We are really glad to have another guest blogger. Kriti from Epidemiology Tales: Stories Exploring Public Health & Life
is the author of the post below. We look forward to more posts in the future, be sure to check out her global health blog for more information.

Female Feticide: from Motherland to Diaspora

Up- country: Diya, an activist who educated women on female feticide, was recently married. She was 20 years old, and about to give birth. She was riding in a car hurtling over potholed roads toward the town hospital. Although at home, they claimed they would be happy for any child, “We like girl-children as much as boy-children,” her father-in-law would say, but she knew the reality was far different. Her mother in-law was next to her, looking tense with anticipation. She lived with her in-laws, customary in rural India, and did not have good relations with them: they were angry she had a love marriage with their son and a mind of her own.

“You had better give birth to a boy,” her mother-in-law hissed to her, as Diya’s labor pains intensified.

City: Jassi, the wife of a successful, well-known Bombay businessman, and already mother of two beautiful daughters, was pregnant with a third child. The women in her society (apartment complex) were anything but congratulatory. They admonished her, “why don’t you have a test done?” implying that she should make certain not to have yet another girl.

I was shocked to hear these stories. Both of these women, loosely based on women I’ve known, had healthy baby boys. But their problem is real, and getting worse: the number of girls for every 1,000 boys (sex ratio) went from 962 in 1981, and with the improvement of sex-testing technology, dropped to 927 in 2001. It was as low as 814 in Delhi.

At first glance, it seems like this is an economic issue, as some middle class families claimIn Spite of the Gods: The Strange Rise of Modern India, he talks about a woman from such a wealthy family, that her dowry included a Mercedes and Switzerland vacation. Even she was forced by her husband’s family to abort her baby girl, although many women themselves believe in this practice.

Shockingly, this practice continues in the US. Census data shows that for every child born subsequent born after the first in Chinese, Indian, and Korean families, the likelihood of that child being a boy increases.

Female feticide is because of many traditions and perceptions, as well as economic and social factors coming together. Girls are seen as economic liabilities destined to leave their homes, as they traditionally go live with their husband’s family after marriage. Male children, who never leave their parents (and doing so would raise eyebrows), support them in old age. Male children earn money for their parents through jobs and dowry. Female children, however, do not. Many are not allowed to work nor offered education, and dowry continues, even among educated, well-traveled, urban elites – furthering an already insidious gender bias.

There are some successful interventions, like empowering women through education, economic power, and allowing them to take greater control of their lives – and this is where I’d like my life to focus. Before translating and preparing training materials at CORD, I never realized how deeply rooted this practice is in Indian culture. To me, Indian culture is laced with quirks, visible and invisible, but I always felt some pride and loyalty in my heritage. But this level of hypocrisy and brutality is astounding. A sign in Mumbai reads, “It is better to pay 500 Rs now than 50,000 Rs (in dowry) later”.

Though the topic makes periodic appearances in international news, and many interventions are taking place, ultimately it rests on changing social norms: At weddings, including mine, there is a prayer to bless the new couple. It states tellingly, “May you have sons”. But Babaji (my grandfather-in-law), the eldest person at the event, added “or girls, because everyone is equal now.”. Andhra Pradesh, a more progressive state, offers hope with a girl-favoring sex ratio, closer to natural patterns. – but female feticide is rising fastest among wealthier couples. In Edward Luce’s

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Thanks for checking back to this blog after a long time! I’m getting re-started, and continuing to explore issues in public health that pique my interest (or deeply sadden me, like this one). You’ll notice some changes in the look and layout, all to be easier for you. Would love your feedback, or forwards this if you know someone interested!

The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the fifth in a series of posts from the conference. Only one or two more after this one.

My reason for attending Forum 2009 was to participate in a session title “Innovation for Remote Populations”. This post is a about that session. What follows is taken from my recent report to the Global Forum for Health Research – edited only slightly.

