This is the second episode of a two-part series about raising the quality of health care in the developing world. Listen to the first episode here: The Videos Saving Lives in the Developing World.
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Even before the onslaught of COVID-19, public health services in many developing countries were chronically strained by a combination of burgeoning populations, severe shortages of trained clinicians, and growing burdens of disease. Noora Health harnesses an untapped resource—the family members of hospital patients in India—by training them in simple medical skills to help their loved ones recover with fewer complications and readmissions once they return home. Noora’s standard of caregiving is already helping to restore trust in India's beleaguered public system and may prove to be a critical element in the country's pursuit of universal health coverage.
This episode tells the story of Noora’s origins as a graduate school project of co-founders Edith Elliott and Shahed Alam and their serendipitous discovery of people's family members as a health resource. Follow their journey as they:
- developed empathy for hospital patients as young teenagers, through the trials of suffering family members of their own (05:02);
- devised a pilot test of their theory of change in an Indian cardiac hospital (10:04);
- determined to turn the school assignment into a professional mission (12:35);
- refined a comprehensive model (14:44) and partnered with the Indian state of Punjab to scale it up (22:47);
- and responded to the COVID-19 crisis in India with novel strategies to help vulnerable families of positive patients stay safe (28:51).
Additional Resources:
- Studies noted or alluded to in the episode:
- Journal of Global Health Reports on the results of the Noora program on cardiac patient recovery;
- BMJ Global Health article citing newborn care results to advocate for the importance of family-focused postnatal education.
- The Noora Health channel on YouTube, providing hundreds of examples of Noora’s materials, including Bollywood-style dramas (mostly in Indian languages).
- Blog post by Noora’s director of training, Anand Kumar, about how Noora began.
The full transcript of the episode is below.
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Edith Elliot 00:09
The first time you visit a big public hospital in India, what immediately strikes you is the crowds, the immense number of people, entire families who literally move to the hospital while their loved ones are admitted as patients. You see people who are sleeping in the grass outside, they're sitting in the hallways with their suitcases, their bags, and they're just stuck in this limbo, waiting to see a doctor. And you realize that family members, who are the people who care the most about helping their loved ones recover, are completely left out of the healing process. So we started thinking, you know, what if we could democratize health care? What if we could unleash the healing power of all of those family members?
Jonathan Levine 00:58
From the Stanford Social Innovation Review at Stanford University, this is Uncharted Ground, stories about the people at the forefront of global development and their journeys in social innovation. I'm Jonathan Levine. Today's episode is the second of our two-part series about raising the quality of healthcare in the developing world.
Jonathan Levine 01:24
Edith Elliot and Shahed Alam never set out to revolutionize the role of family caregiving in the world's medical establishment. They were just grad students who took a course with a required field project in India, when they stumbled on a vast, unused resource: the family members of hospital patients. They found that with just a little bit of training, the families could take charge of their loved ones’ recovery and transform the outcomes of critically ill patients. They converted India's crowded hospital hallways into classrooms, and in six years trained more than a million family members on simple medical skills. In the process, something of a miracle happened. Patients started having fewer serious complications after going home from the hospital. And the rate of readmissions plummeted. Their deep understanding of how to connect with families became even more important when COVID-19 first struck India in 2020. And now that the country is facing a devastating second wave, their nonprofit Noora Health is doubling down on the lessons they learned the first time around. Once the pandemic subsides, Noora will continue rolling out across India and Bangladesh. And they don't plan to stop until their model of caregiving becomes a standard in hospitals around the world.
Jonathan Levine 02:54
If someone you love has ever been in the hospital for something serious, like a heart attack or traumatic injury, you already know part of this story: the nail biting hours of surgery, frustrations with uncommunicative doctors, and the frenzy of discharge day when you barely hear the nurse’s parting instructions because all you can think about is, how am I going to help my mother when she gets home? What if I screw up her medication? What if she develops some kind of complication?
Chhavi Sachdev 03:23
Now imagine this hospital experience in a country like India, with low access to medical care for huge numbers of poor people.
Jonathan Levine 03:32
That's our correspondent in Mumbai, Chhavi Sachdev.
Chhavi Sachdev 03:35
There's a huge shortage of doctors and nurses in the government-run public health system, so care is frequently unreliable. Hospitals are so crowded, the average patient is lucky to get even two or three minutes of face time with a doctor. The result can be alarming. Every year in India, 750,000 newborns die in the first month of life, the highest rate in the world. Nearly half of trauma patients and more than half of heart surgery patients have to be readmitted to hospital because they develop serious complications at home.
