Twice a year, I travel to the Dominican Republic as part of a medical service team. While there, we work in a barrio called Paraiso just northwest of the capital city of Santo Domingo. We provide medical care for urgent needs and are working to establish systems for chronic care management: many of the community’s residents have high blood pressure (often poorly-controlled), and the rates of diabetes and high cholesterol are likely significant (though harder to measure). The residents of Paraiso–especially those in the more-marginalized community of Esfuerzo–face many obstacles to accessing health care. The nearest hospital is about 2 miles away, a distance which might not seem like much unless you envision an 80 year-old woman with arthritis or heart trouble walking under the tropical sun, up the hill and along the rough roads to reach it. She could hire a taxi, but this is expensive when one has no reliable income, and the cheapest taxis are motorcycle taxis (“motoconchos”) which are not the safest method of transportation. If she makes it to the hospital, she faces a clinic that is over-crowded, under-resourced and under-staffed. If she goes to a private clinic, she will need to travel farther and will pay more for both the office evaluation and her medications. As a result, many patients with chronic illnesses do not access care reliably.
These chronic illnesses exist within the context of the “social determinants of health” that adversely impact health, including education, living conditions, poverty, etc. (Read more about the social determinants of health here from the CDC, here, and here from the WHO.) People who lack education, have uncertain employment and uncertain food security, who live in communities without safe drinking water and with endemic parasitic diseases will face greater challenges in achieving good health than would be the case if these barriers were absent.
Some solutions to this include low-tech interventions: regularly taking anti-parasitic medications to reduce the burden of disease, working to provide safe and low-cost drinking water, and helping individuals take better control of their health by providing them with personal health records that will allow more effective care coordination. At the same time, social media (SM) could provide a higher-tech answer to meet some needs.
In the Dominican Republic, as is the case in much of the developing world, mobile phones are becoming more and more widespread. In countries that lack the necessary infrastructure to support “land lines”, mobile telecommunication is a very effective alternative. This article notes that nearly half of the world’s population has a mobile phone, and that nearly one-quarter of the world’s population has internet access. Other articles suggest that mobile internet might become a primary way that people in developing countries will access the internet (here, and here). Finally, some organizations suggest that mobile internet access could affect the underlying social determinants of health in developing countries (here, and here).
In the Dominican Republic, cell phones are widely available. Many people purchase lower-cost phones and purchase “pay-as-you-go” phone cards instead of a month-to-month contract. This indicates that health-related communication that is based on mobile technology could successfully reach communities that traditional models of medical care might overlook. SM (especially if you include SMS or text message alerts from SM sites) could be used to send out public health announcements, suggestions for healthy diet and exercise habits, etc. In addition, public health authorities could receive reports of outbreaks of illnesses or health concerns from individuals via the same means of communication. Expanding this further, individuals with mobile internet access could use SM sites such as Twitter or Facebook to interact directly with health care providers. Patients could discuss health concerns with their health care providers, and providers could contact patients directly to actively manage acute illnesses or to monitor chronic problems (within the limits of a nation’s privacy laws).
Obviously, this is a long way from being the standard, and there are barriers that need to be addressed to make this idea successful. High-speed wireless connections would need to become ever more widespread and robust, and internet-capable mobile phones will need to become ever more affordable. Service plans will need to become less expensive, or the pay-as-you-go cards will need to provide enough usage for people to use mobile net services. Privacy restrictions will need to be defined. Health care providers and public health authorities will need to adapt to these new means of communication, and will need to re-evaluate hierarchical models of health care in which physicians are in charge and patients follow behind. Communities will be best served by having at least a lay health promoter or community health worker who is trained in basic medical evaluation (such as taking blood pressure measurements, assessing a sick child for dehydration, etc) who can help facilitate communication between patients and health care providers. And even if this is all in place, it may be some time before the benefits are noted–time during which costs will need to be covered.
However, envision how this could work once a system is in place: isolated communities could notify public health authorities of disease outbreaks at an early stage. A community health worker could check patient’s blood pressures and relay them to a health care provider, who could suggest medication changes without having to be on-site. Patients and communities can learn about low-cost interventions that could benefit their health, and can have dialogues with health care providers about how to prevent chronic illness and how lifestyle modifications (diet, exercise, etc) could improve one’s health status even if a chronic disease is already present. There is evidence that one of the best ways to improve a family’s health is to educate the mother: SM communication could increase the access women have to information they can use to keep their family healthy.
Mobile telephone and internet technology can be joined with SM tools to allow health care to reach marginalized and distant communities, and to reduce the morbidity and mortality associated with disease. There is much work to be done, but the stepping stones are already in place. More-developed nations (such as the US, Canada, and Europe) could help move the process along by using similar approaches to provide care to rural communities that lack their own health care providers. Small-scale projects have shown promise in the United States, while in India there are a number of services offering physician consultations via the internet and accessible via mobile devices.
We can make this happen, but we need to open our minds to the possibilities.