The nationwide cellphone cancer scare began in January 1993 when David Reynard went on Larry King Live. He had recently lost his wife, Susan, to a brain tumor, which he believed had been either caused or accelerated by her frequent cellphone usage. Before her death Susan had filed a lawsuit against her phone’s manufacturer, Japan’s NEC, carrier GTE (later part of Verizon), and the local retailer that sold the phone. It was the first time a person had sought compensation for brain cancer caused by cellphone radiation.
Though a Florida judge later dismissed the lawsuit, citing insufficient scientific evidence, Reynard’s appearance on King’s widely watched show rattled the country. Frightened by the cancer connection, some users canceled their cellphone service. Consumers who had planned to buy cellphones delayed their purchases. Investors quickly sold off their shares of mobile communications companies.
The CTIA, the U.S. wireless trade group, said the panic was a case of emotion trumping science. Cellphones use radiofrequency (RF) energy, a form of electromagnetic radiation, to send and receive voice and data signals to cell towers, and the mere mention of the word radiation frightened many people. But the RF energy cellphones emit is too weak to cause the type of DNA damage that provokes cellular mutations and can lead to cancer.
Still, the question lingers: Could repeated exposure to RF energy indirectly cause health problems? In pursuit of an answer, health organizations, governments, academics, and cellphone companies have spent tens of millions of dollars on hundreds of studies. Today there is still no conclusive scientific evidence that cellphones cause cancer, but there have been enough mixed signals that many people, including some prominent scientists and doctors, have not ruled out a cellphone–cancer link, either. “More studies involving humans are still needed,” says Dr. Henry Lai, a professor emeritus of bioengineering at the University of Washington and a noted cellphone radiation researcher.
The most ambitious study yet of the relationship between cellphone use and brain tumor risk yielded contradictory findings. Known as the Interphone Study, it compared the cellphone histories of two groups: a case group of people aged 30 to 59 who had brain tumors and a control group of tumor-free people who lived in the same region and were the same gender and roughly the same ages as the people in the case group. The idea was to see if past cellphone use could explain why the case group had developed brain tumors while the control group had not.
Interphone kicked off in 2000. The scientific and medical communities had high expectations for it, since it was a project of the International Agency for Research on Cancer (IARC), an arm of the World Health Organization (WHO), which is globally recognized as the foremost authority on identifying cancer causes. The IARC tapped a consortium of researchers from 13 countries, including Australia, Canada, Japan, and eight European nations (the United States was not involved) to lead the project, which involved approximately 10,000 participants over four years and ultimately cost more than $30 million. Yet Interphone’s conclusions were inconclusive, and the researchers fought for years over the best way to present their results.
These disputes were evident in Interphone’s report, which was belatedly published in 2010. It said that participants showed no overall increased risk of brain tumors from cellphone use, but also that there were “suggestions” that the heaviest 10 percent of users—people who had used their phones at least 30 minutes a day for 10 years or more—had a 40 percent higher risk of glioma, a type of brain tumor.1 The Interphone report ultimately downplayed this finding, noting that potential “biases and errors . . . prevent a causal interpretation.”2 But media coverage of the study focused on the glioma statistic. Newspapers around the world ran disquieting headlines such as SHOCK FINDING: CELL PHONE-CANCER LINK (New York Post)3 and WATCH THAT THING BY YOUR HEAD (The Globe and Mail).4
People grew even more wary of cellphones the following year, when the IARC classified RF energy as a possible carcinogen. To formulate its decision, the agency had convened an international panel of experts to review dozens of published studies. The experts also drew heavily on the Interphone glioma data. The IARC’s ruling basically stated that cellphones could possibly carry some cancer risk, which placed them in the same broad IARC category as coffee and pickles. Nonetheless, the IARC’s classification reignited the global debate about cellphone safety. The New York Times ran an editorial that read, “Cell phone users have every right to be befuddled.”5 The Wall Street Journal published a much harsher editorial that chastised the IARC for promoting a “needless cancer scare” and for “using its public health platform to exaggerate minuscule risks.”6
Just a few months after people had digested the IARC news, two European studies eased fears. The first one, conducted between 2004 and 2008 by the Swiss Tropical and Public Health Institute, focused on approximately 1,000 7- to-19-year-olds living in Denmark, Norway, Sweden, and Switzerland. It compared the cellphone usage of children and teens who had been diagnosed with brain cancer with the cellphone habits of their healthy peers. The second study was sponsored by the Danish government and analyzed the health and phone records from 1990 to 2007 of more than 350,000 adult Danes. It compared brain cancer rates between cellphone subscribers and non-subscribers.
