Medicine by Text Message: Learning From the Developing World

In the last decade, community health efforts have been made more effective by a simple insight: that time, money, and sometimes even lives can be saved through texting. At St. Gabriel's Hospital in Malawi, for example, 75 community health workers were trained to use text messages to communicate patient information, appointment reminders, and other health-related notifications to patients. Through this mobile health, or mHealth, initiative, the hospital saved approximately 2,048 hours of worker time and $3,000 in fuel, while doubling the capacity of the tuberculosis treatment program.

The case for this growing field in the developing world provokes some controversy, however. Tina Rosenberg, writing in The New York Times, argued recently that the field is in flux. "Roughly a decade after the start of mHealth ... these expectations are far from being met," she writes. "The delivery system is there. But we don't yet know what to deliver." Most of the testing done in the field, she goes on to argue, has focused on feasibility, not real health impacts. What's needed, many insist, is the use of randomized control trials -- the gold standard in science -- to help determine what actually helps the world's poor, versus what development workers and funders assume will.

After about a decade of attracting big philanthropic investment without enough measurable results, Uganda and South Africa have both put a hold on any new mHealth pilots in their countries. And as the developing world closes its doors, some nonprofits are turning their sights to the U.S. for further study. "While there is still much to do in low and middle income countries, there is a lot that can be learned and transferred from the experience of designing and implementing mHealth systems in resource constrained settings here in the U.S.," explained Patricia Mechael, the executive director of mHealth Alliance at the United Nations Foundation. If they can improve health outcomes through randomized control trials, they may be able to renew the philanthropic sectors' belief in the viability of the field.

And the U.S. could profit as well. Mobile interventions in prenatal care and chronic diseases, like diabetes, have already proven particularly successful, in large part because they are an easy way for people to take charge of their own health. Price Waterhouse Cooper estimates that mHealth interventions in the U.S. could save $10,000 per diabetic patient per year. The U.S. current spends $218 billion on diabetes every year.

Text messages have a wildly high "open and read" rate -- 97 percent versus 5 to 20 percent for email. What began as a field that mostly tackled approaches to improving care for HIV and AIDS patients has expanded its scope widely in the last few years. In 2011, a Lancet study reported that text messages to remind health workers in Kenya about the proper guidelines for malaria management improved care by 23.7 percent immediately after intervention and continuing to 24.5 percent six months later. One recent project even attempted to reduce depression among teenagers in Auckland, New Zealand using a cognitive behavioral therapy approach gone mobile; over three-quarters of participants viewed at least half of the uplifting text messages sent to them and 66.7 percent said it helped them in getting rid of negative thoughts.

Medic Mobile, a non-profit organization founded in 2009, has used technology -- like text messaging immunization reminders or providing apps with basic, life-saving information about prenatal care -- in over 20 countries on a wide variety of projects. Their efforts, thus far, have reached 3,500,000 people, or 700,000 households. This month and next, it will launch two U.S.-based initiatives.

One program, which will begin on April 18, aims to use text message reminders to increase appointment attendance among the largely immigrant, Latino population served by the San Mateo Medical Center. Those who opt-in will be able to confirm and reschedule appointments via text message. "These kinds of clinics currently have full-time staff devoted to calling and trying to track down patients," explained Josh Nesbit, the organization's CEO and co-founder. "We're trying to harness the power of asynchronicity to interact with as many people as possible in an efficient way."

The other project, launched on March 18, provides low-income, uninsured families with customized tracking and management software created in partnership with the Lucille Packard Children's Hospital at Stanford. The platform includes a reminder system for type I diabetic children and their caretakers, which can receive and recognize various types of SMS "check-ins" for blood sugar levels and respond appropriately to high or low values. Parts of it are structured like a game, where patients receive points as incentive for taking a proactive role in their care.

In addition to gaining the data they need to return to the developing world, the group is hoping to bring some of what they've learned over the last four years in the developing world to bear on these U.S.-focused projects -- global health experts are calling this increasingly common development "south to north" learning. Mechael explained, "Much of our work is focused on the enabling environment for mHealth in low and middle income countries, and frequently I find myself giving talks in the U.S. about what America can learn about mHealth from Africa, Asia, and Latin America."

As Medic Mobile embarks on the San Mateo Project, the tricky system was in the private, not public sector. They quickly learned that navigating monsoons in Bangladesh was a cake walk compared to navigating the deluge of bureaucracy to be found in an American health clinic. "It took us six months to just integrate our approach with their electronic filing system," said Nesbit. "That's really daunting to think about on a per project basis, so part of the work ahead is to figure out how to create mobile tools that aren't threatening to the electronic medical record providers, so we can just hand this off to clinics and they can do it on their own."

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Nesbit predicts that text messaging is just one of many "south to north" learnings that will change the way health care is structured in the U.S. in the coming years; he also believes that the community health worker model, which revolutionized the quality of care in places like Rwanda and Ethiopia, will become increasingly common stateside.

To date, Medic Mobile has affected one million people's lives in Malawi, where the majority of people live off of less than $2 a day. Could the same kind of impact be possible in the U.S. context? This is part of what they are out to learn in the coming months. The results could have far-reaching consequences for the kinds of technological tools that we bring to bear on the U.S. health care crisis in the years ahead.