Jonathan Levine 04:09
But what's most disturbing is that the majority of these deaths and complications could be prevented at home—if only family members knew how. It's a dilemma that Shahed Alam and Edith Elliott knew all too well from personal experience. And in hindsight, it's as though they were preparing to do something about it all their lives.
Jonathan Levine 04:35
Shahed Alam grew up in a Houston suburb, the son of immigrants from Bangladesh, who came to the US for college. His family made trips back to Dhaka every summer, and it left a deep impression.
Shahed Alam 04:46
Bangladesh at the time, twentyish years ago, the level of poverty was pretty immense. It was something that you would have to grapple with day to day. And then going back to suburban Houston, Texas, the juxtaposition of that gave me a perspective that what I was experiencing, what I was doing, is not the world.
Jonathan Levine 05:02
But it was an experience back in Houston that really set Shahed on his career path to medical school, and eventually to co-found Noora health. His grandmother developed the degenerative neurologic condition, and caring for her consumed Shahed’s mother for years.
Shahed Alam 05:19
Just seeing my mother navigate that, I remember how, how lost she felt, and how confused she was by this whole process. And most importantly, what can she do at home to care for my grandmother from, you know, the food she eats to how she gives the medication to the exercise. I saw someone who was so dedicated to this person that they love, so capable, so able to provide that care, but still being so lost. Even such amazing, strong, powerful caregivers—the system sometimes fails them as well.
Jonathan Levine 05:52
In some ways, Shahed Alam and Edith Elliot had led parallel lives. Edith grew up in a small Colorado ski town. And when she was 13, a health emergency struck home: Her mother was diagnosed with a debilitating brain tumor.
Edith Elliot 06:07
My mother had a very long surgery and an extremely long recovery. And I helped her recover—how to feed herself, how to talk again, how to walk. And it was a profound experience for our family and for me. And I just remember being incredibly scared, of course, but then too, the immense amounts of information that were hurdled at us. Just tons of instructions and paperwork that were so complex, when really, whether it was a physical therapy exercise or warning signs to look out for, if you boiled it down and communicated it in a way that was not so medical, it was actually pretty simple.
Jonathan Levine 06:55
Years later, in 2012, Edith and Shahed both found themselves at Stanford University—he was in medical school and she was studying global health policy—and both were drawn to the same graduate course in human-centered design thinking. It's a holistic method of solving big complex problems by digging deep into the needs of people who face an overwhelming burden. People like their own families who had had to navigate an impossibly complex health system.
Shahed Alam 07:26
I had seen so many really incredible ideas within public health and biotech that were being tried out in low-resource settings. But the thing that I really felt was missing was the voice of the people that we were trying to serve through those technologies, through those innovations. And here, here it was—this process of design thinking in this really incredible course applied to the extreme poor.
Jonathan Levine 07:51
The professor assigned Shahed and Edith to work on a real-life problem at a large hospital in Bangalore, India. The hospital's mission was to deliver high-quality but low-cost heart surgeries, and it had huge demand but not nearly enough capacity to serve all the patients who needed it. So Shahed and Edith, and two other students on the team, Katie Ashe and Jessie Liu, hopped on a plane to India and spent a few weeks investigating the problem. They thought their task would be straightforward—to somehow restructure the physical flow of patients through the hospital, to increase efficiency. But when they interviewed doctors and patients, nurses, even security guards, virtually everyone in the hospital talked about something else: the importance of family,
Shahed Alam 08:37
The security guards, honestly, like gave some of the most interesting perspective. They're the ones who day in and day out, were standing inside or outside the ward seeing care unfold. And they noted the people that paid attention to the patients the most, the people who are doing the most stuff, was the family. So slowly the light came on that, wow, like this is an amazing resource within the system.
Jonathan Levine 09:03
Edith says she remembers the fear and confusion she heard in those families' voices, because it was the same anxiety she felt when she was taking care of her mother. Family members like this young woman named Shruthi. Her mother spent five days in intensive care with a heart attack.
Shruthi 09:25
In the past, we've heard of our relatives having heart attacks. But when it happened to my mom, we were much more afraid. My relatives are all right. But would my mom also be okay? I had so many questions fluctuating in my mind. I was so confused.
