Calling for Health

by Angelica Calabrese:

In a bright, whitewashed nurse’s office overlooking Port-au-Prince, a cell phone trills loudly, and a nurse promptly answers.  Marie-Claire, a young HIV-positive mother with an HIV-positive child, is calling with a question about her child’s medication.  Her voice crackles over the phone. The nurse responds to her questions. As the conversation ends, a sob interrupts Marie-Claire’s Creole and she begins to cry, not out of despair or hopelessness, but rather out of gratitude for something small, basic, and increasingly ordinary: a cell phone.

Just a few months before, such an interaction, let alone such a prompt reply to a medical question, would never have been possible. But the growing use of cell phones across Haiti has made communication between health workers and patients much faster and easier. Now, instead of losing hours navigating Haiti’s under-developed transportation systems and scaling its mountainous landscape, patients, community health workers, nurses, and doctors can access one another promptly via cell phone.

Doctor and nurse testing an infant for HIV with the Caris Foundation’s dried blood spot test. (Calabrese/TYG)

Mobile phone usage has grown rapidly in Haiti in recent years. Pay-as-you-go credit plans, increasingly widespread coverage, and handsets equipped with SIM cards for as low as five dollars have allowed mobile phone usage to increase exponentially over the past six years. This phenomenon has been seen in low-income countries around the world, and governments and health organizations have seized the opportunity presented by this expanding mobile infrastructure to move healthcare out of hospitals and city centers and into villages and the hands of local people. Although most agree that there has not been enough proper scientific evaluation quite yet, pilot programs have shown promise in countries like South Africa, Ghana, Uganda, and Malawi.  Organizations such as the International Federation of Red Cross and Red Crescent Societies (IFRC), the Caris Foundation, Partners in Health (PIH), and Health eVillages have followed in the footsteps of those across the Atlantic and are now beginning to execute such programs in Haiti.

PIH and Health eVillages have implemented what are known as patient-facing programs, which focus on the mobile technology used by community health workers (CHWs). Among CHWs, cell phones are used as guides for delivery of care, reporting devices, and means of communication with supervisors.

Organizations like IFRC and the Caris Foundation have chosen patient-based programs, which instead provide the patient with the technology. IFRC has focused on providing information to community members through their mobile phones. They partnered with telecommunications company Voilˆ to develop the Trilogy Emergency Relief Application (TERA), which allows IFRC to send early warnings about hurricanes and educational messages about domestic violence, sanitation, and cholera prevention via SMS to at-risk peoples.

The Caris Foundation has integrated a patient-based program into everyday treatment. Instead of working only with the patients who already own cell phones, and in the hopes of more patient contact and greater adherence to medication, Caris has begun to provide cell phones to individual mothers, like Marie-Claire. In Haiti, Caris nurses support testing and treatment of pediatric HIV. The organization works with HIV-positive mothers who have undergone Mother to Child Transmission Prevention (MTCTP) and tests their infants shortly after birth. If the infant tests positive despite MTCTP, treatment must begin as soon as possible.

Treatment requires a constant supply of antiretroviral medication, and frequent appointments are necessary to keep the medications up to date. If children do not take the drug regularly, they can develop resistance, making the disease much more difficult to control. Moreover, non-adherent patients who miss appointments or don’t pick up their ARV medication can be challenging to track down, especially if they lack a cell phone or a fixed address.

In mid-2010, Caris began to give cell phones to such unreachable and often non-adherent mothers. Since then, contacting and treating patients has become much simpler. Each phone is programmed with the numbers of the local Caris Foundation office and the patient’s health provider, so when mothers have questions, they call the Caris nurses with their cell phone, and Caris nurses can call the mothers regularly with appointment reminders. Nathaniel Segaren, M.D., director of Caris’s pediatric HIV program in Haiti, envisions the new initiative as “a holistic method of integrating the HIV care

system with the individual, so that the actual patient has access to health providers directly and health providers have direct access to the patients.”

But patient-based programs such as those implemented by Caris and the IFRC face two main challenges: illiteracy and lack of electricity access. Many of the most successful patient-based mobile health innovations, such as the SMS-based patient check-up program Project Masiluleke in South Africa, rely on patient literacy. However, in South Africa, the literacy rate is 89 percent, while in Haiti, the literacy rate hovers around 50 percent, meaning that many of the people receiving the IFRC/TERA text messages may not even be able to read them.

Access to electricity poses another obstacle to patient-based programs. According to the 2007 Haiti Energy Sector Development Plan released by the Haitian Ministry for Public Works, Transportation and Communications, only 12.5 percent of the Haitian population has access to electricity, and the 2010 earthquake likely decreased this figure, which means that keeping cell phones charged and in working condition can be especially difficult. Due to these concerns as well issues with confidentiality and reliability, organizations like PIH and Health eVillages find it more appealing to focus on patient-facing programs via community health workers. With such employees, organizations can even provide solar powered sources of portable electricity.

But working with CHWs is not perfect.

Jonathan Payne of PIH pointed out that adding cell phones to the communication interactions between CHWs and their supervisors illuminated some of the problems with the supervision and management of the CHWs. Since most international aid organizations are funded for direct patient care, it is not uncommon to find too few supervisors and managers to oversee the CHWs, what Payne refers to as “thin middle management.” Patricia Mechael, Ph.D., Executive Director of the mHealth Alliance, made a similar observation, affirming that “technology is only as good as the systems it’s supporting.” If there are inefficiencies in those systems, there will be inefficiencies in the use of the technology.

As Josh Nesbit, CEO of Medic Mobile, cautioned, whether patient-facing or patient-based, mobile technology “isn’t a solution. It’s a tool that becomes a solution when people use it effectively and it changes outcomes.” Payne added that although mHealth innovations have great potential to improve remote diagnostics, clinical decision support, and surveillance activities, accomplishing any of these goals effectively requires a large investment into electronic medical records, pharmacies, and lab systems. The current infrastructure in Haiti may not have developed enough yet to support effective implementation of such programs.

The responsibility thus falls on the government. “Governments need to invest their own resources in mobile health as a public health program,” Mechael suggested, citing Rwanda as an example. But between the recent cholera epidemic, reconstruction efforts after the earthquake, and President Martelly’s focus on education, government-sponsored mobile health does not appear to be coming anytime soon.

Women like Marie-Claire find cell phones a blessing. Marie-Claire is young and has not yet disclosed her or her child’s status to her family. When she finds herself with no one to turn to, she often calls the office for the nurses’ help and advice. Her cell phone allows her to care for her child more effectively, even letting her set an alarm to remind her of her child’s regular medication times. She feels supported and, “encourage,” encouraged.

Angelica Calabrese ’14 is a Global Affairs major in Morse College. Contact her at