December 1, 2011

Making Our History

On the occasion of the annual mHealth Summit in Washington it is worthwhile to pause and consider one of the unforeseen benefits of wireless connectivity; how mobile is helping to save lives and improve the quality of lives. I have the privilege of serving as the chairman of the UN Foundation’s mHealth Alliance; in that role I recently delivered these thoughts which now become this month’s Mobile Musing.



The history of the world is dotted with only a handful of transformational moments. We happen to be living through one of them right now. We are building history’s fourth great network-driven transformation:

• The first was Gutenberg’s original information revolution in the 15th century; a technology-based network of commercial print shops whose products produced not only the Renaissance and the Reformation, but also the beginning of modern medicine,

• The next revolution didn’t happen for 400 years when the first high-speed network, the railroad, conquered the forces of geography that had forever defined the activities of mankind and by bringing masses of people to ever-expanding cities created the need for hospitals and health care for the masses,

• On its heels came the first electronic network, the telegraph, whose “lightning messages” eliminated time as a determining factor in communications and whose binary signals became the precursor of the telecommunications technologies of today.

Our fourth network revolution is the result of the inexorable increase in computing power expressed in Moore’s Law and the unprecedented connectivity of wireless communications. Together, they create the most powerful and pervasive platform on the planet. Our history is on par with those earlier transformational moments, including how it is changing the practice of medicine.

John Gardner once observed, “History doesn’t look like history when you’re living it.” With that as a guidepost, let’s take stock of the progress of the revolution we are shaping.

It begins with an example of our living history; a relatively recent story, yet one that sounds so old fashioned that it gives us a measure of just how fast transformation has been happening.

In 1993 I was the CEO of the Cellular Telecommunications Industry Association (CTIA) when we crossed a momentous milestone: the 10 millionth subscriber. Now, this may seem inconsequential from where we sit today with over 320 million wireless connections in the U.S., but in 1993 it was a big deal. Less than a decade previously, AT&T had hired McKinsey & Company to do an analysis of the future of cellular; their conclusion was that by the turn of the century there would be 1 million cellular subscribers (!). There we were in 1993, with seven years before the millennium and we were ten times the size that the big-time consultants had said the industry would become.

The symbolic 10 millionth subscriber was an early example of what mHealth could become. She was a large animal veterinarian in Thibodaux, Louisiana. Over a celebratory lunch she told me how amazing it was to have been in a field the previous week tending to an injured animal only to have her phone ring with a call from a farmer who had a heifer in labor with a breached calf. We all marveled at how she could be reached in the field and how she could give instructions to the other farmer as she packed up and raced to tend to the breached calf. It was mVetHealth. Little did any of us imagine at the time how soon we’d be discussing how that kind of mobile connectivity could be one of the great breakthroughs in human health care.

And the timing for this breakthrough is pretty fortuitous. At the very time when health care costs are dominating our economy – something like 16 percent of U.S. GDP, heading to 20 percent – there emerges a transformational technology that can be applied to help mitigate the problem.

The Western concept of medicine has been built around putting people in hospital beds or constantly bringing them to the clinic for observation – two incredibly expensive activities. mHealth offers – especially in developed countries – the opportunity to eliminate those expensive means of measurement and analysis and to let the patient go about his or her daily activities while reporting in wirelessly.

• The folks who brought us the Jawbone Bluetooth earpieces now have the UP wristband with tiny sensors that monitor activity, even while asleep, and display a report on the user’s activity to their smartphone.

• Smart bandages monitor and report on infections in wounds,

• Connected clothing contains bio-sensors to monitor and report on the wearer’s vital signs,

• Diabetes monitoring can expand beyond a once a day prick to produce an ongoing real-time relationship with the patient 24-hours a day, not just a once a day “snapshot,”

What fascinates me is how medicine is basically the collection of and action upon information. When the doctor takes our pulse, or listens to our heart, or palpates our abdomen she is collecting data. I don’t understand medical diagnosis, but I do understand data collection and transmission. Marrying distributed computing power with wireless collection for monitoring, diagnostics and wellness is simply the collection of information; and in the digital world the zeroes and ones of information can be wirelessly transmitted and then manipulated to produce results.

What we’ve been talking about thus far has been mHealth in the developed world. In the developing world mHealth is characterized by the seemingly contradictory reality of lower technology producing the potential for even greater results.

Last month the United Nations announced that the world’s population had crossed 7 billion. At the same point in time the GSM Association forecast that by the end of this year there would be 6 billion wireless connections and 4 billion unique subscribers.

• It took from the beginning of time until 2001 before 1 billion people were connected on the globe,

• The second billion took only an additional four years,

• The third billionth connection took half that time and happened in 2007,

• The fourth billion in 2009,

• The fifth billion connection in 2010,

• And the six billionth connection in 2011.