Edith Elliot 09:41
All that mattered to those people, and all that I remembered feeling in those moments, was this desperate desire to help. And needing information and not knowing where to go to get it is a really emotional thing.
Chhavi Sachdev 10:04
With the massive shortage of hospital staff, families in India already play a role in their loved one's care. They are constantly bringing food, picking up medicine at the pharmacy, even administering these medicines on schedule—but never anything coordinated with the hospital team. Then one day the Stanford students walked into the intensive care unit and observed Anand Kumar showing photos to a group of families. Anand was an ICU nurse, and he found patients were usually disoriented after waking up from surgery. In their panic, they would often pull out feeding and breathing tubes.
Anand Kumar 10:41
They do not understand the seriousness of the surgery, they do not know they're going to be put on a ventilator, there’s going to be tube in their mouth, there is going to be small tubes put in their chest or, you know, small injections or needles being placed in their body.
Chhavi Sachdev 10:54
Anand found his mini photo lectures helped prepare patients and get family members to keep them calm after surgery. And most importantly, he noticed that patients seemed to recover faster. For the Stanford team, this was a revelation, when the Noora mission began to come into view.
Anand Kumar 11:13
They started discussing with me how I do it. And even I did not know what I was doing was, you know, something that big. All that I wanted was, like my patients—when they wake up in the ICU—they just cooperate with the doctors and nurses.
Jonathan Levine 11:26
The team developed a relationship with Anand and later hired him as Noora’s director of training. By the summer of 2012, they'd come up with a pilot program to teach medical caregiving skills to families of cardiac patients. They called it the Care Companion Program. And after they went back to Stanford, they even made a rough set of homemade videos in the local language of Kannada for Anand to test out with families, like this one teaching the warning signs of a heart attack…
Video 11:52
[Kannada language]
Edith Elliot 11:58
We found the few Kannada speakers on campus at Stanford and looped them into this, and then would film these videos. And then we would send them back and get feedback from family members—most importantly, right? And then, you know, we were testing should something be animated versus live action? Does it need to be storytelling-based versus just information sharing. And to this day, that's work that our team continues to do.
Jonathan Levine 12:25
And the pilot went better than anyone expected. So they prepared a blueprint for the hospital to take forward on its own. And that was supposed to be the end of it.
Edith Elliot 12:35
We had no intention of starting an organization. Shahed was in medical school, I had plans to take a job. The plan was not to be sitting here talking to you today.
Chhavi Sachdev 12:51
But then things started to happen. Not only did the hospital adopt the training plan, but the chairman also wanted the Stanford team to help him roll it out to all the hospitals in his network. And people from the surrounding community in Bangalore, who merely heard about the trainings, started lining up to take the classes.
Jonathan Levine 13:15
By the end of 2013, about a year and a half after the pilot, preliminary data started rolling in about the impact the program was having. And it was eye-popping. Cardiac patients whose families took the Noora training had a whopping 71% reduction in complications after leaving the hospital. And readmissions dropped by 24%, compared to patients whose families didn't get the training. And what's more, the Noora families demonstrated more medical skills and knowledge; their anxiety levels were lower; and they were far more satisfied with their hospital stays. It was hard evidence to ignore when the four Stanford classmates met up on a phone call.
Edith Elliot 13:56
We're on this call and Shahed said, “Guys, I think I want to, you know, I want to do this with you and take a leave of absence from medical school.” And Jessie said, “Okay, I think I'm in, too.” And so we decided, then and there, we were going to see where this went.
Jonathan Levine 14:12
As they debated a name for their new venture, the team thought of a young woman they met who just delivered a baby in need of heart surgery. She didn't speak the local language. She'd been kept in the dark by doctors, and she was terrified about caring for her sick baby. Her name was Noora, which means light in Urdu. She'd endured so many things in the system that were broken, and still she remained hopeful. So the Stanford classmates named their organization in her honor.
Jonathan Levine 14:44
What Noora does for families is not a new idea. As far back as 2004, the World Health Organization started advocating for health providers to empower families to take better care of their own. What sets Noora apart is how it systematically rolls out hospital-based family training across many conditions at the same time. And on a very large scale. On the surface, the Noora blueprint is, well, pretty simple.
Edith Elliot 15:12
It all starts with deep listening and understanding of what is driving death and suffering in the condition area that we're working on. And from there, okay, how do you prevent those things from happening? And where can the family member play a role?
