Engineering change: Of PDAs and maternal medicine in Mongolia

Day 1: Jaspal Sandhu wants to find out if 50 personal digital assistants can help puncture Mongolia's inflated maternal death rate. Photos: Life in rural Mongolia

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Editor's note: This is part one of a three-day series that looks at technologists who are working to assist the world's poor. Click here to read part two, "Finding clean water for the slums of Buenos Aires" or here to read part three, "Plugging Africa's kids in to $100 laptop."

Jaspal Sandhu isn't in Mongolia for its vast, windswept scenery or historic monasteries.

The 30-year-old engineer has technology on the brain--specifically, the 50 personal digital assistants Mongolia's government hopes will help puncture the country's inflated maternal death rate. Although maternal deaths occur throughout the country, which is nearly the size of Alaska, the nomadic herders who make up one-third of Mongolia's population are difficult for health workers to reach and care for.

As a possible fix, Mongolia's National Center for Health Development is implementing a pilot project funded by Japan's Asian Development Bank, and part of that project focuses on making high-risk rural patients easier to treat. Acer PDAs preloaded with case management software have been handed to 50 rural field nurses, who digitally log case details of the patients they visit during their far-flung monthly rounds. The same nurses upload the stored data onto computers at the nearest county health center, often a half-week's journey away by motorcycle, horse or camel.

Sandhu's self-appointed task is to discover firsthand exactly what the PDAs can--or can't--accomplish. "We don't know if they will help," he said. "We need to understand how to integrate the technology into local systems to figure out if they make sense in the first place."

When Sandhu, a product design engineer who interned at Intel and Nokia, caught wind of the Mongolian pilot program two years ago, he began to design his Ph.D. thesis at the University of California at Berkeley around it. He wanted to engage in field work where he could observe whether the PDA program is addressing the nurses' needs--or if it's just a nice idea with no practical benefit.

With his mechanical engineering credentials and corporate experience, Sandhu could be swiveling a mesh-backed chair in a comfortable Silicon Valley office and collecting a six-figure salary.

Instead, he lives frugally on the $25,000 a year his university allots its research assistants. Sandhu's prestigious Fulbright scholarship pays for his basic needs in Mongolia, but it's not the comfortable lifestyle of many college peers who have long since traded burritos for foie gras.

Yet Sandhu isn't alone. More than a few engineers are either walking away or taking a break from traditional tech careers to work with the world's poor, and top tech universities like MIT, Stanford and UC Berkeley are increasingly encouraging their students to think about how the proverbial other half lives.

In a three-part series, CNET News.com will profile Sandhu and two other foreign-born engineers who chose hands-on international development work over the cubicle lifestyle. Their perspective among tech do-gooders is unique: they came to the United States either as children or for education, and carried with them an ingrained understanding that in many parts of the world, Web surfing, social networking and gadget craving take a back seat to the basics of fighting childhood disease and drinking potable water.

Their career decisions come at a personal cost--months at a time away from loved ones and salaries as low as one quarter of those offered in Silicon Valley. Yet, as Khaled Hassounah, featured in part three of this series, stresses, "Very few people can say that their job will help change the world for the better, on a global scale."

Of course, the contributions to the world's poor by people like Microsoft Chairman Bill Gates, who made his fortune in tech and intends to give a sizeable portion of that money away, may well be incalculable. But it's young engineers like Sandhu, Hassounah and Rebeca Hwang, profiled in the second installment of this series, who are putting that money to work while overcoming difficult conditions and language and cultural barriers. They're the feet on the street, bringing technology moguls' lofty philanthropic ambitions to people who may never have heard of those tech billionaires.

From Tucson to Ulaanbaatar

Sandhu packed his bags in June 2006, kissed his girlfriend of two years a temporary goodbye, and boarded a plane for what will be a yearlong stint in Mongolia.

