Tag Archives: mobile health

Lessons for Ebola, from 3 years of water source mapping & monitoring in the African continent

Ebola 2014 — The current Ebola epidemic in West Africa which was first noted in the spring of this year began quietly but has now escalated to include five countries (Guinea, Liberia, Nigeria, Senegal, Sierra Leone) and an estimated 3707 suspected/confirmed cases with 1848 deaths (US Centers for Disease Control and Prevention Ebola Page, August 31st, 2014). The WHO declared this Ebola Virus Disease (EVD) epidemic a Public Health Emergency of International Concern on August 8, 2014 (WHO on Ebola Virus Disease). Despite this declaration, the new Ebola cases continue. Recently the Rt value for this epidemic was reported to be greater than 1 and less than 2 (R>1 and R<2) (Nishiura H. and Chowell G. Eurosurveillance 2014). These numbers soberly reminds us that the number of Ebola cases are not slowing down but are in fact growing which, appeals for immediate and urgent action to reduce and cease Ebola transmission. This plea has been echoed by prominent virologist and infectious disease experts, Richard E. Besse, Michael T Osterholm and “Science Magazine.”

To aid in this global problem, Annie Feighery, an expert in using technology to improve public health, describes lessons she has learned from her work in West Africa with mWater, a mobile water sanitation tracking system, and how these lessons can be applied to the current Ebola situation.



Lessons for Ebola, from 3 years of water source mapping & monitoring in the African continent

by Annie Feighery

The West Africa Ebola outbreak has been said to be the World’s Katrina. This means we are witnessing one of our lifetimes’ worst tragedies which is largely due to the significant gaps in the local health infrastructure. Many of the stressors in what is now the worst Ebola outbreak on record are not directly Ebola-related, but rather legacy problems from generations of broken health systems. For years, the water and sanitation field has worked under very similar conditions in West Africa and learned valuable lessons about frontline health monitoring which we believe can be applied to the Ebola Response. Here we recount lessons learned on Report Systems, Checklists and Public Engagement from our work through mWater in West Africa that may be fundamental to Ebola reporting and management.

In 2011, I co-founded the organization mWater to develop technology to help communities and individuals have access to safe water by harnessing the power of smartphone technology. Our first partners were UN Habitat, the City of Mwanza, Tanzania, and the local water utility in Mwanza. It wasn’t as simple as mapping, though. By creating a unique ID number for water sources, we were able to attach information to a source that could be updated over time. In the case of water, we mapped whether the source was functioning and we used a cheap but highly effective field test to update whether it was contaminated with E. coli, an indicator bacteria for more dangerous contaminants.

Since then, we’ve expanded our application to map sanitation facilities, schools, health clinics, communities, and households. Each is a different type of site that can have a broad range of data associated with it, and that data can be updated over time with mWater surveys. The result is an infrastructure that allows data-driven policies and improved municipal management. Most important, thanks to continued investment in mWater from USAID, Water.org, WaterAid, and The Water Trust, we can now offer this service to any community or organization for free, via the mWater app and online portal. What started in Mwanza has grown to more than 2000 free and independent users in 54 countries and 7 countries where large organizations contract our services for specific projects. Our user base includes communities, governments, utilities, scientists, and organizations who build infrastructure by mapping and monitoring sites, conducting M&E surveys, and deploying health worker checklists on mobile phones and tablets.

We have learned critical lessons about how the approach of monitoring water sources over time can also be helpful in addressing major public health issues. Currently, the biggest health emergency on our planet is the West African Ebola outbreak. Our technology can help. Our team is working around the clock to leverage our software for emergency response, mapping, and monitoring of this Ebola outbreak. But our biggest contribution may be our lessons learned about digital epidemiology.

Listed below are three lessons on Report Systems, Checklists, and Public Engagement which we think encompass the critical knowledge gained over our past three years that could increase the situational awareness and health capacity for the Ebola health crisis.14986886991_799e7067e1_m

Report symptoms Frontline community health workers are the best way to gather information in developing countries. For Ebola-stricken countries, the military is also being deployed as frontline health workers, conducting temperature checks and enforcing quarantines. We found that data from health workers is more accurate when health workers are asked to report symptoms rather than conduct the diagnosis themselves. A diagnosis needs local context. For example, we asked 35 health care providers throughout Mwanza to define the symptoms of diarrhea. We received a range of 18 answers including red eyes, weakness, and fever. The WHO definition of three or more loose stools in a day was only the fourth most frequent response. This is likely because many individuals in this region go their whole lifetimes without a solid stool. A loose stool in this context is not a relevant symptom. However, a case that the health worker finds significant enough to report with a list of symptoms the health worker can tick off in checked boxes makes the data actionable, regardless of the accuracy of the diagnosis.