Innovation for Remote Populations

Thurs-19-Nov-2009, 14:00-15:45, Global Café, Palacio de Convenciones, La Habana, Cuba

Coordinators/Facilitators:

• Patricia Mechael, mHealth and Telemedicine Advisor, Millennium Villages Project, Earth Institute, Columbia University, USA & Egypt (organizer & facilitator)
• Tim Hurson, Facilitators Without Borders (facilitator)
• Charles Gardner, Global Forum for Health Research (focal point)

Speakers (alphabetical order):

• Simon Adebola, NEPAD Council Global Health Commission, Geneva
• Najeeb al-Shorbaji, Director, Knowledge Management and Sharing, WHO
• Caren Serra Bavaresco, Student, Epidemiology, Universidade Federal do Rio Grande do Sul, Brazil
• Karl Brown, Associate Director, Rockefeller Foundation
• Arul Chib, Assistant Professor, Wee Kim Wee School of Communication, and Assistant Director, Singapore Internet Research Center, Nanyang Technological University
• Dziedzom Komi de Souza, Ph.D. Student and Research Assistant, Parasitology, Noguchi Memorial Institute for Medical Research, Ghana
• Bastiaan Hoefman, co-Founder, Text2Change
• Bernardita Labarca, Project Coordinator, Zoltner Consulting Group, Chile
• Claire O’Neill, Chairperson, Cell-Life-South Africa
• Ravi Ram, Head, Monitoring & Evaluation, African Medical Research and Research Foundation (AMREF), Nairobi Kenya
• Marco Salmen, OHR-GMCP Initiative for HIV/AIDS, Global Micro-Clinic Project, United States
• Jaspal S. Sandhu, Design Researcher, College of Engineering, University of California, Berkeley, USA
• Joel Selanikio, co-Founder and Director, Datadyne.org, USA
• Garance Upham, General Secretary, Direction, Safe Observer International, France

Additional participants – from the audience:

• Elmer Zelaya – Fundación Chica/Nicaragua
• Timothy Dye – SUNY Upstate Medical School/USA
• Jane Kengeya – WHO
• Oyewale Tomori – Redeemer’s University/Nigeria
• Lishandu/Zambia (full name/affiliation not available)
• Vargas/USA (full name/affiliation not available)

Summary:

1. Diverse users and uses: The speakers presented a variety of mHealth/eHealth applications involving a wide variety of users, including both the health workforce and community members, e.g. educating teenagers about HIV/AIDS in South Africa (O’Neill), Internet access in western Kenya to improve uptake of HIV VCT (Salmen), mobile emergency response systems in Aceh (Chib), electronic IMCI in Tanzania (Brown), text-based health education and health service promotion in Uganda (Hoefman), training for health workers as a downloadable game package for phones in Kenya (Ram), telemedicine to improve the skills of health workers at primary levels in Brazil (Bavaresco), delivery of health information to communities in Chile (Labarca), a general set of tools for mobile data collection being used worldwide (Selanikio), and handheld computers to support rural healthcare delivery in Mongolia (Sandhu).
2. mHealth/eHealth is about enabling access: A common theme across diverse applications was that information and communication technologies are being used to enable access to health information and services in places where access is difficult because of remoteness and/or cost.
3. Coordination among the various players: Coordination among donors and projects is necessary to avoid unnecessary duplication of effort and to share what works. This is the role of the mHealth Alliance, supported by Rockefeller Foundation among others (Brown). While there were questions from the program side as to what data donors want (Chib), there was a simultaneous sentiment that donors need “stepwise” guidance (al-Shorbaji).
4. De-emphasizing technology: The mHealth Alliance has recently been discussing development of an “mHealth Toolkit”, to provide a common technical architecture and platform for those planning to implement mHealth programs (Brown). The existence of free technology platforms – in this case DataDyne’s tool – enables programs to focus on developing health content (Labarca). It is important to have a generalizable tool, as DataDyne has done, that can be used by anyone; if individual governments must approve technology “you’ve lost the battle” (Selanikio). Programs must focus on understanding people and applications more than technology; in response to a question from Dye about the use of ethnography in this field, three examples were given: ethnography of teen chat rooms in South Africa (O’Neill), multi-year ethnographic fieldwork as the basis for the program in western Kenya (Salmen), and design ethnography of the information management practices of rural health workers in Mongolia (Sandhu).
5. Defining good evaluation: There are challenges to seeing change in population health outcomes (Chib). It is difficult to measure behavior change (Hoefman) and to evaluate systems that provide health content to people (Labarca). Ethnography should be considered more seriously as a complementary evaluation strategy in mHealth (Sandhu). In evaluation, the metrics should match the intervention – mHealth is another intervention; in addition, we want to see the unintended effects of technology (Ram).
6. New modalities of engaging people: Mobile phones enable fundamentally new ways of engaging with people. As opposed to mass communication that is often used in social marketing, phones allow for interpersonal communication that can be tailored and cost-effective (O’Neill). There are two modalities, moving messages out to people and demand-driven services, where people demand the information that they need (Ram). Salmen lent his support to the importance of demand-driven services and argued that phones will bring more equity. This is all supporting the shift to citizen-centered healthcare (Mechael).
7. Cautions moving forward: In natural disasters, the cellular network is the first to go (Zelaya). An open question: Who owns the data? (al-Shorbaji). Nobody is thinking about “real sustainability” (Adebola). Reliable phone networks are a challenge (Lishandu). We should be careful that we don’t become too dependent on one tool (al-Shorbaji).
8. Need to think more creatively: We should be bolder with approaches; if we are, poor countries “could leapfrog” in health and development terms (Upham). Many of the applications discussed focused on SMS and telephony capabilities; we should think about leveraging more advanced capabilities of mobile phones (Kengeya).
9. Who should design technology? There is an assumption that Africans cannot develop software, but that is not true (Adebola). DataDyne software was already developed by Africans (Selanikio). Africans should develop software, but they shouldn’t redesign what has already been built (Brown).

