Monday, May 28, 2007

Trout Fishing in Africa

Friendly Fire
Some time ago, I wrote an article for a US magazine, the basic premise of which was that technology has the potential to bring about a revolution in post-conflict southern Sudanese society, particularly in healthcare. I thought that my arguments, though a little thin, were basically well founded and would meet with a sympathetic audience. Not so, I received a deluge of criticsm. What stung me a little was the amount of ‘friendly fire’ I attracted from my colleagues who described my line of reasoning as little more than a hackneyed and na├»ve view of the power of Western technology that failed to recognize the realities of health and development in southern Sudan and in Africa generally. Chastened but recognizing my discussion was a bit superficial, I pondered the question more seriously, expanded my research and offered a ‘new improved version’ for scrutiny. I have reitereated the argument in this piece.

Bridging the Digital Divide
My contention was that building a new healthcare system for southern Sudan lends itself perfectly to the technologies and techniques of telemedicine. The distance, terrain and climate (8 million people living almost entirely in rural areas of a region one and half times the size of Iraq, where for six months of the year the rains make travel nearly impossible) dictate that resources be concentrated at the primary healthcare level, the point where most patients might reach, despite the constraints of austere terrain and climate. Given the immense logistical challenges of getting patients from primary care to secondary care or even specialists out to primary care the most viable option is to connect the system electronically and in turn connect the regional ‘health intranet’ to the world, enabling economies of scale and access to bodies of medical knowledge hitherto inaccessible. It would bring healthcare to the patient rather than the other way round. The critics argue that the idea of ‘technology jumping’ whilst fine as a ‘vision thing’ ignores the realities of life ‘at the sharp end’. They further contend that the fundamentals need to be in place first: regular electrical power sources, communications, potable water, trained healthcare staff and properly equipped health facilities within reach of communities. They say, in a world of limited resources, the priority should go to immediate needs and not dissipated on ’bridging the digital divide’, an idea whose time has yet to come

Teach a Man to Fish
During my musings I came across a paper in the Canadian Medical Association Journal of September 2001 on the issue of telemedicine in Africa, written by a Dr Ellen Einterz who at the time of writing was working in a rural hospital in Cameroon. The redoubtable Dr Einterz argues powerfully from a position of practical knowledge, she has worked at the sharp end healthcare in Africa for over 27 years. I have critiqued her paper as it crystallizes the doubts and reservations I have heard these past weeks. I hope she will forgive my criticism but she is the only person I have found brave enough to publish her opinions.

She begins delightfully by revising the much-overused aphorism…’teach a man to fish and he eats for a lifetime’, to ‘teach a man to fish and he’ll need to buy a fishing rod, reel, selection of hooks, lines, lures, tackle box and boat’, as a metaphor for the demands and limitations of telemedicine. She acknowledges that [telemedicine] has great potential for continuing medical education, specialist consultation over distance and the exchange of knowledge and ideas but counsels that the ‘seduction of satellites’ should not divert resources from the earthbound problems of healthcare in the continent.

Limitations of Technology
Her catalogue of social and healthcare ‘realities’ in her community is an echo of Sudan and for that matter most countries in Africa. The list includes lack of potable water, unreliable electrical and power sources, no paved roads or telephone system, inadequate healthcare and education, high levels of illiteracy and customs and practices steeped in superstition and myth. I have no quarrel with her argument regarding the challenges faced by her and most healthcare providers in rural Africa. I even agree with her description, borrowed from a Sunday Times of London article, that “the instruments of our computer age are stupid, unreliable pieces of plastic that can, when the wind is in the right direction be so incredibly useful that you can forgive them almost all their faults on the spot”. We diverge in our thinking when she describes the demands and limitations of telemedicine.

She argues, “for telemedicine to work not only must the wind be in the right direction but the rain must not be falling too hard and the electricity must be on; people who until now have never see a computer or used a telephone must be capable of operating, maintaining and repairing equipment; spare parts, updates and upgrades must be budgeted for and available. The increased need for thousands of miles of high-speed telephone lines and large bandwidth must be addressed… Massive droves of teachers, nurses, physicians and surgeons should be trained and induced to serve where they are needed…Telemedicine will not be able to save the millions who die every year of preventable, treatable acute respiratory tract infections or diarrheal diseases… …It will do nothing to halt the spread of TB or HIV/AIDS. Not one millimeter of fibreoptic cable is needed to improve basic obstetric care…”