Jonathan Levine 15:26
Then Noora puts all that complex medical information through its creative filters and pops out a bunch of instructional content: flip charts, YouTube lectures, animated shorts, even Bollywood-style edutainment dramas—like this one about a family learning to prepare more nutritious meals for the pregnant daughter… And they assemble it all into a short curriculum, lessons of less than an hour for new mothers or cardiac patients or cancer patients, and so on.
Edith Elliot 15:56
Then there's the implementation process, everything from who is it going to be that will be running these trainings with families, to when is it going to take place, what needs to be present in the ward—do you need a television—etcetera.
Jonathan Levine 16:10
Next comes the actual training. First Noora's master trainers like Anand Kumar train hospital nurses on everything from medical content to how to engage the families. And then the nurses teach them: how to take a pulse rate, how to change bandages, how to do physical therapy, and on and on for each type of patient.
Edith Elliot 16:29
Then we have a monitoring and evaluation system to understand how things are going—if it's working, if it's not working. And that feeds back into the content creation, the training, the system approach—those insights are feeding back in.
Jonathan Levine 16:47
And finally, once patients return home, families communicate with Noora by WhatsApp. The Noora system pushes out daily and weekly reminders to keep the lessons fresh in their minds, and agents standby to answer any questions that may come up. And that is really important because…
Edith Elliot 17:03
Research shows that patients forget as much as 80% of what their doctor tells them as soon as they leave the hospital or a doctor's visit. And then of the information that you do remember, you only remember half of it correctly.
Jonathan Levine 17:19
I know exactly what she means because I found out the hard way. I had a knee replaced last year, and in my drug-induced delirium, I did not remember the nurse telling me to take the pain meds every four hours. So that first night at home, I woke up at 5 a.m. to pain that felt like a chainsaw buzzing through my leg. I was never in any danger. But it's a cautionary tale of how fast your condition after surgery can deteriorate without the kind of support Noora provides at home… I mean, I know there are a lot of moving pieces. But at a high level, it seems, like, really simple.
Edith Elliot 18:02
Yeah. We make content. We help systems implement it. And we help people once they go home.
Jonathan Levine 18:08
But when you look under the hood of what's really happening, you're tackling some really hard things, like changing mindsets—mindsets of families, that they can even take on this role; of the nurses that they can take their time in the day to do this when they've already got way too much to do; of administrators, of the government authorities to implement this at a high level. You're changing the power dynamics between professional clinicians and lay people. You're revamping entrenched hospital bureaucracies. I mean, those are a lot of formidable tasks. How did you navigate all this?
Edith Elliot 18:46
Well, it's all about behavior change at the end of the day, right? It's all about behavior change.
Jonathan Levine 18:51
And behavior change, it turns out, is never simple. Here again is Chhavi Sachdev.
Chhavi Sachdev 18:56
Getting hospital administrators to buy into Noora’s program wasn't typically a problem. The clinical benefits were strong, and they understood the potential of tapping the thousands of family members clogging their hallways. But convincing the nurses, the ones who would have to conduct these trainings, that was a different ballgame. At first, they would complain that they were just too overloaded with patients to train families. But as an ICU nurse, Anand Kumar knew how to talk their language. He started by telling them how he could fix one of their biggest burdens—the monotonous discharge sessions for eight or 10 patients every day.
Anand Kumar 19:37
For each patient, you have to spend about five to 10 minutes explaining these things. But that is a crucial time patient is not ready to listen to you. At discharge time, they're more worried about did they pick all the stuff that they put in the locker? Did they take all the medicines that they were supposed to receive? They're more worried about that than listening to what the nurse is saying.
Chhavi Sachdev 19:58
And then Anand would close the deal with this: Replacing all those individual sessions with a single group training—when families were calmly waiting in the wards and able to absorb the lessons—that could save nurses more than two hours a day, and get better results!
Jonathan Levine 20:23
Hospital by hospital, Noora slowly built a track record over 2016 and 2017. They expanded their footprint mostly in private and specialty hospitals like cardiac centers and got some recognition by public hospitals for the all-important training on newborn care. India suffers more than a quarter of the world's neonatal deaths. So that's the biggest pain point for the huge public health system. And Noora had a good answer for it. In 2017, an independent research group did a study of nearly 5,000 babies born in public hospitals, and they found that babies whose mothers took the Noora training were less than half as likely to have to return to the hospital for problems, compared to babies whose mothers had no training. Some important behaviors also improved dramatically, like the practice of holding the infant up against the mother’s bare skin to keep it warm—what's known as kangaroo mother care—shot up by 78%. And the results got noticed by medical officers in big government-run systems, like in the northern state of Punjab.
