Dunia Health is a mobile health technology company which provides overworked clinicians in low-resource settings the tools to improve quality of care and reduce the reliance on methods that take them away from direct patient care. I spoke to the co-founder of Dunia Health, Batoul Abuharb on the inspiration behind the initiative, the crisis in Gaza and her desires for the future of this noble and innovative idea, which could radically improve the quality of patient care wherever adopted.
As a co-founder of Dunia Health, what inspired you to begin this project?
The idea for Dunia Health was inspired by a research trip I took to Gaza in June 2012. It was the summer after graduation from Rice University and my department (History) awarded me a travel grant. I went to Gaza, my home, after 10 long years of separation. I initially went there, with what in retrospect seems like a naive idea, to study the quality of life in the area using the incredibly high rates of immunization in the Gaza Strip as a barometer for overall public health conditions. I thought that something about immunizations must carry significant importance with the population since over 95% of the people in Gaza have received all of the WHO-recommended immunizations. Something about these vaccines must impact their lives so much that they have a higher rate of immunization in the Gaza Strip than they do in the US. I worked with UNRWA-run clinics in refugee camps primarily because I was born in one of those clinics and I wanted to be able to go back to my roots.
I found answers to my questions in the most unexpected way: While I was at the Nuseirat clinic, the phone was constantly ringing off the hook and the nurses were moving around the clinic with such a rapid-fire pace that I thought it must be absolutely normal and perhaps even second nature, for them. I spoke with the head of the clinic, Dr Khalil Hamad, and asked him what the biggest problem was for his clinic that served a total catch population of 85,000 patients with only 75 staff members.
He brought in the head nurse to answer this question: she said their biggest issue was the overwhelming number of phone calls and inquiries they received from parents whenever there was a shortage of immunizations. Often times, clinicians had to be diverted from their tasks of caring for patients to answer phone calls or talk to parents about the shortage. During my stay, there had been a 3-month shortage of the Measles, Mumps, Rubella vaccine (MMR). The nurse was also one of these eager parents whose child needed that vaccine. I was floored. This remarkable woman spends her days calming other parents and addressing their concerns while she herself had the same worries.
During my last week in Gaza, the grade 12 students had just completed their final exams and were waiting for their final GPA so they could start applying to university. Their GPA was sent to them via text message. No grades had to be checked online, nobody had to drive or walk to school. An idea was born in my head that evolved on the 48 hour journey from the Gaza Strip back to Houston, Texas.
When I came back, I began relaying my story to my friend, Jordan Schermerhorn, from Rice who had spent time in Malawi that same summer with the New York Times reporter Nicholas Kristoff. She had witnessed a similar situation: a man had walked 2 hours from his home to a clinic in a bigger town for condoms only to find out that there was a shortage. He walked the 2 hours back home disappointed that he had wasted a days wages by not working and was not able to obtain the medical supplies he wanted. Jordan said she then saw him pull out his cell phone and start texting his friends.
We both had the same light-bulb moment. There was a need and an existing device to fulfil the need, so why not make this happen? And so we did.
Did you already have a team behind you or was this something you had to start from scratch and have you met any resistance to your work?
When we started, we had no team or formal infrastructure to support us. I reached out to my friend Cherie Fathy who had interned with UNRWA in Amman previously and, together, Jordan, Cherie and I worked hard to make Dunia Health a reality.
To my knowledge, we have not met any resistance to our work. Most of the hesitation from the people around us comes out of fear for our safety and from a serious misunderstanding of the healthcare needs of people in the MENA region. Many of the people we know, including faculty at our schools, our friends, our classmates, etc. have all at one point or another remarked that the Middle East is too dangerous for us to work in. Frequently, people say to me “come back alive” as if there is a greater risk in going to Amman, Jordan, where we are currently piloting our system, than there is in sub-Saharan Africa where a lot of aid work is done.
In carrying out some of your work in Gaza, have you found the occupation an obstacle to your aims?
Gaza poses a very unique situation for us: it has an incredible need for the services that Dunia Health provides but it also has an incredible number of difficulties that require us to perfect our text alert system before we implement it there. Currently, we are piloting our program in UNRWA’s Taybeh clinic in Amman, Jordan for a number of reasons. Chief among those is the ease of travel.
