Is that a doctor in your pocket?9 December 2014
Non-communicable diseases such as heart disease and diabetes are often thought of as pathologies of affluence, but they’re actually a major cause of premature death in low and middle-income countries. Dr Fred Hersch, research fellow at The George Institute for Global Heath and James Martin fellow of healthcare innovation at the University of Oxford, discusses how the humble mobile phone could help shift the burden and make healthcare more accessible around the world.
Around the world, the challenge of providing quality, affordable healthcare has never been so urgent. Over the past 20 years, the well-being of the world has changed dramatically. The United Nation's Millennium Development Goals have focused global attention on maternal and child health, and HIV, tuberculosis and malaria. While the battle continues, the goalposts are at least now in sight.
As if awakening from a bad dream, the world now faces an even more monumental challenge - and a mostly man-made one at that. Of course, we are talking about non-communicable diseases (NCDs), those mislabelled 'diseases of affluence' like heart disease, stroke, diabetes and chronic obstructive pulmonary disease that dominate our modern healthcare landscape and account for 63% of total deaths each year.
But what could these have to do with global health? As it turns out, NCDs, far from being a 'rich world' problem, are a major cause of premature death in low and middle-income countries; 80% of the global burden of NCDs occurs in these 'developing' countries, many of which are still dealing with ongoing high rates of infectious disease, and unacceptable maternal and child deaths.
This double burden of disease is further exacerbated by the fact that in these countries, NCDs are affecting increasingly younger sections of the population. In India for example, the average age of a first heart attack in men is 53, almost ten years younger than in high-income countries. And they are spreading - fast.
Take for example diabetes. In China alone, a recent study published in JAMA estimated 11% of the adult population, a billion people, has type 2 diabetes. Even more alarming was the finding that potentially 50% of Chinese adults could have prediabetes, a precursor stage to diabetes where there is an abnormal response to glucose. On current trends, the International Diabetes Foundation (IDF) predicts that, globally, more than 500 million people will be living with type 2 diabetes by 2030.
The problem with these chronic diseases is that prevention relies on early intervention. For heart disease, there are often no warning signs, and the first presentation may be with a heart attack or a stroke. In the case of diabetes, the IDF estimates that one in two people remains undiagnosed, leading to a number of preventable complications including blindness and significantly increased risk of premature death (from heart disease). Driven by the familiar set of risk factors - smoking, poor diet, increasingly sedentary lifestyles and excessive alcohol consumption - NCDs pose real threats to economic and social development. If this business-as-usual model persists, NCDs will cost developing countries more than $7 trillion over the next 15 years.
In 2011, world leaders recognised this growing threat and made a historic UN declaration to combat NCDs. Following on from that, and together with WHO, a set of voluntary goals has been developed; the 25×25 calls on countries to reduce deaths from NCDs by 25% by 2025. Achieving this will require concerted efforts across sectors to promote prevention strategies that emphasise health and well-being, and to see the implementation of cost-effective health system interventions to ensure economic management strategies are scaled up - for example, inexpensive multidrug therapy for patients with existing heart disease or those at high risk. Easier said than done.
Not all healthcare is created equal
It will not be a surprise to most that, around the world, healthcare is not equal. Resource-poor settings, especially in developing countries, tend to be characterised by fragile healthcare systems, often with inadequate access and a lack of resources for health - human and financial.
Where care is provided, it is inevitably of variable quality and with a lack of local knowledge; access to a regular supply chain for essential medications and simple diagnostics can mean that preventable problems cannot be addressed. For the rural poor, additional barriers to care include long distances to seek help and the associated costs. Catastrophic healthcare expenses, often due to incidents like heart attacks, drive more than 40 million people back into poverty every year in India alone.
WHO estimates a global shortage of more than four million healthcare workers. For developing countries, this is further exacerbated by the brain drain that has seen an exodus of doctors and nurses to developed countries. The situation is particularly bleak in rural areas, where critical workforce shortages can mean one doctor for tens of thousands of people. In these areas, the focus has increasingly been on frontline health workers, often from local communities, providing basic healthcare services.
Clearly, we are losing the battle when it comes to NCDs. Across the globe, healthcare systems are either being crippled by the rising costs or are woefully ill-equipped to deal with the challenge of chronic diseases. There is no shortage of clear guidance on how to prevent and manage these conditions; the challenge lies in their wide-scale implementation.
