Article © MSF

Interview of Natalie Roberts : Alerte COVID-19 and SMS Afia Yetu projects

Natalie Roberts is Director of Studies at Crash and Program Manager at the MSF Foundation. During the first wave of the COVID-19 pandemic, she participated in the implementation of two digital health applications. Explanations.

How did the apps Alerte COVID-19 in Niger and Afia Yetu in DRC come about?

Digital health is not a new topic for MSF, but the COVID-19 pandemic has prompted us to rethink the use.

The Foundation, through its director, had the opportunity to work with volunteer engineers from Google.org for a few weeks earlier in the year to develop digital projects related to the pandemic. After a comparison of several application publishers, we chose to collaborate with Medic Mobile, a non-profit organization that develops open source software for community health projects in low-resource settings. The challenge for us was to create something that would help our teams or our patients, because the idea was not to implement a tool just for the tool. It had to be simple, adapted to the context and to meet clear operational needs. The Foundation offers this possibility: to manage the risk of trying something new and to initiate a pilot to see if it is useful. We initiated discussions with Epicentre and with the cells and the medical department of OCP. Often, the teams were interested in the topic but did not see the need. Nevertheless, two opportunities arose.

For Goma, DRC, where we support the Ministry of Health's HIV program, the cell and the medical department wanted to understand whether a tool could help monitor patients with chronic disease. At the time of the COVID-19 pandemic, not knowing whether HIV patients were likely to develop a severe form of the disease, the team wanted to reduce face-to-face contact with patients to avoid the risk of infecting them. No longer able to provide regular physical follow-up, the team wanted to develop remote monitoring of their chronic disease but also for any signs of COVID-19 infection, or any health problems related to pandemic control measures that might reduce the patients’ access to care. The idea took shape after almost a month of brainstorming. We evaluated various other projects that follow cohorts of patients with chronic diseases, including HIV, but for a variety of reasons, Goma seemed the most promising place for a pilot. One factor was the strong interest in the idea by some of the patients in the cohort, as well as our counterparts in the Ministry of Health.

In Niger, the health authorities were afraid of missing cases of COVID-19, a disease that progresses quickly and requires a rapid response. In order to strengthen the riposte, patients have to be found early enough. The Ministry of Health therefore approached Epicentre for support in monitoring the epidemic. The SAMU had a call center in Niamey and people who were worried that they might have COVID-19 were being advised to call it, but it was not linked up to the Ministry of Health's decentralized and mobile COVID-19 response teams, who travel to conduct investigations when there is an alert of a potential case (tests, triage, home care, etc.). The application Alerte COVID-19 provides a connection between all of this and allows alerts to be escalated more effectively.

Have these projects put the needs of health authorities and patients back at the center of the MSF approach?

In these two projects, the needs were defined by the MSF and Epicentre field teams, and they continue to take the lead in moving things forwards, proposing new ideas and solutions to problems, supported by a collaboration between the Foundation, the Epicentre team in Paris, the OCP Cell and medical department, the legal department, etc.

For Niger, Epicentre approached the authorities by asking them how we could be of use rather than proposing them a ready-made tool to implement: there was a real collaboration with the authorities who wanted to improve their surveillance system and reduce the time between the moment a case is identified and the response. They would now even like to adapt the same tool for the response to other epidemic diseases (measles, cholera, meningitis).

In Goma, the challenge was different. We did not always have a good understanding of the problems of the patients in our HIV cohort, who we often lost track of. Communication between patients and MSF or the health system in general was usually limited to medical appointments. With this system, in addition to their appointments patients should receive regular SMS messages with questions to help with determining their problems and they will be called back, based on their answers, by the MSF team who would receive an alert in a smartphone application. This gives the possibility of two-way communication between patient and team as the need arises. In addition, the software is programmed to triage these alerts to help staff organize their work. It's simple, easy and we think people will use it. So far, patients are enthusiastic because they finally have the opportunity to be involved in their own care. The idea is to integrate this tool into patients' lives and to be able to monitor them more closely, even when the pandemic is over. The patients have also been very willing to participate in the development of the application, testing the system and giving their opinion. At an early stage, it already seems that the development of the tool could strengthen the relationship between patients and their caregivers. But there are many technical constraints that we have not yet mastered, such as the SMS delivery system and the stability of telecom operators. As with any new system, many new difficulties appear every day that we solve with the field team, one after the other... It's a real long-distance race!

In both situations, we rely on the idea of deploying simple tools adapted to the context that allow patients and caregivers to easily trigger an alert themselves at the appropriate level to allow a quick and appropriate response, while still continuing their usual activities. We believe this could be useful in the approach to epidemics in general, where it is vital to avoid delays.

What obstacles may have blocked the MSF teams?

Initially, it was a bit difficult to start a discussion on the various ways to approach a disease that we didn't know much about, and to propose to devote resources in a crisis situation to a concept that hadn't proven itself. In the early stages of the pandemic, many of the field teams were more focused on establishing treatment centres.

When discussions began in earnest with the medical and operations departments, some seized the opportunity; others were more reluctant to involve a third party company, which led to numerous discussions between the Foundation's director and the legal department. For me, Big Tech is a bit like Big Pharma. We cannot treat patients without drugs and we are not able to manufacture drugs ourselves. So we have to understand how to work with them! It's essential for us to learn how to work with companies whose core business is to develop digital technology.

Another concern was based on the slightly discriminatory idea that in our fields of intervention, the population would not understand the concept, that nobody uses smartphones, people have no internet access, speak neither French nor English... Yet there are very few MSF projects today where our patients don't have access to at least a simple cell phone, and indeed in many places, the use of social media platforms is massive.