This is the first episode of a two-part series about raising the quality of health care in the developing world. Listen to the second episode here: The Healing Force of Family.
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Deb Van Dyke, a nurse practitioner for Doctors Without Borders, grew increasingly troubled over 15 years by the low quality of care provided by local health workers around Asia and Africa. So she set up Global Health Media, an international video production house, to make instructional videos customized for the developing world. They have since been used to train more than one million health workers, transforming the way frontline caregivers are learning essential skills and helping them save lives.
This episode traces the journey of Van Dyke and Peter Cardellichio, the associate director of Global Health Media, as they built the organization from:
- Van Dyke’s earliest inspirations in South Sudan (0:06) and Afghanistan (10:25);
- to their first disastrous film shoot in the Dominican Republic (13:36);
- and to the eventual success of their videos in more than 200 countries (20:38).
Along the way, we learn about:
- the crisis of frontline health care quality from Dr. Raj Panjabi, co-founder of Last Mile Health (7:46);
- how Van Dyke creates the videos to maximize impact for health workers (15:54);
- and why the videos have become so cherished by frontline workers, such as neonatal specialist Dr. Josh Bress (19:38) and S.D. Nyoni, a nurse inZimbabwe (24:16).
Additional Resources:
- Global Health Media videos described in the episode:
- Research from third-party field organizations on the impact of the videos in:
The full transcript of the episode is below.
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Deb Van Dyke 00:06
In 2008 I was running a medical program in a remote part of South Sudan. And late one night I got this urgent knock on my door. It was one of the local nurses and she said, ‘You have to come quickly, there's a baby that's just been born and it's not breathing.’ So we ran through the dark to this birthing tent. I looked around the room as I entered the tent, and I remember connecting to the worried eyes of the mother. And then I saw her baby, blue and lifeless on a table. We had a doctor and midwife that were trying to resuscitate the baby. One was giving chest compressions and one was trying to get the suction machine going. But they did not have the bag and mask which was forgotten in the corner. So I ran over and grabbed the bag and mask because that is what will bring the baby to life, is giving the baby breaths. So we started to give the breaths, and of course time crawls when you're in an emergency. But before too long that baby cried. I was so relieved and so happy for that new mother.
So the baby lived. But I remember realizing that health workers everywhere desperately needed that skill, and I envisioned video showing a lifeless baby coming alive with breaths delivered by that bag and mask. And I thought, I thought at that moment, I have to do something about this.
Jonathan Levine 01:40
From the Stanford Social Innovation Review at Stanford University, this is Uncharted Ground. It's a podcast about the people at the forefront of global development and their journeys in social innovation. I'm Jonathan Levine. We're launching our podcast today with a two-part series about raising the quality of health care in the developing world. In this episode we look at that massive challenge through the lens of Deborah Van Dyke, a family nurse practitioner from Vermont. With no background in filmmaking, Deb started a globe-trotting video production house to help train frontline health workers. Her small nonprofit group, the Global Health Media Project, has produced 200 short live action films over the last 10 years about the basics of childbirth and other tasks at the heart of improving maternal and child health. The films use real health workers and real patients in hospitals from Nigeria to Nepal. And with hundreds of millions of viewers from virtually every country on the planet, these films are transforming the way health workers in the developing world are learning essential skills—and saving lives. And now in this age of viral pandemics, as lock-downs shut down conventional classrooms around the world, Global Health Media's videos have become more vital than ever. But let's start at the beginning—about as far from nursing and the developing world as Deb Van Dyke could get.
Deb Van Dyke 03:13
So I grew up in Michigan. I come from a family that is completely not medical, like my dad is from a Christian Science background, my mother's from a Quaker background. There is nothing in my background that led me to nursing. Nothing. Like it was a complete fluke.
Jonathan Levine 03:32
In fact Deb thought she wanted to be a naturalist like her grandfather, so she got a degree in natural sciences and forestry. And her first summer out of college she got her ideal job: studying vegetation on the coastal zone of Maryland.
Deb Van Dyke 03:47
And I got bored. And I felt uninspired, and it was such a shock to have gone through all the schooling, to be out doing what I thought I liked and realizing I didn't like it.