We are using this lesson for Ebola with our own launched platform for symptom reporting. Within five seconds, frontline health workers can press their finger on a map to indicate location, automatically filing a report to the cloud-based management dashboard. The app works on and offline, which is important in low-resource regions that can have sparse connectivity. If they have time, users can provide more detailed information on symptoms with tick-checked boxes. Previous digital epidemiology attempts have attempted to focus on reports from doctors and other official sources, limiting information to a slow but steady stream from experts. The lesson with crowd-sourced data is that the validity of the data increases with the “n”, the number of reports, as opposed to traditional studies that increase validity with source quality. We are doing everything we can to increase reports, including eliminating barriers such as literacy and time expectations. We are focusing on the point of data being at the biggest interface with the community, the frontline.


Follow checklists Frontline health workers have a lot of information to remember, from diverse fields such as public health, sanitation, and community development. One very simple innovation that has been shown to dramatically reduce complications in hospitals is the use of checklists. We work to apply this same concept to community health workers, who provide the frontline health information interface for communities in developing countries. Mobile technology can help ensure that best practices make it all the way through the last mile and into the frontlines.

We can already use our Surveyor platform to deliver a checklist to smartphones, allowing us to add questions or steps that are automatically pushed to health workers and monitor whether they are using the tools provided. Real time data gathered in a cloud-based database can use checklist results from one survey to trigger another enumerator’s questions. Symptoms queried can be adapted in real time, based on growing situational awareness. All data in checklists can be quickly monitored as indicators in the Portal, a management website that deploys surveys, collects their responses in real time, and allows users to download their data as CSV forms.


Listen to the public. In a large survey of the population in Mwanza, we found that water scarcity was a bigger concern for them than water contamination. As a public health scientist, I know this is due to a survivor’s bias, where only people who survived the age of five and have the gut flora needed to survive high levels of fecal contamination are around to tell their neighbors, their family, or me about what they are worried about. I know epidemiologically that waterborne disease is the second biggest cause of infant mortality on the globe and an indicator for the other big threats to child well-being, namely lung infection and malnutrition. But I have learned that also meeting the self-assessed needs of a community is a critical must to any policy.

In water, focusing on self-assessed needs allowed the city to make a policy decision based on digital epidemiology with local buy-in. We mated the need of water scarcity with the health policy need of protecting water supply by providing more and safer water sources. Our data motivated the city to stop supporting any further construction of shallow wells, which were found to be frequently contaminated, instead approving boreholes and piped kiosks and taps for their own expansion and NGO donations.

Translating this lesson to Ebola, the communities affected are rarely hit with Ebola itself, but instead are regularly hit with diarrhea and lung infection and they have a chronic shortage of medical staff to treat those illnesses. The targeted response to Ebola while these more common life-threatening conditions go under-treated has caused distrust between communities and the emergency agencies. Taking the self-assessed need as a critical priority would mean we should also provide resources for lung infection, diarrhea, and other local health priorities alongside our effort to provide resources and expertise for Ebola.


Annie Feighery is a digital epidemiologist based in New York City and the CEO of mWater, a non-profit tech start-up that develops innovations for water, sanitation and health. The organization provides free and open access platforms for mapping and monitoring infrastructure, for deploying mobile surveys and for real time visualizations of health data. For more information, visit www.mWater.Co and follow @mWaterCo on Twitter. To use mWater’s free Ebola monitoring platform, visit Ebola.BroadSt.org.

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mHealth! Mobiles for Improving Healthcare

In place of a JIDC Postcard this week, the fabulous Derek Ng has written a piece on mHealth.  The potential of mobile phones to deliver health advice and/or information is exciting.   I already see many people using this technology here in Canada.  For instance, many of my pregnant friends receive weekly up-dates on the progression of their pregnancies on their mobile phones.  Although powerful, challenges for implementing these technologies do exist.  In this Blog Post Derek has reviewed the compelling advances in mHealth as well as discussing the challenges. 

What are your thoughts on mHealth and how well do you think it will be accepted in your area?  Are you using mHealth technologies in your area?  Or are you trying to implement a new mHealth technology?  If you have comments or would like to share your experiences in mHealth we would like to hear from you.  Particularly I am interested in the use of mobile devices to track infectious disease outbreaks.  


