I returned to Bastar last month excited to share the progress the developers at BeeHyv and I had made so far on the newly dubbed “Tika Tracker” (the word “tika” refers to a vaccination in Hindi, so I thought it would be a fitting working name for our vaccination tracking/reminder tool). What I found upon my return, however, was that things were really more complicated than I had assumed after my first visit. For example, although my initial field survey indicated that most of the frontline health workers (FHWs) in Bastar could read and write SMS in Hindi, now I was getting reports that many of them could not write at all, let alone type out messages on mobile phones. After learning of several other discrepancies between how I had conceptualized the existing system and how it was in reality, I was no longer confident that the tool we were working on would make sense for this context.

The Anganwadi Center (where most children’s vaccinations are administered) in Talnar village.

After my initial doubts, however, I realized that the information I had collected so far was not entirely incorrect; it just wasn’t the whole story. Even though our project area in Bastar is relatively small, its healthcare delivery networks are complex and varied, and I realized that the best way to expand my understanding of these networks would be to talk to as many people as possible who were involved in them.

An Anganwadi worker shows doctors of the Vivekanand Tribal Hospital (VTH) her immunization register.

I tried to approach each interview without any bias or expectations, but I was repeatedly surprised to learn of large disparities in the backgrounds and habits of the FHWs, each of whom technically had the same qualifications and title. More than the diversity of the individuals themselves, however, it was the massive systemic differences in the vaccination delivery network from village to village that were truly mindboggling. In one village, the ANM (Auxiliary Nurse Midwife) reportedly comes twice a week, without fail, to administer vaccinations to children under 5, and each of these children keeps an up-to-date vaccination card. In the next village over, however, conditions are drastically different. The ANM comes once a month, if even that. No mother keeps up-to-date vaccination cards for her children, and the tracking of vaccination events by FHWs is oftentimes incomplete and inaccurate.

One Anganwadi worker’s vaccination register. Medic Mobile will be introducing an electronic record system that will help Anganwadi workers keep accurate and up-to-date patient records.

Although the significant variation amongst user needs in this community means that designing a tool that makes sense for everybody will take some ingenuity, it also highlights the real need for an infusion into the current system that can provide order, consistency, and accountability from village to village. I am excited to continue working out how Medic Mobile’s resources can best be used to fill in the gaps in vaccination delivery to the dispersed tribal populations in Bastar’s villages, where I believe a simple but well thought-out solution can have a tremendous impact.

Walk into almost any corner store in India, Pakistan, Zambia, Mexico, or Tanzania and you will find cell-phone top-up cards for sale. Corner stores and markets and even street vendors understand that mobile phones mean business. There are now more than six billion wireless subscribers in the world, and more than 70% of them reside in low- and middle-income countries. The Global System for Mobile Communications Association (GSMA) reports commercial wireless signals cover more than 85% of the world’s population, extending far beyond the reach of the electrical grid.

As global health NGOs join governments, health care, and donors begin to build the foundations for a cancer control strategy in places such as sub-Saharan Africa, we need to incorporate mobile health strategies and monitoring mechanisms to unleash the potential of those six billion mobile users to further awareness, advocacy, and behavior change goals.

A 2011 WHO report on mHealth states: “The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks.” If we intend to improve access to cancer control strategies known to be effective such as HPV and Hepatitis B vaccines, and cervical cancer screening, into our global mission to fight cancer in low and middle income countries then the use of mHealth will certainly form part of the tools to accomplish those goals.

Most patients in sub-Saharan Africa walk away from the clinic visit with a cell phone in hand, but lack access to resources about treatment, work-related issues, and transportation to receive the treatments. If they are fortunate enough to have access to treatment, they may have no way to communicate problems or questions as health facilities could be miles away by foot from where they live. Mobile technologies could help bridge the gap for patient support services. As a global health community, we should support adequate resources for more research and development of effective mobile strategies to urgently address cancer and other other non communicable diseases, the cause of 63% of global deaths.

There are few global foundations underwriting programs to support the understanding and development of mHealth in cancer interventions. If foundations, governments and private individuals were made aware of the potential impact that mobile based Cancer applications could have on their dollars already invested in health services there is little doubt that they would get behind the deployment of such technology.

