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Livia Bellina   Medical Doctor, Pathologist Livia Bellina ( born 25 August 1954) is an italian medical doctor pathologist, educator. Livia founded the MobileDiagnosis, a Not for Profit Association and pioneered the concepts of global access to health- care and medical education by m-phone technology and invented a new solution for training work forces in rural areas of developing countries.

Short Bio- Background-

2008, February -working as a pathologist on the Italian Island of Lampedusa, she found herself in the urgent need to confirm a diagnosis of malaria from a blood sample of an African immigrant. With no other means at hand,she took a picture of the microscopic field using the camera incorporated in mobile-phone, without additional devices, and sent it via MMS for tele-diagnostic purposes to a reference center. MobileDiagnosis was born.

2008-April-the described method has been filed for patent with the sole purpose to protect the idea from commercialization and consent its free use and dissemination(EPO application number 09005054.3 2002 - 2008 April).

2009- February -Meeting Eduardo Missoni at congress of the Italian Society for Migration Medicine(SIMM) (Trapani, February 2009) and starting the fruitfull collaboration.

2009-June – The work about low cost diagnostic image transmission (Bellina and Missoni) was published in Diagnostic Pathology (an Open Access Journal) Bellina, L., Missoni, E., Mobile cell-phones (M-phones) in telemicroscopy: increasing connectivity of isolated laboratories, Diagnostic Pathology, 2009, 4: 19 �

2009- with Eduardo Missoni she developed since 2009 the website �http://www.mobilediagnosis.net � 2010- In 2010 founded MobileDiagnosis® Onlus Association with Vincenzo e Giorgio Prestigiacomo, her sons, and Eduardo Missoni. MobileDiagnosis® Non Profit is an association aimed at sharing knowledge and providing diagnostic support to health workers worldwide, by using mobile phone technology. The association also provides educational support and guidance on the use of mobile technology, mainly for resource limited and rural settings. MobileDiagnosis® association is composed of a creative team of young professionals in web design, engineers, project specialists and other professionals. The team works to increase the visibility of Mobile Diagnosis, and to create opportunities for the development of new educational methods such as long distance training, learning, and to keep users up-to-date on diagnosis issues. 2011- MobileDiagnosis have been recognized by Government as Non Profit Association

2012-Rotary conferred to her the Rosario La duca Award, for humanitarian efforts.

2013-MobileDiagnosis-Livia started a collaboration with Yunus Center AIT in Bangkok for expanding the activities in SEA

She attended to several courses about poverty medicine including: �Advanced Course in “Basic laboratory for tropical disease and health cooperation”, at Verona Negrar Hospital (director Dr. Zeno Bisoffi)( October 2008 ) �Advanced Course in “Tropical Medicine and Health Cooperation” (4 months), at Florence Careggi University (director Pro f. Alessandro Bartoloni) (March-June 2009 ) �Course in “Management of transmissible disease in sub saharianan Africa”, at Pemba (Zanzibar) Public Health laboratory, supported by De Carneri Foundation. (July-August 2010). �Master of Medicine of Poverty Marginalizationion and Migration 5° MEMP of Caritas –Rome Idente Foundation- Verona Negrar � - for improve her skills for teaching to low-resource health-workers of poorest communities After that she went to teaching as volunteer medical consultant and "on the job" teacher in rural communities of some of the poorest countries: Uganda (Gulu, 2009) Bangladesh (Bhuapur, 2010) upon invitation of Professor Muhammad Yunus, Bangladesh with PIME (Dinajpur, 2011) and Afghanistan (Herat, 2011). In 2012 February she went to Madagascar to find the best area for future projects, September-November in DRC, where done education at local level, improved local health workers of St Francis Hospital . In 2013 she went to work in Thailand- in refugee champs bordering Mynmar and in DRC for the second time- In less of 5 years she trained more of 100 people 2011 after an extraordinary experience with local rural living woman in Afghanistan. where she went for working as supervisor of Medical Laboratory of Children’s –Government Hospital of Herat, for training local health workers ,she done a study published together Eduardo

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Missoni, on health access for vulnerable subjects (Bellina, L,.Missoni, E. Mobile Diagnosis: Bridging Sociocultural Gaps and Empowering Women “Telemedicine and e-Health November 2011, 17(9): 750-750. doi:10.1089/tmj.2011.9976. http://www.liebertonline.com/doi/abs/10.1089/tmj.2011.9976) and started to explore the mechanism of m-learning, introducing a new communication method,and focusing the actions on the field mainly on local education. Her goal is the worldwide promotion of MobileDiagnosis® methodology for promoting the global access to health care and education

by the use of a mobile-phone for taking and transmitting diagnostic images – (m-health and m-edu) and educate, and on the real time

control and management of diseases-

The main activities of MobileDiagnosis -Sharing-Training-Connecting-Networking MobileDiagnosis works with three main mechanisms

1-Sharing -MobileDiagnosis- the new-original tool for a simple, low cost telepathlogy-telemedicine : how take and transmit image with a simple mobile and a MMS

2-The new orginal method for educate low skill and illiterate people

3-Creating a network for help rural low-resource work forces

4-(ongoing) working to a new open access educative web based platform and an ITC linked network for an education in remote

Sharing images

The Idea

Mobile phones can be easily used without any adapting device to take pictures of the microscopic field and send them for remote reference.