Western Model
My counter to her indictment of technology is that her model for telemedicine seems to be that developed for medicine in the Western world and it fails to take into account man’s ability to adapt technology, particularly in Africa. Why must there be an archetypal electricity supply? Almost every electrical gizmo on sale in Africa for use in austere environments is designed to use minimum power and has a solar power source developed for it, from mobile telephones, to lighting systems, radio transmitters, computers and satellite dishes. When the sun doesn’t shine industrial strength batteries or lightweight cheap generators take over. Copper wire telephones are history; more mobile telephones are sold every day in Africa than in Europe. As computer manufacturers realize the developed world has reached near saturation point in hardware, they have turned to the developing world for markets; computers are quickly becoming more robust, user friendly, reliable, cheaper and easier to maintain. Satellite communication too is rapidly becoming easier and cheaper. Lightweight, robust and inexpensive hardware such as Vsat™, Rbegan™ and the Thuraya™ satellite phone are driving demand and decreasing costs of both equipment and transmission. Digital cameras are dropping in price and increasing in capability at almost the same speed. Digital microscopes, portable ultrasound machines and a host of telemedicine tools for consultations over distance, are becoming commonly available as manufacturers recognize a potentially huge market for rural healthcare the developing world. Above all, the mobile telephone is shaping and driving the communications revolution and economic future of Africa.

Technology and Health Education
The concept of training and deploying large numbers of nurses, doctors and surgeons to rural areas [where the majority population of Africa still lives] is commendable but history has shown, very hard to achieve. A significant reason for the reluctance of healthcare workers to serve in remote areas is the loss of contact with their mentors, peers and the infrastructure in which they trained. Telemedicine is an ideal means of maintaining that contact and a first-rate tool for continuing medical education.

Finally, the contention that telemedicine will not be able to save the millions who die every year from preventable disease, may be true but I contend that neither will the ‘masses of nurses, physicians and surgeons’ she advocates. History shows that the most vital tool in public health is an educated and active public. The same communications technology that provides for medical diagnostics and specialist opinions can also serve to educate the people; we might call it ehealth. Satellite TV is rapidly becoming one of the most powerful and ubiquitous means of mass communication in Africa; the government of South Africa, which has a national health education program using TV, has long recognized its potential as a health education tool. There is currently a plan in train to trial the program in Kenya, using funds from NEPADS

Communications Revolution in Kenya
A glance at the telephone and Internet systems of Kenya shows how quickly technological change is sweeping Africa. Five years ago there were 300,000 copper wire telephone links in a country of 32 million souls. Today there are only a few more but 1.5 million cell phones. They are simple cheap and use ‘scratch cards’ to pay for airtime. Text messaging is cheaper and more popular than voice. People can talk to each other across three countries of East Africa, Kenya, Uganda and Tanzania, and ‘text’ Africa and Europe for a few cents. Already some ‘wealthy’ young city dwellers are using camera phones. Two years ago Internet access from here was expensive, erratic, confined to big cities and slow as a glacier. Thanks to ICT revolutions such as GSM and GPRS, I can now access and send email in the remotest areas, simply by using my mobile phone. I am convinced that within a year, GPRS and 3G phones will be commonplace in Kenya and across east Africa. The Internet has come to Africa, through the mobile phone rather than the PC. Two years ago a friend who is now the Foreign Minister, told me he had a vision that one day every Kenyan would have a personal address [currently there are only Post Office Box numbers for those who can afford them]. When I expressed my doubts he told me it wouldn’t be a physical address [home or office] but an Internet address unique to every Kenyan. I have little doubt that it will happen. Such is the potential for technological innovation here.

Taking Healthcare to the People
Healthcare and technology are converging fast in this part of the world. There is every incentive for it to happen. The people remain overwhelmingly rural and their healthcare is sparse. Like most countries in the world the epicenter of healthcare expertise and resources in Africa remains in the cities. Given the huge logistic costs and social changes needed to physically expand healthcare out to the people it has failed to happen, despite the efforts of governments and international organizations. The result is the people come to healthcare in huge numbers and enormous cost. By innovative and appropriate use of technology it is possible to take healthcare to the people and significantly improve the current quality and access to care. I don’t know what the technological infrastructure that will shape future healthcare in Kenya or Sudan will look like, only that the systems and technology must be simple, reliable, robust and affordable. I am pretty much sure therefore, that it will be based upon mobile phones rather than PCs. I also am convinced that investing in telemedicine and enhancing healthcare resources in the Horn of Africa need be neither a linear progression nor mutually exclusive.

Returning to the metaphor of ‘teaching a man to fish, in the occupation of fishing Dr Einterz compares telemedicine to teaching a man to fish for trout on a river filled with carp. As a veteran fly fisher who has hunted trout in Africa I can assure her the tools and techniques are equally effective on carp. The technology is not important it’s how you use it that matters.

Tuesday, May 1, 2007

Frightened for Fifteen Minutes

My counselor’s name is Mercy. She is in her early twenties and pretty with intensely sad brown eyes. She speaks so quietly I have to lean forward to hear her. I have the strangest flashback, I am eleven years old again and about to be examined for nits by the school nurse. I am suddenly and irrationally anxious. The morning sun is beating on the tin roof; I can feel the radiated heat and begin to sweat. She is cool and dignified in her clinical coat. In matter-of fact tones she explains the intimate biology of HIV/AIDS pausing now and then to ask me, “Do you have a question?” Each time I answer, a little too firmly, “No.”

