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?