To meet the growing healthcare challenges, there is a desperate need for new models of care that aim to prevent the development of NCDs and their initial risk factors, and, for those with chronic diseases, to provide affordable, evidence-based care so as to minimise the development of complications.
Just what the doctor ordered
The spread of mobile telecommunications has been a revolution; the rate at which mobile phone coverage and access has spread is unparalleled in history. Today, there are close to seven billion mobile phone subscriptions, the majority in developing countries, where the growth has been nothing short of staggering, and there has been a leapfrogging of the traditional copper wire stage to, in effect, be 'mobile-first'.
With more than 95% of the world covered by basic voice and text, for the first time in history, people are connected in even the most remote parts of the world. This ubiquity and increasing affordability of mobile communication has made it a potentially transformative force in many sectors, including health.
mHealth is widely defined as the use of mobile telecommunications and wireless technology for health, and early pioneers and researchers in the field have seized on mobile technology to address chronic global health challenges.
There has been a proliferation of pilot programmes and small-scale projects that have focused on improving data collection, and the use of short-messaging systems (SMS) and integrated voice response (IVR) to improve health worker coordination for delivery of care and patient adherence to medication. Most of these efforts have centred on maternal and child health, HIV/AIDS and tuberculosis.
Despite the promise of mHealth and the proliferation of small-scale projects, there has been a problem breaking out of the pilot stage, leading to what practitioners have labelled the 'pilotitis' of mHealth. This is certainly changing as practitioners realise the opportunities of mobile health for overcoming system barriers and as technology itself becomes more pervasive.
Across the spectrum, there are lots of great examples of how mobile tools are improving health. Smoking cessation via two-way SMS is one of the best examples of really good evidence for using mHealth. When you consider that there are more than a billion smokers in the world, 80% in low and middle-income countries, and that tobacco kills almost six million people a year, the impact is potentially huge.
New digital trends provide exciting opportunities for addressing NCDs. Around the world, with the proliferation of lower-cost smart devices and sensors for collecting data, and a shift to powerful cloud computing, we are starting to see the convergence of data services via 3G networks. By 2020, smartphone subscriptions are set to exceed 5.6 billion, with a significant proportion of that growth in low and middle-income countries, driven by cheaper devices - already less than $50 and still falling. This year, India will surpass the US with more than 400 million smartphone subscriptions. These devices are shaping up to be the dominant computing platform, and it's not hard to imagine that developing countries will leapfrog the PC era in much the same way that mobile communications leapfrogged landlines.
An apple a day...
In this modern age, the focus on prevention and wellness has seen a proliferation of apps and activity trackers that promote well-being. This is not limited just to the iWatch or the FitBit. In China, phone-handset-maker Xaomi, the 'Apple of the East', has released a low-cost activity tracker that syncs with its lower-cost smartphone. With the rapid move from feature phone to smartphone, the introduction of the new $25 handset from Mozilla, for example, will allow app developers around the world to develop novel solutions to local problems.
This convergence of technology is creating a closed loop of connectivity. Whereas in the past we have talked about e-Health, telehealth and telemedicine as almost separate entities, today we are connected like never before. This is a big opportunity for addressing the need for continuous care, as is the case for chronic diseases, giving rise to a truly connected digital health ecosystem that could buoy new care-delivery models - supporting patients and healthcare workers alike.
This year, a number of companies in the US and UK launched video-based consultation services. Telemedicine and virtual consultations are nothing new, but what is unique about these services is that they are offering, for the first time, the ability to connect face-to-face with a doctor from the convenience of your smartphone. For resource-poor settings, where barriers to access include long distances and costly travel, this could be transformative. In the meantime, even in the most remote corners of the world, smartphones and tablets are being used to support the delivery of evidence-based care for NCDs and educate healthcare workers around the world.
They say a problem well defined is a problem half-solved. When it comes to NCDs, we know the problem, but the solutions are far more difficult. Understanding the complexity of human behaviour and integrating new solutions into healthcare systems are not simple tasks. But with the widespread availability of low-cost technology and open-source platforms, innovators around the world have the potential to solve local problems.
From Silicon Valley in San Francisco to Tech City in London and the Silicon Savannah of Nairobi, the disruption of healthcare through technology is a hot topic and offers hope of new models for improving the health of the world.