This is a guest post by Amy G. Lehman, Executive Director of Lake Tanganyika Floating Health Clinic (LTFHC). This is the final post of a 3 part series on mhealth in Africa. Click Part 1 and Part 2 to catch up on previous posts.
I want to thank my colleagues, Mbwana Alliy and Karen Cheng for their interesting and insightful pieces on mHealth. I am honored to be a part of the dialogue, and in my usual role of choice – as a “Gadfly” for the ultra-rural populations in sub-Saharan Africa, and for the populations around Lake Tanganyika in particular. I would like to raise some issues for people to think about, and in doing so, hope to encourage closer collaboration between the tech and delivery sides of health care, such that we each help to inform the other about what’s possible and about what works.
As a practitioner in an ultra-rural location, I have long followed developments in mHealth and telemedicine and been excited by the possibilities. Unfortunately, I work in a place that is still largely without cell phone access, much less broad-band, so issues regarding connectivity, 3G availability, bandwidth are of paramount importance to me in discussing how mHealth can change the health care landscape.
There was a short article in The Economist this past August called www.africa.slow that specifically discussed Sierra Leone’s internet connectivity problem, but also listed several other countries with the identical issues. One of those countries is the Democratic Republic of the Congo, which, like Sierra Leone, has experienced tremendous instability due to war, and in fact faces an even greater uphill battle to achieve decent connectivity – due to the massive size of the country, the continued instability in certain areas, daunting infrastructural challenges, as well as investor fear (both founded and unfounded).
The longest coastline of Lake Tanganyika is in the Democratic Republic of the Congo, and so I have personal experience in trying to address the connectivity problem. I also want to add that the second longest coastline is DRC’s neighbor, Tanzania – a country without many of the above listed problems – and yet the western corridor of the country is still largely without connectivity as well. My organization, the Lake Tanganyika Floating Health Clinic, has decided to attempt to crack the problem along the Congolese coastline by adapting simple technologies that have been used for oil and gas surveying in the past, to see if we can create a system that allows the far-flung, mud-hut health centers along the lake to communicate with the Regional hospital. Currently, they cannot – and this is one of the reasons the Regional hospital cannot fulfill its mission to support the health centers.
But in piloting this “proto-network,” several questions are begged:
What kind of information should be transmissible at this stage in the game? What do we expect these health centers to do, given their chronic lack of supplies and access to appropriate health care education, coupled with extreme needs? What do you do when you establish communication, but still have extremely high transportation barriers (One very common example would be this: Currently, if a woman experiences obstructed labor in the villages along the lake, the baby dies and the mother either dies, or develops a fistula. Is it helpful to send a text to the Regional hospital to say this is happening when the outcome will be the same? Yes, we need to collect data on incidence, but we may also create an unintended consequence of raised hopes, and subsequent disappointment or disillusionment when the technology can’t produce an immediate change in outcomes).
Central to health care education is hands-on collaboration and learning in a physical health care setting – regardless of whether that training takes place in a tertiary care American hospital or in the Moliro Heath Center in Moba Territory that has no electricity nor running water. Personal collaboration between health care workers develops several things simultaneously – practical skills, that can also be performed under supervision to achieve proficiency; clinical diagnostic skills; camaraderie; empathy for the patient. These last two elements should not be underestimated in importance, and often are the qualities that can mean the difference between life and death in difficult situations. From my personal experience, it’s clear that this is still the gold-standard in training, at any level. Again, an example from maternal health: If one has never inserted a urinary catheter in a sterile way to treat an acute fistula, chances are you won’t be successful with remote coaching. You also have to have a catheter on hand. This is one of the main reasons why we are working so hard to create an actual physical platform (in the form of a floating hospital) for service delivery and education, that can accommodate the supply chain problems in the basin, as well as the extreme lack of infrastructure.
Technology to Real Solutions
Having said that, I am a true believer in using technology to help augment and maintain skills and knowledge that has been introduced initially in a face-to-face manner. And there are also other uses of technology that can be immediately deployed that don’t focus around direct patient care per se, but instead provide ancillary services and data collection from rural to ultra-rural areas – places that have traditionally had serious under-reporting or mistaken reporting. The National Institute of Medical Research in Tanzania, for example, has been piloting an incredibly innovative and effective program using community health care workers to send epidemiological data via SMS. I am a strong believer in the ability of health care workers, even at the lowest level of formal education – including NO formal education – to learn to use cell phone technology to accomplish important tasks. One of the keys to success is adequate initial hands-on training.
I also think that trying things out in conjunction with local partners is a great way to fasten upon real solutions. We, for example, created electronic medical records for 30 Congolese women (the first, ever, in Moba Territory, and maybe most of the DRC) who traveled with us across Lake Tanganyika to the Tanzanian side, where we were able to provide surgery for their fistula injuries. Working with a long-time AMREF surgeon’s intake form, personal collaboration regarding operation performed, cell phones that could take digital pictures, and my employee Anderson’s tiny laptop that runs on Linux, we created really accurate and I must say beautiful e-records for our patients. Those records now exist in the cloud and are password protected. Because connectivity is still a problem to contend with, we also provided paper records to be kept at the Regional hospital. As our “proto-network” develops, we will be able to access and add to those records. In the mean time, it allows us to remotely keep track of our patients, and when we have a connection, augment the record with our physical follow up visits. This cost us nothing – except a lot of time. Another key to success in the ultra-rural areas is allowing everyone the time they need to develop, trouble-shoot, practice.
My parting thought is the following:
A core concept in delivering health care service in the ultra rural areas is that communities need to be able to “call for help” – whether the call is related to a labor emergency, cerebral malaria, a cholera outbreak, a severely burned child. The communities need connectivity to do that. But it’s clear that this is not enough. Health care systems in general need to be strong and developed enough to be able to realize the full advantages of telemedicine and mHealth services so that we can engage in true capacity-building of local health care workers in pragmatic and effective ways.
Amy Lehman recently spoke at TEDxWomen in Amsterdam- a worthwhile video to understand the challenges and opportunity in her work. Highly recommended for the development and impact investing audience.
Please think about supporting the LTFHC during this holiday season: https://npo.networkforgood.org/Donate/Donate.aspx?npoSubscriptionId=1004645