Jonathan Levine 04:01
On a rainy day off she picked up a random book in the local library, an exposé about childbirth practices in 1970s America. It was called Immaculate Deception by Suzanne Arms.
Deb Van Dyke 04:14
I took the book out and I read it cover to cover by flashlight in my tent that night, and it was riveting. I was so moved by that book and I felt, in my secret heart, that if I could do anything with my life, I would like to make a choice for women to birth in a way they want to birth in America. Because at that time in the ‘70s, childbirth was really—I don't know if I could use the word barbaric—but it was really not a good experience for women. I would say my life direction was quite literally changed by that book.
Jonathan Levine 04:55
That inspiration led Deb to train as a midwife in El Paso, Texas, where she jumped into helping poor Mexican women birth their babies. And to her surprise, she discovered a real passion for helping people, especially disadvantaged women in the developing world. She went on to get a master's degree in nursing and along the way, Deb did a stint at a clinic in Kathmandu, Nepal, where she got hooked on public health.
Deb Van Dyke 05:22
So diarrhea was super prevalent. You see children defecating in the alleys and that goes into the drinking water, and people are drinking unclean water and the diarrhea cycle persists. So you know you're just at the end of the line in terms of helping people when you're a clinician. But if you are dealing with public health issues, you are trying to manage the beginning of the problem, and that felt really compelling, and I got it in spades when I was in Nepal. I really saw it totally upfront.
Jonathan Levine 05:59
Deb went on to spend 15 years coordinating field missions for Médecins Sans Frontières, or Doctors Without Borders, around Africa and Asia. She mostly worked in conflict and post-conflict regions where there were frequently no health care professionals around. Deb and her team would often have to recruit and train local lay people in the basics of medical care—teachers or carpenters—literally anyone who could speak English. That experience made a lasting impression on Deb’s understanding of health care workers in low-resource countries and on the film's she would eventually make.
Deb Van Dyke 06:35
I really recognized that they have a lot of limitations, because a lot of times they don't read and they are not good with math. So it made me realize that people are, you know, they’re on a very basic level.
Jonathan Levine 06:53
That gap in basic knowledge and skills is one of many causes—probably the single biggest reason—for the low quality of care in much of the developing world. And it's a huge barrier to the concept of Universal Health Coverage, a sort of holy grail in the health world that says access to quality care is a fundamental human right, no matter where you live. The global health community has been trying for decades to make that a reality, but so far the skills gap is just too vast . Think about this: Out of a million newborn babies who die each year in Africa, the World Health Organization says about two-thirds of them could be saved if the health care workers who look after them had adequate training and resources. And no one knows that better than Dr. Raj Panjabi.
Dr. Raj Panjabi 07:46
Well, let me start with a story. I was caring for patients alongside some of our community health workers and nurses in Liberia—a very rural part—a few weeks ago, and we were with a young community health worker named Patience.
Jonathan Levine 08:02
Raj is the co-founder of Last Mile Health, one of the premier NGOs working in Liberia and other countries around Africa to expand quality health care.
Dr. Raj Panjabi 08:14
And in this community she had been trained to identify, amongst other clinical conditions, pneumonia and acute respiratory infection. She was making rounds in her village and she found a young girl who was coughing for a couple of weeks, had difficulty breathing, had a fever. And Patience looked at her job aid that the ministry of health provided and identified that this child had a few symptoms of acute respiratory infection, possible pneumonia. She assessed the child's symptoms, looked at the child in a physical exam, and then she got stuck. One of the core indicators that she needed to identify was whether the child was breathing at 40 or more breaths per minute. But she had trouble counting the breath rate. The other thing is during her training she had never seen a child with pneumonia, so she couldn't identify the cardinal signs of respiratory distress. She had read it, she had been taught it with flip charts and markers in a classroom setting, but she'd never seen it herself.
Jonathan Levine 09:26
Ultimately, Raj says, Patience had real trouble diagnosing the child's pneumonia. She gave her some antibiotics but the girl only got worse, so Patience finally had to send her to the hospital for care.
