Here’s the truth – this project involves people, rich in character and experience. It’s not only about the technology. If I’m interested in the tech fulfilling its potential, I’ve got to pay attention to the people.
Case in point:
I spent yesterday mulling over text messages sent through FrontlineSMS over the last four months, noting which CHWs had communicated least. I put together a list of a few CHWs I suspected might be having signal issues. Looking at the map, three of six CHWs on this list were clumped together – clearly, they must not have good reception.
I told Alex about my findings, this morning. He took a look at the names and said, “Well, Bernadeta took her phone with her to Zambia, we’ve discovered that Chrissy is not able to write her own name, and Jereman’s phone battery was stolen while it was charging at the local barber shop.” My time away from the hospital almost made me forget the multitude of stories swirling around these phones and the hospital they’re linked to. With 100 phones in the field, three random problems are to be expected.
Whether or not everyone agrees, I think personal stories convey a project’s successes, as well as their failures. Silia, a hospital attendant who runs the hospital’s TB program, said yesterday, “The SMS project is very, very good – I can get much more work done, instead of driving the motorbike everywhere. It’s very simple – we can expect feedback about patients immediately.” I met the new hospital administrator today, and his second sentence was, “You know, it’s not only beneficial for communication. The volunteers are now committed to their work, and more will follow.”
I’m letting stories from patients, CHWs, and the medical staff at St. Gabriel’s drive my exploration into this project’s value. I turned to people for the direction of the initiative, and I’m turning back to them to measure part of its impact.
This week, another group of jubilant CHWs was trained in texting. Below, you can watch a one-minute excerpt of the training session – Alex is explaining the first steps in operating the phone. At the end, you’ll hear a chorus of ‘success sounds’ – all the phones turning on for the first time by their owners’ manipulations.
The week has gone very well, and the project’s initial success has been noticed by each arm of the hospital. I took a minibus into Lilongwe, which turned out to be a fruitful venture – I rode into Namitete on a bike taxi wielding extra maps, an assortment of push-pins, and a few surge protectors (which will establish a permanent location for CHWs to charge their phones at the hospital).
Each CHW we train and distribute a phone to will be placed on a map of the hospital’s catchment area, with a different color pin, depending on their program (Home Based Care, ART Monitors, Reproductive Health Volunteers, Counseling, or Youth Volunteers). Particularly committed volunteers assume multiple roles in their community – they’re distinguished by blue pins. The idea is to have the maps, with hundreds of CHWs’ locations marked, displayed clearly for the clinical staff at the hospital. This way, a clinician looking to track down a patient need only consult the map, find the nearest, appropriate CHW’s identifying number (written on the pin), and send out a text. Here are the new maps, along with the locations of the first 20 dispersed phones:
Tomorrow afternoon, I’m attending the staff meeting for those involved with the hospital’s antiretroviral therapy (ART) program. I’ll be explaining the project, and the group will determine a protocol for communicating with adherence monitors in the field. Below, you’ll see me, sitting with Grace, who coordinates the hospital’s ARV provision.
As always, thanks for reading. Any ideas, as this expands?
I thought I’d post it in Chichewa, to document its original form. But, it translates roughly to, “There are two patients, very sick of cancer.” Tomorrow, Alex will take the hospital motorbike to Chilembwe, about 60 km away, to check on the patients. A quick text let Zakeyo know to expect him.
From Baxter Lupiya – “Natenga ma A R V omwe anasiya aMwinama, omwe amamwalira dzulo. Ndibweletsa la chisanu. Zikomo.” Translated, “I have collected the ARVs left by a patient who has died, and I will return them to the hospital on Friday. Thank you.”
From Benedict Mgabe – “Mai laulentina adamwalira pa sabata kwa chamoto omweanali pa pa h.b.c.” In English, “Laulentina, a patient in the Home Based Care program, died on Saturday.” Terrible news, by any measure, but it saves the hospital a day-long trip to Chamoto to give Benedict more morphine.
I can’t help but envision each of the hospital’s 600 CHWs with a phone in their hand, the hospital’s number saved as cherished contact.
Any thoughts? I hope all is well, wherever you might be reading this.
Back row, Left to Right: Harold Malanga, Benedict Mgabe, Zakeyo Kaphanthengo, Joana Chimphanje, Pascalia Chiwinda, Moreen Phiri, Verona Kapagawani, Baxter Lupiya Bottom row, Left to Right: Dickson Mtanga, Grace, Alex, Rosemary Bernado
I have to believe today’s events were endowed with the elements of a promising beginning. The first phones are in the field! Before I get too ahead of myself, let me explain what’s put me in such an optimistic mood.
We called the chairs and vice-chairs of the volunteer committees (Community AIDS Committee, Village AIDS Commitee, and the People Living With HIV and AIDS [PLWHA] support group) for a meeting at 9 am this morning. The came in together, some on bikes, most on foot. Considering that some traveled over 50 miles (that’s most definitely an underestimate), this was quite the event.
I had been up since 6:00, testing phones and FrontlineSMS, and I was eagerly awaiting the group – equipped with Cokes, Fantas, lemon cookies and a broad smile.