Medic Mobile is partnering with the University of Edinburgh, Zambia Cancer Diseases Hospital and the Zambia Cancer Society to make these life-saving technologies available to cancer patients in the most hard-to-reach corners of the world. The American Cancer Society is a supporter of the Zambia Cancer Society and cancer control work in Zambia and around the world.

Photo credit: Dianna Kane

In 2009 the complete vaccination coverage rate for children aged 12-23 months in the central Indian state of Chhattisgarh was 57.3%. Among “scheduled tribes,” however, the complete vaccination rate was even lower, at only 46.3%. Scheduled tribes (STs) are geographically and culturally distinct indigenous groups recognized under the Indian Constitution for their historically disadvantaged statuses and resulting low performances on economic, social, and educational indicators. The government has certain affirmative action policies in place for scheduled tribes (as well as “scheduled castes” and “other backward castes”), but as evidenced by the childhood immunization rates noted above, STs are still falling behind on many important measures of welfare.

Since November 2012, I have had the unique opportunity to work alongside local tribal leaders in Bastar District, Chhattisgarh, on a maternal and child health initiative led by the Health and Outreach Division of the Vivekanand Tribal Hospital (VTH). My specific task was to help design a vaccination tracking tool for mobile phones that could be utilized by local volunteers, health workers, and caregivers to ultimately improve vaccination coverage for children under 5 in the tribal villages of Bastar.

Working with members of these communities (mainly from the Halbi, Gond, and Batra tribes) has been a learning experience in many respects, not least because the cultures of these tribes differ in several substantive ways from the Indian culture with which I grew up. For example, in Bastar’s tribal communities, women generally take primary responsibility for bringing income into their households, whereas in many other parts of India men have been the traditional breadwinners. On top of vast cultural differences like this one, each of the tribes I have encountered also has its own distinct language. Furthermore, tribal communities are often geographically isolated from other populations or towns. In Bastar, some of the villages in which we work are remotely located inside a national forest reserve and are only easily accessible to those with a four-wheel drive and a good deal of perseverance. Given such cultural and geographic obstacles, it is not surprising that many broad government and non-profit development initiatives fail to respond to the needs of tribal populations.

I was determined to make this project a success. I knew that in order to design a vaccination tracking tool that would succeed and be self-sustaining in the tribal villages of Bastar, I would have to let go of my generic understanding of the Indian healthcare system and instead focus on the ground realities of these particular communities. To this end, students and staff working with the VTH graciously helped me gather information about the local actors and clinics involved in the vaccination delivery system, and together we compiled survey data as well as qualitative notes that would inform the design of our tool based on the needs of the community.

With notes in hand and inspiration aplenty, I arrived at the offices of BeeHyv Software Solutions in Hyderabad, India, a couple of weeks later to get down to the business of building our vaccination tracking and reminder tool. There was much work to be done…

More to come in Bastar, Part II. Check in again to follow Vina’s progress on the ground!

A fat and smiling baby is supported on a slab of stone by her mother and encircled by close family.  The fair skin of the child reflects in the faces of the father and grandfather.  In a month or so the child will have learned the greeting and gesture of “Namaste” and will utter the word with her hands pressed together before her chest.  Now she reclines glowing against the grey stone and grey monsoon clouds.

the small hotel in Sahartara VDC where we held the focus group with Female Community Health Volunteers

The rain lingered for two days.  The air was colder than it had been in Raha.  The hotel was a tightly constructed stone building.  Outside the ground was saturating and forming mud. Inside most of the space seemed devoted to the storage of rice and biscuits to sell to patrons. USAID bags of rice were stacked at the foot of a bed in one of our rooms.  Flies were everywhere. In the night I was jarred awake by the sound of rats working their way through the mud insulated ceiling.  A black plastic tarp had been hung from the rafters to catch dirt and other detritus that would fall as a result of the rodent excavation.  I barely slept.

