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How New Uses for Mobile Phones, Video Games, and Speaking Books are Scaling up the Fight against Global Epidemics
By Jed Levine
SPEAKING BOOKS ARE TYPICALLY THOUGHT OF AS SIMPLE CHILDREN'S TOYS—ubiquitous cartoon voices blaring from a plastic box, loudly proclaiming the letters of the alphabet or numbered groupings of animals
This was certainly the perception of Zane Wilson, founder of the South African Depression and Anxiety Group (SADAG), before she noticed a peculiar problem with her organization's interventions in poorer parts of South Africa—namely that many rural South Africans simply couldn't read the materials being offered to them.
"It doesn't matter how good [of a publication] I did in Zulu or Sotho or Xhosa, if people can't read and write, they can't read the best brochure in the world," she says.
So Wilson looked for a simple, cheap solution to reach out to those who cannot read and found it in the form of an already existing technology: those boisterous books. "I looked at the books that have been around for several years for children and I thought if I could extend the soundtrack on these, this could be an answer to our problems."
With grant money from the World Bank and financial support from South African mining giant DeBeers, SADAG put together its first speaking book on the subject of suicide. Since then, the non-profit organization Books of Hope, which was borne from Wilson's concept, has created a dozen editions tackling issues ranging from HIV/AIDS and tuberculosis to self-esteem.
Wilson is not alone in her pioneering efforts to find innovative public health functions for existing technologies. Since 2005, Indian software company ZMQ has been using its core competency in video game development to create games that address HIV/AIDS and other public health concerns.
The President's Emergency Plan for AIDS Relief (PEPFAR) is now partnering with a number of private companies in Rwanda to build on a successful initiative there that has utilized Africa's newly expanded mobile phone infrastructure to enhance public health officials' ability to collect, organize, and share vital health data.
These new initiatives mark a turning point in the fight against global epidemics. For the first time in history, advanced information and communications technologies (ICTs) like mobile phones and audio players are cheap enough to be disseminated throughout the developing world, dramatically increasing the capacity to educate and communicate. Programs such as these are truly on the forefront of a global health ICT revolution.
But first, those chatty books.
Of Illness and Illiteracy
While Wilson's speaking books may appear disarmingly juvenile, their impact has been unmistakable. Testing by her organization has shown that groups who were given only the speaking book, with no additional materials or presentations from public health personnel, experienced a 58 percent increase in understanding of the subject matter.
In a region where public health officials are few and far between, Suzi Peel, Vice President of Books of Hope, thinks the books help to fill a significant gap in the health care infrastructure.
"The biggest problem in the field is that there are just not enough community health workers," says Peel. With speaking books, "you don't need a person to explain malaria; the book explains malaria."
The need for such interventions is critical in sub-Saharan Africa where, in most countries, more than 40 percent of adults cannot read and rates as high as 70 percent are seen in impoverished countries like Mali, Chad, Niger, and Guinea.
While these speaking books have been produced by a non-profit company with financial support from the public sector, private companies have been playing a significant role in bringing them to fruition since DeBeers Diamonds provided support for Wilson's first book.
In some cases, companies have come forward to develop an entire book on their own, as did pharmaceutical company Sanofi Aventis, which recently created a book on TB. By utilizing its core competency as a leading researcher on TB, the company was able to develop a relevant tool, which Peel praised as being livelier than the previous government developed version.
Other companies have also come forward to provide funding or content for various speaking books, including Merck, Eli Lilly, Pfizer, and Bayer.
Both Peel and Wilson agree that localization of the speaking books has been critical to their success. Each book is planned and executed for a specific audience. The soundtracks feature relevant local celebrity voices and to date, books have been created in English, Pedi, Sotho, Spanish, Xhosa and Zulu.
While localization is important, so is targeting the book's readership, says Peel. "We're very careful to target it to the user; the ones for pregnant mothers are all in pinks and light hues. The TB books are targeted at men, particularly the tough guys who won't go seek medical assistance for a cough."
A previous effort to utilize speaking book technology by the U.S. State Department in Afghanistan was not as successful as Books of Hope. That effort, says Peel, failed because it was not localized properly and had poor distribution on the ground, in addition to costing up to six times more than her organization's books.
Each speaking book is made at a cost of $10 U.S. and is expected to be seen by an average of 30 people once it's distributed on the ground. Those who receive the speaking books typically show them to friends and family and the books find their way to even more people through sharing at churches, schools, shopping centers, taxi ranks, women's hair salons, and even liquor stores.
