In his wonderful new book The Checklist Manifesto (Metropolitan Books, 2009), surgeon and author Atul Gawande explains how successful surgery depends on the complex interactions of surgeons, nurses, anesthetists and other specialists, who must possess not only highly specialized skills but also the ability to work as a team in the face of rapidly arising challenges. The same applies to an airliner’s pilot, co-pilot and crew. Special tools such as checklists, decision trees and artificial intelligence built into instrumentation are key.
Information technology empowers complex group processes in striking new ways, but the breakthroughs are especially exciting in very low income settings. There mobile telephony and wireless broadband are ending the grinding isolation of rural communities and enabling workers—even those with fairly rudimentary training—to interconnect more successfully and to tap into expert systems and artificial intelligence.
On a recent trip to Africa, I saw two simple but powerful examples of lifesaving protocols enabled by mobile phones. In the Ghanaian village of Bonsaaso, part of the Millennium Village Project, a simple phone-based system is lowering maternal mortality during childbirth. Community health workers (CHWs) with basic training, a skilled midwife, an ambulance driver and a receiving hospital use mobile phones to coordinate as a team. Ever more deliveries now take place in the clinic rather than at home; in the event of complications, the mother is whisked to a receiving hospital about 10 miles away. Mobile phone connectivity among community, clinic, ambulance and hospital makes possible a once unthinkable degree of coordination.
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In the Kenyan village of Sauri, also part of the Millennium Village Project, CHWs are pioneering the application of expert systems for malaria control. In the past, suspected malaria patients had to walk or be carried to a clinic, often miles away, have a blood smear read under a microscope by a trained technician and, if positive, receive a prescription. With clinics few and far between and with trained technicians and microscopes even scarcer, untreated, lethal malaria ran rampant.
In the new approach, CHWs visit households on the lookout for fevers that may signify malaria. They carry rapid diagnostic tests that examine a drop of blood for the presence of the malaria pathogen. Then they send an SMS (short service message) text with the patient’s ID and the test results. Seconds later an automated text response informs the health worker of the proper course of treatment, if any. The system can also send reminders about any follow-up treatments or scheduled clinic visits for the patient. The new system of malaria control includes insecticide-treated bed nets made to last for five years and a new generation of combination drugs based on a traditional Chinese herbal treatment, artemisinin.
This full set of tools constitutes a remarkably effective malaria-control system. Already a partial deployment of the system is reducing the malaria burden dramatically in several parts of Africa. Modest international financial support could greatly accelerate the deployment of the full system, and if it were scaled up throughout Africa, hundreds of thousands of lives could be saved annually at around $7 per person a year in the malaria-transmission zones.
India is similarly scaling up rural public health by deploying advanced information technologies, CHWs and improved management systems. In the past, public health data became available only after rounds of surveys three years apart, and those results were used mainly for research purposes. Now key data will increasingly be available after only hours or days and will be used for real-time health system management.
Checklists, teamwork and telecommunications-based expert systems can revolutionize rural farm yields, disease control, business networks, rural finance, education systems, and much more. Soon farmers will be able to enter local data for advice on specific soil needs, timing on the planting season, drought and rainfall forecasts, market prices and logistics. Mobile-phone-based banking and payments services will penetrate even the most remote regions. With development aid directed toward these new systems, the world’s capacity to reduce poverty, hunger and illness—and the violence that accompanies them—will become more powerful and effective than ever.