The advent of mobile phones has made it considerably easier for people to communicate regardless of where they were in the world. By the mid-2000s, these phones were becoming increasingly powerful with miniaturized computer chip technology that made it possible for users to complete more complex tasks. The mobile phone has evolved from a device that was essentially a phone that individuals could use away from home to something more resembling a handheld computer – an aptly named “smartphone.” Today, users can perform tasks beyond that of simply calling and texting, such as e-mailing, surfing, video recording, word processing and more. The integration of computer-like capabilities to the phone has also resulted in the development of applications that can be designed to perform specialized tasks. One interesting twist in the mobile world is that of mobile health (mHealth).

What is mHealth?

The World Health Organization (WHO) defines mHealth as “the use of mobile and wireless technologies to support the achievement of health objectives,” where the WHO has published a write-up on mHealth.  The concept of mHealth has already caught on with cell phone applications that assist health-care providers by providing up-to-date lists of drugs, information on diseases and so forth. This has already aided physicians in supplementing their point-of-care service. It is also available on the outpatient or receiving end of health care by providing patients with schedules for medications or how to eat or exercise better. The possibilities appear to be even more promising as mobile technologies are still rapidly advancing. Although we can see real applications and benefits for this technology in industrialized countries, the same remains to be seen for developing countries as well.

How have mobile phones changed the developing world?

Cell phone usage in developing countries has skyrocketed in the past and continues to do so in areas such as South America, Africa and Asia [1]. The technology has helped countries without infrastructure to bypass the need to construct landlines which were previously required for telephony to occur. By constructing modern radio towers instead, these countries can leapfrog the older and more expensive telephone technology, which has resulted in countries that possess a well-established mobile network despite lacking paved roads, electricity or landline internet connections [1]. This situation has allowed for an unprecedented number of individuals who are now connected to each other, as well as the internet. One key aspect about this far-reaching technology is that it has been made very affordable in these areas. For example, China and India have over 800 million cell phone subscribers each, whereas in contrast, Canada has 24 million active cell phone accounts [1]. When I visited China, I spent about 20 Canadian dollars on a prepaid plan that offered me more minutes and data usage than I could use in a month. In Canada, my cell phone plan is often over 50 dollars a month.

Why mHealth?

An advantage of mHealth is that it can be utilized to allow a broad base of users (many of which are already subscribed to a cell phone plan) to be instantly informed on wide range of issues. These topics could range from outbreak detection and notification, drug or therapy adherence (such as that seen in TB treatment), HIV awareness, and so forth. For example, Grand Challenges Canada is promoting innovative ways in which to solve global health issues [2]. Furthermore, the use of mHealth to improve healthcare has been reported in countries such as Kenya and Cameroon [3–8]: some articles of which are Open Access, Implementing medical information systems in developing countries, what works and what doesn’t by Fraser 2010, The Cameroon mobile phone SMS (CAMPS) trial: a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy by Mbuagbaw et al., 2011, and Global Networking of Cancer and NCD Professionals Using Internet Technologies: The Supercourse and mHealth Applications by Linkov et al., 2010.

Two interesting proposals of the Canadian Rising Stars in Global Health from Grand Challenges Canada we recently came across here at the JIDC were ‘using mobile phone text messaging to reduce maternal and infant death in rural areas in China’[8] and ‘mHealth for Maternal and Newborn Health: Clinical decision support for community health workers in Western Kenya’[9]. The first idea, proposed by Ri-Hua Xie from the Ottawa Hospital Research Institute and University of Ottawa, is to deliver educational material from the World Health Organization to expecting mothers who might not have received the information otherwise. Her proposal aims to reduce both maternal and infant deaths, by connecting healthcare providers to expecting and new mothers in rural areas.  You can watch a video describing her idea here.

The latter proposal by Astrid Christoffersen-Deb at the University of Toronto is in collaboration with Moi University Schoolof medicine inKenya. She would like to provide citizens with a unique barcode and identifying health card, which can be scanned by a community health worker. This provides the workers access to electronic medical records for sending and receiving information to and from medical facilities.  You can watch a video describing Astrid’s idea here.

Thus far about 80% of all WHO member states offer at least one mHealth service – the majority of which are in higher-income countries[1]. The highest reported rate of mHealth use was in countries inEurope, whereas Africa was least active. The majority or about two-thirds of projects in mHealth are still in a pilot stage, which poses some problems in its widespread implementation.

