Stanford pediatrician Paul Wise stooped below the black tarp roof of a cinderblock house in Guatemala to offer his condolences to a mother who had just lost her child.

“Doctor Pablo,” as he is known in the communities around San Lucas Tolimán, talked softly as he relayed his sympathies to the mother, whose 9-year-old son had been a patient of his.

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Video by Nicole Feldman and Michelle Joyce

Stanford’s Children in Crisis Initiative seeks to save the lives of children in areas of poor governance. In Guatemala, their efforts work toward eliminating death by malnutrition for children under 5.

The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months. They found the doctor through the Guatemala Rural Child Health and Nutrition Program, a collaboration between Wise and the health promoters to eliminate death by malnutrition for children under 5.

While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.

Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.

The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.

Children in crisis

As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.

“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.

Dr. Paul Wise examining a boy in rural Guatemala

“Doctor Pablo,” Stanford pediatrician Paul Wise, examines a boy in the community of Nueva Vida. When local health promoters think a child may have a serious medical condition, they like to consult Wise during his visits to Guatemala. (Image credit: Nicole Feldman)

Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.

Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.

The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.

“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.

This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.

The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.

Role of nutrition

When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.

“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”

First-year medical student Tori Bawel plans a career improving health in areas of poverty. Fátima shows off her Stanford gear as she gets a ride from Bawel. Because of contributions from FSI, children like Fátima are getting the nutritional supplements they need.

First-year medical student Victoria Bawel plans a career improving health in areas of poverty. Through the Children in Crisis Initiative, supported by the Freeman Spogli Institute for International Studies and Stanford School of Medicine, children like Fátima are getting the nutritional supplements they need. (Image credit: Nicole Feldman)

Wise and his colleagues – Stanford medical student Victoria Bawel and Stanford associate professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.

Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.

It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.

Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.

“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”

With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.

Research assistant Alejandro Chavez works with mothers and health promoter in a health center in Guatemala

Working with the Guatemala Rural Child Health and Nutrition Program, Stanford research assistant Alejandro Chavez collaborated with local health promoters to design an app that has made tracking nutrition faster, easier and more accurate. (Image credit: Nicole Feldman)

Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.

“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”

Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.

However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.

“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”

It takes the health workers about three years to learn to graph and then interpret the results for intervention.

Wise said, “So we all got together and said, ‘How do we make this easier to do?’”

The app was the answer.

‘Let’s create an app’

Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.

Health promoters with a tablet computer using app to track children's nutrtion

As of April 2016, health promoters throughout the rural communities are using the health app to track the children’s nutrition. (Image credit: Nicole Feldman)

“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who travels often to work in Guatemala, where he gets feedback from the health promoters.

“I feel like they’ve been very honest with me about things I need to improve,” he said.

Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.

“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”

Looking forward

With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.

Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.

Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”