Piya Sorcar, of the Learning, Design and Technology Program at Stanford University is leading Interactive Teaching AIDS (ITA), an initiative to develop “an animation-based curriculum to teach HIV/AIDS awareness and prevention strategies.” There are currently two versions of the application in development, one for India and one “general Asian version”.

I had the opportunity to speak with Piya about her work:

Why cartoon animations?

When I started this project last year, as part of my research I interviewed dozens of people on this subject. I couldn’t understand why so much misinformation was out there about a virus which many organizations have tried to combat through strong dedication and millions of dollars. After many interviews and running an IRB-approved study in India, I realized that people averse to discussing HIV/AIDS because of the stigma associated with its connection to discussing sexual practices. The educational materials are actually quite simple, it is getting the education to the people that is hard. Fighting stigma is not easy and we know this because people are so embarrassed and frightened of asking simple questions that in the long run might save their lives. I wanted to use cartoons to make the subject less embarrassing, to enhance learner comfort. When I originally ran the IRB-approved study in India, I gauged the comfort of students in learning HIV/AIDS material with various illustrations. People were most comfortable with simple graphics and actually, the simple graphics seem to get the points across just fine. It was important to me that individuals learn about this subject while feeling comfortable. I felt that cartoons accomplished this mission.

Why emphasize the biology of HIV/AIDS?

HIV/AIDS is a difficult subject to talk about. There are schools that won’t teach the prevention strategies because of its close ties to sexual practices. What we often forget is that HIV is just a virus, and we study viruses in biology classes all the time. By bringing the subject back to the basics, we can discuss it more openly and clearly. In order to prevent the spread of the virus, it’s important to build a coherent conception of where it lives, how it works and how it is transferred. In order to fully understand this, it’s important not to merely memorize a list of safe actions but to understand why a virus spreads.

What is the underlying pedagogy of this initiative?

There are many pedagogical principles utilized, but I would say the most important is based on the cognitive theory that it is important to create a coherent conception in the mind of the individual learning the material. Since in many countries there are few, if any, requirements for students to learn about HIV/AIDS in educational institutions, they tend to learn about it from mass media campaigns through television, billboards and radio. Although there are strong efforts to disseminate HIV/AIDS information in India (among other countries), because of the nature of the aforementioned education strategies, individuals must make sense of short, out-of-context pieces of information on their own. This often leads to misunderstanding as well as the memorization of random fragmented data, which doesn’t build a clear conceptual map. Interactive Teaching AIDS provides calculated learning steps to provide scaffolding for learners, allowing them to develop a coherent conception of basic biology, bodily fluids, transfer of bodily fluids into the human body, and their application to various actions or scenarios. In addition to building on a cognitive approach, we relied on other learning techniques including the use of mnemonic devices as well as Vygotsky’s scaffolding techniques. [See also: ITA Learning Theory & Rationale]

What is the current status of the projects in India and Korea? What makes those initiatives different from one another?

The Asian version of Interactive Teaching AIDS was fully funded by the Medical Research Information Center in Korea, which is funded by the South Korean government. The storyboard, which was developed at Stanford University, was animated by a professional development team and now needs to be translated into several different languages. We plan to test the production version of the project early next year. The prototype for the Indian version is complete and we have just received funding from a couple donors to create a more industry-ready version. Once that is complete we plan to test it throughout India. We hope the testing will provide us with useful data so we can iterate and make the project more effective. Finally we hope to give it away for free to various AIDS control societies, schools and eventually port to mobile devices so the information can truly be viewed in the privacy of one’s home. We are hoping also to partner with various organizations who are interested in the same goal as us – to promote awareness and prevention methods to people all over the world.

What is the overall assessment plan?

As I mentioned earlier, we hope to test this project with many students in Asia in order to inform our design and create a more effective learning tool. We hope to compare and contrast our work to other AIDS and general health education materials.

