Why Can’t You Just Ask People? Tacit Knowledge and mHealth in Malawi

This post was originally featured in Digital Diversity, a series of blog posts curated for National Geographic by anthropologist and innovator Ken Banks. The series discusses how mobile phones and other appropriate technologies are being used throughout the world to improve, enrich, and empower billions of lives.

After driving south to the end of the pavement, we continued on gravel and dirt roads for a few hours, long enough for me to fall asleep and wake up several times before arriving at the district hospital. Temperatures can reach 125 degrees Fahrenheit near the Nsanje River in southern Malawi, so I was grateful to arrive in a milder season when midday temperatures hovered just under 100. For more than a year I had been using mobile phone technology to improve health services and I expected this project to follow the typical routine: discuss the plan with leaders at the local district hospital, install software on phones and computers, and train frontline health workers to deliver routine reports using a mobile phone-based data collection app called FrontlineForms.

In Malawi, government-employed community health workers (CHWs) treat children in rural villages for malaria, pneumonia and diarrhea. Although highly effective medicines exist, these three ancient afflictions remain leading causes of death among children in developing countries, often because medicines are out of stock or only available at distant locations. My goal in Malawi was to improve the flow of information from CHWs to the district hospital, so that these life saving medicines could be resupplied efficiently to remote communities.

Malawi has two major mobile network operators: Airtel and TNM. I had surveyed all 50 health workers about which mobile network had a stronger signal in each of their communities. When the training began, I was bewildered and frustrated to find that there was almost no signal for the network that 8 out of 10 had requested. I had offered to connect them to either network; why would so many choose the one with much poorer coverage? Reluctantly, they explained that although Airtel had weaker signal locally, they sold airtime in units of 25 Malawi Kwacha, while the smallest increment for TNM was 50 Kwacha. These CHWs typically had 25 Kwacha on hand but may not have 50 in their pocket when they wanted to buy airtime for personal use (work related airtime was to be reimbursed). This experience was eye opening, almost unnerving. I was distributing $100 phones to people who considered 25 Kwacha (about 15 cents in US dollars) a greater barrier to access than walking or bicycling several kilometers to reach mobile signal.

Money on hand for airtime is one of several important considerations for rural health workers. A few weeks ago I spoke with a volunteer health worker who provides immunization and antenatal care services in coastal Kenya. Mary has a solar panel on the roof of her house and one other volunteer in her community group has grid electricity, but the other 38 volunteers must travel to the market to charge their phones. Charging a phone just once costs 30 to 80 cents. For a volunteer health worker whose cash income may average a few dollars a day, the financial burden of charging a phone this way is similar to filling a car with gasoline in North America or Europe. Walking or paying for public transit to the market are inconvenient, so many volunteers wait a day or two after their phone runs out of battery.

Working in these circumstances for the last three years, I’ve learned that the key to understanding how mobile health services can proliferate is in understanding what technologies these communities are already using. There is wisdom embedded in the observed preferences of ordinary villagers. The technologies that are driving change in society today are, as a rule, already being used at a massive scale. For the urgent change-maker, cutting-edge technologies are hardly relevant, ubiquitous technologies should be captivating.

One such captivating technology is the mobile phone that costs $15 and can last a week or even two on one charge. Clunky nine-button keypads and black and white screens the size of a half-dollar coin can make these phones look second-rate, but they fill an enormous gap in households surrounded by neglected rural roads, with ineffectual postal service, no car and no land-line telephones or internet. The first-generation phone is a quaint memory in developed markets but in Africa, everyman’s phones are referred to with familiar terms such as Kabambe in Kenya and Mosewalelu in Malawi. They have become cultural icons of progress not unlike the early model T Ford, a cultural icon as the first everyman’s car in America. The low cost, long battery life, familiarity and ease of use, being less prone to theft, better supply chains, sales and repair outlets and the promotions put on by mobile network operators all contribute to the statistic that in 2011 there were 32 non-smart phones for every smart phone on the African continent.

During my first design research trip to Kenya in early 2010 I learned something about $15 phones that most Kenyans already knew: every phone can have apps – you don’t need a smartphone. I was talking with ordinary consumers about using mPesa, the wildly successful mobile banking service that lets users send money to and from any phone. I learned that mPesa is available and familiar on any kind of phone, from Android smart phones to ordinary $15 phones. This is possible because mPesa actually sits on the SIM card, not the phone itself. Many North Americans do not even realize that inside of their phone is a small chip called a SIM card that handles the phone’s connections to the mobile network. Throughout Africa, however, people frequently change their phone’s SIM card from one mobile network to another, to take advantage of evening calling rates or other sales promotions. SIM apps are viewed through the phone’s native menu which means that if you know how to check your contacts list or text message inbox on a particular phone, a SIM app on that same phone will look familiar.

The challenge with deploying health related SIM apps is that mobile network operators strictly control which apps are installed on their SIM cards. But I kept tinkering with SIM cards and after several months I discovered that some groups in the financial and security sectors, as well as hackers trying to jailbreak iPhones, use paper-thin parallel SIM cards that slide underneath the mobile network operator’s SIM. Using any standard GSM phone, we’re able to put our SIM apps on the parallel SIM and still use an ordinary SIM card to connect to any GSM mobile network in the world. About a year ago I announced that Medic Mobile would be the first mobile health organization to develop and deploy SIM apps, and since then the Medic Mobile team has started SIM app projects in several African countries.

