Let’s talk a little bit about leapfrogging and global health technology. The basic idea of leapfrogging is going from an underdeveloped state to a modern one without going through the historical intermediate steps. A good discussion of leapfrogging technology can be found here. The classic example is cellphones: countries going from few landlines to many people with cellphones, skipping over the slow creep of landline networks throughout the land.
The first great leapfrog project in global health I heard of was at Fogarty orientation a few years ago, when Krista Pfaendler spoke about her work in Zambia in cervical cancer (1 and 2). At the time Zambia had one of the world’s highest incidence of cervical cancer, and only one pathologist who could read pap smears. Obviously a pap-smear based screening program would not work. This project leveraged the relative abundance of nurses and midwives relative to doctors to allow screening for cervical cancer using visual inspection with acetic acid. A cheap digital camera is used by the nurses/midwives in the screening to ensure quality control and for assistance with clinical decision making and triage, with the assistance of an attending gynecologist. What most impressed me about this project was the ability of a cheap digital camera to leverage the assets of a developing world health setting - nurses and midwives – to reach patients with useful interventions. In 2.5 years the program was able to screen 20,000 women for cervical cancer in a country with a very high incidence of cervical cancer where there was previously no real screening program. I’m incredibly impressed! I think this is an excellent demonstration of the global health technology that works.
While in Mbarara I checked out a few global health technology projects. One is the UARTO study, which monitors treatment adherence in HAART treatment for HIV. The study currently uses a device called Wisepill
to monitor treatment adherence. Wisepill is a digital pillbox that sends a signal through the cellphone networks every time it is accessed. If no signal is received by the study center for 48 hours, that is considered a treatment interruption and a field team goes out to see if it is a wisepill problem or if the person has stopped taking their meds, and why. I went on an interruption visit one day (photo at left). One of the participants we visited only needed a new battery for his wisepill, another had stopped for unclear reasons since her husband had been released from prison, and a 3rd wasn’t home when we visited. I think it’s an excellent approach to monitoring and helping with treatment adherence, and again one that uses technology to optimally use human resources.
In many parts of the world travelling to clinic to get results of tests costs a lot: both literally and in terms of opportunity cost with missed work. There is clearly tremendous potential to use cellphone networks to deliver test results in these settings. Dr. Mark Siedner and I sat down to talk about a project he is developing to look at the feasibility and acceptability of delivering testing results via mobile phone. Given issues of confidentiality and follow up treatment or testing it will be interesting to see where the project goes. This is an under-developed area with a lot of potential.
Technology can be also used in decision aids. Dr. Data Santorino, a Ugandan pediatrician, and I sat down to talk about a project he runs which uses smart phones to guide village health workers through algorithms for clinical decision making for treating and triaging sick children. In this way, community volunteers with a few hours of training can used symptoms-based algorithms to treat common diseases like pneumonia and malaria, and refer to a health center when appropriate. The data is reviewed by Dr. Santorino in the referral hospital at which time he can contact the village health worker to follow up or change triage decisions where appropriate.
Global health technology does not have to mean the fanciest new device that can detect x disease with 100% sensitivity and specificity. To me it means the utilization of appropriate technology to leverage local assets in a way that benefits the local population in a cost-effective manner. A development technology example I love is sanitary napkins to keep girls in school. Educated women and their children have better health outcomes, and this is an incredibly simple way to impact school attendance.
My excitement about global health technology is its potential to help with resource allocation, clinical decision making, training, and development to be able to multiply the effect of people working hard to improve the health and lives of those in their own communities. I leave you with a great website on global health devices to whet your appetite for the future ...