What are the key challenges ahead? (development, deployment, adoption, behavior change)

I would love to see the educational content available on all mobile devices across Asia. Perhaps governments and mobile service providers would be interested in partnering with us in order to either make this content freely available to download online or better yet, be preinstalled on the buyers cell phone or PDA. In terms of development the challenge is, of course, to develop something that is fairly short yet still gets the message across using limited screen real-estate. Once we have tested this project widely, hopefully we will have a better idea of what works and what doesn’t work and this will inform us in designing a mobile version of the project. Secondly, since there is no universal platform for cell phones, it will be challenging (not to mention expensive) to develop the animation using various scripts. When I ran the study in India, I was appalled that so many college-educated students were misinformed. The number one question was whether there was a cure for AIDS. My goal right now is to inform masses about the virus and prevention strategies. I think we have a huge problem if the population of the country with the greatest number of HIV/AIDS cases in the world doesn’t have a general understanding of how the virus spreads. Once the goal of educating people has been met, this will hopefully lead to behavior change.

Pharmacies, as specialized services with specialized staff, are often the limiting factor for the delivery of health care in low-resource settings. I work with a small clinic in South Africa that has more than 1,300 patients on ARV treatment. We’ve worked with an NGO Cell Life to bring in a computer-based ARV dispensing system, iDART, to speed dispensing and decrease clerical work. Simple solutions to help pharmacies such as pre-packaging drugs, dispensing two months supply to stable patients, and easy to use registers can make a big difference, however as clinics grow, there comes a point when a computer system will keep the clinic ahead of the crush.

Here are a couple of systems that we’ve come across for dispensing at the clinic level with some key attributes. We’re not exactly clear which will work the best and would love input if you have used these, or know of others.

* Cell Life, iDart – Built for ARV dispensing, iDART incorporates the ARV start date, treatment supporter contact info, and defaulter tracing. Reports cover the necessary requirements for government (stock dispensed, etc.), and will soon allow for easy PEPFAR reporting. Bottle labels print with a click of a button speeding the consultation. The system can be used for dispensing directly to the patient or to keep track of drugs that have been packaged for individual patients at a central pharmacy and then distributed at local clinics. The system is Open Source, but no outside developer base exists as far as I know.  It is downloadable at their site.

* ProPharm – Built for retail dispensing ProPharm has a large customer base and fast and easy customer support (a key need when computer skills are lacking). The system is more complicated than iDART but can be modified to include ARV specific dispensing information. An NGO manages thousands of patients on numerous studies with this, and, as far as I know, likes the system. I don’t think, however, that they are using it at the clinic level. The learning curve is steeper given greater complexity and features that are not used in public sector dispensing. It’s a proprietary system.

The question was raised on the Pienso blog [Dec 18 "Link Drop"] in reference to a Harvard Business School newsletter Q&A [Dec 13, "Improving public health for the poor"] with Michael Chu, Harvard Business School lecturer and one-time micro-financier. Chu developed Project Antares [course description at bottom of HBS link] with colleagues at Harvard School of Public Health to explore means of delivering public goods and services via the private sector.

Microfinance may offer a window on new methods for widening access to healthcare for the poor, says Harvard Business School’s Michael Chu… Bringing together public healthcare and market forces “could have huge impact,” he says.

I have two problems with the interview and some praise for taking on issues outside the standard purview of business schools.

First criticism: The language in the Q&A comes off at times as naive -

Martha Lagace: What is missing by defining health, as we do today, as a public good?

Michael Chu: …right off the bat you need scale and permanence. Both private and public philanthropy, when they work well, play a key role in fostering the birth of new concepts and ideas. But neither philanthropy nor development agencies are structured for scale or permanence. Some really powerful instruments of philanthropy, like the Bill & Melinda Gates Foundation, are putting hundreds of millions of dollars towards the eradication of a disease. Huge as that is, it’s not an effort that can be permanent.