While research has shown that the books can be successful without complementary education, Books ofHope still organizes workshops in rural areas before disseminating them, in order to enhance their effectiveness. Wilson says it's at these events that she sees how much of an impact the books are having. "I run these workshops in rural areas, and the excitement when they hear the voice coming out of the book of someone they know," she says. "It's a very overwhelming feeling."
Tech Toys with a Mission
While video games have traditionally served as a form of escapism, some innovative companies have been looking to them as an educational tool for reaching out to young audiences.
Indian software company ZMQ has developed dozens of video games for computers and mobile phones through its Freedom HIV/AIDS initiative, tackling a variety of health issues in both South Asia and sub-Saharan Africa.
Entertainment giant Warner Bros. and technology leaders Dell and Intel have teamed up with PEPFAR in a public-private partnership called Challenge AIDS: Playing for Life, that will develop a line of video games addressing HIV/AIDS behavior-change issues. The initiative will target 10-24 year olds and utilize the know-how and talent that Warner Bros. has developed through its popular franchises. Equipment and expertise donated by Dell and Intel will make the games accessible to low-income urban youth in Kenya, where the program will be piloted.
"We believe in using available technology—elearning, gaming, use of mobile technology," says Hilmi Quraishi, Project Director of Freedom HIV/AIDS. "We had put it in our company philosophy to give back using our core competency." Quraishi, who is also one of the founders of ZMQ, says that the company has dedicated up to 15 percent of its profits to its public health initiatives, which have been an extension of the company's e-learning base.
To date, ZMQ's games, which tackle behavior-change issues ranging from HIV/AIDS, TB, and malaria to cholera and child trafficking, have reached 40 million people through 20 million completed game sessions.
The development of each game has been the result of a public-private partnership. The company's successful Health Mela (or Health Carnival) game, for example, was the result of a collaboration with the Health Communication Partnerships at Johns Hopkins University and Avert Society, with additional support from USAID-India.
That game is composed of a series of carnival-like activities that promote healthy behavior, including one in which the player must help the main character make important life choices. Others have lighter premises, such as a cricket match that incorporates HIV/AIDS messages.
Realizing the limitations of computer-based gaming within the context of the developing world, ZMQ has also begun creating games for mobile phones.
"We believe that mobiles are the technology of the future, the device that the common man will carry," says Quraishi. His company has already launched a successful mobile phone initiative focusing on East Africa, with applications in both English and Swahili.
Like the speaking books, ZMQ's games have been highly localized to incorporate well-known personalities who resonate with youth. "We are using characters who are very popular in Kenya from Matthare Club [a football team] and are playing in European leagues," he says of the East African game.
But mobile phone initiatives are not limited to gaming; ZMQ is beginning work on programs to increase mobile phone information exchange. One project encourages women to track their pregnancies through mobile phone updates, and provides additional information for HIV-positive expectant mothers.
Such innovative re-castings of the mobile phone as a public health tool, while in the vanguard, are already being piloted in one African country.
For Antiretroviral Therapy, Press 1 Now
The tiny landlocked nation of Rwanda is perhaps most remembered for the horrific acts of genocide that occurred within its borders over ten years ago. Today the country is trying to shake that image and reestablish itself as the ICT hub of Africa.
Perhaps it is appropriate, then, that Rwanda should be the first African country to pilot communications company Voxiva's TRACnet application, which uses mobile phones to collect, organize, and share data regarding HIV/AIDS care and treatment services.
Since its launch two years ago, TRACnet has expanded to cover 75 percent of Rwanda's 340 clinics, attracting the attention of PEPFAR, which entered into the multilateral Phones for Health alliance in February of 2007.
"The purpose is ultimately to provide a two-way communication network, to track both resources as well as patient information," says Mark Landry, Senior Informatics Specialist for PEPFAR. "It's using SMS technology for real-time collection of information to create efficiency."
Most of sub-Saharan Africa and developing parts of Asia and Latin America currently rely on paper for medical data collection.
"I've walked into clinics all over rural Africa where medical charts are piled on shelves in utter chaos, there's no alphabetical piles, no dates next to entries," says Laurie Garrett, a Pulitzer-prize winning science writer and Senior Fellow for Global Health at the Council on Foreign Relations. "Most places I've been they don't even have filing cabinets."