As we take on larger SIM card projects, our goal is to work closely with mobile network operators so that the apps sit directly on the native SIM card and don’t require parallel SIMs. This will be cheaper and it’s true to the strategy that has served Medic Mobile well: no one understands the communities where we work better than the people who live in them every day. Our best chance of deploying mobile health services that are locally appropriate and manageable at a large scale, is to leverage the phones and other technologies that are already in their hands.

mHealth Innovator & A Book About Medic Mobile

As I type this I’m looking out over the Columbia Gorge from my parent’s home in The Dalles. Can’t get enough of my first autumn in North America since 2008. I spent two weeks in Montreal and Toronto singing at a friend’s wedding last month, and I will be in San Francisco next week with Echoing Green.

Work with Medic Mobile is still going very well and I would really appreciate your help with an online vote. I’ve been nominated as one of the top 11 mHealth innovators in 2011, and made it to a shortlist of 30 candidates. The top 11 will be selected based on an online vote. If you’re willing to help me out, you’ll have to first login (you have to create an account or login using your Facebook account). Once logged in, you should visit the Top 11 voting page. To vote just click on the rectangle that has my name, click the green Vote button at the bottom, and then confirm your vote. Not too much effort, and becoming one of the top 11 would be great for me because I’d get to attend the major mHealth Summit in Washington DC this December free of charge. Thanks in advance!

I also wanted to let you know that last night was the launch party for a book that has a chapter about Medic Mobile and the personal stories of Josh, Nadim and myself. The book was written by Jill Iscol and Peter Cookson, with a forward by President Bill Clinton. Getting interviewed and preparing for the book launch has been a rather humbling experience because the authors are so supportive and the young people featured in the other chapters all seem amazing. I’m happy to get the word out about our work, and proceeds from book sales go to Medic Mobile and the other featured organizations. If you’re interested, you can read more at www.heartsonfirebook.com, or read a recent article in The Daily Beast.

Voting closes this Friday the 11th, so thanks again for supporting me with the online mHealth innovators vote. Hope you have a glorious autumn!

The Appealing Poison of Unmanned Aircraft

This opinion piece was published in The Oregonian on Sunday, August 21st.

My family tells the story of war with two voices. The first is the voice of my grandfather, who started working as a typist at the Portland recruiting office, volunteered to enlist in the Army Air Corps a week before Pearl Harbor, and would eventually lead a group of C47 airplanes dropping paratroopers on D-Day. He talks about the exhilaration of flying, the people he evacuated from concentration camps, and the men with whom he made the sharpest memories of his life.

The second voice is of my grandmother, who took the train from Portland to Missouri to marry her young lover before sending him off to Europe. Worry like a thick blanket, woven with pride. Of miscarrying while he was away and being afraid to tell him.

War is wrenching. In small towns you know which families have sons in the service. You see mom at the grocery store, she looks OK, but you wonder if she loses sleep. She’s weary of people feeling sorry for her. The child of a high school teacher comes home with limbs missing. On Aug. 20 our governor ordered that Oregon flags be flown at half-staff in memory of Ryley Gallinger-Long of Cornelius, who died in Afghanistan.

What if we never had to fly the flag at half-staff? I doubt the Prince of Peace will end all wars in my lifetime. I’m talking about a new era with drones fighting in place of people — soldiers strafing bad guys in Afghanistan and making it home in time to tuck in the kids and host poker night. Will we fly our flags at half-staff when we lose another machine? When we kill the bad guys? When we kill children who were too close to the bad guys?

War establishes its moral significance in the stories of people we know. My buddy was pulled out of a full-tuition merit scholarship to college to serve an unlooked-for second tour in the Middle East, and I thought “Good God, are we doing the right thing over there?” War became real to me then, and in 2008, I spoke against war at the ballot box. Fighting with drones could take away opportunities for civilians like me to wake up to carnage 10,000 miles away. It could take away my grandmother’s voice and the role of civilians who experience war personally even though they never enlist.

Professional soldiers already bear enough burdens on our behalf. Asking them to judge whether their leaders are acting prudently is unfair because it feels disloyal. Every rank-and-file soldier I’ve ever met thinks such restraint is above his pay grade.

The voice of restraint needs to come from civilians, from public servants and ordinary voters. Making war means a lot of short-term jobs for soldiers and companies that make guns, planes and bombs. How many needless wars will we fight if civilians’ only personal experience with war is a comfortable job building machines?

I don’t think we should stop or even cut back the role of drones. In the long run of history, the censor and the Luddite have always lost; technology is too appealing. The only remedy for dangerous ideas is better ideas.

Civilian casualties, which happen with or without drones, are just a distraction from the greatest question facing public servants who stand for peace: In a world where Americans can make war without ever flying the flag at half-staff, how will we make ourselves care enough to exercise restraint?




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