Dr. Raj Panjabi 09:39
So I share that story about Patience to humanize what I think is a quality crisis in primary health care, especially in rural areas, and especially primary health care at the community level where community providers like Patience are the frontlines of the healthcare system, but have not been supported to the extent that they need to be to deliver the care that they could.
Jonathan Levine 10:09
Deb Van Dyke, of course was all too familiar with the reality of frontline health care workers like Patience. But it wasn't until one day in Afghanistan, that the light went on about the potential of video to bridge the gaps in their skills.
Deb Van Dyke 10:25
In Afghanistan, I was developing a training curriculum for the whole country for doctors, nurses, and midwives. And I happened to use a short video to teach doctors how to insert an IUD. And I remember flipping on the lights, and they were so excited by that video, they told me that video helped them understand more about female anatomy than they'd ever understood through words or pictures. So they were transfixed by it, and they wanted me to find them more videos. And you know, I know video is a great teaching tool, but I had never really thought of it until I saw it through their eyes.
Jonathan Levine 11:06
And then came that pivotal night in South Sudan, when Deb resuscitated that newborn baby by simply pushing breaths into his lungs, through a ventilating mask. And in that split moment, Deb's life path would change once again.
Deb Van Dyke 11:23
That was a really incredible experience for me, not only to bring that baby to life, but to think about how we could spread that knowledge around the world. I thought about it the next day, and I remembered the experience of those Afghan doctors and realized that health workers everywhere really needed that skill. And I envisioned the video showing how a blue, lifeless baby can come to life with the simple practice of giving breaths. I thought at that moment, I have to do something about this.
Jonathan Levine 11:58
So Deb started calling NGOs and searching medical libraries around the world for videos that would meet the basic needs of doctors and nurses in poor countries. But nothing turned up. She even lobbied Doctors Without Borders and other big NGOs to make the videos themselves. But no one took the bait.
Deb Van Dyke 12:18
And I remember having a discussion with one of these high-level people. And I have a lot of respect for him because he knows a lot about training. He said to me, forget about the large NGOs. They’re too bureaucratic. This is a good idea. You need to do it yourself.
Jonathan Levine 12:36
Did you know anything about video production?
Deb Van Dyke 12:40
No, I didn't know anything about video production. In fact, I've never owned a TV in my adult life. And I don't really see movies that often. And I'm not very techie. So I was not the right fit for getting into a very technical field. But I had this passion, I could so clearly see the need. So I think that drove me through so many obstacles. You can't imagine the number of obstacles.
Jonathan Levine 13:05
Deb turned to an old friend, Peter Cardellichio, an economist who like her had no background in film production.
Peter Cardellichio 13:13
At first, I thought this is just too much to take on. But when I understood the need for better teaching tools and the ability to leverage the internet, I really started to appreciate the impact something like this could have. So I came around to the idea—well, if you can do this and do it well, it can be kind of a no-brainer. It's a really a big win for global public health.
Jonathan Levine 13:36
While Peter handled setting up the organization, Deb started writing scripts for the first series of videos on newborn care, each about five to 10 minutes long on a different skill—managing infections, recognizing danger signs in newborns, and so on. From that point, things really started to move. They raised their first $10,000 from a donor in Vermont. They hired a documentary filmmaker and made arrangements to film at a hospital in the Dominican Republic. But that first film shoot turned into a disaster. The health workers selected to demonstrate the skills were stiff and uncomfortable in front of the camera. And what's worse, they didn't actually follow the internationally accepted best clinical practices that Deb needed to show in the film. And the filmmaker? Her footage might have worked fine for a documentary, but it failed to capture the step-by-step close-ups at just the right angles needed to teach proper technique for an instructional video.
Peter Cardellichio 14:40
We were so in the dark at this point, we didn't even understand how to hire a filmmaker.
Deb Van Dyke 14:46
And I looked at the footage at night and I just, I felt like I was going to have a nervous breakdown. I was so, I was beside myself. I couldn't believe that we were so off the mark.