Dr. Baljit Kaur 21:26
Our first year, we were in six district hospitals.
Chhavi Sachdev 21:29
Dr. Baljit Kaur is an assistant director of the Department of Health and Family Welfare in Punjab, and she has run the Noora program here from the start. The trainings expanded in the second year to all the state’s 22 large district hospitals. And she says they went through a transformation. The number of sick babies needing to be readmitted to hospital for complications like jaundice dropped by 63%. She says nurses were excited to finally share their medical knowledge and became more attentive to patients. And the good word spread, so much that the number of outpatient clients shot up.
Dr. Baljit Kaur 22:10
You know, it means a very big thing. When you have satisfied clients, then you have more and more people visiting you. So the kind of message that was going in the population was definitely positive.
Chhavi Sachdev 22:21
But it was more than about numbers. There was a universal intuitive understanding of the need for Noora’s program.
Dr. Baljit Kaur 22:30
We all feel that this was the need, and health education is the key to bringing about health-seeking behavior. So that's where we thought that this has to work, and this will work, and it has worked.
Jonathan Levine 22:47
The Noora team had always hoped to expand to more large public hospitals, and Punjab’s success presented the perfect opportunity. During 2018 and 2019, Noora and the state rolled out a broad new bundle of trainings with lessons for everything from general surgery to chronic diseases like diabetes. That meant that the scope of Noora's program was now relevant to the vast majority of patients who pass through any of India's district-level hospitals. And it triggered a groundswell of interest from public hospitals around the country. Until the second wave of Covid hit, Noora was on track to be operating in nearly 290 hospitals by the end of this year and serving a population of more than 400 million. They may fall short of that target given the chaotic state of hospitals in the country right now.
Jonathan Levine 23:41
Why the Noora program gets results links back in many ways to the design thinking the team learned in grad school. From training in the wards to follow-up support after returning home, the end-to-end system helps families absorb and retain lessons. And families are encouraged to try out their new skills while the patient is still in the hospital—routine tasks like taking temperatures and doing physical therapy. So nurses are freed up to provide better quality of care to the most critically ill. But maybe the most important reason is timing. Edith Elliot says the urgency of the hospital experience sharpens the family's focus.
Edith Elliot 24:20
We have an audience for whom this is top of mind. Their loved one is in the middle of something potentially catastrophic. And so when you tell someone, it's important to wash your hands before or after touching the patient's wound, that then becomes more relevant. And when people are in the hospital, that small window is open.
Jonathan Levine 24:42
Chhavi, it's kind of a compelling argument that catching families in hospital when they're most alert to their loved one’s condition is the peak opportunity to train them. What did you find when you talked to families who went through Noora's training?
Chhavi Sachdev 24:55
You know, for me, the biggest takeaway is that a little well-crafted information—the kind Edith was so desperate for when her mother was ill—goes a long way towards building families’ confidence and reassuring them that their loved ones will get the best possible care. Dr. Kaur from Punjab tells one story about a grandfather who attended a class for the birth of his second grandson. After the training, he went up to the nurse.
Dr. Baljit Kaur 25:22
And he says, “When my first grandson was born, you were not there. You didn't tell me all these things. And my grandson developed jaundice. We did not know how to check that he was having jaundice. And we took him here and there very late, and we were taking medication from unqualified people. And that child is deaf.” And imagine, I get goosebumps even when I think of it now.
Chhavi Sachdev 25:53
But the nurses had taught him a simple test for jaundice this time, and so much more that the family, she says, is now confident that they can care properly for the new grandson.
Dr. Baljit Kaur 26:04
Now he knows how to check. He says, “I'll go and tell more people.”
Chhavi Sachdev 26:13
It was a similar story with Shruthi. You remember her from earlier in our story. Her 65-year-old mother, Akkamahadevi, suffered a heart attack and left her deeply worried. But Shruthi says the many things she learned at the hospital training gave her peace of mind. Now she knows the importance of a healthy diet, and of seeing a doctor or nurse when they're ill, instead of self-medicating, as they were used to doing before.
Shruthi 26:40
I honestly didn't know much about heart attacks until it happened to my mother. But after attending this class and seeing the treatment that was provided, I was confident that my mom would recover and come home soon, and that God is there to take care, and I calmed myself down.
