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One of the People-people

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"Oh, you're one of the international people," a young nurse from Washington, D.C. said to me at last week's mHealth Summit, an annual gathering that attracted 3,600 participants this year (up from 300 attendees in 2009), united in their desire to use of mobile phones to improve health care quality and access.

This woman was acknowledging my poster presentation -- a study on how text message alerts could improve maternal health in rural Ethiopia -- but her comment was delivered with such exasperation that I had to request she clarify her point. What did it mean that I was one of the "international people"?

Before she could answer, I had an inkling of her intention, as I had noticed a dichotomy at the gathering myself. Half of the summit-goers appeared to be U.S.-centric: the entrepreneurs behind the 12,000+ health apps currently in the iTunes library, the venture capitalists eager to foster the industry to avoid a bubble burst, and the businesswomen and men showcasing clever tools that, for a price, promised individuals the chance to manage and meet their health goals once and for all, from chronic disease management tools, to diet monitors, to prescription drug adherence reminders.

But I barely batted an eye at these tools, because I belonged to the other camp -- "the international people" -- the foreign aid agency representatives advising developing country governments on their technology investments, the international non-governmental organizations deploying innovation in communities without electricity or running water, the designers and researchers worrying about malnourished children, not first-world "well-being."

This young nurse felt understandably offended by such an attitude, which insinuated a moral superiority over any mobile tool with origins in a rich-country like America. Listening to her stories, it was immediately clear to me that her daily struggles in D.C. were just as complex and challenging as the ones I have been facing in Ethiopia. And her point is one that would do the mHealth community well to consider in a bit more depth: that the world's greatest needs -- and perhaps the most promising opportunities for mHealth to transform health outcomes -- are not defined by national borders.

In my work in Ethiopia, for example, a text message reminder about child vaccinations are geared to address the tragic under-five mortality rate (more than 10 out of every 100 children), as 90% of these deaths are entirely preventable. Although most American children are properly vaccinated, is it any less tragic that every five hours, one child in the US dies from abuse or neglect? Who is building an app for that?

It is also noteworthy, as articulated by the Black AIDS Institute report "Left Behind", that there are more Black Americans living with HIV in America than there are Ethiopians living with HIV in Ethiopia. In fact, there are more Black Americans living with HIV than people with HIV in seven of the 15 focus countries of the U.S. president's Emergency Plan for AIDS Relief, even though few international observers would consider America as a country with an AIDS problem.

This is not to say that Americans should only be concerned with America, or to each their own nation. However it is crucial to note that the world is no longer divided, and perhaps never even was, by the boundaries of America vs. the rest, or developed countries vs. developing, or rich vs. poor nations. Within every country's borders there are marginalized communities in need of improved access to quality healthcare. And this is where the true promise of mHealth lies: in deeply understanding the needs, behaviors, and norms of people at most serious risk of disease and death.

Fulfilling this promise means, at a most basic level, sharing knowledge and innovations across borders. Preferably, mHealth solutions will continue originating all over the world -- like mPedigree in Ghana fighting drug counterfeiting, or MiDoctor in Chile assisting chronic disease management, or Pesinet in Mali ensuring quality care for under-5 children, or mCare in Bangladesh improving access to emergency obstetric care. After all, a sub-population might be more similar than we think between cities like Bamako and Baltimore.

Even more ideally, the mHealth community will continue generating rigorous evidence that innovative mHealth tools are actually improving health outcomes, like the now famous study by Weltel in Kenya, in which 62% of HIV-positive patients who received text message reminders about their medication adhered to their regimen, compared to 50% in the control group. Additionally, suppressed viral loads (meaning a patient becomes biologically less likely to infect others) were reported for 57% of the text message recipients, compared to only 48% in the control group. Sharing and discussing research designs and methodologies is even more crucial for this fast-moving field. As several Summit sessions discussed, testing specific tools, that could be rendered obsolete in a matter of months, will be a less useful tactic than testing how phone functionalities (adaptable to different devices) can impact health outcomes.

After all, as noted mHealth mythbuster Dr. Kentaro Toyama wisely warns, "technology only magnifies human intent and capacity" - mHealth apps won't make people inherently more healthy decision makers, but they can assist people with good intentions to reach otherwise impossible goals.

Investing in understanding end users will also require resources, and so while a tool's ability to generate a profit should not be a criteria of its legitimacy, all mHealth innovators would benefit from having a sustainable business model attached to their plans. In some cases this means large-scale public private partnerships, like MAMA - the Mobile Alliance for Maternal Action, between USAID and Johnson & Johnson, who hosted a large-scale brainstorm session with mHealth practitioners and researchers at the summit. In other cases mobile network operators will need to step up, like by agreeing to support a Switchboard-style closed network for doctors. And social entrepreneurs like Praekelt, a South African company with a sister non-profit arm, will also play a role -- in a pilot of Project Masiluleke the company dedicated space at the end of over 690 million text messages to provide HIV testing information in six local languages. The effort resulted in 1.5 million calls to a local AIDS helpline.

The real dichotomy that will continue to divide the community of mHealth advocates, and the terms on which I would rather be judged, is whether or not the design of a an mHealth tool is actually paying attention to people, or not.

Paying attention to people entails a spending more face-time with end users than screen-time behind a laptop. It means sharing ideas and remaining open to feedback, and adhering to the philosophy of one Fail Fare participant (a remarkable event bringing 'mobile-for-development' failures to public light), that "the only failure that will kill you is the failure to learn."

On the surface it seems a world away from the U.S., when my project involves getting solar panels out of customs and considering donkeys the next best ambulance alternative to walking to seek care. But I hope that by next year's mHealth Summit, the mHealth community's conversations are comparing not just geographic struggles, but strategies to understand end-user experience, human behavior, and how people function before technology enters the picture, no matter where they are on the planet. That way, we can fall into line not as two separate camps of international or domestic people, but more effectively, as thepeople-people.