There are numerous examples of public sector health programs in the past 200 years that have operated at scale and achieved lasting impact. Two immediate examples contradict his odd statement on disease control: global eradication of smallpox led by public sector agencies and the history of the March of Dimes, an innovative charity that financed the research for and distribution of the polio vaccine [Amazon link: Patenting the Sun: Polio and the Salk Vaccine].

Second criticism: This interview indicates a partial understanding of what is involved in protecting the public’s health. “Public health” consists of activities across several domains: research, education, service delivery, and disease surveillance. The ratio of social and private returns varies across those domains and in only one do health care services, both public and private, figure prominently.

However, the idea of incentivizing the health care for the poor via the private sector is an applaudible effort. It’s well known that the poor in low-incomee countries, when they seek care at all, disproportionately use private sector services.

In the majority of the sub-Saharan African countries for which DHS [Demographic and Health Surveys] data were available, of those children seen by a medical practitioner, the use of public services by the rich was not significantly different from that by the poor. On average, of those children seen by a medical practitioner, most of those from the poorest quintile sought care from private providers for both diarrhoeal disease and ARI [Prata et, al. 2005 "Private sector, human resources and health franchising in Africa" WHO Bulletin].

Chu’s work does underscore the need for greater investment in innovative schemes to bring scaled health services to the poor and lessons from microfinance would certainly apply. Identification of the appropriate services is key as is targeting the right service to the truly poor patient.

Q: What are your next steps for Project Antares?

A: We want to refine the matrix that will allow us to propose what the high-impact interventions are and develop commercial delivery systems for them. Next term, we’re looking towards establishing teams of HBS and School of Public Health students who will work on independent field study projects in the development of commercial approaches.

THDblog recommends the Disease Control Priorities Project with its exhaustive chapters of cost-effective interventions across the full range of human illness.

Microfinance also has unique targeting properties that may hold some lessons for targeting of services to low-income patients. Micro-finance brings limited but critical credit to customers. The customers self-select in the applicant pool for screening. Better-off individuals do not apply. One example where this happens now is in the hugely successful Indian NGO, Aravind (Aravind Eye Care System). Aravind provides a no-frills eye care services including cataract surgery at little cost for low-income patients. The same medical procedures are sold to high-income patients but additional customer service amenities are added to enhance the experience and justify the expense. And Dr. Chu’s program will certainly add new insights in the entrepreneurial approach to public health.

ADDENDUM Dec 20th:

There’s a great discussion started last August at NextBillion.net about the new found consumer potential at the bottom of the pyramid. Should the poor be empowered as consumers or producers? Perhaps simplistic to group low-income earners as “either-or” but interesting discussion.

And Laurie Garrett writes in the Jan/Feb 2007 issue of Foreign Affairs ["The Challenge of Global Health"] on the importance of local private sector investment in health if increases in healthcare provision and innovation are to be sustained beyond limited donor horizons in low-income countries.

…it is curious that even the most ardent capitalist nations funnel few if any resources toward local industries and profit centers related to health. Ministries of health in poor countries face increasing competition from NGOs and relief agencies but almost none from their local private sectors. This should be troubling, because if no locals can profit legitimately from any aspect of health care, it is unlikely that poor countries will ever be able to escape dependency on foreign aid.

Following Forum 10 in Cairo, the Global Forum for Health Research will be holding it’s next annual meeting, Forum 11, in Beijing from 29 October – 2 November 2007. They have announced a call for abstracts with a deadline of 31 January 2007. From the website:

The Global Forum for Health Research invites you to submit an abstract for Forum 11 in any area of health research relevant to the overarching theme of Equitable Access: Research challenges for health in developing countries.  Papers addressing these areas from a national, sub-national or regional perspective are particularly invited. The Global Forum welcomes submissions from all parts of the world and encourages participation from lower income countries.  Submissions of abstracts from students are especially encouraged and the best papers will be specially featured in Forum 11.

