the end of next week, there will be 50 phones in the field - next Wednesday, we're adding Reproductive Health and Youth Counseling volunteers to the network.

Below, you'll see some of the CHWs re-teaching SMS steps to the rest of the group - a key component of the training sessions.










Once the session ended, a few of the CHWs reviewed their notes:

Walking through a village this afternoon, I happened upon three separate barber shops, each advertising Phone Charging services.










Malawians understand mobiles. It's time to put the technology to work.

Next week, amid further CHW orientation, we're holding comprehensive training sessions for hospital staff - so that TB officers, ART directors, pediatric nurses, PMTCT coordinators, clinicians, and VCT volunteers alike can use FrontlineSMS to contact the CHWs.

A Diesel-Fueled Response

Today, Alex and I headed into the field. The goal was to find seven patients - the hospital had been alerted of their declining health, by SMS, through seven different CHWs. The motorbike-enabled, text-message-guided journey through the catchment area completed a (once) theoretical cycle: The CHWs surveying communities, then communicating their most urgent needs; the hospital gathering resources (diesel, drugs, and medical advice), then traveling to the villages.

Often, we stopped by the CHW's home. Above, Pascalia directs Alex to the patient's location. After the picture, she ran home, put on her St. Gabriel's Hospital 'Positive Living' shirt, and joined us for the consult.

A brief overview of some of the cases:

- An HIV-positive man, on ARVs, with Karposi's Sarcoma and wet beriberi.

- A 13-year-old girl with stomach cancer and massive ascites. Pascalia is the closest CHW, but her bicycle 'ambulance' is not operable. So, we texted Moreen, who is just a few villages away. She'll bring her ambulance, and get the girl to the hospital.

- A 72-year-old man, who is sputum-positive for TB, and was complaining of severe joint pains.

- An man, suffering from epilepsy, fell into a fire two weeks ago. He has developed a massive ulcer on his left heel. Left, Alex is explaining how to wrap gauze. The man happily let us take a picture of the scene.

We met with the hospital staff when we returned - after traveling 100 km in 6 hours, and visiting 7 different villages. Everyone agreed that the day was a success.

The entire hospital staff is now fully aware of the project and its goals. We're all moving in the same direction. The consensus is that a second, simple cycle, once disseminated, will greatly aid follow-up and monitoring programs: The medical staff (looking to follow up on a TB patient, for example) consulting the CHW map, and contacting the nearest CHW; the CHW checking on the patient, and responding to the hospital re: their status.

Tomorrow, we train another 15 CHWs.

Increased Coverage

This week, another group of jubilant CHWs was trained in texting. Below, you can watch a one-minute excerpt of the training session - Alex is explaining the first steps in operating the phone. At the end, you'll hear a chorus of 'success sounds' - all the phones turning on for the first time by their owners' manipulations.

The week has gone very well, and the project's initial success has been noticed by each arm of the hospital. I took a minibus into Lilongwe, which turned out to be a fruitful venture - I rode into Namitete on a bike taxi wielding extra maps, an assortment of push-pins, and a few surge protectors (which will establish a permanent location for CHWs to charge their phones at the hospital).

Each CHW we train and distribute a phone to will be placed on a map of the hospital's catchment area, with a different color pin, depending on their program (Home Based Care, ART Monitors, Reproductive Health Volunteers, Counseling, or Youth Volunteers). Particularly committed volunteers assume multiple roles in their community - they're distinguished by blue pins. The idea is to have the maps, with hundreds of CHWs' locations marked, displayed clearly for the clinical staff at the hospital. This way, a clinician looking to track down a patient need only consult the map, find the nearest, appropriate CHW's identifying number (written on the pin), and send out a text. Here are the new maps, along with the locations of the first 20 dispersed phones:

Tomorrow afternoon, I'm attending the staff meeting for those involved with the hospital's antiretroviral therapy (ART) program. I'll be explaining the project, and the group will determine a protocol for communicating with adherence monitors in the field. Below, you'll see me, sitting with Grace, who coordinates the hospital's ARV provision.

As always, thanks for reading. Any ideas, as this expands?

Ready for More

I was excited to hear that PC World picked up an article that Ken Banks (founder of kiwanja.net, and the man behind FrontlineSMS) wrote, titled, "Witnessing the Human Face of Mobile in Malawi." If you're interested, you can read it here.

We're ready to expand a bit. We heard from every one of the CHWs in our pilot group (some, many times). In just a few days, we saw some tangible results. Here's one example:

1. Verona Kapagawani, who lives in TA Mavwere, alerted the hospital that a patient had run out of his meds.
2. A nurse at the hospital, familiar with the patient, responded that he should fill his prescription (he has chronic congestive heart failure) as soon as possible.
3. Verona responded, noting that she counseled the patient. He wasn't feeling well enough to travel, so she came to the hospital to pick up his drugs.
   
