From computer scientist to global health techie:

a preliminary report

Neal Lesh

Alerts for Pediatric AIDS meds

• Pediatric review

Outline

• Background: The simplicity and complexity of global inequity

• Field reports:AIDS treatment program in urban TanzaniaSocial justice organization in rural RwandaPDA research project in South Africa

• Transition to discussion …

Simplicity: rich vs. poor

Simplicity: rich vs. poor

Simplicity: rich vs. poor

Simplicity: rich vs. poor

Infant mortality: 5Maternal mortality: 8 per 100,000 births

Life expectancy: 78 years

Infant mortality: 95 per 1000Maternal mortality: 500-1000 per 100,000

Life expectancy: 45 years

per 1000 births

Simplicity: rich vs. poor

Infant mortality: 95 per 1000Maternal mortality: 500-1000 per 100,000

Life expectancy: 45 years

Complexity• Corruption, careerism, tax write-offs• 5-star poverty alleviation meetings• Paying volunteers• Imperialism, foreign experts

“If you want to build a ship, don't drum up people to collect wood and don't assign them tasks and work, but rather teach them to long for the endless immensity of the sea.”– Antoine de Saint-Exupery

Outline

• Background: The simplicity and complexity of global inequity

• Field reports:AIDS treatment program in urban TanzaniaSocial justice organization in rural, RwandaPDA research project in South Africa

• Transition to discussion …

My last few years

• Sep 2004: back to school

• Jun 2005: off to Tanzania

• Oct 2005: overland to Rwanda

• Since Jan 2006: bouncing around among Tanzania, Rwanda, South Africa and New York

Tanzania

MDH

• MDH= Muhimbili University + Dar Es Salaam + Harvard University.

• US government AIDS treatment program, currently about 25,000 HIV+ patients.

• Reason for going: they needed a new data person, because current was leaving.

MDH data capture

• Doctors fill in paper forms for each client visit• Carbonless copy goes to HQ for double-entry• Data stored in Microsoft Access• Processed in SAS to produce useful reports

– Patient monitoring– Program monitoring– External funders and government reports

Missed-Visit List

More alerts

One Page Patient Summaries

Issues

• Mistyped IDs• Missing & conflicting data• Backlog • Efficiency & scaleability

Challenges

• Missing or late lab results• Use of reports to improve decision making.• Detect important trends in data

Rwanda

Every situation different…

• Tanzania -> Rwanda• AIDS treatment -> Social Justice• Urban -> rural

• Rwinkwavu is now a functioning district hospital

First Year Rwanda Milestones

• Rwinkwavu is now a functioning district hospital

First Year Rwanda Milestones

PIH Rwanda HIV & TB Scaleup

• Over 400 Community Health Workers (Accompagnateurs)

First Year Rwanda Milestones

A food package provide for all at the start of ART and TB treatment

First Year Rwanda Milestones

Milestones• Program on Social and

Economic Rights (POSER). – Housing assistance– School fees (cost of school is

subsidized for over 1450 children).

Milestones:Malnutrition Program

5 semaines plus tard

How old?11 13 9

Overall ICT Mission

• Develop and install OpenMRS:– An open source framework for medical record

systems in low-income regions– Reducess duplication of effort– Fast-growing collaborative effort– Installations in Kenya, Rwanda, Lesotho, Tanzania,

and Kenya– Join today! Come to meetings!

• Or come to Rwanda to teach Java. Contact Christian (callen@pih.org) or me for details.

ICT task: keep the internet running

ICT task: manage data collection

ICT task: satisfy reporting requests

Lab System

Hard to get on top of it!

• Hard to hold on, let alone make progress.

• Pulled in a lot of directions.

• Data quality a struggle• Data use a struggle• Might be close now...• Probably about to be the

national standard…

South Africa

Screening on Mobile Device

Patient doing well?

Patient goes home with

meds, to return next month

Patient referred to nurse or

doctor

YES

NO

Screening on Mobile Device

Shortage of Doctors

COUNTRY Doctors per 1000 population

HI+ people per 1000 population

HIV+ people per doctor

South Africa 0.489 215 439

Tanzania 0.023 88 3826

Rwanda 0.025 51 2040

United States 1.629 6 3.69

Conclusion: The shortage of doctors and nurses requires that future expansion occur in rural clinics with most patient visits being managed by health workers with minimal training.

Plan

• Currently validating interface & protocol– Double blind study in top-notch hospital clinics– Revising questions after first round

• Next step: operationalizing system– Link to OpenMRS– Deploy in down-referral clinics– Remote supervision– Reports delivered to clinics

Integrated Management ofChildhood Illness (IMCI)

Potential benefits of point-of-care protocols

• More consistent and accurate use of protocols• More sophisticated and dynamic protocols• Easier to update• Less training• Improved supervision & monitoring• Data collection

Discussion

Some questions I don’t have answers to• Is there ‘real’ computer science to be done here?• Too much focus on health? What about water,

education, economics, etc?• How do we evaluate if these systems are worth their

cost?