Conclusions/Recommendations:

1. There is a need for increased knowledge-sharing about mHealth/eHealth within the global health community. This should definitely include policymakers. As Prof. Tomori elegantly stated, while we are thinking about how to reach remote populations, we should think about “hard-to-reach” African leaders.
2. While there was discussion of both eHealth and mHealth, the discussion focused primarily on the latter.
3. There is a need for a continuing dialogue about mHealth. It is unrealistic to expect policy recommendations to come out of this meeting given the state of the field (many open issues) and the limited engagement at the meeting.
4. Major mHealth topics to be discussed at future meetings: definitions; standards, including how to conduct evaluation; and successes and failures from the field.
5. The value of the meeting was threefold: (1) it helped extend the network of those working in mHealth; (2) it provided those outside the field with an understanding of the opportunities and challenges of using mobile phones to improve population health; and (3) it placed a much-needed emphasis on prioritizing people and applications over technology.
6. Mechael suggested reviving the Mobile Metrics and Evaluation Group as a means of maintaining an active mHealth community discussion outside of official meetings.

Other observations:

1. The fishbowl format was successful in eliciting relevant commentary from a large group of speakers as well as from the audience. Time was an issue, though, as several invited speakers only spoke once and several audience members had comments or questions that they were unable to share.
2. One key issue that was not explored – as I stated at the end of the session – was the link between social entrepreneurship and mHealth. This is especially relevant to issues of demand, incentivization, and sustainability.
3. There is a need for an ongoing discussion of these issues at Forum 2010 and beyond – while the conversation will continue in other settings, the Global Forum for Health Research should continue to be involved because of its systems focus, its emphasis on actionable research, and the unique mix of parties (policymakers, donors, implementers) it brings together.

My PictureRx is designed for the domestic US market, but I thought I would post it on the off chance that it might stir up some ideas for situations in low resource settings. Not clear if they have gone mobile with this. While there are a slew of SMS pill reminders (first used in a widespread way in the “South”) it is important to think about this in development context due to the coming wave of chronic diseases – how well do SMS only medication remdiners work for people with co-morbidities and complex drug regimines? Also important to note – this is just one type of tool among many, and doesn’t seem like it helps with remembering whether you took your pill or not (have you ever looked at your watch for the time and then forgotten the time 10 mintues later?). The design looks slick and you can sign up for email reminders, however I am not sure what the efficacy is. Other issue to keep in mind with SMS reminders or something like this – while you can improve pill popping rates (adherence), there are many situations where people don’t want to take their meds (side effects or getting plan fed up with the polypharmacy).

