CHIKWAWA, Malawi — Community health-care worker Stephane January had never used a cell phone before a text message-based nutrition-monitoring program was introduced to his rural Malawian community's district in September 2012. Now, January spends every Thursday sitting outside the Makwira Health Center in Chikwawa, punching children's measurements into simple messages that are sent to a central hospital in the country's capital of Lilongwe.
Each text message is formatted identically, beginning with "GM" for growth monitoring, and followed by a string of numbers representing the child's identification number, date of birth, weight, height and arm circumference.
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"When children are malnourished, we can find out in less time and send them to get food supplements," January explains, as he waves his Nokia feature phone in the air to find a signal.
Each week, some 250 mothers bring their under-five children — secured around their backs in brightly colored, sarong-like chitenges — for a monthly check-in at Makwira. The young ones scream and squirm, as their mothers repurpose their chitenges, attaching the fabric to a scale that dangles from a low-hanging tree branch where a health worker logs their weight. The children are then swooped up, and placed lying flat on their backs on a picnic table, where another set of health workers yank on their feet and shoulders, recording their height. The workers also tape-measure each of the children's upper-arm circumferences.
These measurements are then passed along to January, who copies the digits scribbled by the health workers into an SMS, which he sends using RapidSMS technology. Within minutes of pressing send, January will receive a reply from the central server located more than 250 miles away in the capital, which has determined whether the child is showing signs of malnutrition, and needs further medical attention.
"The technology has helped us to analyze data and give feedback on the spot," John Mugawa, the district's program coordinator says. "The data doesn't need to pass through the hospital, and can go straight to the clinician in Lilongwe."
Although monitoring a child's growth cannot fix malnutrition's root causes, such as poverty, access to nutritious food and health knowledge, it holds enormous potential to improve treatment by identifying at-risk children. Growth monitoring allows district hospitals, for example, to properly identify which children need nutritional supplements such as Plumpy'Nut, a product that was developed to treat severe acute malnutrition at home, and eliminates the need for hospital stays.
Lessening the burden on Malawi's hospitals is crucial because the country lacks adequate medical resources. In addition to the long distances to health centers, medicine is scarce, and there's only one doctor for every 44,000 people.
The country's medical challenges are particularly prominent among its young population. There's an 8% chance that a child in Malawi will die before reaching his or her fifth birthday, according to UNICEF; acute malnutrition is at the root of at least one-third of these fatalities. Nationwide, 17% of children under five are underweight, and 47% are stunted, which means they're severely shorter than their age group.
Malawi's staggering figures for stunted growth — among the world's worst — have a crushing impact on the nation's economic activity. As opposed to when children are underweight or wasting (acute malnutrition that causes muscle and fat tissue to deteriorate), the effects of stunted growth are mostly irreversible, and mostly occur before a child turns 2. Stunting affects a child's cognitive development, school performance, economic productivity in adulthood and maternal reproductivity, according to UNICEF. What's more, the effects of stunting can be passed onto the next generation.
Image: Mashable, Zoe Fox
Combating these effects are why the SMS-based growth-monitoring program presents such enormous potential to save lives. Prior to the program's debut, paper notebooks would be sent to Lilongwe, where the children's measurements would be analyzed manually. At best, reports of malnutrition would get back to the district clinics after two months. At worst, the process could take a full year, at which point the condition of at-risk children would have likely seriously declined.
In addition to the lengthy response time, a study found that more than 14% of the handwritten data was illegible (as reported by the national hospital). In contrast, during the initial pilot of the RapidSMS program, just 2% of the data contained improbable figures. The central server can also catch when erroneous measurements are entered, and health workers can resend corrected numbers.
The servers are currently hosted by UNICEF, which has completely funded the program to date, although plans are in place to pass off this duty to Malawi's Ministry of Health. The growth-monitoring initiative is now used in 14 of the country's 29 districts, with hopes for a complete nationwide rollout by the end of 2014.
The program was developed by graduate students at Columbia's School of International and Public Policy, who were tasked with finding sustainable technology tools that could be used to gather and distribute child-nutrition data within Malawi. Similar SMS-based initiatives have been employed in other remote regions of the developing world, such as tracking disease outbreaks and holding governments accountable.
Beyond this improved growth-monitoring program, UNICEF launched a radio initiative emphasizing good nutrition practices in an effort to improve the nationwide lack of education on healthy eating.
"There's a lack of dietary education," UNICEF nutrition officer Benson Kazembe says. "Children should be eating five to six food groups everyday, but that message hasn't gone deep into the minds of people yet.
More than 90% of Malawians have access to the radio, so outreach on community stations is the most effective way of informing a large portion of the population, according to Kazembe. Traditionally, household food distribution prioritizes the man, while children eat last. This means that children generally have the worst, least-diversified diet in the house. The radio campaign explains what young children at different ages should be eating on a daily basis.
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This reporting was made possible by the United Nations Foundation