Interview: mHealth Alliance Executive Director David Aylward

By Brian Dolan
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David AylwardThis morning the United Nations Foundation appointed David Aylward as the first executive director of the mHealth Alliance, which is a partnership recently formed by the UN Foundation, The Vodafone Foundation and Rockefeller Foundation to support and advance mobile health initiatives in the developing world. In anticipation of the announcement, Mobihealthnews interviewed Aylward about his previous experience, plans for the mHealth Alliance, differences between mHealth solutions in developed and developing markets and whether mHealth could be used as a starting point to build a larger eHealth system from the "outside-in."

Mobihealthnews: During conversations with the founders of the mHealth Alliance back when it was first formed earlier this year, we discussed how the executive director of it would have to be someone with a strong mix of both healthcare expertise and technology experience. Can you describe your background and how it weaves those two areas together?

Aylward: Yes, and I was particularly pleased with this position exactly because of that blending of both health and technology. To be honest, though, there is a third leg to this stool, and it is really knowing the developing world. I don't, but I grew up in it. My dad was a foreign service officer and ran the United States Government Food for Peace refugee program in the Far East, specifically Hong Kong, which is where I grew up. I never had that international job. In the U.S. for the past 13 years I have been working on emergency response, specifically emergency medical response. All of that to one degree or another involves taking modern communication technology into two spaces that don't use it: healthcare and emergency response. For somebody with 30 years or more in information and communications technology, which is my field, it was really surprising when I first ran into it. The whole range of issues that arise from trying to modernize healthcare that the administration is wrestling with from electronic health records and their various uses have been things that I have been up to my neck in for quite some time.

I also noticed in your early experience that you were worked on the regulatory side of telecommunications working in the House of Representatives?

Yes, I went up to the Hill in 1977 to work for a young congressman from Colorado who had decided his mission in life would be to bring competition to telecommunications. I became his sacrificial lamb in that process. [The congressman], Tim Wirth is now head of the United Nations Foundation so in some sense I am coming full circle.

What's on the docket for the next year in terms of initiatives at the mHealth Alliance?

Well, it's a very exciting time in that there is a lot going on in the developing world and the developed world. I got to know mHealth in the U.S. context or the developed world context. To see that move forward with all the different trials, demonstrations, discussions and conferences about mHealth, there is a lot swirling out there. What has not happened in either the developed or developing market is taking mHealth to scale or even to really big trials. Most of what is out there are small, non-sustainable proofs of concept. We are really looking for how to support and facilitate the integration of services so that rather than having a series of point services, like SMS to people about behavior change needs to get connected to reporting to clinical health workers in their community.

All of these mHealth services that touch these various communities need to be connected in some fashion. Integrating those services is one mission. Integrating those kinds of services into underlying healthcare systems, e-health to use the short language, is a second. Getting sustainable economics under both of those is a third. Researching and showing the health and economic effect of doing that is a fourth. Underneath those there are more procedural activities, support activities like communications and connecting people together to technology initiatives. Fundamentally, though, it's those four goals that we are after.

Having had the developed world experience and now looking ahead to the developing market initiatives, what differences do you see between the two markets when it comes to the solutions themselves. Text message reminders or nudges for behavior change, for example, seems to be one that could work in both markets -- where do you see these markets as really differing?

That's a great question and I don't have an answer to it, but I am thinking about that a lot. There is a danger, a real danger of taking and projecting our own experience on the rest of the world by saying well, this worked for us so it will work for others. When you have a healthcare system that is so phenomenally backward, as it is in this area, in the United States, I don't think that that is a model for anybody anywhere. It's not clear to me what we have that is going to be exportable. It would make our lives simpler if there was a continuum in mHealth and eHealth that we could point to and say look the developed world has done this, what we need to do is get this to the developing world. That's not true at all. It is true on the technology side. The nice thing here, the very exciting thing is to see what the private sector has done with wireless and be able to project forward what kind of platforms will be available. I think we can do that with a high degree of certainty at this point, which you couldn't do five years ago. Just the fact that there are cellphones everywhere now, makes mHealth a critical part of the solution, which is a statement we couldn't have made eight to nine years ago. We didn't know this was going to happen. I have had as many discussions with the U.S. carriers about participating in healthcare as I have had with them participating in developing country markets. They are trying to figure it out.