It is incredibly difficult to travel to the Gaza Strip without the proper permits and documentation. I hold a Palestinian ID card issued from Gaza so I cannot obtain a permit to enter Gaza through the Erez border crossing, which is the Israeli border one the northern side of Gaza, so I must wait for the Rafah border to open, which has currently been closed for more months than I can remember. Another obstacle we must work around is the unreliable power supply in Gaza. In order for our program to work, we must be able to compile a list of patients needing a particular immunization and send them a text message when their immunization is in stock. Since the texts are sent remotely from the US, we only need electricity in Gaza for a short amount of time while we compile the patient list. We are working to make sure this time is as short as possible. Finally, because of the shortages of the other medical supplies and the incredibly high patient to clinician ratio, we chose to pilot in Amman where there are fewer potential confounders for our research.
Who else/what other countries do you work with and what are the regions that require the most aid? Do you work with refugee camps outside Palestine?
Jordan is home to its own problems that make our services useful there. Overworked clinicians, patients who miss (default) their appointments, and issues with patient mobility are all challenges that allow us to create a better system overall.
The needs of the countries where UNRWA has clinics have changed dramatically since we began our work in 2012. Lebanon now hosts over 1 million Syrian refugees and the Zaatari camp in Jordan is now the second largest city in the country. Furthermore, the polio outbreak among Syrian refugees has sparked a public health crisis that threatens the stability of the region and the willingness of host countries to continue to accept more refugees. I do not believe that one country requires “more aid” than another country. This type of thinking is the reason why so much of international aid work has been concentrated in sub-Saharan Africa with only a recent shift to other places like India and South Asia. The need of each country is uniquely shaped by its history, politics, and the context from which whatever crisis it faces emerged. Some populations have been put at a greater disadvantage than others; Palestinian double refugees are a good example this. These Palestinians lived in refugee camps in Syria and then became refugees again when they left Syria because of the current situation.
Our goal is to be able to use our program to help any population that has a need to reduce the burden placed on clinicians during shortages of vaccines or medications for non-communicable diseases, like diabetes, regardless of why the shortages happen: torrential rains, border disputes, or warehouse stocks expiring.
How do you raise funds?
Our biggest donor to date has been the Houston chapter of the National Arab American Medical Association. They provided us with a grant that allowed us to conduct our pilot study last summer.
We have also been fortunate enough to have a group of family and friends who believe in us and the work we are doing. They have been huge financial supporters and it is really the best feeling. Our universities have also been generous supporters of our travel abroad and our travel to conferences like the Clinton Global Initiative last month. Their commitment to us and to global health speaks volumes of the importance of improving access to healthcare worldwide.
That being said, we will not be students forever so we are hoping to diversify our funding sources with more private donations. People interested in supporting our work can donate online through our Rally account. Our universities provide us with a rigorous and academic approach to our work that encourages us to accurately evaluate the impact we have on the patients we serve. We apply for every grant we qualify for and reach out to as many people as possible for support. It takes a village!
Finally, how do you hope to see Dunia Health develop in the future?
The challenges we face are immense, and we can’t meet them alone. We would love our system to be sustainable enough to transfer over to UNRWA so that they can expand our mobile health programs throughout their entire clinic system, and we expect to get there within the next 3-4 years. This summer we’ll be conducting a randomized control trial to see exactly how much our programs reduce vaccination delays. We’ll also be piloting appointment reminders for older patients with chronic diseases like high blood pressure and diabetes. Overall, we want to continue to direct global health work to the Middle East on a regular basis – not just during crisis situations.
We hope to standardize our SMS system so that we can distribute it to any low-resource clinic interested in triaging patients in an area in need of a particular vaccine and alerting patients via SMS when stock ruptures conclude. We are avidly working to ensure that our system can eventually also help clinics track distribution and predict future demand of vaccines and other medications to predict and prevent stock ruptures before they ever become a reality.
Thank you for talking to Thaqafa Magazine, Batoul. Best of luck to you and Dunia Health, you have begun a truly wonderful initiative and we hope to continue to see it grow!
Sample text from Dunia Health to patients: ‘The time for your child’s vaccination has passed, please contact to organise a new date.’