We met in the old Nutrition Rehabilitation Unit, which had been stocked with assorted chairs. After everyone sat down, the hospital’s matron greeted the group. After making sure each of the CHWs could understand slow English, she opened the meeting:
I know that times are difficult, but we must make improvements step by step. Do babies just start to run? No, they start just sitting. Then, when they see something beautiful, they wiggle their stomachs and arms, trying to reach for it. Soon, they can crawl; then they start walking. We can take steps forward, together. This is a pilot – we are learning new vocabulary today, too! You are the first to do this. It is not enough to try. We must do it.
After that poetic introduction, the matron told them they’d be receiving cell phones. This news was greeted, almost immediately, with cheers and applause.
The matron handed the ecstatic audience over to Alex and me, and we explained how to operate the phones (Alex is a male nurse, who works within the Home-Based Care program). I had every single ounce of the audience’s attention, as I started, “First, just open your phone!”
*A disclaimer: That’s Alex’s handwriting.
We had an outstanding time teaching the CHWs how to use the phones. It started with group chants of, “Messages! Compose Message! New Short Message!” The majority of the CHWs hadn’t texted before, so we spent some time teaching them – by the end of the session, each of the health workers flawlessly typed ‘St. Gabriel’s Hospital,’ apostrophe and all.
After a few hours of rigorous concentration and seemingly inexhaustible patience, we took a break for snacks. During break, we discussed logistics.
The CHWs all claimed to have access to electricity. It seems that most will have to pay 10 kwacha (a few cents) to use the nearest electricity hub. When it’s necessary, they (or someone from their village) will travel to the hospital to recharge the phone, free of fees. This isn’t altogether rare, as the CHWs often accompany patients to the hospital.
After the matron and Alex explained baseline expectations for communication, the CHWs took over the meeting. Pascalia and Verona, the two Community AIDS Committee chairs, were especially emphatic. Pascalia stood, declaring, “The hospital does what it can to help the volunteers. We must do what we can to work hard. Remember, just because we are the ones who came to the hospital today does not mean the hospital loves us more than the others.” Verona responded, looking straight at me and pumping her fists, “I will work much harder!”
The frequency and type of communication the CHWs will maintain with the hospital will depend on the program the CHW is enrolled in. For example, those involved in TB drug adherence monitoring will alert the hospital when a patient is deviating from a regimen. Similar expectations were agreed upon for the ARV monitors. Home-Based Care volunteers will be messaged when a patient needs to be traced or if a follow-up is needed. Those involved in organizing peer support groups will use the system to coordinate meeting times and locations. With any luck, and plenty of commitment, they’ll be a working network of CHWs, with St. Gabriel’s Hospital as a coordinating agent.
Before leaving, the group sent a sample text to the hospital’s number, and we showed each CHW their respective message as it popped up in FrontlineSMS. It was an animated scene, for sure. I recorded some of their information (name, number, village, and respective program), checked their starting units, and let them loose on the catchment area.
Needless to say, I’m looking forward to tomorrow, and the possibility of the first messages trickling in. With a smile on her face, Verona asked me, “So, when can we start messaging?” A few of the CHWs joined me in responding, “Now!” As they started home, I could see they were exchanging phone numbers.
I’m very happy with how things have started off. Almost immediately upon arriving, I pitched the communications program at the hospital’s management meeting. Most of those in attendance I knew from my previous stay in Namitete, and they seem happy to have me back.
I’ve discovered that props are useful. So, I lugged my suitcase into the conference room, revealing about one-hundred cell phones. I also flopped around the ~100,000 units of communication credit I’d purchased at the airport. After a quick demonstration of FrontlineSMS, ideas started flowing – and not just in one direction. I’m finding that ideas developed in the US regarding the program’s potential usefulness (e.g. patient follow-up, TB and HIV drug adherence monitoring, fielding the community’s medical questions, etc.) are really resonating here.
After a bit of grudge work (putting in SIM cards, implanting the initial Celtel units, recording numbers, testing FrontlineSMS, etc.) we are ready to start the pilot.
I am calling the Chairs and Vice Chairs of both the Community AIDS Committees (CACs, “cacks”) and the Village AIDS Committees (VACs, “vacks”) for a meeting on Monday morning. It’s set for 8AM – I’m hoping they’ll trickle in by 10:00. This first ‘batch’ of CHWs will be the pilot within the pilot. After monitoring their activities for a week or so, we’ll look to expand to another group – as the Matron says, we’ll start with those who are “hardest working.”
I spent the day in Lilongwe, trying to find decent maps of the area the CHWs hail from and work in. First, I tried the District Health Office. No maps, but the doctor coordinating health information for Lilongwe was very interested in the communications initiative – specifically, the possibility of scaling up to cover the entire Lilongwe district. In an attempt to stay ambitious but grounded, I kindly left her my e-mail and other contact information.
Next, I headed to the Department of Surveys. Like the government hospitals, the state buildings are treacherous. Quite literally, I had to guess which alleyway to wander down – I was finally consoled by a piece of paper, duck-taped to a door, which read, “Digital Mapping.” I put in an order for TA Kalolo and TA Mavwere (don’t ask me what ‘TA’ means, because I have no idea), and was told to come back in a few hours. After a few bribes (‘fees’) and hitchhiking excursions, I had my maps (below).
I’ll leave you with an image of some of the goods. Before the week ends, I am creating some step-by-step instructions for operating the phones and FrontlineSMS, which Alex is going to translate into Chichewa tomorrow. I’ll probably fall asleep testing the hand-powered, wind-up chargers – the motor is strangely soothing.