Neither study found a cause-and-effect relationship between cellphone use and brain tumor risk, but both studies attracted considerable attention. The Swiss study was seen as important because children’s skulls are thinner and have more water content in their bone marrow than adults’ skulls. That could theoretically make children more vulnerable to harmful RF exposure, since phone radiation could penetrate deeper into their brains. The Danish study was deemed significant because of its size, relatively long study period, and unique methodology.
Doctors and scientists have criticized some cellphone health studies, including Interphone, for relying on people’s ability to remember their cellphone activity from long ago. Experts warn that “recall bias” can skew a study’s results. The Danish study avoided this problem. Instead of asking people whether they owned cellphones and when they acquired them, researchers pulled phone subscription data—though not usage data—directly from carriers’ billing records. But that study had its own limitations. Because the Danish researchers didn’t interview their study subjects, they knew only whether a person had a cellphone plan; they could not discern how much the person actually used the phone, which is valuable information in any cellphone health study.
There has been a dearth of meaningful research on cellphones and cancer since 2011. Two ongoing studies appear promising because of their size, focus, and methodology. MOBI-KIDS is a companion study to Interphone, with some of the same researchers. MOBI-KIDS is similar to the Swiss study, though larger in scale; researchers have said they plan to recruit as many as 3,000 young people aged 10 to 24 in 16 countries, mostly in Asia and Europe and question them about their past cellphone exposure. About one third of the participants have brain tumors, and the remaining two thirds are healthy. MOBI-KIDS was launched in 2009, and its results are expected to be available in 2015 or 2016.
COSMOS aims to be the most comprehensive cellphone health effect study ever. It is similar to the Danish study but larger in scope. COSMOS plans to follow its participants (aged 18 to 69) for 20 to 30 years. The study, which began in 2010, is monitoring about 300,000 people in five countries: Britain, Denmark, Finland, the Netherlands, and Sweden. Like the Danish study, COSMOS is evaluating its subjects’ behavior in real time, so there should be no recall bias. In contrast to the Danish study, COSMOS consists of volunteers, so it will be able to track more details about its participants’ phone use through questionnaires, phone bills, and health records. COSMOS also addresses perhaps the most common criticism of these kinds of studies—their brevity. Since brain cancer can take as long as four decades to develop, studies can’t be considered authoritative unless they gather information for decades, too.
One caveat with long-term phone health studies is that they must release results on a rolling basis or their conclusions will be outdated. Phone technology advances so quickly that study findings can be irrelevant if they’re more than a few years old. Devra Davis, an outspoken epidemiologist who has made cellphone health risks her leading cause, says the industry’s rapid pace hinders analysis. As she describes in her 2010 book, Disconnect: The Truth About Cell Phone Radiation: “Because cellphone use has grown so fast and technologies change every year, it is as if we are trying to study the car in which we are driving.”7
SAR LEVELS
No health studies have specifically assessed whether smartphone users absorb more or less RF energy overall than those who use basic phones. Lai says newer generations of phones tend to emit less RF energy than older ones, because they are more power-efficient—an encouraging fact for smartphone users. But he also says that the lack of formal studies on the subject makes it difficult to conclude that 3G is “more potent” than 4G. In addition, the frequency bands a network uses, which usually vary from carrier to carrier and from region to region—for example, between the United States and Europe—can also affect the amount of RF energy a phone emits.