The Female Community Health Volunteers (FCHVs) were reticent, and weathered.  The focus group with the FCHVs was held in a large open room on the second floor of the hotel.  Two small windows and the doorway let in a natural light.  A woven plastic mat was placed on the floor for sitting.  Conversation picked up after tea was served.  Earlier we listened to an FCHV’s account of a mother struggling to survive after an incomplete breech delivery—a massive complication where the baby’s feet came out first, but the shoulders became stuck in the birth canal.  With no obstetric care provider capable of handling the complication the woman and her half-delivered baby were carried in a basket for seven hours along the trail to the main district hospital in Dunai.  When they reached the hospital they were told they needed to fly the mother to a larger hospital in Nepalgunj where such a complication could be handled.  Before the money was raised to buy the plane ticket the baby died.  Remarkably, the mother survived the ordeal.

Volunteers sharing stories

In a region of Nepal where health volunteers fill the role of physicians and travel by foot is challenging for even the young and fit, my mind’s images of women giving birth on the trail, or suffering for days only to face a mortal outcome were confirmed as terrible reality.

Alex Harsha (Medic Mobile Researcher) watching Pawan Acharya lead conversation

In this VDC there was a sense of hopelessness in the stories told by the FCHVs unlike in other regions of Nepal we had visited.

A conjecture as to why this sentiment revealed itself so acutely is embedded in the combination of geographical barriers to care, and a breakdown in the VDC’s local health system.  Sahartara is a seven hour walk from Dunai along a rocky trail that at times is flush with the river it follows—a real danger if the river was to swell suddenly during monsoon season.  In addition, the village’s own health post is staffed at best once a month by a government employed health worker.  These impositions have left the FCHVs in Sahartara to bare a great burden in the care of their community, and they bare it with little support or regular training.

Here, FCHVs have no other option than to counsel expecting mothers to travel to Dunai to give birth.  However, this fact is complicated by a cultural inhibition on the behalf of pregnant women to inform someone once labor ensues.  The laboring mother now unable to make the trip to a birthing center gives birth at home, or as some traditional practices dictate, outside in the family’s goat shed.  Outside, in completely unsanitary conditions, and quite possibly in below freezing temperatures is where many births take place.

the hotel owner's son, and the husband of an FCHV who could not make the meeting

In this situation there is a small chance the birth may be attended by a skilled birth attendant, or a Female Community Health Volunteer, but is it more common that an FCHV is called only in the event of a complication—in which case little can be done if at all.

The initial response from the group of Sahartara’s community health volunteers to the proposed maternal and child health project between Medic Mobile and One Heart World Wide was not entirely positive.  It became clear from the discussion that while the reminders function of the SIM application seemed useful, the group felt the SIM application would be of little use during emergencies.  However, in those instances the phone would be used to call a skilled health worker at the local health post, or in Dunai.  It would seem that at the very least an FCHV equipped with a Medic Mobile phone would not feel entirely alone in the face of an impossible situation.

While there was some intermittent cell service in the VDC, the reality is the health post in Sahartara is staffed too infrequently to expect someone to be available in an emergency, and while a skilled health worker could be reached in Dunai, that person is too far from the emergency to be of any immediate aid, other than advice over the phone.  The group of FCHVs expressed that they wanted to take on more responsibility—acknowledging their solitary role as care providers in the VDC.  Yet, their desire to serve their community seemed to be consistently undermined by forces out of their control.

The group warmed to the idea of reminders to see patients, and alerts about upcoming deliveries. The FCHVs thought that with this function they would be better prepared to bring a pregnant woman to a birthing center before labor began. The project’s focus on antenatal and postnatal care will hopefully allow for community health volunteers to track the course of a woman’s pregnancy.  This rapid availability of patient information is crucial in places like Sahartara because FCHVs can then plan ahead to escort an expecting mother to a birthing center while the mother is still capable of traveling.

In the case of the tragic breech delivery, a phone equipped with a Medic Mobile application could have at the very least provided rapid support to the FCHV by establishing a means of direct contact with a skilled medical professional.  However, since the proposed  project will address the longitudinal care of pregnant women, ideally the breech position of the baby would have been recorded during an antenatal care visit, and the FCHV would have been reminded through the mobile tool to bring that mother to a birthing center prior to her due date to safely deliver her child.