4. While chatting with the nurse, Verona charged her cell phone.
   

I ran into another CHW, Benedict Mgabe, at the hospital today. He's the chairman of the Community AIDS Committee, and he's texted me every day. With a smile on his face, he shook my hand and said, "This is a very good program! It is really helping us a lot." Those short sentences confirmed that I want to have longer conversations with the CHWs, to gather their reactions.

We're using the pilot group to contact the next wave of CHWs, another 10 volunteers, to be trained and given phones Monday morning. Above, you'll see Alex (a nurse, who does most of the Home-Based Care community work) and Grace (who coordinates the ART program) using FrontlineSMS to text the group.

I had a long discussion with Dr. Mbeya, the medical director at St. Gabriel's, about making very definitive links between the hospital and the CHWs' activities. As the project grows over the next weeks, we'll create guidelines for reporting and follow-up, based on the specific program. For example, the hospital has a lively prevention of mother-to-child transmission (PMTCT) program, aimed at reducing vertical transmission of HIV. We'll develop a protocol for utilizing the CHW network to follow up on mothers who've missed their appointments, and the CHWs will provide a link to the communities' pregnant population.

I'd love to get some other perspectives on this.

Sending good wishes from Namitete.

The Inaugural Texts

From Zakeyo Kaphanthengo - "Ineyo ndinayenda mapesent awiri sakupeza bwino amenewa ndiavuto lakhasa."

I thought I'd post it in Chichewa, to document its original form. But, it translates roughly to, "There are two patients, very sick of cancer." Tomorrow, Alex will take the hospital motorbike to Chilembwe, about 60 km away, to check on the patients. A quick text let Zakeyo know to expect him.

From Baxter Lupiya - "Natenga ma A R V omwe anasiya aMwinama, omwe amamwalira dzulo. Ndibweletsa la chisanu. Zikomo." Translated, "I have collected the ARVs left by a patient who has died, and I will return them to the hospital on Friday. Thank you."

From Benedict Mgabe - "Mai laulentina adamwalira pa sabata kwa chamoto omweanali pa pa h.b.c." In English, "Laulentina, a patient in the Home Based Care program, died on Saturday." Terrible news, by any measure, but it saves the hospital a day-long trip to Chamoto to give Benedict more morphine.

I can't help but envision each of the hospital's 600 CHWs with a phone in their hand, the hospital's number saved as cherished contact.

Any thoughts? I hope all is well, wherever you might be reading this.

"When can we start messaging?"

Back row, Left to Right: Harold Malanga, Benedict Mgabe, Zakeyo Kaphanthengo, Joana Chimphanje, Pascalia Chiwinda, Moreen Phiri, Verona Kapagawani, Baxter Lupiya
Bottom row, Left to Right: Dickson Mtanga, Grace, Alex, Rosemary Bernado

I have to believe today's events were endowed with the elements of a promising beginning. The first phones are in the field! Before I get too ahead of myself, let me explain what's put me in such an optimistic mood.

We called the chairs and vice-chairs of the volunteer committees (Community AIDS Committee, Village AIDS Commitee, and the People Living With HIV and AIDS [PLWHA] support group) for a meeting at 9 am this morning. The came in together, some on bikes, most on foot. Considering that some traveled over 50 miles (that's most definitely an underestimate), this was quite the event.

I had been up since 6:00, testing phones and FrontlineSMS, and I was eagerly awaiting the group - equipped with Cokes, Fantas, lemon cookies and a broad smile.

We met in the old Nutrition Rehabilitation Unit, which had been stocked with assorted chairs. After everyone sat down, the hospital's matron greeted the group. After making sure each of the CHWs could understand slow English, she opened the meeting:

I know that times are difficult, but we must make improvements step by step. Do babies just start to run? No, they start just sitting. Then, when they see something beautiful, they wiggle their stomachs and arms, trying to reach for it. Soon, they can crawl; then they start walking. We can take steps forward, together. This is a pilot - we are learning new vocabulary today, too! You are the first to do this. It is not enough to try. We must do it.

After that poetic introduction, the matron told them they'd be receiving cell phones. This news was greeted, almost immediately, with cheers and applause.

The matron handed the ecstatic audience over to Alex and me, and we explained how to operate the phones (Alex is a male nurse, who works within the Home-Based Care program). I had every single ounce of the audience's attention, as I started, "First, just open your phone!"

*A disclaimer: That's Alex's handwriting.

We had an outstanding time teaching the CHWs how to use the phones. It started with group chants of, "Messages! Compose Message! New Short Message!" The majority of the CHWs hadn't texted before, so we spent some time teaching them - by the end of the session, each of the health workers flawlessly typed 'St. Gabriel's Hospital,' apostrophe and all.














After a few hours of rigorous concentration and seemingly inexhaustible patience, we took a break for snacks. During break, we discussed logistics.