When assessing possible RF energy health implications, the most important piece of information is how much emitted energy a user absorbs. Lai says body absorption depends on a number of factors, including the user’s distance from the nearest cellular network base station, since phones emit more RF energy when they have to transmit signals across long distances. Other important factors are the duration of use and the phone’s proximity to the user. On a smartphone, those two factors are likely to temper each other. Smartphone users tend to interact with their phones constantly, but since they’re usually doing things like checking e-mail, browsing websites, and playing with apps, they keep their phones far from their heads. Even people who take a cautionary stance on cellphone radiation don’t consider that type of usage particularly risky. “RF energy decreases exponentially with distance from the body,” explains Lai. Holding a phone two centimeters away from your ear instead of one would cut RF exposure by 75 percent. A person who primarily uses his smartphone for nonvoice applications would still absorb RF energy in his hand(s), but sensitive areas, such as the person’s torso and head, would absorb little.
Consumers don’t need to try tracking all these data points themselves. Smartphone makers calculate an RF exposure number for each of their phone models and disclose that information as a value called “specific absorption rate.” SAR is a measurement of the RF energy that people absorb when they hold actively operating cellphones close to their bodies, and government regulators in each country specify a maximum SAR value for user safety. In the United States the FCC has this responsibility. Its SAR guideline for operation near a user’s head is 1.6 watts (of RF energy) per kilogram or 2.2 pounds (of a person’s body weight), which means a cellphone must have a SAR under that level in order to receive FCC certification and be sold legally in the United States. The iPhone 5S has a SAR of 1.18, the iPhone 5C’s is 1.19, and the iPhone 5’s is 1.25 on AT&T. Samsung’s Galaxy S4 has a SAR of 0.75 to 0.98, depending on the carrier model.
Whether consumers should pay attention to a phone’s SAR and how phone makers, carriers, and retailers should convey SAR information are subjects of considerable debate. Lai says, “common sense suggests” that less RF exposure—as indicated by a lower SAR—is better for consumers’ health.
Phone makers list SAR values in the user safety manuals they package with new phones. They also file this data with the FCC, which in turn makes SAR information available to the public on its website. But people need to know a phone’s FCC ID in order to look up its SAR, and FCC IDs aren’t easily accessible; they are typically stored inside the phone’s battery compartment and/or printed inside the user manual. Consumer advocates say carriers and retailers should clearly display SAR information in stores. They want people to be able to take the value into account when they are shopping. Lai, too, believes providing cellphone/smartphone SAR information to consumers is useful. He says that it is “not a perfect gauge,” but because it “at least gives a general idea of [a user’s RF] exposure,” and is used industrywide, it is the best index of RF energy absorption that currently exists.
The FCC, carriers, and phone makers oppose the idea of prominent SAR labels or signs, saying they represent the maximum amount of radiation phones emit in worst-case scenarios rather than the RF energy a phone generates during normal use. In other words, a higher SAR number doesn’t necessarily mean a greater radiation risk, so people shouldn’t use the SAR level to compare cellphones.
This same basic argument springs up whenever anyone introduces a phone radiation-related consumer rights law. In 2010, California, Maine, and San Francisco separately proposed legislation that would have listed a phone’s SAR value or a radiation warning either on the phone’s packaging or on store displays. CTIA lobbied against all of the bills, and the California and Maine bills never passed. San Francisco’s ordinance did but was never implemented, because CTIA successfully sued to block its rollout. CTIA filed a lawsuit against San Francisco, saying the ordinance would force retailers to make misleading statements about cellphone safety, which would violate their First Amendment right to free speech. San Francisco lawmakers accused the wireless industry of “trivializing the First Amendment” and “quashing the debate about the health effects of cellphone radiation.”8 The fight dragged on for nearly three years, until San Francisco agreed not to enforce the ordinance and CTIA agreed not to ask the city to pay its attorneys’ fees.
In 2011, Oregon and Pennsylvania introduced their own cellphone radiation bills, and in 2012 Representative Dennis Kucinich (D-OH) backed a more extensive federal bill. All three initiatives were ultimately shelved. In 2014, there was another burst of state-level activity in Hawaii and in Maine, which tried, but failed to pass a modified version of the bill that was rejected in 2010.