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• Text Message Reminders help Teen Transplant Patients (textually.org)

Jose from Little Devices That Could (LTDC) is going to be helping out with a fantastic looking course being offered by Harvard-MIT. The post below, with permission, is from LTDC. The course has some very bright minds involved. Could you imagine a collaborative course like this on every campus? I would bet there would be some great results. If you have any input or project ideas, send Jose an email (see his website below). 

UPDATE: This course will be available via:
1. opencourseware
2. telecast (with hope of reaching overseas univs also)
3. open access to materials
4. potential roll out in other schools in 2009

From Little Devices that Could:
LTDC Goes to Graduate School: Harvard-MIT announce HST 939,  Designing and Sustaining Technology Innovation for Global Health
        
Following a long history at MIT of incredible classes like D-Lab, Developmental Entrepreneurship and S-Lab from Sloan School of Management,the joint program in Health and Technology by Harvard and MIT have announced HST 939:Designing and Sustaining Technology Innovation for Global Health.

The class will focus on exploring new ways and avenues of answering global health’s most vexing problems at the intersection of business, public health, and disruptive technologies. Hands on participation in real life projects with international community and corporate partners will allow students to experience global health development 2.0 from the start.

The class is the brainchild of HST affiliate Jeff Blander, a social entrepreneur and global health expert, who teamed up with Utkan Demirci, a scientist and inventor at Harvard with a shared focus on global health technologies. They’ve asked Yours Truly to participate in the design and instruction of the technology and bottom-up innovation aspects of the class, and I’ve heartedly agreed.

If my posts have been infrequent lately, I apologize, but the there has been a lot of work to set up some exciting projects which I will be sharing with you shortly. We are continuing to receive a lot of interest from corporate and foundation sponsors about their own projects and the door is open for continuing collaboration. One of the most exciting aspects of the course is its commitment to cross-institutional collaboration. The current partners include companies, NGOs, and other academic institutions beyond Harvard and MIT. So get ready, in a few months, we’ll be highlighting the next little devices that could—and the business report cards that go along with them! Everything starts in Spring 2008, but you can submit your projects now!

From Little Devices that Could

Tomorrow is World AIDS Day and instead of “barraging you with [another set of] statistics, gruesome photos, or heart-wrenching stories” (quote credit to Mr. Casnocaha), I want to alert you to something we prefer here – solutions, problem solving, technology, and creative thinking. Piya Sorcar, a doctoral student in Stanford’s Learning, Sciences & Technology Design program has used her considerable skills to figure out how to reach the minds of children in devleoping countries when it comes to HIV/AIDS education.

Incorporating a variety of techniques from several disciplines Piya has generated an animation based educational technique and curriculum, the first of its kind in this area. The first results from this groundbreaking technique are in and they have been outstanding. The indefatigable Sorcar has plans to disseminate the educational curriculum free to schools and other organizations. She also has plans to launch the animation on social networking sites such as Orkut (very popular in some developing countries) and Facebook.

This educational technique and curriculum has taken over 2 years to develop and as far as we know  no one else is using this animation based method. This work is truly inspirational, overcomes various methodological barriers and just as importantly political barriers (especailly in countries where sex education is banned). The early results indicate  tremendous success. I highly encourage you to read the full story below and visit the website where the animation can be viewed:  http://www.interactiveteachingaids.org/

We previously covered Piya Sorcar’s work in a post last year and it has been the most read post on this blog with over 1700 visits. You can view that here for further background information.

Lasly, there is much more to say about Piya’s work which we will save for another post. I have placed some links about World AIDS Day below this entry and as a side note – even rock group Queen is getting into the action with their first new recording in a decade to mark the event.

Enjoy!:

Doctoral student creates groundbreaking animation to teach HIV/AIDS prevention in developing countries

To combat the stigma associated with discussing HIV/AIDS and sexual practices in India and other developing countries, doctoral student Piya Sorcar has developed a groundbreaking animation-based curriculum to teach HIV/AIDS awareness and prevention in a culturally sensitive manner to young adults around the world.