Ranju Sharma (Nepal Projects Manager) explaining the proposed project

Leaving our conversation in Sahartara it was clear that when something vital like a staffed and operational health post is missing from a community’s health system, caring for a community becomes near impossible for health volunteers who try to fill the gap.  Medic Mobile hopes to establish a mobile tool that supports Female Community Health Volunteers in their task of providing care to their community.  However, as a humble observer of these meetings and the proposed project, it seems that while Medic Mobile tools are novel, powerful, and potentially quite empowering, the project is a small part of what should be a large and targeted effort to correct inequities in access to care not only in Sahartara, but throughout Dolpa, and all of rural Nepal.  Currently, there are real barriers to implementing Medic Mobile’s project in Dolpa such as unreliable cell network coverage, and a struggling government supported health system. Fortunately One Heart World Wide’s mission is to build birthing centers in the region, as well as train and equip skilled birth attendants to create a “Network of Safety” around women and their babies.  We left Sahartara feeling deflated and overwhelmed by the severe reality of health care in this region.  While we came to discuss solutions we were reminded of our limitations, and that any success would be achieved only through collaboration.  Medic Mobile tools are just tools.  In order to fully realize their potential these tools require adequate health systems and partners like One Heart World Wide to use them.

view of the river valley leaving Sahartara VDC

Text and images by Lewis Feuer.

A small gauntlet of community health volunteers gathered on the other side of the school’s stone gate to preside over our departure.  As we stepped before the group we bowed our heads and one by one they took their thumbs and pressed a pink tika into the skin between our eyebrows and up onto our foreheads.  The chalk pigment flaked down onto our noses and the fronts of our shirts.  After the tika was applied fine linen scarves were tied around our necks…

In the picture there are three girls, students at the school in front of which they are standing.  Most all of the school building is out of frame and the girls stand before a small section of mud brick wall.  The girl on the right has her head wrapped in a scarf.  It forms a fringed wool halo from the top of her head to her chin, and she is looking directly at the camera.  She is wearing a paisley dress over a baggy long sleeve shirt.  The collar and sleeves of the shirt are stretched from many consecutive days of wear.  The two girls to her right are younger and both cast a look of disdain or awe or both.  They look out beyond the camera, possibly at some adult trying to get them to smile. 

Two community health volunteers look out over the valley.

I was thinking about the four-hour walk back to the district capital, Dunai.  How long would it actually take us?  We had grossly underestimated the steep terrain on the way to Raha.  We were to leave Dunai the following day and there were still numerous supplies to be gathered and arrangements to be made for the next two weeks on the trail.  The team from Medic Mobile, Alex Harsha, Ranju Sharma, Pawan Acharya, and I, had been in Dolpa for five days.  Raha was the first Village Development Committee (VDC) we visited and getting there and back was in many ways a warm up for the type of traveling we would be doing in the coming weeks.

On the trail. Before we realized it was a 1000m climb to Raha.

Dolpa is a remote mid-western district of Nepal, accessed only by small plane, and once in the district all travel is done on foot.  Everyone walks.  It is not uncommon to walk for days between villages.  Lower Dolpa, where we were traveling, lies within the Himalayan Mountain range, and so the walking is done along rugged and winding trails and over mountain passes.  In Dolpa, Medic Mobile is partnering with the non-profit One Heart World Wide to implement a maternal and newborn health system that will use a SIM application to collect patient data, as well as provide community health volunteers with reminders to see pregnant women and their babies, and alerts to nearby health workers to facilitate support during delivery and emergencies.

The general plan for our trip was to visit three VDCs.  At each VDC we planned hold a focus group with female community health volunteers (FCHV) on the proposed plan to implement Medic Mobile’s tools.  We would also invite community leaders to a secondary meeting to hear their thoughts and concerns about the proposed project.  We were looking for more information.  Where were the problems going to be?  What improvements would this project make?  Was there any cell service?

Introducing the SIM application

The meetings in Raha were held in the classroom of a small school building.  Unlike the other classrooms in the school this room had a wood floor.  Extra chairs were brought in and arranged along the walls.  Pawan Acharya, a bright 25 year-old with a degree in public health, led the introduction of the project to the group of volunteers.

