I promise I’ll explain the title – in a bit. First, here’s a re-cap of some of the week’s developments:
Above, I’ve provided a snapshot of today’s activities in the Home-Based Care (HBC) office, the new home of FrontlineSMS and the CHW maps. From left to right – Neggie, a nurse in labor ward; Grace, the hospital’s ART coordinator; Alex, the HBC nurse. Neggie showed up at the office with a list of mothers – they were enrolled in the hospital’s PMTCT program, but they’ve failed to report for their 6-week follow up (when blood samples are taken in order to determine the child’s HIV status by DNA PCR). Alex is locating the mothers’ villages, and reading off the ID numbers of CHWs in their vicinity.
These days, the majority of the patient visits made by the mobile team are responses to SMS requests for immediate medical attention. Still, certain visits are scheduled follow-ups after patients have been discharged. Traveling with Alex, I realized that, at least half the time, the patient is nowhere to be found. Alex now sends a few quick messages to the CHWs overseeing the patients he’s planning on visiting, letting them know he’ll be stopping by. While he’s out in the field, any response from the CHWs is forwarded to his cell phone. This assures that he sees patients who are available – and avoids 40-mile journeys to discover a patient is away, selling maize in Mozambique.
A CD4 outreach initiative funded by the World Bank starts up later this week. They will use the CHW communications network to inform villagers of testing sites and dates – aiming to increase client turnout, thereby bolstering access to the free testing services.
This past Saturday, we gathered the first 30 CHWs for a refresher course – explaining the automatic unit top-ups and the drug keywords (we’ve already had BB Paint, TEO, Panadol, and Multivitamin info requests). After the session, I video-interviewed four of the CHWs, in English.
I’m leaving Malawi this coming Friday, and when I’m back at Stanford I will be uploading the videos. I’m planning to embed them in individual posts – so you can hear the stories of care from those who have lived them. Their general attitude might be described as thankful, yet realistic about the pressing needs of their families and friends – hence, the title of this post. Malawians are said to spend roughly 10 percent of their waking hours at funerals. The statistic does reflect troubling times – but it also demonstrates the blurred boundaries between family and fellowship. Villages are full of brothers, sisters, and mothers – some share heredity, but all share circumstances. Every text message sent by the CHWs has invited me to appreciate the true meaning and function of community.
*title credit: Maggie Chen
At the weekly ART meeting, the “Prevention of Mother-To-Child Transmission” (PMTCT) staff reported on the number of children from their program who have been confirmed HIV-positive.
Mothers are given a single dose of nevirapine, to be taken during labor (whether they deliver at home or in the hospital), and children born at the hospital to HIV-positive mothers receive short-course AZT, in an attempt to deter transmission of the virus. Each case that the PMTCT staff reported had a story. Some examples:
- Mothers enrolled in the program for their first birth, but neglected to contact the hospital during a subsequent pregnancy
- Faced with substantial travel costs, some mothers played their (rather, their children’s) chances – delivering without PMTCT ARVs
- Mothers from a certain village failed to deliver at the hospital, afraid the care-seeking behavior would reveal their status
These mothers might bring in their children for testing after 18 months, or only if symptoms present. This delay in determining HIV-seropositivity dramatically decreases the child’s chances of survival. Because the drugs (single-dose at birth, followed by a one-week course) are so effective in halting vertical transmission of HIV, every child born HIV-positive to women enrolled in the PMTCT program is deeply troubling.
After talking with hospital staff, we’re going to integrate the new SMS network into the hospital’s Voluntary Counseling and Testing (VCT) services. As part of their post-test counseling, every client who tests positive will be paired with an HIV-positive CHW with a cell phone. Many of the CHWs we have trained to text are committed members of the HIV-positive community – leaders of support groups, impressively drug-adherent, and people who spread a ‘Positive Living’ message.
These CHWs, along with their mobiles, will provide HIV-positive individuals a link to hospital services, a way to privately ask questions, and someone to look over their health. It will also provide a means by which to track pregnancies for HIV-positive patients, and follow deliveries for mothers in the PMTCT program.
Above – the fourth group of CHWs. After the training session, Alex and I situated each CHW’s ID pin on the map of the catchment area. As promised, new colors appeared – youth counselors and reproductive health volunteers are now connected to the hospital.
At the week’s medical meeting, a new category was reported – “SMS Follow-Ups” – for the TB and ART programs.
Above – another happy group of health workers, the program’s newest inductees. By the end of next week, there will be 50 phones in the field – next Wednesday, we’re adding Reproductive Health and Youth Counseling volunteers to the network.
Below, you’ll see some of the CHWs re-teaching SMS steps to the rest of the group – a key component of the training sessions.
Once the session ended, a few of the CHWs reviewed their notes:
Walking through a village this afternoon, I happened upon three separate barber shops, each advertising Phone Charging services.
Malawians understand mobiles. It’s time to put the technology to work.
Next week, amid further CHW orientation, we’re holding comprehensive training sessions for hospital staff – so that TB officers, ART directors, pediatric nurses, PMTCT coordinators, clinicians, and VCT volunteers alike can use FrontlineSMS to contact the CHWs.
I was excited to hear that PC World picked up an article that Ken Banks (founder of kiwanja.net, and the man behind FrontlineSMS) wrote, titled, “Witnessing the Human Face of Mobile in Malawi.” If you’re interested, you can read it here.
We’re ready to expand a bit. We heard from every one of the CHWs in our pilot group (some, many times). In just a few days, we saw some tangible results. Here’s one example:
- Verona Kapagawani, who lives in TA Mavwere, alerted the hospital that a patient had run out of his meds.
- A nurse at the hospital, familiar with the patient, responded that he should fill his prescription (he has chronic congestive heart failure) as soon as possible.
- Verona responded, noting that she counseled the patient. He wasn’t feeling well enough to travel, so she came to the hospital to pick up his drugs.
- While chatting with the nurse, Verona charged her cell phone.
I ran into another CHW, Benedict Mgabe, at the hospital today. He’s the chairman of the Community AIDS Committee, and he’s texted me every day. With a smile on his face, he shook my hand and said, “This is a very good program! It is really helping us a lot.” Those short sentences confirmed that I want to have longer conversations with the CHWs, to gather their reactions.
We’re using the pilot group to contact the next wave of CHWs, another 10 volunteers, to be trained and given phones Monday morning. Above, you’ll see Alex (a nurse, who does most of the Home-Based Care community work) and Grace (who coordinates the ART program) using FrontlineSMS to text the group.
I had a long discussion with Dr. Mbeya, the medical director at St. Gabriel’s, about making very definitive links between the hospital and the CHWs’ activities. As the project grows over the next weeks, we’ll create guidelines for reporting and follow-up, based on the specific program. For example, the hospital has a lively prevention of mother-to-child transmission (PMTCT) program, aimed at reducing vertical transmission of HIV. We’ll develop a protocol for utilizing the CHW network to follow up on mothers who’ve missed their appointments, and the CHWs will provide a link to the communities’ pregnant population.
I’d love to get some other perspectives on this.
Sending good wishes from Namitete.