Guest Post By: Arthur Allen
Billions have been spent to bring AIDS medicines to patients in Africa, but a technology with just as much lifesaving potential can be had for pennies: the text message.
As African leaders gather for a summit with President Barack Obama this week, U.S. health agencies are beginning to invest in programs to help expand mobile health technology, which has the potential to dramatically improve life for millions in sub-Saharan Africa, the world’s poorest region. Simple mobile telephone text messages can be used to help keep AIDS medication stocked at a remote clinic, or to summon an ambulance in time to save a baby’s life.
In the current Ebola outbreak in West Africa, the Centers for Disease Control and Prevention has freely distributed a mobile app version of software that transmits diagrams that help field workers visualize the outbreak and its spread. It also has automated tools that let health workers speed up data analysis and help track the contacts of people who have fallen ill.
But mobile health was making steady headway in Africa before the Ebola outbreak, including with the decades-long fight against AIDS.
In June, National Institutes of Health’s Fogarty International Center announced a $1.6 million eCapacity training program to build health IT knowledge in developing nations. By September, the center expects to announce separate grants it is awarding for mobile health interventions with five other NIH centers and institutes.
Sub-Saharan African nations have leapfrogged into cellphone use over the past two decades. In countries like Kenya, where only about 1 percent of the population had land lines, more than 90 percent now access to their own mobile device, or at least one owned by a relative or a village elder.
“In Uganda, there are now more households that own mobile phones than have a latrine,” says Sean Blaschke, a UNICEF official.
Such technology could be crucial in countries where a bus ride to the clinic costs a month’s wages and 40 percent of the people diagnosed with HIV never get follow-up treatment even though it is often free.
Texts and mobile phone conversations allow doctors to tell patients in distant villages that a test for AIDS, tuberculosis or malaria test was positive and they need to come in. Or they can say that a test was negative, sparing the patient the need to spend hard-earned cash or lose a job because of the long trip to town.
In Uganda, texts sent through a phone-based system called mTrac keep isolated AIDS and vaccine clinics stocked with drugs. In the past, they often ran out for weeks. Uganda’s nationwide program has funding from USAID, the CDC and British aid agencies, but is moving toward self-sufficiency. UNICEF is launching software based on mTrac for use in other countries. It is about to be tried in Afghanistan and Somalia.
During a 2012 outbreak of Marburg virus, which causes terrible symptoms similar to Ebola, Uganda’s Ministry of Health used mTrac to send 9,900 SMS messages to 825 health workers and health teams in the affected districts.
South Africa began an initiative in June to enroll all pregnant women in a digital mobile health messaging service that allows the Ministry of Health to lead them to prenatal and postnatal services, including HIV testing.
In rural Rwanda, barefoot health workers have phones and use them to call for an ambulance when a baby is sick. Before, the baby might die without ever seeing a doctor.
Within five years, text messaging for drug adherence will become standard practice in sub-Saharan Africa, predicts Alain Labrique, a professor at the Johns Hopkins University School of Public Health.
“Vaccines require major investments to store, transport and deliver,” he says. “What’s unique about mobile health is that for the most part there’s little investment in the widget. We’re showing up in an environment that’s already connected.”
Researchers also are developing apps that can be attached to cellphones in low-income settings. USAID’s Global Development Laboratory, for example, funded a tool that captures the image of a field diagnostic test for a disease like malaria, then sends the test result to a laboratory via mobile phone.
Yet mobile health technology in Africa suffers from the same lack of overall consistency as it does in the United States. One scientist calls the phenomenon “pilotitis”: Hundreds of pilot projects have tested out different mobile tools and methods, but there’s been precious little research on what really works.
“We need some standards for how this information is going to be managed,” said Luke Davis, a University of California-San Francisco critical care specialist who has research projects in Uganda. “We need more evaluation of different approaches.”
The Fogarty Center, which funds the training of researchers in the developing world, earlier this year began an initiative to support research into mobile health tools or interventions for an array of health issues.
“Right now we’re on the fence on what works and what doesn’t,” said Laura Povlich, Fogarty’s program officer for mHealth. “We want to see some robust evidence. I think that in the next five years we will get to some best practices.”
Not everything that sounds good works well, says Richard Lester, a University of British Columbia infectious diseases professor whose research showed that some daily medication reminders have had no impact on treatment adherence. In most cases, they are viewed more as a nuisance than a support.
But text messages that come once a week, or even once a month, that include the option of speaking with a nurse or doctor, are successful at getting patients to take their drugs correctly and consistently.
“Patients aren’t looking for a reminder. They can set their own watches,” says Lester. “What they want is access to an expert who can synthesize information and give them care and advice.”
The most successful approach, during Lester’s work in Kenya, involved sending a weekly text with the single word, “Mambo?” meaning, “How are you?” If the patient responded “Shida,” — Swahili for trouble — a nurse called.
Privacy is also a serious concern in sub-Saharan Africa, where stigma surrounding HIV is high, and a cellphone may be shared with relatives or even others in town. Dr. Mark Siedner of Harvard is using an NIH grant to study the best way to use text messages to communicate the results of an HIV test to patients in Uganda. The texts can make it easier for a patient to get care, but they are just a start, he points out.
“It’s not a panacea. It’s data. But just getting the patient’s information doesn’t benefit them if they are not empowered or can’t afford to do anything about it,” Siedner said.