That’s what living history looks like. There are now more people connected to the mobile network around the world than are connected to the electric grid. There are more people around the world using mobile phones than there are using toothbrushes.

I had a personal experience with this amazing phenomenon recently in Zambia. Along the banks of the Zambezi River is the small village of Siankaba. About 360 people live in this village of crude huts with no running water and no electricity. I wandered through Siankaba one evening as the women were cooking dinners outside their huts over open campfires. The men were setting up the evening’s entertainment by hooking up car batteries to radios.

Ubiquitous throughout this village were roaming chickens. Thus it was no real surprise when I saw a crudely painted sign nailed to a tree branch advertising “Mrs. DR’s fresh eggs.” What amazed me, however, was that the sign also contained her cellphone number! Here, in a village with no electricity or running water, there was cellphone coverage – and one villager was using it to expand the market for her eggs. It’s no wonder, then that the World Bank calculated that for every 10 percent increase in mobile phone penetration in a developing country, the country’s GDP increases by 1.2 percent.

The goal of the UN Foundation’s mHealth Alliance is to enable similar results in the area of human health. Putting that in perspective:

• Fifty-seven countries have critical shortages in health care workers (for a total deficit of 2.4 million professionals). In India, for instance, 70 percent of the population lives in rural areas and 80 percent of the doctors live in urban area. When the need is “here” and the skills are “there” how can the space be bridged? Sometimes it is as simple as a mobile phone call to a phone-based clinic where the doctor listens to the symptoms and prescribes next steps.

• Every year 4.7 million infants die in the first 30 days of life. Midwives, wanting to get the baby crying and needing to clean them wash them in cold water, with resulting pneumonia in little lungs that are just beginning to learn to operate. Sometimes it is as simple as a text message to midwives to teach them best practices.

• Every minute a woman dies from complications tied to pregnancy or childbirth (525,600 annually). Imagine the advantage of a simple phone call when a complication occurs – to get assistance from a doctor or to get an ambulance without needing to have someone run to the next village to find a phone.

Notice how none of these solutions are fancy. While in the developed world mHealth is “Moore’s Law meets mobile,” in the developing world that will also be important…but the first steps are much more basic. There is so much that can be done with simple accessibility to a voice device and text messaging.

Think back to the 10 millionth wireless subscriber, the vet in the field. It was a huge breakthrough then which we tend to overlook now because it seems so commonplace. We are at a similar point around the world; nothing fancy and people’s lives can be affected.

But mHealth is not just about technology. All the technology and dedication in the world falls apart without the proper support. It is in this area that the mHealth Alliance is especially focused. The technology is turning out to be the easy part. The challenge is to take mHealth “beyond the technology.”

First, mHealth must transition from stand-alone solutions to integrated, interoperable systems. There are n+1 trials that are interesting, important, and producing worthwhile results – but not all of them are scalable. It is time to move from trials and silos of activity to implementation at scale. This is going to require that mHealth applications are integrated with national health systems as well as the infrastructure of mobile carriers; that there are open standards, and open APIs; and that there is interoperability that allows for the aggregation and sharing of data.

Second, that for mHealth to move from demonstrations to decisive results the key stakeholders in the existing health care structure are going to have to see and support what is possible. I was depressed, for instance, to be in one African country recently and learn that the local association of health care professionals had added a new position to their staff: Director of Unnecessary Technology. Clearly, until mHealth proponents solve the first issue of scale-less silos it is going to be difficult to get the attention of the medical and governmental establishment. Yet at the same time, the establishment has a responsibility to assist rather than resist the potential represented by mHealth.

Thirdly, mHealth investments need to stand up to cost-benefit analysis. The trials to date have been principally funded by private donors; it is now time to apply the harsh discipline of the business world. Unfortunately, not every well-meaning idea is sustainable and scalable. It is time to learn from the trials, decide what works and what does not, and feed the winners and shoot the losers. This is the harsh reality of every other innovative activity and just because something is “doing good” is no excuse for it to avoid such realities. As a venture capitalist I am forced to do this with companies all the time; it is neither easy nor fun, but it is essential to the proper allocation of resources so that the greatest good can be done for the greatest number.

Finally, the key stakeholders from government, NGOs, and wireless carriers need to come together on a framework that will allow the first three suggestions to take place. This is what the UN Foundation’s mHealth Alliance is attempting to do. We are the forum, the convener, the mHealth “commons,” if you will, to identify the agenda, build a shared knowledge base, and facilitate the kinds of activities I’ve identified.

These challenges are non-trivial; but they are not non-solvable. The three great network revolutions that preceded our history-making experience all faced similar realities. Technological innovation always produces problems before it provides stability. The challenge for those of us living history at this moment is to step forward, embrace the challenge and implement the solutions that the miracle of wireless connectivity enables.