Garrett is quick to note that the situation is not all that different from the United States, which she says is in the "Dark Ages" when it comes to medical information coordination.
"Every time you change jobs or your employer changes its insurance carrier, your whole medical history gets lost," she says, pointing out that it's normally up to each patient to remember his or her own history when they change doctors. "And I don't think there's very many people who can tell you what drugs they were taking in 2004."
The same problem afflicts health care systems in the developing world. But with more pervasive public health threats like HIV, TB, and malaria, the effects of poor medical data coordination are harder-felt there.
The possibilities for an integrated mobile phone network for public health in the developing world are endless: medical personnel in understaffed rural clinics can consult with doctors in major hospitals; pharmacies can collect patient data quickly, allowing for faster deployment of life-saving drugs and supplies; barcode systems can root out counterfeit pharmaceuticals and reduce the significant loss of medical supplies to theft and graft; and patients on heavy drug regimens like antiretroviral (ARV) therapy can receive regular reminders about dosage and medical checkups.
Landry sees a wide array of possibilities stemming from a coordinated mobile phone campaign, including educating youths, which, like Quraishi, he sees as a key target audience. "Certainly ICTs are very attractive to a cohort that we're interested in reaching out to before they make decisions in adulthood that are going to make an impact on HIV prevalence."
Garrett believes programs like Phones for Health are on the right track to help African health systems better collect and coordinate vital information.
"It's a huge leap forward, it's too bad it's just a leap forward for one disease, or for that matter just one aspect of one disease: treatment," she says, noting that in a country like Rwanda, TB and malaria are more urgent problems than HIV. "I would love us to get way beyond HIV/AIDS and get to the total patient."
The Battle for Hearts and Minds… and Lungs and Livers, Too
ARV treatment, TB vaccinations, and anti-malaria bed nets may be critical to ending those three epidemics, but the latest ICT revolution is providing the opportunity to enhance the reach and impact of such stalwart interventions and influence genuine behavior change.
"While doctors take care of the lungs or liver of people, it's actually the media and entertainment industries that have had greater resonance with their hearts and minds," says Dr. Neeraj Mistry, Vice President of Knowledge, Evaluation and Performance at the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria. "The latter is far more important to influence behavior change—to use condoms, to engage in safe sexual practices, to follow particular diets, or to exercise regularly."
Though he cautions that many ICT interventions have yet to prove their efficacy at changing behavior, Mistry sees enormous potential in the ICT revolution to influence change globally, allowing public health interventions to reach more people than has ever been possible.
"Conventional public health approaches are failing to actually scale up and meet large population needs," he says. "Now with the high mobility of people and improved access to information, we have the opportunity to achieve scale in public health messaging and interventions through the medium of information and communication technology."And it is behavior-change initiatives like Books of Hope and Freedom HIV/AIDS that are delivering critical public health messages to youth, the illiterate, and to rural populations—messages such as: AIDS is not a death sentence; TB is treatable when detected early; and malaria can be prevented with a simple bed net.
Capacity-building programs like Phones for Health also hold enormous potential to increase the effectiveness of public health interventions in the developing world, arming both doctors and patients with accurate information that can mean the difference between life and death.
Considering the enormous potential of this rising ICT tide, the future of global public health interventions, it seems, may have less to do with the brochures and pamphlets of the past than with the silicon and SIM cards of tomorrow.
Take Action
How can other technologies support my efforts?
- Project planning: Project planning tools can improve program efficacy by enhancing forecasting, allocations, roles and responsibilities, timelines and budgets.
- Epidemiological trends and demographic monitoring: A number of software platforms allow for greater trend monitoring, including SPSS, which is used specifically for demographic analysis, and the Public Health Information Network, which enables consistent exchange of public health data.
- Patient monitoring and program evaluation: The rapid proliferation of mobile phones and Internet access is allowing for greater monitoring and evaluation in hard to reach areas, with particular impact in the field of telemedicine.
- Data gathering and knowledge management: Programs like Voxiva's TRACnet are revolutionizing information gathering and management in the developing world.
- Awareness and education: Interventions can be greatly enhanced through digital solutions like company-wide intranets, electronic newsletters, e-forums for knowledge cocreations and virtual platforms.
- Edutainment: Gaming technologies, like those developed by ZMQ, and other entertainment platforms can have practical applications for education and behavior change.