Once in Ulaanbaatar, Mongolia's capital, Sandhu settled into a furnished apartment and began contacting everyone he could who was centrally or peripherally involved in the initiative. He spoke with health ministers, toured facilities and stayed with field nurses in their tent-homes in the countryside. He improved his Mongolian ( khalkh) through intense classes, read up on social graces, and realized that as a vegetarian, he would have to creatively and politely decline any meat offered by his nomadic hosts.

At UC Berkeley, Sandhu's identity is defined by his work. In Mongolia, it's by his foreignness. Mongolians constantly ask about his ethnicity, some guessing him to be Indian or Cuban.

In fact, Sandhu's "differentness" partly accounts for why he wound up in Mongolia. Born in England to Indian (Punjabi) immigrant parents, Sandhu moved with his family to California for his father's electrical engineering career before they settled in Tucson, Ariz. Sandhu's studies took him to Boston, and his fieldwork to India, Uganda and Guatemala. "I think that growing up between cultures has given me a different outlook on the world," he said.


Among his MIT classmates, Sandhu is a rare breed. More than 50 percent of MIT alumni gravitate toward high-paying jobs in tech, consulting or financial services at companies such as Microsoft, McKinsey and Goldman Sachs. In 2006, only 13 percent of MIT graduates went into academia, reports MIT's career center, and the majority of those technophiles avoid field work that takes them offline from family and friends.

Yet Sandhu's friends weren't too surprised he carried on with his research instead of joining them in corporate America. "I really got my taste of research when doing my MS at MIT--the individuality and creativity required" was motivating and rewarding, he said in a recent interview. "I found something that I was really passionate about and decided to stay the course."

He has an uncommon perspective for a mechanical engineer, added Alice Agogino, Sandhu's professor and adviser at Berkeley. "There's a saying in the engineering community that the civil engineers make the targets and the mechanical engineers shoot them down," she said. With many mechanical engineers working in the defense industry, Sandhu's educational projects are "very unusual."

But Sandhu has always been willing to roll up his sleeves, Agogino said. When the lab was working to protect migrant workers in central California from repeated pesticide poisoning, Sandhu decided to stay the night with a family in the affected town to fully analyze their real-world situation.

In Mongolia, Sandhu is drawing on the so-called human-centered design approach of Agogino's Berkeley lab, a bottom-up philosophy that begins the design process in communities, not in concrete rooms. "We discover their needs and then match those needs to the best solution," Agogino explained.

That field-first approach might sound like an obvious methodology, but it's not usually what happens. "There's so much bull sometimes with all that technology can do for the poor and starving in the third world," Agogino said, referring to cases in which technologists formulate solutions based on a largely theoretical approach. "But that's not always appropriate for rural environments. (Sandhu) really understands that."

That's why, when he first learned of the PDA pilot program online, Sandhu contacted everyone who might be involved or could lead him to someone who was. "Friends, colleagues, strangers would put me in touch with people here in Mongolia and I slowly got closer and closer to the people I needed to talk to," he said.

Why Mongolian mothers are dying

The same Mongolian landscape that awes Sandhu endangers its inhabitants, and the low-tech lifestyle of Mongolian herders presents thorny health challenges for pregnant women in need of frequent, specialized care. Though Mongolia's casualties remain one-tenth that of many African nations--Zimbabwe averages 1,100 maternal deaths every year per 100,000 live births versus Mongolia's yearly average of 100 deaths per 100,000 live births--they are high, given the country's relative wealth and training standards for field nurses.

For nomads, the widespread lack of electricity and running water are a challenge, and a staple diet of meat in winter and dairy in summer takes a nutritional toll. However, the vast distances to neighbors and hospitals (up to 40 miles away), eroding transportation infrastructure and limited first aid equipment all push the maternal death rate to 10 times above the U.S. ratio.

Hemorrhages that could be plugged with surgery, sutures or proper medications bleed freely due to scarce supplies. The challenge to regularly treat nomadic patients scattered over vast unpaved terrain strains the nurses' ability to keep qualifications current.