Some consumer advocates have since shifted their focus from public information campaigns to pushing the FCC to update its cellphone radiation standards. The FCC established its radiation testing rules in 1996 and has not revised them since. These tests usually entail pouring liquid into a plastic mold shaped like a human head and body and torso. Technicians place smartphones near the dummy head and mechanical probes measure how deeply cellphone signals permeate the liquid, which simulates the electrical properties of human tissue. Those measurements are used to calculate a phone’s SAR.
Consumer advocates say the testing methodology has two major flaws: the model for the head is a (theoretical) large, adult male who stands six feet two inches tall and weighs more than 200 pounds. There is no testing model for young people. As Davis, the epidemiologist and activist, wrote in her book, the FCC used “a big-guy brain and body as the basis for all standards for everyone.”9 The second problem: by using liquid as a stand-in for the human brain, cellphone radiation tests erroneously assume people’s brains are uniform in consistency.
Lawmakers have also expressed concern about the adequacy of these tests. In 2011, several members of Congress asked the U.S. Government Accountability Office (GAO), a congressional unit that audits federal programs, to evaluate cellphone health hazards and the FCC’s radiation safety standards. Following a yearlong inquiry, the GAO issued a report that recommended the FCC “formally reassess and, if appropriate, change” its cellphone testing requirements to ensure phones are meeting SAR guidelines “in all possible usage conditions.”10
According to the GAO, one red flag was the way people hold active phones against their bodies, such as when people conduct conversations through Bluetooth headsets while leaving their phones in their pants or shirt pockets. Since the FCC does not ask phone makers to test this type of usage, instead measuring “on the body” RF exposure using smartphone belt clips or holsters, people could be exposing themselves to RF energy above the FCC limit, the GAO said. People are supposed to keep active phones a specified distance—usually a centimeter or two—away from their bodies, but many people don’t realize this. Phone makers bury these specifications in their user safety manuals, which consumers typically discard without reading.
The cancer question will linger—and confuse—people for years. While there is no proof of adverse health effects, respected lab studies have shown cellphones do affect the brain. A 2011 study that placed active cellphones by people’s ears for 50 minutes found participants’ brain activity sped up, even though the phones were silent. This activation manifested as increased metabolism of glucose, a sugar the brain consumes, in the areas nearest the phone’s antenna. The study, which was conducted by the National Institutes of Health, essentially showed that the brain is sensitive to RF energy, but it did not determine whether this sensitivity is detrimental to the user’s health.
Brain cancer’s long incubation period is another reason fears persist. Diagnosis and death rates, both globally and in the United States, have changed little (when adjusted for age) in the three decades cellphones have existed. Brain cancer remains a rare disease. The National Cancer Institute at the National Institutes of Health estimates there will be about 23,000 new diagnoses for all of the United States in 2014. However, cellphones have been popular for only about 20 years, and most health studies have looked only at periods shorter than 10 years. The COSMOS study will fill this gap, but its long-term results won’t be available until after 2030.
Cellphone health studies tend to end with the same cautionary note: “More research is needed.” While even the scientists spearheading cellphone health research admit that this has become a “tired refrain,” they also note it “fully applies in this instance.”11
SMARTPHONE ADDICTION
Cancer scare or no, smartphone users remain attached to their phones. But how much smartphone use is too much? Smartphones have already altered the way people interact with each other. In her 2011 book Alone Together, Massachusetts Institute of Technology professor Sherry Turkle talks about the “world of continual partial attention.”12 It’s what happens when mobile technology invades conversations and meetings, stealing people’s focus away from their partners, friends, colleagues, parents, and children. Global studies have estimated people check their cellphones every six and a half minutes, on average. Assuming a 16-hour day (with an 8-hour break for sleeping), that means people look at their phones 150 times a day. In 2013, the New Yorker satirized this trend in a cartoon depicting a wedding ceremony in which the entire wedding party is preoccupied with their smartphones. Immersed in her phone, the bride mutters to the officiant: “Huh? Oh, yeah—I do.”13
Simply taking away people’s phones isn’t a solution. In 2008, the British market research firm YouGov coined a word for the intense anxiety people feel when separated from their cellphone: nomophobia, referring to the fear (“phobia”) of being without (“no”) our mobile phones (“mo”). And people have been joking for years about the need to use or check their smartphones as a form of addiction.