Jonathan Levine 15:00
But Deb learned fast from those first few mistakes. She tried again at a clinic in Nigeria, and this time she nailed it. What she learned, and what has guided her ever since, is the power of live action.
Deb Van Dyke 15:13
Real live health workers in real settings, similar to where health workers are working: It's instantly relatable and relevant. It's very empowering. Clinical signs, for example, are much more believable and memorable in live action footage, like babies have breathing problems or jaundice or lethargy. A real baby will make a deep and lasting impression. And there's the whole other aspect of modeling care that you don't get through animation—a gentle touch, a reassuring smile, eye contact—all the nuances and facial expressions and body language that we’re trained from birth to read.
Jonathan Levine 15:54
Can you walk me through one of your films and explain some of the things you do to convey the knowledge you want health workers to absorb? Maybe you could describe the film about how to identify the position of the baby in the womb just before delivery, and we'll listen along to bits of the actual video.
Deb Van Dyke 16:12
The Position of the Baby is one of our birth videos, and that helps birth attendants understand how to examine a woman's abdomen to determine how the baby's lying…
Video 16:29
…It's important to check the baby's position early in labor. Is his head down? Which way is he facing?
Is he making progress moving down through the pelvis? This information can alert you to potential problems and a need for referral. This video will show how to feel where the baby is within the uterus.
Deb Van Dyke 16:44
It’s a process of feeling for the parts of the baby, such as the back or the head so they can feel if the baby's breech, if the baby is actually side-lying or if the baby is in a good position for birth or not. So in our video we have the midwife doing the proper hand movements on the belly, and then we've superimposed an image of a baby. So as the narration is describing what the midwife is feeling, we see the parts that she's feeling…
Video 17:13
…First, put both your hands flat on the mother's belly and feel the top of the uterus with the palms and fingers of both hands. Most often you will feel the baby's bottom here. You will feel soft irregular shapes that don't move easily under gentle pressure from your hands. If instead the baby's head is in the top of the uterus, it will feel hard, round and immoveable in relation to the rest of his body.
Jonathan Levine 17:44
So what we're seeing on screen—it’s as if we're looking right through the abdominal wall at the baby's body parts while the narrator is describing what the birth attendant is feeling with her hands.
Deb Van Dyke 17:58
That's right, yeah. When we were in the field, I anticipated that I wanted to do that, so we,shot the footage above the woman—like the camera man is over her, I think—he's even standing on the bed above her, and we have the midwife kind of tucked in among his legs doing the hand movements. We had to anticipate that ahead of time.
Jonathan Levine 18:24
Yeah, tell me what it's like to have to find these situations. I mean, especially the emergency types where the baby is in convulsions or whatever. Live action has a lot of benefits, but it must be awfully difficult to find them and shoot them.
Deb Van Dyke 18:38
So we just filmed our Birth Complication and Resuscitation series, and you're right, we have to be on hand for many, many, many delivers in order to have the opportunity to film rare occurrences. We ended up going to this large maternity in Kathmandu and they have more than 50 births a day. So anytime anything was happening, we would just run to that location and start filming—the mother would have already given permission—and then we were in place. We had to literally run many times! It also takes knowing what we need to film. The fact is that I'm a clinician as well as a filmmaker, so I understand the angles that we need to shoot but I also know the clinical aspects and what we need for these videos.
Jonathan Levine 19:30
That combination of clinical expertise and filmmaking makes all the difference to practitioners in the field.
Dr. Josh Bress 19:38
There are two things that make Global Health Media Project’s work stand out for me…
Jonathan Levine 19:42
Dr. Josh Bress is a San Francisco-based specialist in neonatal care who's worked in some of the most neglected countries of the world, like the Democratic Republic of the Congo where he first came across Global Health Media’s videos online.
Dr. Josh Bress 19:59
One is that it's trustworthy. So yes, there are many videos out there, many of which are wrong. So having a trusted source where you know that medical people have been involved in creating and editing the videos is key. The second thing is that the video can be applied regardless of material setting. Just to give you an example: Let's say I show you a video of how to identify a sick child, but I show you that video in a United States neonatal intensive care unit, with all of its monitors and all of its technology. You're going to have a hard time applying that in a low-resource context. So the way the Global Health Media designed its videos is really around universal use. It's why I think they've been so successful.
