TakePart Exclusive: Q&A with Frontline SMS:Medic

Editor's Note: FrontlineSMS:Medic is an organization dedicated to developing mobile technology and open source software for use by community health workers in the developing world.  Led by a team of web developers and medical students, FrontlineSMS:Medic won first prize at the NetSquared Conference for their work with mobile technology for social good. I sat down with Lead Developer Dieterich Lawson and Medical Director Lucky Gunasekara to discuss the organization's work and its future.

What is FrontlineSMS?

Lucky Gunasekara: FrontlineSMS is the creation of Ken Banks, founder of the Kiwanja Foundation, and it's a very simple and effective software application that turns any laptop connected to a mobile phone into a two-way text messaging hub, regardless of whether the computer is connected to the Internet or not.

Ken was living out in Sub-Saharan Africa, and his big passion in life before FrontlineSMS and mobiles was primate conservation. He was working on a conservation project in South Africa, when he was tasked with coming up with a communication network for use on the preserve and in the surrounding countryside. He quickly noticed that while a good deal of people had mobile phones, Internet access was sparse at best, and he hacked together the first version of FrontlineSMS from that insight. From there he started distributing it amongst friends in Africa and it sort of took off. About two years ago, he came to Stanford as a Reuters Digital Vision Fellow and, with some funding from the MacArthur Foundation, the Hewlett Foundation, and the Open Society Institute, he created a more robust version of FrontlineSMS.

You can kind of see how it's proliferated around the world. I think the major goal of FrontlineSMS is to support end users. Ken's not interested in creating a vast empire. He's just more focused on coming up with the best tools for people in the nonprofit world, whether it's human rights, environmental issues or, in our case, healthcare.

How is Frontline SMS:Medic related to FrontlineSMS?

Dieterich Lawson: From a technical perspective, FrontlineSMS is a text message management hub. It's the basic communication system that makes the rest of our platform possible. We're taking that basic platform and retooling it with an eye for clinics. We're integrating FrontlineSMS with an medical record system, OpenMRS, so that the community health worker in the field can make changes to patients' medical records remotely. You enter the name, the weight, the height, any information that would be useful to the clinics, and it enters into the patient's medical records automatically.

You can also query it remotely so that you can get information in the field. We're also talking with these guys at UCLA (Aydogan Ozcan's lab) who have developed what amounts to cellular-level imaging on a cheap. It's a modified smart phone, and you just put a dab of blood on a little glass lens, it'll take a picture, and send it off to a server via MMS (picture mail). The computer can diagnose diseases like malaria, test water for cholera, and do CD4 counts for tracking the progress of AIDS. It's really revolutionary because these tests used to take a lot of lab equipment, money and time. And it does it for less than a dollar, in seconds, at the point of care in the field. FrontlineSMS is the core communication system, we're just taking it in a medical direction.

LG: FrontlineSMS:Medic has kind of evolved as a sponsored project. Ken has crossed the threshold where he's realizing that multiple organizations around the world are using it for applications in agriculture and healthcare. Ken has been nothing but supportive of what we do. I think down the line we'll see other initiatives spring up from different users.

How was Frontline SMS:Medic born?

LG: Ken was here at Stanford a few years ago and our Executive Director, Josh Nesbit, was here as well. Josh's family goes to Malawi every summer, and so Josh has been going to St. Gabriel's hospital for the past couple years. While he was there, he noticed that they have hundreds of community health workers serving a quarter million patients around that area, but he never saw a single one the entire summer. The reason why was that they would come only on a semi-regular basis to turn in their patient notes. They had to walk 50 to 60 miles or take a bus to turn in these notes, and some of these guys weren't paid. So he was sort of puzzled at that situation.

He had heard that Ken was at Stanford and the two of them met and that was the birth of what became the Mobiles in Malawi Pilot. Josh came back to Stanford and basically piloted the FrontlineSMS system for healthcare on his own initiative, very intuitively setting this up. Josh is not a trained clinician. The most amazing thing about it was that he intuitively figured out a lot of details, and within a day he set up a system that the hospitals just quickly took over. Now, we're seeing improved drug adherence, more patient uptake and saved staff hours.

At the same time, I was working in Japan. I had just been accepted to medical school and I moved to Japan after doing a little bit of work in Sri Lanka after the tsunami, and started reading about cell phones in developing countries. I started thinking about how we could get electronic medical records onto phones. I sort of tabled that until I got to Stanford.
[Director of Clinical Programs] Isaac Holeman was up in Portland, Ore. and he was thinking about the same things after reading about Josh's work. Things came together in January of this year. Josh and I just bumped into each other at lunch and we started talking and things started from there. Isaac started emailing Josh about further interest in what he was doing in Malawi and so we took everybody together and started up in February 2009.

Who is using the technology in the field, and how is it being used?

LG: The important thing to keep in mind is that in the developing world, there aren't that many doctors. There are between 2 and 3 billion people living on $2 a day. There are only 22.9 million doctors or health care workers in general serving their needs. Doctors themselves do not really interact with the software, most of the work is done by community health workers—individuals selected from their villages and families who receive basic medical training as public health nurses. They are sending text messages about drug adherence, about illnesses, basic health alerts. When the clinicians receive that info, they respond with directions. Sometimes they'll deploy an ambulance. What we're learning is that you can automate a lot of this. So if a community health worker wants information on drug dosing, we can program algorithms that will just bounce that back automatically based on trigger keywords. The doctors provide maybe 25 percent of what we see of the input, but the real input is being done by the community health workers.