Sandhu believes the right resources can greatly reduce the death rate, but are PDAs the key? He's trying to find out, and he's not entirely sold on using handheld devices to track vulnerable patients. What's crucial to patient health, he thinks, is the field nurses' access to continued education. The more up-to-date they are, he reasons, the more effective their caregiving can be. Indeed, he's not certain the PDA project will enable the nurses' learning.

Bayanhongor and Övörhangai are two of Mongolia's 21 provinces, or aimags. Though geographically diverse, their centrality to Ulaanbaatar makes it practical for Sandhu to keep his base in the capital and conduct his fieldwork. Like in central California, he will spend several days soaking up his subjects' needs, carefully noting the work habits and needs of the 20 field nurses he'll visit.

Shadowing the nurses as they feed their horses, goats or camels, prepare food and care for patients will show Sandhu which of the nurses' common challenges may have a clear high- or low-tech solution. That only a handful will have PDAs gives Sandhu a base for comparing how the PDAs impact the nurses' quality of patient care, if at all.

"I see my work as an approach to solutions," Sandhu said. "The entire objective is not just to design the technology, but to design an entire technological intervention."

Can handhelds clear health hurdles?

"Hold the dogs!" Sandhu will holler in a customary Mongolian greeting, as he and his translator pull a car, a luxury mode of transportation, up to the white felt tent ( ger) where a field nurse and her family live. Other rituals script the visitation--the polite inquiry about whether the animals are fattening nicely, the assigned seating on stools within the ger: men to the West, women to the East. They will admire each other's snuff before sipping cups of salty, bitter tea splashed with yak's milk and enjoy a celebratory taste of vodka or airag, fermented mare's milk, as early as 9 in the morning. Courtesies given, Sandhu may begin his three or four-day interview and observation.

As Sandhu explains it, PDAs could help clear several hurdles, including shaving down the time nurses spend writing case reports during scheduled visits to the county health center. Though not currently a primary function, future project iterations could include loading the PDA with educational presentations and medical reference information.

Nurses could use the presentations to persuade pregnant herdswomen with complicated cases that journeying to a provincial hospital in frigid temperatures may be less life-threatening than giving birth in an underserved clinic. PDAs could also potentially store training material for nurses to review while traveling between patients' tents.

Though the case information now being entered into field nurses' PDAs could be useful for keeping track of periodic neonatal care scheduling, the project's goals don't include training. Sandhu may also discover that other solutions are more effective, and that the PDAs are fussy, expensive replacements for notepads and pens.

Or what if they are useful, but imperfectly designed? Batteries could lose their charge in excessive heat or cold. Physical or digital corruption could wipe stored data. A complicated user interface could make cases difficult to manage.

Sandhu could also recommend changes or additions to the current program: weather-proof hardware, additional open-source software for greater storage or emergency data recovery, a more efficient battery charging and distribution routine.

Of course, the recommendation process is just as meticulous as Sandhu's methodology. After field trials, Sandhu and his supporting team of Mongolian health researchers--ideally seven dedicated analysts in all--will analyze the interviews and observations, and derive conclusions.

Faculty and students from the University of Health and Sciences in Ulaanbaatar, as well as design engineers, will chime in as well. These independent teams will then share their proposed solutions, and Sandhu will present the best ones to the PDA program's sponsors, Japan's Asian Development Bank and Mongolia's National Center for Health Development.

In the meantime, Sandhu is testing his interview protocol in the field and happily blogging about his memorable experiences as an outsider--the street stalker who only asked if Sandhu speaks Russian (he doesn't); the people who break into Indian song and dance when they confirm his heritage; the joyous festivals and towering cakes; the polluted haze of coal burned by ger dwellers on the city's edge for warmth during the minus-20-degree winter nights.

Sure, he misses home, his girlfriend, family and friends. He misses Silicon Valley's casual work atmosphere and being able to find a variety of vegetarian food. Better transportation would be nice (once Sandhu carried a jug of airag on his lap for 10 hours on a minivan "bus" while being jabbed, jostled and jerked by uneven roads). But overall, he said, "I feel as if I live comfortably, am enjoying life and am always meeting interesting folks. Maybe it's early in the year for me, but things are really great all around."