For many, being without their phones is an experience akin to withdrawal, but the medical community has not formally recognized smartphone or cellphone addiction as its own mental disorder. “It is very difficult to determine at what point mobile phone use becomes an addiction,” wrote a British researcher in a 2013 analysis of cellphone usage among Spanish teenagers published in the British journal Education and Health. “We are not yet in a position to confirm the existence of a serious and persistent psychopathological addictive disorder.”14
Mental health professionals who believe smartphone overuse is its own disorder consider it a problem of impulse control similar to compulsive gambling. Dr. Kimberly Young, a psychologist who has been studying Internet addiction since 1994, deems smartphone addiction a form of that condition, because “the issue is not the device. . . . [I]t is what [people] are doing online.”
Young founded the United States’ first hospital-based treatment center for Internet addiction in 2013 at Bradford Regional Medical Center in northern Pennsylvania, and she defines Internet addiction as “any online-related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones, and one’s work environment. . . . It is a compulsive behavior that completely dominates the addict’s life.”15
To determine whether someone is addicted to the Internet, Young uses a diagnostic questionnaire she created back in the 1990s. Questions include:
• Do you repeatedly make unsuccessful efforts to control, cut back, or stop Internet use?
• Do you jeopardize or risk the loss of a significant relationship, job, educational, or career opportunity because of the Internet?
• Do you use the Internet as a way of escaping from problems or of relieving . . . feelings of helplessness, guilt, anxiety, depression?16
The questionnaire has become one of the world’s most frequently used Internet addiction tests, and Young also uses it to diagnose smartphone addiction. “Other tests and quizzes have been developed to address new [online] trends,” she says, “but I see this as a waste of energy, [because] if a person meets [the Internet addiction test] criteria, they are addicted—it doesn’t matter to what.”
To devise her questionnaire Young adapted the criteria used to identify pathological gambling as outlined in the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the authoritative guide health care providers use to diagnose mental disorders. Internet addiction is not classified as a mental illness in the DSM-IV, which was published in 1994 and updated in 2000. But the manual’s fifth edition, which was published in 2013, does list Internet Gaming Disorder in a special section titled “Emerging Measures and Models,” where it describes the disease as “persistent and recurrent online activity [that] results in clinically significant impairment or distress.”17 In a 2012 CNN interview, Charles O’Brien, a University of Pennsylvania psychiatry professor who chaired the Substance-Related Disorders Work Group for the DSM-5, explained what kind of work would be necessary to get Internet addiction listed in a future DSM: “We would need studies done in multiple sites. People would have to get together and decide on criteria for the diagnosis. There are . . . a significant number of American therapists who are treating cases like this, but they are generally writing up studies as clinical experience. This is not evidence. You have to do careful studies.”18
Although smartphone addiction is not a formally recognized disorder, Young says it is “more problematic” than other forms of Internet addiction, because mobile devices make the Internet easily accessible and are difficult for other people—psychologists, parents, spouses—to monitor. Smartphone-based social media, gaming, online gambling, and texting can all be addictive, she says.
Young has privately treated thousands of people for Internet addiction since the 1990s. She typically meets patients for three months of weekly sessions and uses a three-phase process she developed that combines cognitive behavioral therapy with harm-reduction therapy. Since the Internet is a core part of most people’s daily lives, Young focuses on promoting “moderated and controlled” usage of the Internet rather than total abstinence.19 She says she uses the same treatment method for smartphone addiction, and the Internet addiction inpatient program that she developed for the Bradford Regional Medical Center also follows this method. Patients spend the first three days of that ten-day program without access to any digital devices, then “learn to use technology in responsible ways that add to [their lives].”20
Young is one of the global experts on Internet addiction, but South Koreans, who have a long history of monitoring and treating it, are now leading the way in smartphone-specific addiction research and treatment. Korea was the first country to open a national Internet addiction treatment center, in 2002, and it now spends about $10 million a year running a nationwide network of treatment centers. The dangers of Internet addiction were plainly apparent in some recent Korean events. In 2009, a Korean couple let their three-month-old baby starve to death because they were immersed in an online 3D fantasy role-playing game. Around the same time, two young Korean men separately killed their mothers after they criticized them for online game playing. People have died after multiday Internet gaming marathons—in China and Taiwan, as well as in Korea. In 2011, Korea instituted a shutdown law that locks people younger than 16 years old out of gaming websites from midnight to 6:00 A.M. to discourage minors from indulging in online gaming binges.