The challenges in implementing mHealth

However, not everyone is as optimistic about the impact of mobile phones in these countries. In fact, mHealth faces several barriers, despite the many promising ideas outlined earlier. Some issues include the lack of convincing studies that outline a positive benefit for the cost of implementing mHealth. The studies also need to show more evidence that mHealth can improve health outcomes. In countries where funding is already limited, the governments may decide to fund other important health care programs whose outcomes are better established. There is also a lack of standardization because some of the studies have been launched to tackle one specific problem in that one region. The WHO is currently developing a tool kit that may offer a standardized set of guidelines for using mHealth in the future.

The future of mHealth and summary

mHealth offers a promising way to deliver different health care programs and services to the individuals who have traditionally had difficulty accessing such resources. With the increasing capabilities of mobile technology and its penetration into remote and rural areas, we can look forward to emerging fields within mHealth. Ideally such applications (some of which previously mentioned) would benefit both health-care providers and patients alike. Health-care providers may see advanced telehealth technologies for communicating with experts for assistance in complex or difficult procedures outside of sophisticated care facilities, such as in remote or underserviced areas. An extension of this is that it could also allow physicians to more easily follow-up and monitor their patients. Yet another application branching from this is education of citizens for public health purposes.

With any new emerging technology, it is important to assess its benefits and risks. Studies must be made to produce a standardized set of guidelines – an undertaking which is already in progress through the WHO. Following such guidelines, it would also be useful to validate the technology according to the needs of an individual country and its citizens, since disease burdens and health-care services would vary.

While the verification of the benefits of mHealth and whether it is a valuable investment over other health services in countries where resources are already limited are important considerations, there appears to be a potential for mHealth to make a significant impact on health care in the future

Derek Ng

What are your thoughts on mHealth?

Please feel free to leave a comment.

Derek is from Toronto, Canada and is now a second year medical student at the University of Western Ontario.  Comments or questions contact Derek: cng2014@meds.uwo.ca or myself:  akelvin@jidc.org 

Derek on Left


Reference List


      1.   World Health Organization W (2011) mHealth New horizons for health through mobile technologies.

      2.   2011 July) Grand Challenges Canada. http://www.grandchallenges.ca/.

      3.   Chang LW, Kagaayi J, Arem H, Nakigozi G, Ssempijja V, Serwadda D, Quinn TC, Gray RH, Bollinger RC, Reynolds SJ (2011) Impact of a mHealth Intervention for Peer Health Workers on AIDS Care in Rural Uganda: A Mixed Methods Evaluation of a Cluster-Randomized Trial. AIDS Behav . 10.1007/s10461-011-9995-x [doi].

      4.   Tamrat T, Kachnowski S (2011) Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World. Matern Child Health J . 10.1007/s10995-011-0836-3 [doi].

      5.   Mbuagbaw L, Thabane L, Ongolo-Zogo P, Lester RT, Mills E, Volmink J, Yondo D, Essi MJ, Bonono-Momnougui RC, Mba R, Ndongo JS, Nkoa FC, Ondoa HA (2011) The Cameroon mobile phone SMS (CAMPS) trial: a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy. Trials 12: 5. 1745-6215-12-5 [pii];10.1186/1745-6215-12-5 [doi].

      6.   Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA (2010) Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 376: 1838-1845. S0140-6736(10)61997-6 [pii];10.1016/S0140-6736(10)61997-6 [doi].

      7.   Fraser HS, Blaya J (2010) Implementing medical information systems in developing countries, what works and what doesn’t. AMIA Annu Symp Proc 2010: 232-236.

      8.   Linkov F, Padilla N, Shubnikov E, Laporte R (2010) Global Networking of Cancer and NCD professionals using internet technologies: the Supercourse and mHealth applications. J Prev Med Public Health 43: 472-478. 201011472 [pii];10.3961/jpmph.2010.43.6.472 [doi].

      9.   RI-HUA XIE, Canadian Grand Challenges (2011 July) USING MOBILE PHONE TEXT MESSAGING TO REDUCE MATERNAL AND INFANT DEATHS IN REMOTE AREAS IN CHINA. http://www.grandchallenges.ca/canadianrisingstars_round1grantees/rihuaxie_en/.

    10.   ASTRID CHRISTOFFERSEN-DEB, Canadian Grand Challenges (2011 July) MHEALTH FOR MATERNAL AND NEWBORN HEALTH: CLINICAL DECISION SUPPORT FOR COMMUNITY HEALTH WORKERS IN WESTERN KENYA. http://www.grandchallenges.ca/canadianrisingstars_round1grantees/astridchristoffersendeb_en/.


Filed under Kenya, mHealth, News, Science Tools