Sorcar’s project, Interactive Teaching AIDS, is already being used in several countries…The animation emphasizes the biology of HIV/AIDS, presenting a storyline with a dialogue between a curious student and a friendly yet authoritative cartoon “doctor” on the biological facts about HIV,its spread, and its prevention.
 
“What’s groundbreaking is that she’s shown that we can inform people about AIDS while respecting the culture,” said Communications Prof. Clifford Nass, an advisor to Sorcar’s Ph.D. project. “That’s an enormous accomplishment.”

“The result was Interactive Teaching AIDS, an animation-based tutorial featuring a friendly cartoon doctor and patient who guide participants through the biological aspects of AIDS transmission. The tutorial is available online and on a CD.”

RESULTS
A recent study of the application in India by Sorcar with 423 students in private schools and colleges in North India, showed significant gains in learning and retention levels after interacting with the 20-minute animated tutorial. Prior to testing, only 65% knew that HIV was not spread through coughing; after the tutorial, this percentage increased to 94%. Students stated that they were comfortable learning from the tool, and more than 90% said they learned more about HIV/AIDS through the animated tutorial than any other communication method such as television or school. One month after initial exposure to the tutorial, students were rapidly seeking and educating others about HIV/AIDS prevention through their networks, with nearly 90% sharing information they learned from the tutorial with someone else.

Full story and above sources from here and here

More links:
CNN Student Learning Activity, link
MTV and KFF Partnership, link
NPR story, link
Reuters article, link

I think this is a brilliant idea, partial excerpts below (via Salon), full story of “A Business School for the Indian Poor”:

“In an age when business schools have become synonymous with stratospheric tuition fees and blue-chip faculties, the Mann Deshi Udyogini, or Udyogini Business School (estb. January 2007) is India’s, and perhaps the world’s, first and only B-school for unlettered rural women…”

“Funded largely by HSBC, one of the world’s largest banks, coaches poor women in entrepreneurship, accountancy, bank finance, marketing skills and confidence-building for a piffling Rs150 (US$3.70) for a three-month basic course and Rs600 for a six-month advanced one…Plans are also brewing for a “Business School on Wheels” to target women in remote areas who can’t travel to Vaduj.”

Founder Bio:
“Economist, farmer and activist, Gala Sinha works for social change in some of the poorest and most drought-stricken areas of rural India…Her bank is the first in its region to provide life, accident and hospitalization insurance for women…Gala-Sinha has succeeded in changing government policy and law regarding property rights for women…”

Full news article here.

I want to acknowledge my team members Melissa Ho, Mahad Ibrahim, and Sonesh Surana for co-authoring the winning proposal (PDF linked here) in the Berkeley CITRIS IT for Society Challenge calling for the integration of next generation mobile phone technologies in the scale-up of Uganda output-based aid voucher services (link to the PDF presentation).

The University of California at Berkeley has a strong record in health services research and development of innovative information technologies. The team proposes to investigate the potential for smartphones to improve health service delivery financed in the Ugandan output-based aid (OBA) model. Findings on the feasibility of using smartphones could improve the efficiency and effectiveness of health service delivery with implications for scaling in many developing regions with poor healthcare and limited information technology infrastructure. The proposed strategy will tackle a critical gap in low-income countries’ health care: improving the reporting speed and quality of clinic data between healthcare providers and centrally located managers. Responding to an existing project’s need for improved information infrastructure, the team will test the feasibility of implementing a data reporting system at private clinics treating sexually transmitted infections (STIs) in a largely rural population of southwestern Uganda.

The Berkeley CITRIS IT for Society Challenge takes place as interest continues to grow in the use of mobile computing for healthcare delivery. There have been hundreds of blogposts in the last several months on the topic. I’m reposting ours from Feb 13th just to revisit the topic and a NYT article that got a lot of play in the blogsphere. Talking with researchers since the March 5th article, it’s not clear that Rwandan healthcare providers are as connected as the NYT reported (patient-level data portability is still a difficult goal to achieve at large scale), but I’ll have to get into that in another post.

