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Mapping One Million Community Health Workers


Community Health

The Research and Analysis Team is at the headquarters of technology company Esri for an intensive ten-day collaboration to developing mapping applications for the One Million Community Health Workers Campaign. Director of Research and Analysis, Andrew Schroeder, is sending regular updates. Check back to read the latest behind-the-scenes account of the project.

Days 7 & 8: Week Concludes, Preparation Begins for Operations Room Launch

The week is over. The applications are not entirely complete. But it’s OK. They’re close. And with the help of our colleagues at Esri this week has exceeded all expectations.

Thursday morning kicks off with a deeper dive into this emerging concept of a social landscape tied into tactical workflow tools. Sharon is at the whiteboard diagramming the general structure governing community health worker (CHW) distributions in Ghana. This is in many ways a classic problem of resource allocation under conditions of scarcity, with the added requirement of spatial precision. CHWs ought to serve an estimated total population of around X persons, who will in general be reached via pedestrian transit, within zones of Y area defined in part by political boundaries, in part by need, and in part by proximity to existing health infrastructure. The specifics of that problem describe a set of base data requirements, analytic rules, and possibly agent-based rules for interactions under varying conditions.

What if, instead of simply dispensing consulting advice on this problem, non-governmental organizations (NGOs) actually contributed to the composition of the base data requirements and analytic models? What if a tool could be built which encoded the contours of health access scenario planning? What if that tool could be deployed collaboratively between public, private and non-profit stakeholders, across national and international scales? What if the methods and data so deployed could be standardized and commonly referenced as part of a generalized baseline understanding? How would that change our concepts of the known, the know-able and the possible in global health, development and relief operations? Let us call this idea, “social landscape design” – part science, part aesthetic and part collaborative social practice towards a better set of solutions to the world’s most difficult problems.

Heady stuff. But to get there you still have to write proposals, schedule meetings, attract resources, write blog posts and tweets describing what the heck is going on in those fishbowl conference rooms. Afternoon hours fill up with coding, art design and planning for an imagined future of genuinely geo-enabled, strategic humanitarianism.

Friday morning comes early and brings with it the pressure to tie up any remaining loose ends. One of those is my frustration with the open data portal. As expected, once I know which settings to put in place the development arc cascades smoothly. By 10 a.m. I’ve got datasets populating to the Campaign site, making good on the promise to make maximal data sharing the new default assumption.

3:30 p.m. is group photo time for those of our Esri colleagues we can track down. Sharon is heading back to LAX. Jen, Jon and I are laying the last bits of groundwork in place. Communications strategies are plotted for the launch of the operations room sometime in early October and the participation of our team in Esri’s GIS for Health conference in Colorado Springs in early November.

The team is scattering for now to the far corners of the country. But the world’s community health workers are gaining a new set of tools for visibility, advocacy and analytic integrity. We’re all incredibly grateful to Jack Dangermond, Hugh Keegan, and the entire team at Esri for making these fantastically productive days possible.

Days 5 & 6: Building a Map That Shows Where Gaps in Health Services are Greatest

Perhaps we lost a few members of the Esri team, but we’ve gained Sharon Kim, our colleague from the Earth Institute at Columbia University and the 1 Million Community Health Workers Campaign. The Operations Room mapping application is essentially Sharon’s project, and we’re a little anxious to know what she thinks of our work.

Following the decision to break our singular comprehensive application into three or more specialized applications, we did review things over the phone. But Tuesday morning is the first time we’ve demonstrated the new applications live for someone not already sitting with us in the prototypes lab.  And it’s a success. At least for now on the conceptual level. Sharon approves of the direction we’re heading. Phew!

With the demonstration of current development out of the way we can refocus for a moment on some of the longer-term visions. The path leads back to Nigeria.  Based on contributions to the polio eradication effort in Nigeria, Esri has compiled what is arguably the world’s most accurate, detailed and comprehensive population map ever built.

That work was led by their chief demographer, Earl Nordstrom.  The key innovation in this population map, as I understand it, is to have linked the best of the raster image-based population datasets and national census data with new means of extracting settlement locations and extents from satellite images to create a high resolution surface model of total persons per 250 square meters. Each of those grid cell locations is called a “Nordy point,” after Earl Nordstrom’s last name. Only a select few geographers can aspire to such branding.