The five thematic strands are: access to health, innovation, research resources, decision-making, and communication. The website suggests a particular emphasis on gender equity.

Fascinating story in today’s NY Times about the impressive population wide impact of iodized salt and also the difficulty in implementing this very technologically “simple” intervention: “putting iodine in salt, public health experts say, may be the simplest and most cost-effective health measure in the world. Each ton of salt needs about two ounces of potassium iodate, which costs about $1.15.” The article details what happened when the Soviet Union fell apart and the following public health consequences. For those of you in a rush, the video synopsis by the NY Times of this article is great (see article for “multimedia”).

This article is part of a series that examines diseases that hover on the brink of eradication, and the daunting obstacles that doctors and scientists face to finish the job.

NY Times 12/16/06 In Raising the World’s I.Q., the Secret’s in the Salt
Excerpts:

Studies show that iodine deficiency is the leading preventable cause of mental retardation… Putting iodine in salt, public health experts say, may be the simplest and most cost-effective health measure in the world. But the effort has been faltering lately. When victory was not achieved by 2005, donor interest began to flag as AIDS, avian flu and other threats got more attention.

The cheap part, experts say, is spraying on the iodine. The expense is always for the inevitable public relations battle.In some nations, iodization becomes tarred as a government plot to poison an essential of life — salt experts compare it to the furious opposition by 1950s conservatives to fluoridation of American water. In others, civil libertarians demand a right to choose plain salt, with the result that the iodized kind rarely reaches the poor. Small salt makers who fear extra expenseoften lobby against it. So do makers of iodine pills who fear losing their market.

Rumors inevitably swirl: iodine has been blamed for AIDS, diabetes, seizures, impotence and peevishness. Iodized salt, according to different national rumor mills, will make pickled vegetables explode, ruin caviar or soften hard cheese…Breaking down that resistance takes both money and leadership. “For 5 cents per person per year, you can make the whole population smarter than before.”

FULL STORY

As I like to contend, non-public health people from various disciplines are starting to have dramatic impact on public health, unlike never before … and folks in public health are far behind the curve in many respects. One of which is keeping up with others who are jumping in and changing the face of global health. The following story in today’s Wall St. Journal is a great example of how industry/private sector immigrants in the US are going to eventually make big strides overseas in the health arena. This particular case has been already well documented in the IT services sector and even though not many are talking about it, I do not see why the same will not hold true for the health care sector, to a more limited extent. Professor Anno Lee Saxenian just released a book about succesful immigrants in the high tech/IT arena going back to their home countries to start up ventures. The book, “The New Argonauts”, is well worth checking out. In my opinion, a similar potential exists for the pharmaceutical and medical device sectors. Admittedly, the process will be much harder with pharmaceuticals, but stories like the one below in the WSJ are promising for developing regions. The team over at the Canadian Center for Genomics and Global Health have begun to study this pheonomena in the biosciences, check out their article for a discussion on the potential and limitations faced – Scientific Diasporas.

If you don’t believe the capacity of regions across the world is growing, click on the map below to see biotech clusters around the world. It is a bit strange that they do not highlight Cuba’s well known biotechnology capacity. To be fair, there are challenges, for another take on the limitations of R&D in places like India see this article on Innovators without Borders.

Many thanks to Katie for passing the WSJ article along!

WSJ 12/14/06 Patent Remedy: Indian Scientists Return Home

PUNE, India — For more than 20 years, Rashmi Barbhaiya lived a comfortable life in New Jersey…Now, in a move that hints at a big shift in the global pharmaceutical business, Dr. Barbhaiya is back home in India. He’s still trying to discover new drugs, but he’s doing so with an all-Indian-born research team at a company he founded in this center of Indian high technology. Dr. Barbhaiya runs Advinus Therapeutics, a company whose new-drug research would be powered by Indian scientists returning from the U.S. and other countries.

