In October 2010, under the heat of the mid-afternoon sun, a 27-year-old woman presented to a small hospital in the rural town of Lacolline, Haiti. She had lost consciousness shortly after falling ill with abdominal pain, vomiting, and severe diarrhea. Her family, who lived in a remote village, carried her more than four kilometers on a makeshift stretcher to the hospital. I was working that day and was receiving patients when her family arrived. Her pulse was weak and barely discernable, so I immediately placed two intravenous catheters in her arms and began to administer intravenous fluids. There was little else I could do at this small hospital in rural Haiti; we were already over full with patients at over 200 percent capacity in our inpatient unit, had too few staff to deal with the deluge of people coming to the hospital, and had no advanced diagnostic or therapeutic tools to help care for the sick.
Just two weeks prior, Vibrio cholerae, a deadly bacterium that causes the diarrheal disease known as cholera, had suddenly emerged in Haiti after a 100-year absence. The genomic sequence of this strain of cholera was nearly identical to the predominant strain in Southeast Asia, widely thought to be introduced to Haiti inadvertently by a group of UN peacekeepers.
The young woman recovered quickly with the simple administration of fluids and antibiotics and left the hospital within 72 hours after she first arrived. However, just 24 hours later, the same family returned—only this time with the young woman’s mother on a makeshift stretcher. Her mother had arrived in time for treatment, but her father didn’t make it in time and had died back in their village.
There are a myriad of conclusions that could be drawn from this episode—the role of poverty and unequal access to essential medical services, the absence of modern sanitation and access to clean water in the setting of cholera, the failure of the public health system within Haiti, the lack of available resources at the hospital, the absence of oral re-hydration salts in the community, the lack of access to the cholera vaccine, etc.
But I’d like to draw attention to a question that may be less obvious but no less significant: what is the role of technology in an epidemic like this? Or alternatively, what is the role of technology in settings such as rural Haiti, even in the absence of epidemic cholera? Could technology have made a difference in the spread of the disease? Might technology have helped lower the death rate, say, or prevented cases, saving lives? The question is not as straightforward as it may seem, as Haiti is the poorest country in the hemisphere. The health system is sorely lacking in basic resources, not the least of which is adequate infrastructure. Is it anathema to the basic dogma of most public health experts to suggest that technology can (and should) be introduced to help bridge the gap of health care delivery in these settings?
These are some of the questions we think about at ThoughtWorks as we endeavor to leverage software and technology to improve healthcare delivery to the world’s poor and marginalized. What is abundantly clear, however, is that technology is not a panacea—it certainly cannot replace the need for delivery of essential medications, say, or provide tried and true diagnostic services essential to the delivery of high-quality health care.
Despite the limitless number of issues that plague resource-constrained settings, technology has proven to be extremely transformative. Let’s consider, by way of example, technology outside of the health domain. M-Pesa, the mobile phone-based money transfer service launched in Kenya in 2007. Most recent estimates in 2014 suggest it is used by more than 17 million people in the country, with a staggering US$1.62 billion occurring in transactions each month [1]. There are undoubtedly many reasons for its success, but the most fundamental reason, in my view, is that it addresses a crucial unmet need in Kenya and elsewhere—the need for the urban and rural poor to be able to participate in the financial sector. Prior to the advent of M-Pesa in Kenya, nearly 38 percent of the population was excluded from financial services (either formal or informal) [1], and Internet banking via computer was out of reach for most of the population. M-Pesa disrupted the traditional banking sector, and more importantly allowed millions of adults to manage their money electronically and turn a cash-based system into a system that is now heavily leveraged with technology.
This type of “leapfrogging”—with this degree of impact—has yet to occur in the health sector in most resource-constrained settings. The peer-reviewed research that has been done to date—in addition to meta-analysis—has demonstrated low to moderate benefits on established endpoints [2], such as interventions for appointment reminders [3], and behavior change through messages, and preventive healthcare [4]. In contrast, there is an abundance of evidence that reveal the benefits of electronic medical records for care providers and for patients in resource-poor environments [5].
What Does This Collection of Evidence Tell Us?
The improvement of care delivery in health that comes with the implementation of technology should not be the sole province of the Global North. The lack of dissemination of technology with demonstrable improvements in health care serves as a window into the significant equity gap in between resource-rich countries and their resource-constrained counterparts. We should be endeavoring to further disseminate rational, affordable, proven technology like open-source electronic medical records (EMRs) to hospitals that desperately need them [6] to improve care.
We also need to remember to always keep the patient at the center of our work. It’s often easier to create software in a vacuum, devoid of—and often divorced from—the realities of the very people we are striving to serve. Human-centered design is a start, but we have much to learn from local communities when creating new software. The best software is written with – not for – these communities.
What Could Have Been:
As of April 2015, cholera has claimed over 8,500 lives and sickened almost 750,00 people [7]. What if, in addition to access to clean water and effective sanitation, the Haitian government had a cadre of community health workers who were distributed in every village and every city in the entire country? And, what if those community health workers had mobile devices with which they could be capturing information, in real time, about who was sick in their communities and were able to coordinate care with the nearest health facility? What if the community health workers were able to convey their actual stock of oral re-hydration solution in the village such that they would never stock out? What if, after someone fell ill, technology enabled communication to streamline the delivery of water purification tablets and teams to evaluate both sanitation and access to clean water?
The potential of rational technology and its ability to improve the delivery of care in these settings is endless, often limited by our own failure of imagination. Implementation is never easy, but that shouldn’t stop us from working with the right partners, those who understand and embrace health as a right that should be accessible to all in our human family. We should endeavor to fail fast and learn from our mistakes rather than to sit idly by, paralyzed by the complexity of these issues.
Notes:
[1] di Castri S, Gidvane L (July 2013) The Kenyan Journey to Digital Financial Inclusion. GSMA. http://www.gsma.com/
[2] Househ M. (2014) The role of short messaging service in supporting the delivery of healthcare: An umbrella systematic review. Health Informatics J. 2014 Jul 18. pii: 1460458214540908.
[3] Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD007458. DOI: 10.1002/14651858.CD007458.
[4] Vodopivec-Jamsek V, de Jongh T, Gurol-Urganci I, Atun R, Car J. Mobile phone messaging for preventive health care. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD007457. DOI: 10.1002/14651858.CD007457.
[5] Mohammed-Rajput NA, Smith DC, Mamlin B, Biondich P, Doebbeling BN. OpenMRS Collaborative Investigators. OpenMRS, a global medical records system collaborative: factors influencing successful implementation. AMIA Annu Symp Proc. 2011;2011:960–968.
[6] Fraser, H., S. Choi, M. Galipot, D. Jazayeri, and N. Mangubat (2006) Successful transfer of a Web-based TB medical record from Peru to the Philippines. Proc AMIA Symp, 2006: p. 924.
[7] Epidemiological Report Cholera 3 April 2015 . Pan American Health Organization. http://www.paho.org/hq/index.