Pawan Acharya at work

It was evident from the first session that the list of impediments to the project was to be long: illiteracy, extreme geography and inexperience with mobile phones were just the beginning, not to mention unreliable cell service.  However, the conversations in Raha were lively.  The oldest FCHV, assuming her position of experience in the group, spoke vehemently about how difficult it is to get pregnant women to the district hospital in Dunai because they do not have any stretchers.  Gesturing with painted hands, she described how they often organize family members and neighbors to carry women the four hours to Dunai.  Another volunteer expressed the sobering sentiment that with a program like this the government would finally “see” their work.

So much of the health care in rural Nepal depends on these volunteers.  It is a fact that can not be detached from a sense of injustice.  While these volunteers have the capacity to form a strong and vital arm of the Nepali health care system, too often the position they have volunteered to fill is undercut by the government’s inability to provide regular training and access to simple resources like operational health posts, and stocks of medicines.

FCHV explaining the numerous difficulties to providing care in Raha.

FCHV trying out the Medic Mobile phone with a daughter's help.

At the second day’s joint meeting with community leaders the principal of the school sat holding his youngest daughter in his arms. Occasionally stretching and twisting in her father’s lap, she was asleep and her body paid no attention to the room.  The principal, engaged in the conversation, simply adjusted his grip according to the unconscious whims of the child.  Here was a room of concerned but ordinary people talking about a novel approach to implementing a health care system.  A rough circular diagram of arrows had been drawn on a black board depicting the chain of communication between a central server and the health workers with cell phones.  The principal’s daughter, still oblivious, napping, laid out on her back across the platform of her father’s knees, her legs and head falling victim to gravity.  Her sleeping presence seemed to qualify the room.  Her sudden groping into empty space and her father’s shirt sleeves somehow offered a simple reminder that after the meeting things would be just as they had been in Raha, at least for the immediate future.

Students at the local school.

For the past two days we had listened to the stories of the FCHVs and other members of the community.  During the breaks in our conversations we drank tea together, and ate firm early season peaches then tossed the pits into the dirt.  We hadn’t saved any lives, or passed out any clothes, or made any grand promises.  Rather we ate and slept in the village, walked through the hills that envelope the compact clusters of homes, and we listened.

After the last meeting a final round of tea was served.  I collected my camera gear and the other team members arranged their bags and filled water bottles for the trail.  It was nearly two o’clock in the afternoon and we were leaving later than we had planned.  We said our goodbyes to the principal and the village’s health worker, and then headed across the small dirt courtyard towards the stone gate of the school.

…As the scarf was tied around my neck I swallowed an involuntary gasp knowing that if it escaped tears would follow.  I looked up to see the face of the oldest FCHV.  Her hands were pressed together before her chest and she smiled back at me.  Pawan, once we were on the trail, suggested that the neon pink tika (which was not the traditional red) had probably been found in a last minute effort to piece together the small ceremony.   His thought barely registered in my mind.  I was lost thinking back to the ten-minute span of time that was our departure.  My thoughts once preoccupied with the days ahead were now struggling to absorb that humble and hurried ceremony.  I was in awe.  I looked out through the lenses of my sunglasses.  They were covered in tiny specks of pink.

Text and images by Lewis Feuer

The road from Dhangadhi changes between a rough paved surface and unpaved. We weave past beach ball sized boulders fallen from the cliff to our left. Our wild haired driver accelerates in the straights before tapping the brakes and applying the horn in short jarring pumps all the way through the corners. The technique is customary on this road that’s just wider than a single lane. The horn warns oncoming traffic before we enter the blind curves. The only oversight by our driver is the blasting Hindi pop music drowning out any possibility of hearing a warning from the other direction. In this way we maneuver through the hills and into the night…

…Occasionally passing through small towns, clusters of tin three-walled shacks open to the front in between more permanent mud and wood constructed homes built into the hillsides. Approaching the tin fronts, the candle lit rooms transform into pantheons of packaged butter biscuits, cigarettes, and sundries for sale. Other fronts contain families sitting shadowed inside open kitchens with open hearths (in rural Nepal a family’s size is most accurately described by how many people eat in a particular kitchen). Burnt flour, chilly spice and manure pervade the air. To the right the road bends past the last home into darkness. To the left it is the same.