As big drug companies shut down some research facilities in the U.S. and other rich countries, labs in India and China are increasingly picking up the slack…Eli Lilly & Co., Wyeth and GlaxoSmithKline PLC all have outsourced chemistry work to Indian firms…Now Indian companies are increasingly conducting clinical trials, performing contract chemistry work and, as Dr. Barbhaiya’s journey shows, carrying out original research aimed at discovering new drugs.

One of Dr. Barbhaiya’s passions is discovering drugs for diseases that are prominent in poorer countries but rarely get attention from Western drug makers…Dr. Barbhaiya steered Ranbaxy into a pact in 2003 to develop an antimalaria drug with the Geneva-based Medicines for Malaria Venture. The drug is now in midstage clinical trials.

Full story at WSJ.

Yesterday the National Institutes of Health announced the halt of two randomized control trials on male circumcision for HIV prevention. To continue the studies, the investigators believed, would be unethical. From the NIH news release posted on Politics and Policy of HIV/AIDS*:

The trial in Kisumu, Kenya, of 2,784 HIV-negative men showed a 53 percent reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48 percent in circumcised men.

More from the NIH press release …

“Many studies have suggested that male circumcision plays a role in protecting against HIV acquisition,” notes NIAID Director Anthony S. Fauci, M.D. “We now have confirmation—from large, carefully controlled, randomized clinical trials—showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse. While the initial benefit will be fewer HIV infections in men, ultimately adult male circumcision could lead to fewer infections in women…

Scaling the intervention will be interesting, to say the least. The procedure can be conducted safely on infants, boys and young men in a clean field clinic setting. Risk of minor adverse events is low, though present. It is low cost; one South Africa study estimated the average cost to be $55 per patient and considering that it’s a one-time procedure with an estimated 50-60% reduced rate of infection, it’s likely to be highly cost effective in populations with a high prevalence of HIV.

However, in my own limited time in East Africa, questions about circumcision for HIV prevention raises mixed responses among colleagues. It’s a topic weighted with ethnic and religious identities. Yet, Culture should not be overplayed especially in light of the incredible potential implied by the recent findings. The early response in southern Africa to a similar study finished in Orange Farm last year (see “Swaziland to endorse male circumcision“) suggests that the intervention, given its solid science and policymakers’ strong endorsement, can quickly gain public interest and save lives. A detailed mathmatical model published last July (“Potential impact of male circumcision on HIV in sub-Saharan Africa“) estimates that 1.1 to 3.8 million lives can be saved in the next ten years if male circumcision is scaled quickly across sub-Saharan Africa.

*full disclosure: I help run the Politics and Policy of HIV/AIDS blog and the link and NIH news quote are from a post I made Dec 13th when the MC news was first released.

Technorati Tags: HIV, public health, developing countries, male circumcision

UPDATE: Both the Center for Global Development and Owen Barder have added there thoughts about the Summit.  

I wanted to highlight the LIVE webcast (via KFF) of the Whitehouse Malaria Summit tomorrow.

Several different news items worthwhile reporting plus one unrelated video I found very interesting:

1) Improved Diagnostic Technologies for the Developing World

A Great series of articles published in NATURE – Description from SciDev.net: “Improving people’s access to tests for the major diseases of the developing world and making the tests more accurate could save hundreds of thousands of lives, say researchers. Millions of people in developing countries die each year from illnesses that are preventable or treatable because the diagnostic tests are too expensive, complex or inefficient to use. A series of papers published in Nature (7 December) calls on scientists, policymakers, and global health organisations to work towards making these tests appropriate for use in poor countries.”

2) Whitehouse Malara Summit – LIVE WEBCAST, 12/14 (8:45am EST)

The WSJ (via Brown Global Health Blog) has an interview with Melinda Gates. “She is stepping into the limelight as an outspoken advocate for closing the global health gap. On Thursday, she plans to announce an expanded initiative with President Bush and first lady Laura Bush’s summit on fighting malaria, a mosquito-borne disease that kills one million people a year, mostly children under five.” The White House Summit on Malaria to bring together international experts, corporations and foundations, African civic leaders, and faith-based organizations to raise awareness of the issue of malaria. Kaisernetwork.org will provide a LIVE webcast of the summit.