Though smartphone addiction has yet to produce such extreme results—and may never—Koreans are some of the world’s most enthusiastic smartphone users, and the country’s leaders appear more concerned about smartphone addiction than those of other countries. Korean government agencies regularly conduct studies and surveys on the issue and in 2013, Korean media quoted government officials saying, “Children’s addiction to the Internet and smartphones is becoming serious,”21 and “We felt an urgent need to make a sweeping effort to tackle the growing danger of online addiction . . . especially given the popularity of smart devices.”22
Korean doctors have defined smartphone addiction as users’ unwanted reliance on the devices, and they say it “manifests tolerance, withdrawal symptoms, and dependence, accompanied by social problems.”23 In 2013, the Korean government reported that more than 18 percent of Korean teenagers were addicted to their smartphones, up from 11 percent in 2012. The percentage of afflicted Korean adults also increased year over year, from about 7 percent in 2012 to around 9 percent in 2013. One government survey, which polled students in the fourth, seventh, and tenth grades, found that the number of students who exhibited signs of smartphone addiction was more than twice the number of students who appeared at risk of Internet addiction. Another 2013 Korean government report said smartphone addicts spend seven hours a day browsing the Web, playing games, and sending messages—almost twice the amount of time average users spent on the same activities. Korean research found that online messaging apps are most responsible for keeping “addicts” glued to their phones, followed by mobile games.
The Korean government is particularly worried about smartphones’ effects on young people, their educations, and their futures. Korean doctors have reported rising rates of “digital dementia”24 in teenagers and blamed the overuse of smartphones and other technologies for hindering young people’s brain development, including their ability to recall information. In May 2013, one in three Korean middle- and high-school students admitted that excessive smartphone use had caused their grades to fall. A similar percentage said they had tried to cut down their smartphone usage but failed. Almost half of the surveyed students said they could not live without their smartphones.
In 2013, the Korean government said it would require schools to teach students as young as three how to limit gadget use and Internet time. “Young people’s smartphone use has increased rapidly in recent years and, truthfully speaking, the government’s response has been insufficient,” explains Hwang Tae-hee, a representative of Korea’s Ministry of Gender Equality and Family. Hwang says the government was partly held back by the lack of smartphone-specific addiction research, so her agency, which helps run Korea’s Internet addiction program, is surveying young people about their smartphone use and will use the data to develop a counseling manual.
With support from the Korean Ministry of Health and Welfare, Korean researchers also modified and expanded Young’s questionnaire to create the world’s first smartphone addiction scale (SAS). The diagnostic test consists of 33 statements, including:
• I feel impatient and fretful when I am not holding my smartphone.
• I feel that my relationships with my smartphone buddies are more intimate than my relationships with my real-life friends.
• I have tried time and again to shorten my smartphone [usage] time, but [keep] failing.25
Responses range from “strongly disagree” to “strongly agree” and are graded on a point basis. The researchers hope the creation of an SAS will “serve as an opening for the clinical diagnosis of smartphone addiction.”26
The Developing World
Manu Prakash wasn’t expecting to be shocked when he dropped by a rural clinic during a vacation to central India. Prakash was born in India, and he attended college there before moving to the United States to pursue a master’s degree in applied physics at MIT. But Prakash was surprised when a medical student in the village of Sevagram told him about the area’s high rate of oral cancer.27 And he was shaken when the student showed him images of the untreatable lesions inside these patients’ mouths. It was too late to save the majority of the patients.
Oral cancer is the most prevalent cancer among Indian men, primarily due to the consumption of cheap chewing tobacco. If oral cancer is diagnosed early, patients have an 80 percent to 90 percent survival rate. If it is discovered in its late stages, the morbidity rate is high. Dentists can identify oral cancer lesions, but Prakash says that rural areas in India typically have only one dentist for every 250,000 people. The dearth of high-quality, standardized medical imaging in rural India further hampers treatment. Lacking funds for imaging machines, health workers may resort to sketching diagrams of their patients’ mouths by hand to document their conditions.
