BBC News, Anne
Soy and Anna Lacey, Health Check, 21 Sep
2013
 |
| Verbal interviews with relatives of the deceased are recorded onto the mobile phone app |
Health
Check
Two thirds
of deaths worldwide go completely unrecorded, making it impossible to know if
public health money is being spent in the right places. But could a mobile
phone app be the answer?
Birth and
death are perhaps the most significant moments of any human life - worth
writing down for posterity.
But in many
countries around the world, the systems set up to collect vital data about
citizens have such low coverage that many deaths slip through the net.
Not knowing
who has died, and what they have died of, makes it impossible to build an
accurate picture of a nation's health.
Now
technology - in the form of a specialist mobile phone app - could make all the
difference.
Using a
technique known as "verbal autopsy", field workers visit relatives to
ask them about the circumstances of a family death.
By
collecting the information digitally from currently hard-to-reach places, it
has the potential to revolutionise our understanding of global health.
Mobile
phone autopsies
In Malawi,
any death that occurs outside a medical facility is not recorded.
Dr Carina
King, a fellow at University College London, is overseeing the implementation
of the mobile phone autopsies in the Malawian district of Mchinji.
"We
found everyone surprisingly open, and I think they find the phone quite an
interesting thing when we go for interviews," she told the BBC.
Verbal
autopsies have been in use for about 20 years but the information was
traditionally recorded on a paper questionnaire.
These often
lengthy documents were supposed to be analysed by two doctors, who would use
the answers to deduce the likely cause of death.
However the
sheer scale of the task was often too great, meaning that many of the
questionnaires ending up languishing in dusty rooms, completely unread.
"The
mobile phone has been very good and means we don't have lots of paper
forms," says Dr King.
"We
have very quick access to the data and we can analyse it quickly to get the
causes of death."
The phone
software, known as MIVA, presents a series of questions that a trained field
worker uses to find out information from the family.
Each
question has a range of possible answers and the software intelligently skips
to the next relevant question depending on the response.
Most
important of all is that it is designed to quickly compute the most likely
cause of death.
The result
is stored in the phone and can be sent to a central database either by text
message or internet upload.
'Cheap and
robust' technology
Dr Jon Bird
of City University, London, who was part of the team involved in creating the
software, says mobile phones provide a particularly convenient way of
collecting data.
"Mobile
phones are probably one the most widespread technologies in the world. They're
cheap, they're robust and everyone knows how to use one," he told the BBC.
"The
everyday nature of mobile phones also makes them really valuable because the
people that are being interviewed don't find them intrusive."
In Malawi,
mobile phone autopsies are currently being used to record the cause of death in
children.
The project
is called Mai Mwana, meaning mother and child in the local Chichewa language,
and it focuses on children who died before their fifth birthday.
The
under-five mortality rate in Malawi is 71 per 1,000 live births according to
2012 figures from the World Bank - compared to just five per 1,000 live births
in the UK.
 |
| Families are interviewed in the community by trained fieldworkers |
Lazaro Cypriano lives in the village of Mzangawa in Mchinji district, central Malawi with his wife Magdalena and their toddler.
The couple
lost their first two children.
Their
second child died about a year ago, after a series of hospital visits due to
fever. It is this death that will be the subject of the verbal autopsy.
'Highly
sensitive'
Outside
urban areas, one of the main problems for collecting data is finding out when a
death has occurred.
To get
around this, field reporters from the local community take on the
responsibility of alerting the MaiMwana team of people who have died in their
area.
This is how
Lazaro's family was identified, and the visit now affords him his first
opportunity to narrate what happened to his son and have that information
recorded.
The
interviewer asks the couple standard questions and matches their answers to the
choices provided in the application's template.
It's a
highly sensitive and skilled job - and one which field interviewer Nicholas
Mbwana can see is made easier by using a mobile phone.
"We go
to the households, ask about the causes of death - what really happened - and
we also record the GPS in order to trace the household in future," he told
the BBC.
Dr King
says the system is key to the success of the project.
"GPS
gives us the location of every household in the district so we can actually
plot out on a map where people are dying of what, which means that you could
design more sophisticated programs for targeting specific interventions."
The bigger
picture
Mobile
phone autopsies are being used on a limited scale at present. But the long term
aim is to roll out the technique much more widely.
"The
beauty of the system is that it's standardised and can be translated into any
language you want," says Dr Bird.
"It's
important when you're collecting data on a large scale that everyone is
answering the same question, so that you know that the results are directly
comparable from town to town and country to country."
 |
| Interviewees' answers are inputted directly into the mobile phone app |
The World
Health Organization (WHO) is already supporting the initiative and is working
with institutions from the UK to Sweden to develop the technology further.
The data is
currently being collected in a range of databases that can be accessed by
researchers interested in public health.
As the
project grows, researchers from the University of Umea in Sweden will
co-ordinate the growing number of translations and the distribution of the
technology around the world.
The
government in Malawi is already keen to see the results of the project.
"It is
important for us as a ministry to know what is killing Malawians out there so
that we can plan ahead and put appropriate interventions in place to prevent
that - and also to put out health messages," says Dr Charles Mwansambo,
Malawi's Health Secretary.
The
Ministry of Health has so far only been using information collected from
medical facilities, which the health secretary concedes is biased data.
"We
need comprehensive data from the hospitals and the community to plan well. We
find ourselves planning for the small community that comes to hospital, not
realising there is a bigger community out there that we need to budget
for," he adds.
Significant
inroads
Dr
Mwansambo also acknowledges that a cultural practice of burying health
documents with the dead makes it difficult to collect important information
about deaths.
"When
somebody dies people want to forget everything about them - those memories that
will remind them of their loved ones. So unfortunately they bury the health
passport along with their clothes and other possessions and we lose vital
information in the process," he explains.
The health
passports are documents issued to parents, which record the birth weight of the
baby and its gain over time, as well as which immunizations were administered
and when.
An elder at
Mzangawa village, Kangkwamba Piri, is already talking to members of his
community to drop that cultural practice.
"We've
been doing this for a long time but it is wrong. What needs to be done is not
to bury the documents and that's what we're encouraging people to do," he
says.
For now, it
is likely that millions of deaths will still go unnoticed by official figures.
But verbal autopsies recorded on mobile phones are making small but significant
inroads into solving the problem.
And for and
his wife Magdalena, the chance to give information about what killed their
child to an official is important.
Magdalena
says: "What I have learnt from this interview will help me take care of my
third baby so he can be healthy and live long."
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