Why is this useful for community health workers (CHWs)? Because it potentially lets us achieve, in combination with a bunch of other data layers, a new level of precision in understanding where gaps in health services are greatest, along with where and to what degree CHW outreach programs may need to be scaled up.

We have a meeting set up with Earl for Thursday afternoon to discussion spatial modeling of access to health services. Partially in anticipation of that conversation, we have a long and fruitful dialogue with Esri’s Ed Carubis about how such population and health access modeling might work, both theoretically and practically, to help the country of Ghana with its immediate planning needs. There’s something coming together there if we can align the pieces properly.

Wednesday is, however, at least for me, mostly a day of frustration. One of the things that really drives me nuts about information technology is encountering a process that really seems like it ought to be straightforward and obvious but for whatever reason just … won’t … work. I’m building an open data portal for the campaign and no matter what I do my data layers will not show up in the portal. By late in the day, I’m reducing to peeling through a dense screen of code which is for the most part impenetrable to me. I turn my laptop around and ask Jon, “Say, can you help me understand this?” He laughs and says that he’s seen that somewhere before … in The Matrix.  Fortunately, tomorrow, I’ll have help.

Day 4: Moving Forward With the A-Team

Monday morning at the Esri prototypes lab is a hive of activity.  Some of the engineers are being assigned to new projects which require immediate travel.  A couple of them have been working with us for the past few days to get our ideas into shape. We’ll miss them — a lot. But fear not: Jack Dangermond, Esri’s CEO, assures us that we still have the A-team with us for the next wave of development through Friday.

Twenty minutes later the A-team piles into our side conference room to review our app storyboards from Friday. These designs evolved in my mind over the weekend as I had a chance to reflect on the previous three days. I get to work early, so well before anyone else arrives, I’ve already erased and re-written all of our designs a couple of times. With the rest of the group gathered around now this iterative design process continues. Inspired by apps like the Urban Observatory, we’re narrowing in on the concept that community health worker (CHW) programs should be compared across a landscape which varies based upon demographic and health conditions.

Within a single space, across a common scale and extent, we want users to see how program activity for multiple organizations relates to key issues in the local population. Our closest measure locality is the administrative district. This is an intellectual trade-off — one of many which need to be made during app development. On the one hand, we need as much spatial granularity as possible. On the other hand, we need to have as much comparable and consistent data as possible at the same scale. The imperfect outcome of this trade-off  is to use the first administrative level below the national level as our unit of local analysis. These applications are, however, designed to be active, living documents. In the future, based on data availability, this set of analytic and design trade-offs may change.

Data availability is also, not coincidentally, the theme of our phone conversation with Partners in Health’s (PIH) monitoring and evaluation staff in Boston. At least a few of PIH’s African programs (Rwanda, Malawi and Lesotho) have been able to use GIS effectively to map clinical service locations and estimate values like service availability and travel distance from area villages. While we cannot supply data like this for all programs represented in the map, the PIH discussion feels like a starting point toward a new level of locality and a more detailed understanding of where community health workers may be needed most.

Meanwhile, Jon continues to wrestle the Javascript into submission. In a matter of hours Jen builds the base web map which powers our comparative app. Perhaps it’s not all working exactly as predicted, but the pieces are definitely coming together.

Day 3: Conversations on Comparative Mapping

Mid-morning Friday finds me scribbling on a large whiteboard in a low-lit conference room before a cluster of Esri’s technical advisers. We’re going through the storyboarding process for a new mapping application aimed at making dynamic comparisons between community health worker (CHW) organizations, demographics and health issues across space and time. Storyboards are a technique borrowed from film and video production to make sure we have the links between our ideas and our screen images properly thought out in schematic form before we actually spend time building something.

Hugh, the director of the prototypes lab, is grilling me on the problem of scale. For cartographers, digital or otherwise, scale is always a core issue. Maps are visual abstractions which stand in as representations of real-world space. If we don’t have our scale right from the start then we can end up presenting serious distortions of that real-world space. Values such as disease rates or population densities at one map scale may take on entirely different meanings at another map scale.

What might seem at first like an arcane cartographic debate actually leads us to discard a few of our initial ideas and focus on a handful of new ones. We’re trying to help users understand two different things with different scale dependencies. How do CHW programs measure up against one another across different locations? And how does the same CHW program measure up against different demographic and health variables within the same location? Turns out, we may need more than one mapping application. Over the next hour, the whiteboard fills up with diagrams and sketches. Our best options for linking intellectual value to visual display come into focus.