View from the jeep, a brief straight section before the next turn.

“It’s all about food and disease here,” said Dr. Bibhusan Basnet.  He smiled, but his humor was not far from the daily truth.  His life as Medical Director at Nyaya Health’s Bayalpata Hospital in Achham is composed of little more than eating, sleeping, and doctoring.  We chatted over tea sitting on a rock ledge built below a massive Peepal tree (pronounced like “people” and coincidentally the place where everyone gathered in the evening).  The ledge and the tree were at the top of a hill that overlooked a small village of tin structures including the cantina from which we ordered our tea, and further out on the ridge the hospital newly painted a pale yellow and earthen red in honor of the Nepali flag.  To the right and left the land fell away into the valley, and out beyond the last building of the hospital the grey and distant river soon to be swollen with Monsoon rain.

Inside Bayalpata's Emergency Room, (in the center Urmila Didi, Auxillary Nurse Midwife)

Our conversation dominated by the doctor was light and full of laughter.  About halfway through his cup of tea, and halfway through apprising me on the many ways in which I would eat the same meal each day in Achham, the doctor was called back to the hospital to make a referral for a Caesarian section (the hospital’s own operating room was a few weeks from complete). Within five minutes he was back with his tea in hand, further detailing the monotony of the diet in rural Nepal.

Dal Bhat: a massive pile of rice (sometimes USAID, sometimes from the People of Japan), a bowl or ladle full of lentil soup, and hopefully a small portion of curried vegetables…whatever is in season, or more commonly potatoes.  There are some differences in the techniques for consumption, but most often the components are mixed into an amorphous pile and eaten with one’s hand.

Chandrika, a long time Nyaya Health Aide at the ER's Nurse's Station.

For westerners the latter piece is a point of preference as spoons are generally available.  The lead trainer in Bayalpata’s community health office, Ranju Sharma, chided me at dinner one night, “rice does not taste as good when it’s eaten with a spoon.”

Ranju (a natural teacher), who was recently added to Medic Mobile’s team as Nepal Projects Manager, proved to be an amazing asset to implementing Nyaya health’s data collection project for which Medic Mobile would be supplying the mobile tools and training.  With Ranju acting as interpreter and trainer, Alex Harsha (Medic’s project manager and research coordinator) squeezed out every minute of internet access (down every time the hospital’s generator quit…which was often) communicating with the development team back in the states.  Most of the troubleshooting had to be done in very early hours of the morning which was good for having things ready for the mid morning trainings, but hard on Alex who rarely slept.  After a crash course in the project design, Ranju spearheaded the training of the Community Health Worker Leaders (CHWLs) on the application that they would be using to collect patient data via mobile phones.

Ranju and Alex leading the trainings of the CHWLs.

The SIM application will hopefully take the place of paper reporting forms, and store data to the central server where the information will be instantly available for the community health staff to analyze. The secondary purpose of the application will be for reporting on the status of local health posts.  A simple but critical question in Achham: is anyone staffing the post? Are the medicines and supplies that the Nepali government claims each post is stocked with actually there and available?  The real benefit in the implementation of Medic Mobile’s tools will be in the rapid availability of data that will give Nyaya Health a vital source for accountability in its continued work with the Nepali government, and within the government supported health system.

Watching messages arrive on the server, (left to right) Satya Sunar, Pabitra Kunwar, Tulcha Devi Khanal (Community Health Worker Leaders), Ranju Sharma, and Community Health Worker Leaders Kamala B.K., Sunita Kumal, and Lalita Khadka

It was clear from the moment that the CHWLs entered the small community health office that they were a unique group of women.  They all wore matching aquamarine saris, a blue that contrasted against their dark skin and complemented the bright crimson tika that most wore on their foreheads.  They were striking.  Intelligent and progressive, each Leader had walked at least an hour or two to attend the training, and did so as representatives of their own groups of female community health volunteers (FCHVs) that live much further away from the hospital.  The faces of the CHWLs filled with skepticism at the onset of Ranju’s instruction, and then with timidity and surprise as phones were placed in their hands and they began to work through learning how to use the application.  Constantly joking and ribbing one another, the group in the end seemed optimistic that they would be able to use the new mobile phones.