We are sitting facing each other; she looks into my face and tells me this is a voluntary test and asks me if I wish to carry on. She follows this by asking me if I am prepared for the result to be positive and what I intend to do. I reply with an overly firm “Yes” and “ I will tell my sexual partner(s). ” She has one more question. Do I understand there is a “window period” between infection and antibodies being produced and if I have had “risky sex” within the last six weeks or so I could test negative but still be at risk? I assure her I am not at risk but have another bout of white-coat hypertension.

Mercy explains the procedure we are about to embark upon. She unwraps the RapidTest. It is a small flat white plastic strip with a long “V” running its length. The test takes ten minutes. She will place one drop of my blood at the cleft. It will disperse and move down the “V”. After about two minutes it will leave a fine red line about three quarters up. This is the control line. If within the next eight to nine minutes a second line appears between the cleft and the control line it will indicate that I am almost certainly HIV Positive (but another test will be made to be certain) if no line appears I am negative.

She produces one of those awful little stabbing instruments; I suppress a shiver and offer the middle finger of my right hand. She cleans it with a soapy disinfectant and squeezes the last knuckle until the pulp is dark red. She picks up the “stabber”…my cell phone rings! I frantically search for the phone to switch it off but she insists I answer it. It’s the garage, my car is finished its service. Sotto voce I answer, “Can I call you back, I am in the middle of…something.” I wonder what his reaction would be if I had said “ an HIV test.”

I apologize. She stabs; I wince and watch the drop of blood ooze to the surface, she deftly places it the cleft of the “V”. We both stare at the plastic strip in silence. I search for something to say. I ask how long she has worked as a counselor, she tells me three years. She is a volunteer counselor, which means she gets paid a stipend whilst she trains and looks for paid work. All the time, I have one eye on the test strip. A line appears three quarters along! Mercy whispers it’s the control line. Inanely I answer “Oh good!” We carry on with the small talk. I ask her if later I can interview her and the other staff for an article I want to write on VCT. I don’t hear the answer; my eyes are glued on the strip. I was last tested in 1997 and although a lot of water has gone under my personal bridge since then I am neither promiscuous nor stupid. But I live in East Africa where hundreds of people die of HIV/AIDS every day; it’s easy to be irrational even if you are sure you are not at risk.

Mercy looks at her watch. Ten minutes are up, no second line. I am negative. I cannot suppress a grin of relief. I thank her (a little too profusely?) and tell her I will be back in a short while to do the interview. Outside, the day looks even more beautiful as I join the throng from our office We have come for a group VCT, an idea dreamed up to promote a national VCT and “know-your-status” campaign. The argument being we cannot exhort people to do it unless we do it too. We all admit to being anxious waiting for the second line. They clamber into vehicles chattering happily and roar off in a cloud of dust. I cannot help thinking how lucky we are; relatively well off, educated and having the support of our friends. What must it be like to come to this place poor, alone and worried?

I return to the small, neat blue-painted building. It is one of a number dotted around the periphery of a huge slum at the edge of the city. The staff is made up of one paid and three volunteer counsellors.
Between them they counsel about 15 clients a day. Few are local, they prefer not to be recognized going into the centre. The majority too (about two-thirds) are women. Most seek help because they are worried or unwell or both. Mainly they come alone but married Muslims almost always together. The test costs the equivalent of $0.50. The key is continuity of caring. Whether the result is positive or negative, clients are encouraged to join the “Post Test Club” which meets frequently in the largest of the center’s rooms. The aim is promote self-help and for the negative to mix with and care for the positive. They also take part in ‘Income Generating Activities’. The NGO that runs the VCT will bank whatever money they can muster until they reach the equivalent of $8.00 which qualifies for a loan to begin a small business such as selling charcoal, or cooked maize snacks. In the face of abject poverty and huge levels of disease in the slum, it may all seem too little too late. But my time in Africa has taught me that only community solutions work and that small is best.

I am buoyed by the moment and the sheer dedication of the staff. Then I witness the classic VCT client case; a metaphor for HIV/AIDS in SSA. She is 32 years of age, a single mother of one small daughter. Her only living relative is a brother who does not want to know her. She is a ‘commercial sex worker’. She uses Depo-Provera as contraception and tries to insist that her clients use condoms but they most times simply refuse and find another sex worker. She needs the money so she takes the risk. She has come to us because she is worried. Her test is negative. She is more determined than ever to give up sex work but desperately needs money to feed herself and her child. She agrees to join the ‘Post Test Club’ and to start saving what little she can of her earnings, to make the key $8.00, so she can get a loan; she thinks she can make a living selling children’s clothes. I look at her face, full of desperate hope, know that the only way she will save that money is from continuing to sell her body, and pray she stays negative for another three months.

My interview finished I head for a cold beer. I think about Mercy taking a two-hour ride to her brothers and sisters totally dependent on her and the mother whose only hope is to get out of commercial sex work. I think back to this morning and my own experience with VCT. I remember the feeling of being ‘frightened for fifteen minutes’. And I feel a fraud.