Jonathan Levine 20:38
And popular. The videos have been viewed more than 450 million times on YouTube, and they've been downloaded more than 200,000 times in 200 countries, all for free directly from Global Health Media's website. The project is mostly funded by foundation grants and individual donations, and more than 7,000 organizations—NGOs like Save the Children, national ministries of health, the WHO, UNICEF—they all use the videos in their country programs. And many of them pay for translation of the videos into dozens of local African and Asian languages—widely spoken ones like Swahili and Hindi, but also narrow dialects like Kinyarwanda in East Africa and Chuukese in Micronesia. That's a strong sign that the films are valued by the people who use them. In fact, based on feedback from these organizations, Peter Cardellichio estimates the films have helped train well over a million healthcare workers.
Peter Cardellichio 21:42
On average, right now, our videos are being watched at a rate of about 500,000 times a day, something on the order of 400 times a minute. So I always like to think somebody somewhere is always watching a Global Health Media Project video.
Jonathan Levine 21:56
That's not even counting three special films from Global Health Media, The Story of Cholera and The Story of Ebola, and new for this year, of course, The Story of Coronavirus. These films use animated storytelling rather than live action to communicate life-saving information. They grew out of Deb’s deep public health roots to address the 2010 cholera outbreak in Haiti, followed by the Ebola epidemic in West Africa in 2014.
Video 22:25
This is the story of how cholera changed my village. Tiny germs of cholera, too small to see, spread through the river…
Jonathan Levine 22:36
All three films have won numerous awards, and the new two-part Coronavirus films have already become a YouTube hit, with more than 12 million views only a few months after the release in early 2021, with translations in more than 30 languages and counting. All that said, the overall impact of Global Health Media is still hard to quantify. A comprehensive study is in the works for 2021 to evaluate the videos’ effect on healthcare workers’ knowledge and skills. And in full disclosure, I'll be part of that evaluation. I've been managing and evaluating health programs around Africa for years, and after talking with Deb and Peter for this podcast, they invited me to help them structure the study. So they'll soon have a clearer picture of their videos’ impact. In the meantime, what they do have, Peter says, is loads of testimonials about how the films are making a difference.
Peter Cardellichio 23:34
One story we heard was from Pakistan, of a health worker who decided to show our videos on Warning Signs in Newborns to mothers upon the discharge from the maternity. So when they were leaving she would set up a laptop and run through the movie and watch it with them, see if they had any questions. And she told us over the next several months, they saw a sharp increase in mothers returning to the hospital with babies who had jaundice and sepsis. And this can be life-saving, because reducing the time in seeking care—the time it takes for mothers to recognize the problem and bring their baby back to the hospital—can mean the difference between life and death.
Jonathan Levine 24:16
I had heard these kinds of stories before myself. In fact, I first learned about Global Health Media when I was running a primary health care program in Zimbabwe a few years ago, and I was looking for a way to reinforce the maternal and child health training for nurses in our rural clinics. So I copied a bunch of the videos on flash drives for all the head nurses, but I never got a chance to follow up to see if they made any difference. So I called up S.D. Nyoni. S.D. oversees several clinics in the Zimbabwe program. And I have to say, I was thrilled to get her update. S.D. can't prove it scientifically, but she believes the videos have helped reduce the number of newborn deaths in her small clinics in the past year to zero, compared to three deaths the year before she started showing the film—thanks to the improved quality of care. The phone line from Zimbabwe was a little rough, but here's how she tells it.
S.D. Nyoni 25:16
I will say it has improved the quality, yes. So why I'm saying that is because the fatality rate is at zero, like for the last year. Most of the complications are identified earlier and the mothers are referred. No fatality rate or no perinatal cases have been reported in 2018-2019.
Jonathan Levine 25:39
Are you saying that during 2018-2019, you think the videos have helped improve the delivery quality?