Prakash returned to the United States determined to invent an inexpensive gadget that could detect oral cancer early enough for effective treatment. He started building a prototype in 2011 after moving to Stanford University to teach bioengineering. Called OScan, for oral scanner, the system consists of a mobile app, a circuit board with two rows of fluorescent light–emitting diodes (LED), plastic housing that fits over the circuit board, and a plastic mouthpiece with a mechanical track that connects to the housing. A health worker could check a patient for oral cancer by placing the mouthpiece in the person’s mouth and snapping a few photos. The LEDs illuminate the patient’s oral cavity and expose any lesions while the track enables the worker to move the smartphone/camera steadily and collect a standardized set of images. The OScan app would then upload the images straight from the phone to a cloud-hosted database, enabling doctors in nearby cities to view the images on a separate, password-protected website and screen for oral diseases. (Images can also be saved and uploaded later, if workers lack access to a stable Wi-Fi or data connection.) James Clements, an engineer who worked on OScan as a Stanford graduate student, says a trained worker can take the necessary photos in less than two minutes and the device will work with most camera-enabled Android phones, would cost only about $5 in terms of materials, and can be sterilized after each use so that it can perform hundreds of scans before the mouthpiece needs replacing. Though OScan is still in development at Stanford, Clements says some small, preliminary clinical studies are planned for the United States and in India.
OScan represents one way smartphones can revolutionize health care in the developing world. A few other researchers are also enabling small rural clinics to engage in telemedicine, i.e., health care over long distances via computers, phones, and the Internet. Harvard Medical School researchers have paired iPhones with a $4.99 video camera app and a commonly used ophthalmic lens to capture high-quality images of patients’ retinas for the diagnosis of eye diseases. Compared to the cameras that ophthalmologists normally use, which cost tens of thousands of dollars, the iPhone setup is “relatively simple to master, relatively inexpensive, and can take advantage of the expanding mobile-telephone networks for telemedicine,” the researchers wrote in the Journal of Ophthalmology.28 Australian medical students have created a low-cost, easy-to-use, smartphone-based system that can detect pneumonia. The system, which consists of an Android and Windows Phone app called StethoCloud and a digital StethoMic stethoscope that plugs into the phone’s audio jack, records a patient’s breathing, performs basic offline analysis on the patient’s respiratory rate, and then uploads the data to the cloud for deeper analysis.
Smartphones are also helping health workers access medical guidelines for rapidly and accurately assessing patients. Health workers in Malawi’s southern districts Blantyre and Chikwawa are using Android phones to evaluate children who have meningitis. With support from the Britain-based Meningitis Research Foundation, five health centers in Blantyre and two in Chikwawa have deployed an app that lists the World Health Organization’s Emergency Triage Assessment and Treatment protocol for meningitis. Health workers consult the app when sick children are brought in to the centers to help them decide which children need to see a doctor immediately, which get priority to see a doctor soon, and which can wait. The app also generates an ID number that can be used to track children who are sent to hospitals, to ensure that they receive proper care. D-tree International, the Massachusetts-based health nonprofit that created the app, says more than 120,000 cases have been logged through the app since it was released in December 2012.
In these circumstances, smartphones can be lifesavers. “Smartphones have great potential for more advanced, two-way types of communications and for health professionals who are engaging with different populations in real time,” says Julie Pohlig, chief strategist at the California-based Vital Wave Consulting, which focuses on emerging markets. “In health care it can be highly advantageous to have the advanced cameras and video and diagnostic tools that are available on smartphones.”
International aid and development organizations started using PDAs and cellphones in their outreach projects as early as the 1990s. Joel Selanikio was one of the first epidemiologists to experiment with mobile devices. “Back in 1995, I was a young outbreak investigator for the CDC [the U.S. Centers for Disease Control and Prevention], and exploring the use of things like the Apple Newton, and later the Palm PDAs, for data collection,” he recalls. “Not much was being done at the time, but we used [Palm OS] software . . . to put forms on PDAs.”