3) Health Affairs Blogging about Health Insurance – Private Insurance For Developing Countries

4) The Dove Campaign – this is unrelated but I found this short clip fascinating, which I originally saw over at From Tribeca to Tanzania.

[youtube=http://www.youtube.com/watch?v=I09Mud8kguQ]

The Washington Post yesterday (“For Some, Laptops Don’t Compute“) reported on an model ICT rollout in a DC area suburban high school system. In the fall of 2004, the Alexandria school system gave every high school student a new laptop leased by the district over four years. The rollout was part of larger effort to modernize the city, probably driven in part at the time by the nascent buzz around municipal wireless clusters. The initiative’s goal was, according to the Post, “to make the machines indispensable, linking them to electronic textbooks, classroom projectors and other academic tools” as well as linking them to the web on new wi-fi networks.

I couldn’t help but think of the One Laptop per Child project with plans to distribute millions of laptops to school children in low-income countries. There are important lessons to be learned from the Alexandria experience and similar places (state wide programs in Michigan and Maine according to the same Post article) if OLPC is to truly be the great leap forward its promoters promise.

Two years into the Alexandria rollout some are now arguing the $1.65 million expense has yet to produce justifiable improvements in student performance. The question about impact is hard to estimate without a strict evaluation strategy beforehand (read the first comment in this OLPC wiki post “Parable 2“, in the same vein as Easterly and others on rigourous eval). And not surprisingly some school officials were quick to defend the program.

Alexandria officials say it is too soon to gauge laptop-driven achievement gains, because T.C. Williams started issuing the machines in fall 2004 to sophomores, juniors and seniors, and the Minnie Howard School, which feeds into T.C., began distributing Dell laptops to ninth-graders in fall 2003.

Others pointed to the significant difference between introducing new technology for its own sake and thoughtful rollout of effective pedagogy reform.

“I think they made the realization that they may have put the cart before the horse,” said G.A. Hagen, a technology resource teacher at T.C. Williams. “It was like, ‘Okay, teacher, here’s the laptop — go with it,’ and [teachers] were like, ‘What do you mean, go with it? Is there a Web site I go to?’ “

Lessons have been learned, if not formally evaluated, and teachers are now trained on software apps and curriculum strategies while students are offered instruction on effective ways to get more from the laptops. One web application now in place at the Alexandria system is Blackboard, an electronic space built for instructor and students to post lectures, provide mentored forums, and backend grade management if needed. Only now, two years into the program are nearly “all T.C. Williams teachers … trained on Blackboard. They will be required to make their courses available on the system by Jan. 8 and to use the program regularly by June.”

I’m surprised I haven’t been able to find much on incorporating appropriate educational tools into the OLPC project yet. A quick check of the OLPC wiki had a paragraph about educational strategies, limited text on documentation and incorporating OLPC into effective pedagogy in low-income settings as well as long laundry list of questions from the interested and curious. You should definitely browse the wiki if you have any interest in the OLPC project. And anticipating criticisms in the Post article, the OLPC wiki does mention teacher training, recognizing that it will be an obviously important element driven by local experts but no greater detail yet.

The OLPC has a admirable goal to take the information age to children who have little chance to be part of it now. Yet to see OLPC as a success five years from now, more thought and effort must be put into user-centered design. There are some entertaining images of village children cranking the machines by night to watch DVDs with their family gathered ’round, but more needs to be done (and shared with an eager world) to indicate how this tool will improve student performance in grossly under-performing educational settings; or in five years’ time we might be reading about the OLPC in the same underwhelmed tone of today’s Washington Post article.