S.D. Nyoni 25:47
I will say yes, because we are really starting at the waiting mothers—teaching them on what to do, when to report, and what to do during labor.
Jonathan Levine 25:59
S.D. went on to explain how she has integrated the videos into her daily routines with patients and co-workers. For example, she used to see a lot of pregnant women showing up dangerously late for their deliveries, when they were dilated to eight or nine centimeters. But once she started routinely showing one particular video to all of her waiting mothers—the one about how to know if you're in labor—the women started coming in much sooner so they could be safely monitored before delivering. Community Health Workers in the rural villages have also been watching the video about how to tell danger signs in newborns—the same one Peter mentioned was used in Pakistan. So they're now bringing sick babies back to the clinic earlier and dramatically reducing the risks from life-threatening conditions like respiratory distress and sepsis. This is something S.D. says she could almost never get the health workers to do before the videos.
S.D. Nyoni 26:55
I think they have improved a lot.
Jonathan Levine 26:57
Okay, well, that's really good to hear. I mean, that's exactly why we wanted to deliver the videos in the first place. It sounds like you're still using them, yeah?
S.D. Nyoni 27:04
Yes, we are still using them, we're really using them.
Jonathan Levine 27:09
As compelling as they are on their own, the videos may have even greater impact when they're embedded in an education curriculum. Remember Patience, that Community Health Worker in Liberia who had trouble diagnosing a case of pneumonia? It turns out that she later enrolled in a Liberian Ministry of Health training program about pneumonia and a bunch of other topics which included Global Health Media’s videos—all put on a smartphone so that Patience could tap into them offline. When her supervisor came to assess her skill level a few months later, Raj Panjabi of Last Mile Health says Patience was able to diagnose and treat a case of pneumonia with about 95% accuracy, in large part, he says, because of the visual lessons she learned from Global Health Media's videos. And when video training is combined with in-person training and ongoing support from a supervisor, the benefits can last a surprisingly long time. Last Mile Health measured health workers’ knowledge retention for up to two years after training them on some child health programs, using just that kind of integrated approach, and they found that workers retained 25 to 30% more than they did when they simply attended classroom lectures. Now that's a huge win when you think about the millions of dollars spent every year on old-fashioned training courses around the developing world, trying to whack away at the massive skills gap. Here's Raj Panjabi.
Dr. Raj Panjabi 28:43
This collision of modern technology with weak health systems, this collision of modern technology with the human compassion that someone like Patience brings, the combination of high tech and high touch care—I think is absolutely essential to addressing that quality gap. And I think Global Health Media is transforming the way community health providers and other frontline health providers learn. And that's very exciting.
Jonathan Levine 29:10
Especially now since the Covid-19 pandemic has restricted in-person training, these kinds of videos are more essential than ever. It's little wonder that traffic to Global Health Media's website doubled over the first three months in early 2020, just as the virus was spreading around the globe. And by the way, remember that video Deb Van Dyke first imagined back in South Sudan—about how to resuscitate a newborn baby? She says it was one of the hardest films she ever made. But she finally finished it this year…
Video 29:46
Reassure the mother that her baby is breathing now. Put the baby on the mother's chest.
Jonathan Levine 29:52
…And it’s out now, online. Thanks for joining me today on Uncharted Ground. Remember, this is the first episode in our two-part series about raising the quality of healthcare in the developing world. Be sure to check out the second part about…the healing power of family.
Edith Elliott 30:17
The first time you visit a big public hospital in India, what immediately strikes you is the crowds—entire families who literally move to the hospital while their loved ones are admitted as patients. And you realize that the people who care the most about helping their loved ones recover are completely left out of the healing process. So we started thinking, what if we could unleash the healing power of all of those family members?
Jonathan Levine 30:46
That's the story of Noora health—next time, on Uncharted Ground. And if you enjoy our stories, please subscribe wherever you get your podcasts and tell your friends. This episode was produced and written by me and edited by Jennifer Goren, with sound editing by Marty McPadden and sound design by Tina Toby. Special thanks to Deb Van Dyke and Peter Cardellichio for sharing their story. You can see all of their videos online at globalhealthmedia.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.