Community Health Worker Leader Satya Sunar testing out the phone.

Female Community Health Volunteers at their weekly meeting in Chandika VDC

At the end of the week in Achham we were able to visit a community health meeting in a village a few miles from the hospital that was being lead by one of the CHWLs that we had been working with days prior.  Sitting in a circle beneath a Peepal tree on a raised platform of earth a group of FCHVs received a brief training, and shared their weekly summaries for the CHWL to record on a paper report. Eventually this CHWL would be using the Medic Mobile phone to collect the summaries, and each FCHVs patient list would be instantly updated to the server where Nyaya’s Community Health Department could aggregate and analyze it to observe changes in the community health status.  The significance of the visit was getting to observe how and when the phones would be used once the project becomes fully operational.

Weekly community health meeting in Chandkia VDC

The CHWLs are continuing with weekly reporting and training using the phones at the hospital.  There have been (and will be) some difficulties, but with feedback from the Nyaya community health staff, namely Ashma Baruwal, Medic Mobile’s team has been working on improving the application. It is Medic Mobile’s first project in Nepal, and so the team is anxious to learn how to make it as easy as possible for the CHWLs to collect data and perform their reporting duties from the most basic phones.

Patients waiting at registration

Aside from the cows grazing past the latrines in the open center of the hospital campus, or the stray dog asleep on the shaded concrete floor of a hallway, things moved like they do at any hospital.  A swell of patients accompanied by family members grew each morning before the registration window, and by four in the afternoon that swell had passed through the hospital. The only evidence of its movement the low din of the various waiting areas rising in volume punctuated by the cries of infants getting weighed and measured. After seven in the evening dinner was ready.  The hospital staff, as well as visitors like us, sat down to eat.

Text and images by Lewis Feuer.   Lewis is a visual artist and poet.  He is currently pursuing a Master of Fine Arts degree in Creative Writing at UMass Boston. Please check back in the coming weeks for more installments in the series Artist in Arms.  Future posts will cover other projects beginning in Nepal.

This milestone is particularly meaningful for me because it also marks the end of my service as Medic Mobile’s Chief Strategist. Just over four years ago I read a blog post by Josh Nesbit and reached out to discuss using text messages to coordinate community based health workers. A few months later we set out to build an organization together. Neither of us had backgrounds in software or work experience in global health, we had no shared history or any friends in common, but we did have a common understanding of our opportunity. I spent the first year in Malawi and have remained focused on the internal operations of our team. Josh has been externally focused; together our approach has been to inspire people with a sense of the mHealth opportunity, rally the resources to hire the most fantastic people we meet, really listen to them, and make sure the best ideas win.

This month I am handing off day-to-day management responsibilities in order to begin a graduate program at the University of Cambridge, where I’ll be using the social sciences to better understand the kind of work we do at Medic Mobile. This is not a transition away from Medic so much as a transition to a different role. I’ve been craving more time to read and write, to do research, and the space to be a more thoughtful advisor for our growing team. I’ll continue as a board member and active champion of our cause. The tasks I’ve been responsible for to date are in very capable hands: Dianna is our human centered design evangelist, our newest team member Maeghan is off to a great start managing projects in East Africa, our CTO Dave and West Africa Region Director Marc play increasingly important roles in tech strategy, and Josh will remain our connector, a leavening force.

From my view, perhaps the most remarkable aspect of this experience is that I have learned so much and somehow emerged even more curious. As our circle of knowledge expands, so does the circumference of darkness surrounding us. As our team gets better at using technology to improve health services and at measuring our impact, our sense of the mHealth opportunity continues to grow. We have good work to do; I hope you’ll join us.

Medic Mobile works with partner organizations that provide high-impact health services in challenging settings. We see communication gaps through the eyes of their staff, and guide them towards low-cost tools and more effective health services.

We’ve used free and open source software to boost immunization rates by more than 20%, to contain disease outbreaks, and to make drug stock reporting 4x cheaper and 134x faster. Our efforts have impacted the care of over 600,000 patients.

Most mobile phone owners live in the developing world, yet many mobile health initiatives fail to grow beyond a few dozen people. We can close the gap and reach scale by using the phones that are already in people’s hands.