Dr. Baljit Kaur 27:00
The Noora class was so helpful and the staff so attentive, Shruthi says it changed her perception of the government-run health system.
Shruthi 27:14
These days no one goes to government hospitals. We think they are careless. They won't look after us properly. I was so happy seeing how good the government hospital is. Private hospitals charge us a lot more and also scold us. But here the rates are reasonable, they take care of us nicely and do things for our well-being.
Chhavi Sachdev 27:34
That is high praise indeed for a public health system that has such a poor reputation that many people pay high prices for private care, even when they can't afford it. In fact, the government estimates some 60 million people are pushed into poverty every year by paying up for private services because they're afraid of public health care. So the bottom line is this: If Shruthi’s experience becomes the norm, it could start to make low-cost public health care more acceptable in India, and lessen the financial burden on families.
Jonathan Levine 28:09
And if that happens at national scale, it may also one day help to move the country closer to what the experts call universal health coverage, that is, making quality health care more available and affordable to everyone, especially for the rural and urban poor. Think about it this way: If you can dramatically free up hospital beds by reducing complications and readmissions, and if families take better care of themselves at home so they avoid hospitals in the first place, then suddenly, more of that low-cost public care becomes available to more people who need it.
Jonathan Levine 28:51
When the first wave of COVID-19 hit India in 2020, Noora was well prepared for some of the biggest challenges of the early pandemic. Remember the public confusion about how to prevent the virus, about how to reach the isolated and protect the most vulnerable? That all played directly to Noora’s strengths in communicating with families. Of course, no organization on its own could possibly contain the catastrophic second wave this spring. Still, some of the lessons Noora learned from the early days of COVID are now more critical than ever. Barely days into the first wave last year, Noora surveyed more than 7,000 citizens and health workers across India to learn exactly what they understood about how to prevent COVID, or in many cases, misunderstood. For example, more than half of those surveyed believed myths like you could contract the virus from eating chicken or eggs. So Noora developed a series of videos and other content, like this one describing how the virus actually spreads… So they pushed it out through their regular trainings to families in hospitals, but they didn't stop there. They magnified their reach by teaming up with about 70 governments and large groups that had trusted contact with a lot of people—groups like microfinance lenders and agricultural extension agents out in remote villages—and trained them to disseminate the materials around the country.
Chhavi Sachdev 30:17
Then around June of 2020, after the first countrywide lockdown, Shahed Alam says the Noora team came up with a way to modify their core strength in teaching caregiving skills to the people who needed it the most.
Shahed Alam 30:31
Hospitals started filling up and there was just not enough healthcare resources out there to support all of the COVID patients. And who was on the front lines taking care of those patients were the family caregivers, because for the most part, people would be healing at home. But we needed to keep the families safe, we needed to keep the community safe—and then, of course, let them know what to look out for and how to provide those basic caregiving skills.
Chhavi Sachdev 30:56
So Noora arranged with the governments of two large states and the national government in Bangladesh to get the contact information for every COVID patient as soon as they tested positive. Then Noora’s research team called every patient's family—not to contact-trace, but to educate them about how to care for their sick patients while also staying safe themselves. In the communities where they did this outreach, there's some evidence that it made a measurable difference. By August, one city just outside of Mumbai was ranked as having the best patient recovery rate in the entire country, which the municipal commissioner there attributed, in part, to Noora’s family support.
Jonathan Levine 31:39
Now, since the second wave, you would be hard-pressed to find any trace of that success. Still, Edith Elliot says the massive challenge has driven Noora to double down on their efforts. By early May they increased their calling teams to reach 10 times more families of COVID patients. They created new content to teach families how to help the critically ill at home when hospitals were no longer taking patients—with skills like how to carefully turn them on their stomachs to increase the flow of oxygen. Edith says they also set up a system to disseminate information about local sources of help. Noora’s own staff members themselves have been slammed hard by COVID, so they need that support as much as their patients. Noora even secured a couple of hundred oxygen concentrators in the US to help one especially hard-hit rural area where they work. The challenge is overwhelming. But Dr. Rebecca Weintraub says the organization has established some valuable principles for future pandemic responses. She's a former Noora director and an assistant professor of global health at Harvard Medical School, where she's led a COVID-19 global response team.