As lunchtime approaches we’re heading towards a newfound clarity about exactly what comparative mapping will help us to accomplish and how those comparative dimensions should be represented. The whiteboard gives way to the projector screen as our schematic diagrams are linked to a set of concrete examples based on apps previously developed for other issues, from climate change to criminal justice.

Later on in the afternoon, we have the opportunity to sit in on a presentation by a group of astonishingly talented interns finishing up their summer stints at Esri. They’ve been hard at work for the past three months on application development. One shows off an Android app, built in just two weeks, called Snap2Map, which allows users build complete Esri story maps right from their phones. Another demonstrates how Flickr’s geo-referenced photo-sharing API allows users to map subjective urban landscapes of attention and interest. Alongside our own ideas about using GIS to improve the health of people in vulnerable situations around the world, we can see more of the future of GIS as a medium coming into being.

Day 2: Solving Kinks Through Collaboration

It’s 11 a.m. on Thursday and our coder Jon Zaid is neck deep in Javascript. When I ask him about the vaguely pained look on his face he replies, “Well, there’s good news and bad. The good news is that I managed to upgrade the application programming interface (API) to the new version. And now everything is running much faster than it was before.” And the bad news? “Of course, now none of our data is displaying.” None? “Nope. Nothing. And I’m not sure why – it’s probably something that was programmed incorrectly before, then was fixed in the new version, but knocked something else off in the process, and now we’ve got nothing but blank polygons over Africa.” Unfortunate. But this, I tell him is exactly why we made the trek down to Esri.

Around the corner in a glass paneled office sits one of Esri’s best Javascript coders. He grabs a cup of coffee and joins us for about 15 minutes, during which time he redirects the reference calls, notes several syntax changes and a series of subtleties buried deep in the documentation. Almost like magic, up pops the demography for Nigeria. A cry goes up around the table, “There it is!” At least for a moment, all is right with the code. “How long,” I ask Jon, “might that have taken to uncover without help?” “Oh I don’t know, he says, maybe a day and a half?” Exactly.

Later, we meet with members of Esri’s team that have been assisting with the World Health Organization (WHO) project underway in northern Nigeria to bolster polio eradication efforts through intensive mapping support. They’ve come up with some remarkable methods for extracting data from imagery, linking that data to vaccination teams in real time, and understand down to a granular household level whether the campaign is meeting its goals. The discussion is about how this sort of work can be extended out from specific diseases like polio to support much broader global health and mobile outreach efforts. CHWs may be a perfect application.

We’re joined by a new employee at Esri who has just arrived from Partners in Health Rwanda. He’s full of tremendous insight into the issues we’re dealing with in terms of mapping support for community health workers. The brainstorming leads to a discussion of open spatial data, inter-organizational coordination and the deep trouble facing Ebola containment efforts in West Africa. Early stage ideas are emerging which may have a significant impact on how we can help our local partners manage epidemiological crisis.

By the close of the day we have brand new spatial feature services populating our Javascript interface, corrected health center program locations and a host of emerging ideas around geographic information systems (GIS), crisis response and global health. Several important steps forward toward the finish line.

Day 1: Arrival at Esri’s Prototypes Laboratory

I arrived at Esri’s Prototypes Laboratory in Redlands, Calif. yesterday with two colleagues for an intensive ten-day collaboration to develop mapping applications for the “Operations Room” of the One Million Community Health Workers Campaign (1MCHWC).

A joint effort by the United Nations and Columbia University’s Earth Institute, 1MCHWC aims to highlight community health workers (CHWs) and their efforts to deliver life-saving health care services in poor rural communities – particularly in sub-Saharan Africa, where 10 to 20 percent of children die before age 5.

The “Operations Room” will play a vital role in the larger campaign by gathering and displaying information on where CHWs operate, what services they provide, how many people they reach, which health concerns they impact, and where needs are greatest.

As the campaign scales its efforts over the coming years, the Operations Room will offer continuous insights into the landscape of CHW activities, needs and outcomes.

Over the next 10 days, we will be documenting our progress on these mapping applications, demonstrating the power of public/private partnerships, and offering insights into how these sorts of humanitarian data products are produced. Stay tuned for more updates.

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