In 2001, the charity Save the Children deployed handheld computers loaded with Microsoft’s Pocket PC software to survey remote Nicaraguan communities about nutrition and other topics. Collecting health-related data on PDAs was faster and more accurate than paper records, but obtaining and maintaining the devices in developing countries was challenging. As Selanikio wrote in a 2013 blog post: “Unfortunately, PDAs were aimed at the rich world market of businesspeople and other professionals [and] in order to use them for a health survey in Namibia, for example, the difficult and expensive burden of getting them to Namibia was placed squarely on the shoulders of the global health system. . . . This was too heavy a burden to bear: the PDA-based data collection activities typically collapsed after just a few years.”29
The other drawback to using handheld computers for international development work at that time was the inability to transmit data from the field. As a 2001 Reuters article explained, when Save the Children wanted to upload data from its Nicaraguan aid workers to its network, the charity had to “whisk” the devices “by motorcycle through the jungle” to its offices.30
Though the PDA projects flopped, cellphones later became a mainstay of development work, because governments and development organizations didn’t need to import them and data could be uploaded and downloaded in the field, since networks had improved. Today there are mobile health programs that provide health care over phones, mobile money programs that give the poor access to financial services via their phones, mobile agriculture programs that connect farmers to useful information through their phones, and mobile education programs that teach people skills, such as English, over their phones.
Many of these projects assist people who live on less than $2 a day. Some outreach projects donate phones to poor communities, while others rely on local people to use their own. Since few people in those communities own smartphones, the latter type of project usually focuses on basic cellphones. The GSMA estimates that only 8 percent of people in the developing world own smartphones, and that figure dips lower in rural areas, where network coverage issues, battery life, and literacy barriers—both reading and technological literacy—further limit their adoption. Smartphone ownership in rural Africa, for example, is estimated to be about 1 percent.
Yet as technology advances, development organizations are keeping pace by investing in smartphones and apps. Experts say smartphone outreach projects can offer greater gains than basic phone projects if they are carefully planned and executed. “Smartphones have a higher cost but also offer higher opportunity,” says Patricia Mechael, the executive director of the mHealth Alliance, a Washington, D.C.–based nonprofit that aims to advance mobile health technology globally. “Health outcomes can be greater with smartphones, as can [data] efficiencies.”
Picking up where the PDA projects failed, one of the most effective ways smartphones are being deployed for public good is the collection and transmittal of public health data via Android-based apps. Smartphones are a natural choice for these tasks, because they enable workers to record, analyze, and share data more easily than paper records. Laptops and tablets offer similar capabilities, but they are bulkier and more expensive.
SEND-Ghana, an Accra-based NGO, says smartphone-based surveys are helping it reduce health care inequality. To achieve this goal, SEND closely monitors the National Health Insurance Scheme (NHIS), a program the Ghanaian government established in 2003 to provide universal health coverage to its citizens.31 In 2011, SEND recruited hundreds of volunteers to interview residents of Ghana’s 50 poorest districts about their ability to access NHIS services. The group provided its volunteers with Samsung Android phones to record interview responses in a custom-made survey app. The smartphones yielded more accurate data and enabled faster reporting than previous methods. Analysis was quicker, too, because the smartphone data could be directly exported to spreadsheet software for study. After joining forces with other NGOs, SEND was able to use that information to successfully lobby the Ghanaian government to improve access to NHIS services.32
Smartphone-based development projects have gotten a boost from software tools that let organizations create their own, locally relevant apps without having to construct and maintain the infrastructure and back-end support systems necessary to collect, store, and analyze masses of data. A Ghanaian developer built the SEND app using free, open-source Android software called Open Data Kit Collect, which is partly financed by Google and maintained by researchers at the University of Washington in Seattle. Other global development organizations have written apps based on software from Akvo, a Dutch nonprofit, and DataDyne, a Washington, D.C.–based social enterprise run by Selanikio, the trailblazing epidemiologist, technologist, and social entrepreneur. Workers and volunteers in Africa and other regions are using these apps to conduct field surveys, audit health facilities, and gather information about water and sanitation conditions.