What has been the response to Frontline SMS: Medic been since the program officially launched in February?

LG: The first piece of feedback that we were really astounded by was how easy it was to set this up. A few years ago when they were talking about increasing funding for AIDS globally, the Administrator of USAIDS was complaining that people in developing countries don't understand technology. There was this huge scuttlebutt in the international health community about that comment, and we really learned quite the opposite. These were individuals who had never used cell phones; some had never seen a computer, especially in the hospital. But even if you've never owned a cell phone or seen one, you can really intuit your way through it pretty quickly, and it was the same for the software itself.

The other piece of feedback that was really important was that this was increasing capacity. In that one pilot that Josh did in 2008, we were able to double a TB program within just a matter of weeks, and save them several thousand staff hours. We saw that this was being used as a 911 or triage system. That's been very valuable for the hospital. They've been able to save a thousand dollars annually on those fuel costs, because of the efficiency in deploying their motorbike public health nurses to actual patient needs as opposed to a stochastic schedule. All of this is on a system that only costs the hospital a couple hundred dollars a year. Rather than having this be a very intensive investment, it's actually becoming a cost saving operation for a lot of them.

Once we started blogging about what we were doing in Malawi, we were just inundated with emails. We get at least three emails a week from different clinics around the world, asking for this software. When we started in February, I went on a global health web portal, and I just introduced us and just said, "We will be developing software and if anyone has any questions..." This guy in India said immediately that he wanted the software and we had to write him back and say that we could set up a basic implementation, but we're working on the software. He said, "No, I want it now." He wasn't ready to hear that it wasn't going to be ready for a year. So, I think the overwhelming demand in the community has been a really big piece of feedback to keep going ahead with this.

Frontline SMS:Medic was the first place winner at this year's Net Squared Conference to "remix the web for social change." What does the NetSquared award-and the $25,000 prize-mean for your organization?

DL: Before NetSquared, we had no substantial funding. We were pretty scrappy and had rounded up a bunch of partners and clinics that wanted to pilot our stuff, but we didn't have any money to do software development, website development, etc. Really what this means for us is that we get to do software development, deploy to a lot more clinics and expand our operations in general. It was the shot in the arm that we need to really get rolling and push us up to the next level. Now, we're applying for larger grants, but it was really that first boost that we needed.

Currently, we have several people working with us. We have people at Stanford and we're working with two people in Uganda. Our first line of code was actually written today (June 9). We have clinicians on staff, Lucky's going to med school, Isaac's going to med school. We are talking to clinicians and we're also in contact with the people in Malawi and our end-users. Ken Banks has a great network of end-users from FrontlineSMS, so we also have that available to us. We're really trying to focus on extreme usability.

What's do you see in Frontline SMS:Medic's future?

LG: We would like to get to the point where we can get just provide a download link and you can get the software from wherever you are in the world. And the other thing that's great is we have a program called Hope Phones. It's a public-private partnership to recycle used cell phones from around the country to be re-monetized so that we can purchase handsets for our clinical partners. Hopefully we can get to the point where, on the software and implementation end, everything can be done straight out of the website. My personal hope is that eventually we get to the point where on the short term we preserve our independent clinic base and go viral with healthcare NGOs like Partners in Health and Doctors without Borders. Eventually it would be nice to be sponsored and housed by a major nonprofit foundation, or be incorporated into the tech portfolio of an agency like the WHO or the State Department. Crossing that threshold where we can say that we have thousands of end-users around the world, millions of patients being served, and going to an angel or a foundation and saying they need to fund this for the long-term and include this into their roster of programs. It would be nice to have some agency. I don't think it's about having substantial funding, but it's about having stable funding year-to-year will matter a lot for keeping this sort of software development going as well as making sure that our end-users are continually supported.

DL: We want to do this very well and then give it over to the community at least as far as the source code goes. We are going to go open source after our initial release. Our goal is to create an open source community around this so that they can take it and develop it as they see fit. Really, we'd like to do this so well that we work ourselves out of a job and just let the community take it.

How can our readers TakePart in FrontlineSMS:Medic's programs?

LG: We're getting inundated with clinics around the world begging us to come to their clinic. What we've done really well is connect young people around the country to those clinics. There was one guy from Northwestern University who really wanted to go off somewhere in Sub-Saharan Africa and implement our system, so we connected him with a hospital in Rwanda where he can setup an electronic medical record system in parallel with a FrontlineSMS:Medic network. Emailing us is just a great way for people to put themselves out there in terms of supporting us with implementation, helping us write code, and website redesigns. We're still early on in our development, so any sort of contribution would be very valuable. We want new people to come up and we're more than willing to talk to people wherever they are around the world to come and work with us. Beyond that, well a little bit of financial love would be nice. We spend 100 percent of all of our grants on software development and implementation. We're all students, and so none of our staff take a salary. That's simply not what we're about.