November 13, 2013
Consider the cell phone.
As an engine of change, it is a romantically disruptive one, a technology that crisscrosses borders and thrives on connection in all its forms – to networks, to people, to the world. Already, in areas of Africa and India, mobile phones play every part at once, bankers and pharmacists and secretaries rolled into one. In developing countries, the path of least resistance to modernization is flung up one phone tower at a time. They have taken a platform we have spent on Angry Birds and advertisements, and woven a way of life.
Building for the developing world means peering into a box of paradoxes – this is a world where mobile phones eclipsed first computers and then plumbing, where in some countries there are more usable phones than toilets. In my own research developing mobile-phone-based diagnostic tools specifically for this audience, I have already uncovered the scope and strangeness of building for an audience enmeshed in preconceptions that obscure its unique demands. Studies show that locally-run health clinics with limited capital sacrifice quality for immediate affordability, rendering advanced devices irrelevant in the face of cost. More worryingly, research reveals the extent to which existing models for localized healthcare have failed; in fact, studies show that patients tend to avoid even existing clinics, fearing the quality of available care. When the nearest hospital is many miles away, patients avoid seeking treatment until symptoms become unavoidable, raising the risk of contagion or the severity of illness. Volunteer physicians, in short supply and faced with the impossibility of maintaining any meaningful contact with patients on their transient circuits, must deal with a bracing reality: serving the other 90 percent – the world’s global majority – requires connecting patients directly to doctors, wherever they are.
Developments on every front have steadily chipped away at traditional arguments against action. The question has never been one of a lack of demand – estimates from the World Health Organization peg the global population without access to adequate healthcare at a staggering 2 billion – and, increasingly, we can no longer claim that the problem lies rooted in a lack of technology, the idea of using telecommunications networks to deliver medicine an idea too early for its time. The pieces are there – cellular networks and a skyrocketing population with access to phones, smaller and cheaper electronic components than ever before, and wireless technology baked directly into phones so that medical tools can send the beating pulse and biometrics of patients to doctors nearly anywhere.
Instead, telemedicine has raced forwards – but not for the patients who need it. From AliveCor’s iPhone EKG, to the iBGStar, a smart-phone-based glucometer, the most recent crop of devices targets platforms too expensive to reach the patients who need them most. Behind the release of waves of shiny gadgets, designed for developed nations already drowning in them, lies a stark reality – the global majority still lives in a feature phone world. Realizing the possibilities offered by telemedicine for the developing world means harnessing the technology that exists, the tools that are already there.
Outside of medicine, there is a broader realization of the opportunity offered by huge swaths of populations linked by a single technology, and companies have already dived wholeheartedly in. Kenya’s mPesa system puts banking on feature phones, lets its enormous user base transfer and deposit funds with little more than a text message. Tech companies have jumped on the bandwagon as well – Facebook On Every Phone, a new program that adapts the ubiquitous social network for simpler devices, reflects an understanding that there are platforms beyond the walled garden of smartphones. Harnessing the global audience means leapfrogging the desktop, reaching directly into the hands of the other 90 percent.
Over lunch, once, I sketched out the blueprint of my dreams to a doctor from India. Even now, I told him, the technology exists to build a network linking patients everywhere to doctors anywhere, on the framework laid by millions of mobile phones. Think of the promise of letting a physician many miles away hold a virtual stethoscope or EKG leads to the chest of a patient, I said. Let medicine exist democratically, let it fall unfettered by brick-and-mortar clinics into the hands of the phone-carrying needy.
There were pockets of change already back in India, he told me, and waxed rhapsodic about one of the better hospitals there – cutting edge by local standards, it owned a newly-purchased MRI machine. This was progress, I agreed, and asked whether anyone feared that cavernous scanner, whether patients new to the clinical strangeness of medicine found it uncomfortable lying for stretches of time on the hard surface of the MRI bed. He stared at me blankly. In this state of the art clinic, he said, they slid patients in on pallets of cardboard. Even here, they clamor for access to better medicine, hunger for change. Every revolution reaches a tipping point.
After lunch that day, I promised I would follow up soon, would send him an email that day. No, he told me, he did not use email. My contact information, my questions and ideas and dreams, would need to be sent somewhere else.
He took out his phone.