Right, we have heard from the CTIA that many carriers have healthcare as the number one vertical they are currently pursuing.

There is a very interesting couple of trends that I think are global, maybe for different reasons. One is the diversification of healthcare. When I was a child we spent a couple of years in the U.S., most of it was in the Far East, but in the 1950s (just to date myself) 40 percent or so of doctors' visits were home visits in the U.S. I remember in the evenings when I was seven or eight years old, the doctor would come to visit our house here in Washington D.C. when I was sick. Since then we have spent 50 years building facilities to bring people to the healthcare. We have these massive structures with clinic after clinic added onto them that are incredibly expensive. We have discovered that they are not only disease pits, but also an incredibly inefficient way of treating the dominant illnesses we have as a society. The dominant illnesses, of course, are chronic diseases. We find in the developed world that 80 percent of our healthcare costs are caused by chronic diseases. I don't mean to say that 80 percent [of our healthcare spending] is spent on obesity or diabetes, but it is caused by those. What we see in the developed world is this huge trend of trying to take care of people in their homes and try to keep them out of hospitals, because we know that as soon as they walk into that facility's door it's a couple thousand dollars and plus they'll catch infections and so on. In the developed world we see all these discussions about ways to keep people at home, get information from them while at home, export the knowledge at the center.

In the developing world we are seeing exactly the same thing, but for a completely different reason. We are seeing the same trend because they don't have the resources to build the hospitals and related resources. Worldwide we have this very, very powerful trend that we and your publication are right at the forefront of, the edge of. In that sense we can benefit directly from the development of the protocols and knowledge base that result in long distance care for health problems. In that sense the developing world will benefit a lot, but not because they figured it out in the West and can now bring it to the South, but because we are all facing the same problem together.

There's also a number of people out there who believe that these problems could be and will be figured out in the developing world and maybe the developed world will learn from the mHealth programs there.

That's a hubris that I hope comes true. I have said that to a few people and they nod their heads, but we haven't seen an example of that yet. We have seen people aspire to that. It's an interesting question: Can you drive the creation of a rational eHealth system from the outside in, from mHealth into an eHealth system and I don't know the answer to that. Certainly that's what we are talking about, what we are certainly looking for programs to do and for countries to do this in where the leadership wants to do that. Getting a rational eHealth system with a sophisticated mHealth system extending it into the community, is certainly where we are trying to go. We certainly don't have either in this country. Even if we do find a good model, it's not clear to me that we would import it back into this country. What could happen though is a whole bunch of consumer-based health services that were one step removed from the core health system in the developed market could be a result of success in the developing markets. The industrial barriers to interoperability in the U.S. -- and I don't know about Europe but I suspect the same thing -- are so powerful that even a whole bunch of good examples from Africa and Asia is not going to overcome the vested economic interests in the United States.

That's fair. I was hoping you could also describe the talks leading up to your appointment to head the mHealth Alliance, and if there was a moment when you were convinced of the opportunity mHealth presents to the developing world. Was there a particular anecdote, moment or case study that was particularly poignant and convinced you that you wanted to make this your next step?

Yes, it was about one minute into the conversation with Tim Wirth. He explained what the U.N. Foundation has been doing by giving out grants and I had already known about the technology partnership. I knew Paul Margie [Senior Director for Technology Partnerships at the U.N. Foundation] who had done it before, I knew very well. I had met with Claire Thwaites and Mitul Shah and knew what they were doing, and when Tim called and said that the U.N. Foundation wants to make a big deal out of this and make mHealth a big initiative, I said that I have been training my whole life for this.

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