MDR-TB: Is Innovation Within Reach?

hospitalAs a participant in the recent Pacific Health Summit, I was struck by the bold talk of innovative approaches to addressing the global threat of multi-drug resistant tuberculosis (MDR-TB). And yet few of the projects that were presented involved partners from outside the public health community. (The lone exception at the conference was Chevron, which has made a big commitment to leadership on infectious disease through the Global Business Coalition.) Innovation requires openness. The two go hand in hand.

I was particularly disappointed that there were no mobile operators present, particularly from countries like South Africa and China that are hard hit by TB and increasingly vulnerable to a large scale MDR-TB epidemic (for more background on MDR-TB checkout my first post in this series). Both countries have first-world communications infrastructure and are great proving grounds for mobile health innovation (as we have learned with Project Masiluleke, frog's mHealth partnership that targets HIV/AIDS, a condition that is increasingly linked to TB).

cellular storeOperators in emerging markets, particularly in sub-Saharan Africa are making huge profits from the very same low-income communities that are hardest hit by these infectious diseases. In fact, much of the growth in the mobile business over the next decade is expected to come from the expansion of services to poorer communities in emerging markets. So these companies have a vested interest in the health and well-being of their BOP customers. The gap in mobile phone ownership between $1/day and $2/day families is quite significant. Improved health = improved income = more minutes. Pretty simple.

We have been very fortunate to have MTN as our partner on Project M, the second largest operator in South Africa. MTN has donated a massive amount of their messaging inventory to our initiative—between 1 and 2 million messages a day, over the course of a year. Can you think of any other way to reach almost 5% of the lower income population in South Africa on a daily basis with health information and services? As we face truly steep challenges in the public health sector I believe that mobile technologies are one of the only new levers that we have to shift the dynamics in our favor, for a few reasons:

1) Mobile technologies reach people: Mobile technologies provide more than simple access. BJ Fogg has discussed the design principle of Kairos: "Finding the opportune moment to present your message". But Kairos is a two-way street. Mobile technologies tuck health information in a discrete and convenient place so that the recipient can also wait for an opportune moment to respond. The channel is personal, confidential (in most cases) and trusted (unless we screw this up). The user has control over when and if they respond. But once they do it, it's easy to follow up and initiate an ongoing dialogue.

2) Mobile solutions are cost-effective: I am a big believer in learning by doing. These tools are cost effective to pilot and easy to adapt. But here is the catch: You have to accept the limitations of lowest common denominator technologies. It can be very hard for designers and heath officials to grasp the power of very simple text-based messaging channels as the primary access point to information. The profound influence of these channels is very counter-intuitive to someone who sits at a PC all day on a broadband connection in Bethesda Maryland.

3) Mobile solutions are replicable: This is the most interesting part. mHealth pilots have been launched all over the world targeting a broad range of health conditions, everything from cleft palette to infant mortality. Yet each one is an isolated incursion, like the little leaf rafts that carry foreign organisms to distant shores (to continue the Galapagos metaphor I introduced in last week's post). These efforts are still small scale. Few have been extended across the full lifecycle of care. Few have been extended across multiple geographies. This is even true of Project M, which has sent out 250 million mobile messages, making it one of the largest initiatives to date.

community chatThere are signs that the public health community is getting serious, and that meaningful collaborations with mobile operators are beginning to take shape. The most high profile is the mHealth Alliance that brings together the UN Foundation, the Rockefeller Foundation and the Vodafone Foundation. I have personally met with folks at Gates who are taking a serious look at opportunities for mHealth in China. And the NIH is sponsoring an mHealth conference this fall for the first time. Progress.

The question remains: Will mobile technologies take hold within health care in the same way that they are sweeping through other industries, such as finance (M-Pesa), media (Mxit), education (Meraka, Bridgeit) and even politics (Iran)? And will they successfully deliver at scale? Many promising information technologies fail to deliver on the scale of a large enterprise, much less an entire country. None other than Neal Lesh from Columbia University wrote a recent post cautioning against too much exuberance regarding mHealth. I share his anxiety. As I look ahead to the future of mHealth I see a huge divide emerging between the two camps:

Maximize Efficiency: Many public health professionals see mHealth primarily as a way to improve data gathering and measurement. It is largely a one-way 'delivery' model that takes advantage of the reach of mobile technologies but not their true nature as communication platforms. As I stated in my last post: Health is not 'delivered' to people. It relies on active engagement and participation. The only way to improve outcomes around personal health behavior is to engage in a meaningful cross-cultural dialogue.

Maximize Engagement: Just as we don't always prefer to speak directly with a salesperson or bank teller, we don't always prefer to ask someone very personal health questions. Services like Google SMS Health Tips in Uganda have shown that there is a pent-up demand for alternate information channels, not just because they are cheaper and more efficient. They can be better, provided that they are in tune with the local culture and integrated into an overall patient-centric engagement model—that provides an easy escalation path to more immediate and personal support.

Mobile health is not a standalone activity but a way of extending and amplifying the human relationships at the heart of the public health system. I truly hope that we will see mobile health evolve beyond it's current status as the latest fad to play a central role in public health planning. And I truly hope that acute threats like MDR-TB will galvanize the mobile community to get involved before it is too late.

Read parts 1 and 2 of Robert's MDR-TB series:
MDR-TB: A Health Care Crisis of Our Own Design
MDR-TB: The Galapagos Effect in Health Care

Read more of Robert Fabricant's Design4Impact blog

Robert is a leader of frog's health-care expert group, a cross-disciplinary global team that works collectively to share best practices and build frog's health-care capabilities. An expert in design for social innovation, Robert recently led Project Masiluleke, an initiative that harnesses the power of mobile technology to combat the world's worst HIV and AIDS epidemic in KwaZulu Natal, South Africa.

Robert is an adjunct professor at NYU's Tisch School of the Arts where he teaches a foundation course in Interaction Design. In 2009, he joined the faculty of the School of Visual Arts in New York and is a faculty member of the Pop!Tech Social Innovation Fellowship Program. A regular speaker at conferences and events, Robert recently gave a keynote speech at the 2009 IxDA Interaction Conference. He is a frequent contributor to a wide variety of publications, including I.D. Magazine, The Wall Street Journal, and Wired.

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