THD post Feb 13th “Phones 4 Health Partnership with PEPFAR”

NYTimes March 5th “Wireless Technology Speeds Health Services in Rwanda”

Acumen Fund March 20th “Empowering with mobile phone technology“

The hype around a variety of global issues (microfinance, climate change, sustainability) continues to grow and based on the coverage this also seems to be true for global health. There must be something in the water this past year as there have been announcements by several universities about starting new global health divisions, departments or courses. Many schools of public health are leading the charge and are being backed up by real money in some cases. While there have been some universities that have had international health tracks, this set of developments is certainly a new phenomena that is widespread and not restricted to the typical large public health institutions (such as Hopkins). I hope that these schools are thinking outside of the typical public health box in how they develop their curricula, but that hope may be foolish on my part. Please find below a summary of recent news in this area, if I have missed any schools/programs I would be happy to add them. The amount of money and activity listed below is unprecedented for public/global health programs at the higher education level:

Real Money:
1) $110M for Emory Global Health, Jan 2007, & their $786M windfall, April 2007
2) $50M for UNC school of Global Public Health, Feb 2007
3) $30M for Duke Global Health, Sept 2006, Feb 2007
4) $30M with $100M more sought for UWashington Global Health, Sept 2006, Feb 2007
5) $4M for Oxford Global Health Sciences, April 2007

In addition to the above it looks like Harvard or Harvard affiliated clinicians will receive a total of $120M from Eli Lilly to tackle TB, read the story here. University of Washington wants to start a Health Metrics Institute and Emory will have an initial focus on vaccine and drug discovery, so there will be a large roll for measurement/evaluation and technology. There is a potential $324 million in funding for these new institutes, all announced mostly within the past 6 months. I did not have time to dig too much deeper into the list below, but you can see there is quite a bit of recent activity at many other schools:

-Colorado State Micro Rx, “MicroRx, a first-of-its-kind enterprise to speed the transition of life-saving research on infectious diseases from the academic world into the global marketplace.”

-Northwestern classes, “demand for global health education is up”

-Cornell global health minor & “Global health is a major focus of Cornell’s $1.3 billion campaign”, story

-U of Virginia public health/global health minor

-UCSF, Debas’ Bold Vision for the Future of Global Health

-DMU, new global health program

Before we get excited about all this movement, let’s not forget about things that plague many organizations: academic inertia, fiefdoms, turf wars, and major political battles. Some of these new initiatives may be revolutionary and some should be taken with a grain of salt. Without naming names, there are some universities with THREE or more, not one, but three centers for global health all at the same institution. These announcements, however, do indicate a very strong expanding interest in global health issues. In addition to this, a Feb 2007 commentary by Fitzhugh Mullan in the Journal of the American Medical Association calls for a sort of global health professional peace corps to tackle HIV/AIDS: “HIV/AIDS is “essentially the black death of the 21st century, killing on a massive scale and threatening to cripple economies and topple governments…the US should mobilize health workers ready to commit to working abroad in the long-term battle against HIV/AIDS.” It is a fascinating time for global health education, we will have to keep an eye on what happens with these investments.

FYI, Rethinking International Health — a fine online teaching-learning aid.
For a very nice example of a low cost, high value open-access introduction to the importance and complexities of international health check out http://rih.stanford.edu/.

“Rethinking International Health” (RIH) was developed by students, faculty and staff at Stanford and includes interviews with 13 international health leaders (five are open access and the others will be soon) along with supplementary readings and resources. Course features include: Video interview, broken down into segments by question; Biography of interviewee; Links to related resources including primary and secondary literature, websites, video clips, images and more. For more information: rih-information@lists.stanford.edu

Wayan Vota, director of Geekcorps, is in town and will be talking informally about Technology and the Developing World – from the Peace Corps, Geekcorps, to the One Laptop.

Date – Tuesday, Feb 27, 2007
Time – 6:30 PM
Place – 21st Amendment, at 563 2nd St, San Francisco.

Come on by, have a drink, and chat with Wayan.

In Guyana, Peace Corps volunteer Pam Kingpetcharat teaches computer repair.