Rebecca Weintraub 32:49
In many ways Noora has thought upstream from the beginning, thinking through what are the new solutions I need to prevent transmission? What are the new ways I need to communicate? How do I actually get an early warning sign out to the populations that I'm serving? There are lessons of how Noora has been able to establish trust, and truly a brand of family caregiving. And pairing directly with the government helps them reinforce, “This is the same message you're receiving from this trusted brand, Noora, as well as your Minister of Health,” and that enables this to scale the message.
Jonathan Levine 33:25
Another critical reason the Noora concept works is that hospitals take ownership of the family training program. As Noora starts up in each hospital, it pays for most of the expenses for training the nurse trainers, developing new content, setting up monitoring systems. But after the program is established, the hospital bears the bulk of the ongoing costs, mostly for hospital staff, which they're already paying anyway. And so far, state governments have willingly written those costs into their annual budgets, making the operations highly sustainable,
Chhavi Sachdev 33:59
Noora’s expansion continues to be funded mostly by donations from family foundations and other relationships they developed back at Stanford. With a budget of $4 million in 2021, Noora is beginning to replicate the program next door in Bangladesh, a move that was supposed to have started last year until it was postponed by COVID. Noora may also have the chance this year to see how its model flies in the United States. Just before COVID hit, a team from the Henry Ford Health System, a network of five hospitals around Detroit, visited the India operations, and they now plan to adapt it to their system in Michigan with Noora’s guidance.
Edith Elliot 34:41
We know that Noora Health cannot be in every hospital around the world, nor should it be. But can we, can we act as a thought partner? Can we be the spark that lights a movement in another part of the world without our boots having to be on the ground?
Jonathan Levine 35:03
That's a big question—just how well the Noora model will translate to other places. For one thing, it relies on a concentration of family caregivers, all congregating in one place at the same time. So one big limitation may, in fact, be in places like the United States and other countries where families are not always as physically present and connected in the hospital as they are in South Asia. Another constraint is the underlying health care system. One of the biggest lessons Noora teaches families is how to tell if their patient develops a serious complication and what to do, which is usually to take them to a local doctor for follow-up. But in many countries, doctors and even nurses often just aren't there.
Edith Elliot 35:45
There are some parts of the world where the health system is so broken, that training a family member on what to do if there's an emergency is only going to go so far when the health system is not there to meet that family when they do the right thing. And so there absolutely will be areas where this is not as effective. However, that said, there are billions and billions of people for whom this works.
Jonathan Levine 36:15
You're not going to run out of market anytime soon.
Edith Elliot 36:17
Exactly. No, exactly.
Jonathan Levine 36:20
You've come a long way since grad school. Which reminds me, I meant to ask you earlier, you know the design thinking class back at Stanford, where all this started? How did you guys do? Did you get an A on the project?
Edith Elliot 36:32
You know, it's so funny. You're not the first person to ask me that. But yes, we did. Well, we got an A-plus.
Jonathan Levine 36:39
Really!
Edith Elliot 36:40
Yeah! It's the first A-plus I think I've ever gotten. And I remember at the time thinking, like, really? We were so focused on what was happening in the hospital, we were less focused on what we were delivering as students in the class as part of the project. That was our obsession.
Jonathan Levine 37:01
I guess the professor was prescient.
Edith Elliot 37:02
Yeah! So I guess that maybe, that was the right approach.
Jonathan Levine 37:13
Thanks for joining me today on Uncharted Ground. Remember, this is the second of our two-part series on raising the quality of health care in the developing world. So if you haven't already, be sure to check out the first episode about the remarkable work of another pioneer in the field, Global Health Media. In our next episode: When a local chief in Sierra Leone sold off the land of dozens of farm families behind their backs, they won an historic judgment against him. Now the country is considering legislation that would set a precedent against land grabs around the world. Putting the power of the law into the hands of ordinary people—next time on Uncharted Ground. This episode was produced and written by me and edited by Jennifer Goren, with sound editing and design by Tina Tobey. My thanks to Chhavi Sachdev in Mumbai, and of course to Edith Elliot and Shahed Alam, and all their colleagues and patients for sharing their story. A special thank you to the Solutions Journalism Network for its support of this episode. SJN is a nonprofit organization dedicated to compelling reporting about responses to social problems. You can find them at solutionsjournalism.org. Uncharted Ground is produced and distributed in partnership with the Stanford Social Innovation Review at Stanford University, and online at ssir.org. I'm Jonathan Levine, and you've been on Uncharted Ground.