In with the old, out with the new?

As the field of Mobile Health (mHealth) continues to grow exponentially, the question arises: should those implementing mHealth in lower- and middle-income countries (LMIC) make greater use of new, high-tech and expensive smart phones or should they rely on the more antiquated, but more affordable and durable, previous generation of cell-phones? Here are two sides to this debate:

On January 5, GOOD published an [article]( extolling the Nokia 1100, a cell-phone released in 2003 that can do little more than text and make calls, as “the world’s most revolutionary phone.” Surprised? Don’t be. Despite the popularity of smart phones (such as the iPhone, Blackberry, and Android) in North America and Europe, there are only about 73.5 million iPhone users around the world, compared to about 250 million Nokia 1100 users! This disparity is mostly due to the large and growing markets for cell-phones in Africa and South Asia, a niche which the Nokia 1100, strong and capable of enduring harsh conditions, fills perfectly. According to [](, smart phones, with their high bandwidth requirements, will have a hard time competing with the Nokia 1100, which it refers to as “The AK-47 of the Cell-Phone World” due to its simplicity and ubiquity. Indeed, a variety of health organizations cater their mHealth programs to be used by these simple cell-phones - such as [mPedigree](, [Project Masiluleke](, and [Cell-PREVEN](, to name a few. As Alissa Walker from GOOD suggests, “For anything to truly be impactful on a global scale, it’s definitely not going to be an app.”

Despite these convincing arguments from GOOD and, Pyramid Research published a [report]( in December saying that there are more than 200 million mHealth apps (applications for smart-phones) and that this number is expected to _triple_ by 2012! In addition, the report posits that about 70% of people worldwide are interested in having access to at least one mHealth application and that they’re willing to pay for it. An interview with Nandu Madhava, Founder and CEO of [mDhil]( (which, incidentally, uses technology for both basic and smart phones), supported the conclusion that the smart-phone market will continue to grow in developing countries. Mr. Madhava explained how low-cost smart-phones are exploding onto the Indian market – selling for as low as 3000 Rs (about $66) – and how 3G (mobile internet) service providers such as Tata DOCOMO offer access to five basic sites (including Gmail, Yahoo and Facebook) for only 10 Rs (about $0.22) per month. This affordability makes smart-phones available to more and more people. As Mr. Madhava sees it, data traffic on mobile web is an exponential curve and we are just at the point where the line begins to curve up! Clearly, there is some strong evidence that mHealth will/should move in the direction of smart-phones. [CommCare]( and [Epihandy]( are examples of programs that have already taken advantage of this technology.

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As a final thought, I’d like to cite a passage from Dr. Paul Farmer’s book, _Infections and Inequalities_ (1999), in which he describes a visit with a local priest to new concrete latrines in a remote Haitian village where most people live in tin shacks:

>_“Unwisely, I asked whether the latrines were really “appropriate technology” for such a poor village. The priest was furious. “Do you know what ‘appropriate technology’ means?” he finally answered. “It means good things for rich people and [expletive] for the poor.” He wheeled away, fuming, and refused to speak to me for a couple days.”_ (p. 21)

What do you see as the direction of mHealth in this new decade? Should implementers focus on basic cell-phones or would this be settling for less for the poor, as Paul Farmer describes? Alternatively, should the focus be on smart-phones? Or is this an impractical and expensive option that would place health applications out of reach for the majority of the poor? Feel free to post your thoughts!