The CHWs all claimed to have access to electricity. It seems that most will have to pay 10 kwacha (a few cents) to use the nearest electricity hub. When it's necessary, they (or someone from their village) will travel to the hospital to recharge the phone, free of fees. This isn't altogether rare, as the CHWs often accompany patients to the hospital.

After the matron and Alex explained baseline expectations for communication, the CHWs took over the meeting. Pascalia and Verona, the two Community AIDS Committee chairs, were especially emphatic. Pascalia stood, declaring, "The hospital does what it can to help the volunteers. We must do what we can to work hard. Remember, just because we are the ones who came to the hospital today does not mean the hospital loves us more than the others." Verona responded, looking straight at me and pumping her fists, "I will work much harder!"

The frequency and type of communication the CHWs will maintain with the hospital will depend on the program the CHW is enrolled in. For example, those involved in TB drug adherence monitoring will alert the hospital when a patient is deviating from a regimen. Similar expectations were agreed upon for the ARV monitors. Home-Based Care volunteers will be messaged when a patient needs to be traced or if a follow-up is needed. Those involved in organizing peer support groups will use the system to coordinate meeting times and locations. With any luck, and plenty of commitment, they'll be a working network of CHWs, with St. Gabriel's Hospital as a coordinating agent.

















Before leaving, the group sent a sample text to the hospital's number, and we showed each CHW their respective message as it popped up in FrontlineSMS. It was an animated scene, for sure. I recorded some of their information (name, number, village, and respective program), checked their starting units, and let them loose on the catchment area.

Needless to say, I'm looking forward to tomorrow, and the possibility of the first messages trickling in. With a smile on her face, Verona asked me, "So, when can we start messaging?" A few of the CHWs joined me in responding, "Now!" As they started home, I could see they were exchanging phone numbers.

Maps and Meetings

I'm very happy with how things have started off. Almost immediately upon arriving, I pitched the communications program at the hospital's management meeting. Most of those in attendance I knew from my previous stay in Namitete, and they seem happy to have me back.

I've discovered that props are useful. So, I lugged my suitcase into the conference room, revealing about one-hundred cell phones. I also flopped around the ~100,000 units of communication credit I'd purchased at the airport. After a quick demonstration of FrontlineSMS, ideas started flowing - and not just in one direction. I'm finding that ideas developed in the US regarding the program's potential usefulness (e.g. patient follow-up, TB and HIV drug adherence monitoring, fielding the community's medical questions, etc.) are really resonating here.

After a bit of grudge work (putting in SIM cards, implanting the initial Celtel units, recording numbers, testing FrontlineSMS, etc.) we are ready to start the pilot.

I am calling the Chairs and Vice Chairs of both the Community AIDS Committees (CACs, "cacks") and the Village AIDS Committees (VACs, "vacks") for a meeting on Monday morning. It's set for 8AM - I'm hoping they'll trickle in by 10:00. This first 'batch' of CHWs will be the pilot within the pilot. After monitoring their activities for a week or so, we'll look to expand to another group - as the Matron says, we'll start with those who are "hardest working."

I spent the day in Lilongwe, trying to find decent maps of the area the CHWs hail from and work in. First, I tried the District Health Office. No maps, but the doctor coordinating health information for Lilongwe was very interested in the communications initiative - specifically, the possibility of scaling up to cover the entire Lilongwe district. In an attempt to stay ambitious but grounded, I kindly left her my e-mail and other contact information.

Next, I headed to the Department of Surveys. Like the government hospitals, the state buildings are treacherous. Quite literally, I had to guess which alleyway to wander down - I was finally consoled by a piece of paper, duck-taped to a door, which read, "Digital Mapping." I put in an order for TA Kalolo and TA Mavwere (don't ask me what 'TA' means, because I have no idea), and was told to come back in a few hours. After a few bribes ('fees') and hitchhiking excursions, I had my maps (below).


I'll leave you with an image of some of the goods. Before the week ends, I am creating some step-by-step instructions for operating the phones and FrontlineSMS, which Alex is going to translate into Chichewa tomorrow. I'll probably fall asleep testing the hand-powered, wind-up chargers - the motor is strangely soothing.

Introduction

Hey Everyone,

I'll be using this space to issue updates regarding the project in Malawi. If you've been invited to the blog, I thought you might enjoy and/or appreciate staying linked to what I'm doing here. I'll save political, (most) philosophical, and other, discretionary commentary for my journal. If you'd like more 'charged' stories, feel free to e-mail me:

jnesbit@stanford.edu
joshuanesbit@gmail.com

Also, I'm on skype whenever the internet is up and running:

jlnesbit (Josh Nesbit)

When you get the chance to read through the updates here, leave me your thoughts. Any and all comments are welcome.

All the best! Thanks, ahead of time, for reading.