     

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                                                                                                                                                                                                                   Technical note : MobileDiagnosis® is based on the simple concept of using a mobile phones (m-phones) to capture clinically relevant images at the point of service (the nearest as possible to the patient's home) and send them via Multimedia Messaging Service (MMS) to a distant reference center for confirmation of diagnosis, second opinion and advice. The possibility to both capturing and sending images taken from the microscope, and by extension from any optical eyepiece of other medical devices (enteroscope, colposcope, etc.), with an MMS via the mobile cell- phone network represents an enormous breakthrough in terms of ease and access, given the penetration of the mobile network and transmission costs, in comparison to the landline broadband network or satellite connection on which the internet needs to rely. The ability to do this without recurring to additional complex and expensive devices represent an enormous comparative advantage with respect to other known solutions. While the initial experience was based on images taken just with the in- built camera of an m-phone from an optical device (microscope), preliminary testing shows that in several other situations the use of m- phone in bio-medical imaging represents an effective and cheap methodology in order to make a correct and timely diagnosis. In order to contribute to achieve a universal access to appropriate health care in low resource countries and most remote areas, the project intends to apply MobileDiagnosis methodology on a wider scale, by introducing and disseminating the use of m-phone based tele-diagnosis and health workers training. This would be accomplished by associating the local use of m-phone based diagnosis and training with an adequate review of how information flows through local and national health systems, as well as by taking advantage of a global expertise network made available through ad hoc agreements. An unconventional / creative approach to quality health care Traditionally, the access to specialized diagnostics was limited to population groups belonging to higher social classes, because of costs and concentration of specialized care in major urban centers. �The MobileDiagnosis methodology will allow public access to world class quality diagnostics for a large number of conditions, to everybody irrespective of the patients' economic capacity or distance from specialized health centers. Significant improvement will be possible thanks to three work- innovation (or introductions – or also changes ). One is the ease, after a specific training , of taking and sending picture using a very common tool - the m-phone – “as it is”, i.e. without recurring to any additional device. The second change is the use of the m-phone as an educational tool which may empower health-workers and caregivers at every level, even at family and community level, to interact directly with the near referent of care. The use of simple, relatively cheap m-phones for directly capturing images and sending them via MMS for tele-diagnosis represents a breakthrough in terms of appropriate use of technology (ease, accessibility, affordability) as compared with previously described and used telemicroscopy and other tele-diagnostic approaches, including both those based on complex photographic equipment using computers and broad band data-transmission network, and those based on tricky and still comparatively expensive, thus inappropriate, ad hoc cell-phone-connectable microscopes. M-phones are nowadays available, affordable and commonly used in the most remote and poor areas of the world. Not everybody owns one, but hardly any community lacks one. Thus, using the use of m-phone for diagnostic purposes bears a negligible cost. The use of m-phones as an educational tool represents a relevant change.

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Independently from the connectivity aspects, the possibility to share images on the m-phone screen and discuss them in a group, as well as comparing them with reference images in collections in print (atlases) or uploaded in the same m- phones, facilitates participatory learning and reduces learning times as compared with traditional teaching methods. Literally anybody can quickly learn how to take an image from a microscope or other device. The third change relates to increased connectivity: to exploit the full potential of the adoption of MobileDiagnosis, the methodology facilitates the information flow in the health system. Through appropriate community based training, people “where there is no doctor” may be empowered to deal locally with a number of pathologic conditions by resorting to distant advice. Health workers (MDWorkers) in remote duty stations can receive distant training and support in their daily work. Diagnostic confirmation of diagnosis based on microscopy can become almost immediate and epidemiological surveillance more accurate. As a result of mentioned improvements, transferral of patients for diagnostic purposes and related costs can be reduced. Social Business for improving local income and economy –a future development The innovative side of this project, it his particular caracteristic, respect to any of the other projects, is that this project is not looking for external funders but it same will generate a gain thanks to a local mechanism of Social Business All local MDWorkers (local MD referent and MD operating work forces) after an adeguate training will become local referent for Community and will provide diagnose for the local mainly present diseases (water-born diseases, soil-transmitted worms diseases , and finally some mosquito transmitted-diseases as malaria ). The local, rural referents , named MDWorkers, will receive a gain for each diagnosis done , and this new opportunity will produce a local improvement of income This local job opportunity generated by will generate a local money flux and a local sustainibility of project -work . Free from external funders or donors . Finally, an opinion by a specialist obtained through national or transnational networking may represent a decisive asset in even more difficult cases which may not find a solution at the highest complexity level in a given country. The innovative methodology will ignite a review of traditional information flow, both nationally and internationally, including integrating a solidarity based alert system that can make world class expertise available (at very low cost and ideally for free) 24/24, 7/7. * Investments in mobile-health technology and associated process improvements have the potential to improve the efficiency of health care delivery – enabling improved access to specialty care, a continuing challenge in remote rural communities by acting in a capillary way, bringing the care to the isolated, poor communities . Instead of having a patient trip to see a specialist or vice versa, the specialist sees the patient sample using MobileDiagnosis®, the m-phone based technology. This has considerable potential to reduce travel associated with serving remote rural populations and to extend the reach of a specialist to isolated, poor and underserved populations, and to educate low skill local workforces . We focus on the use of mobile “store and forward” (analogous to e-mail with attached images and data) communications technology to transfer patient information via rural md worker to the referent specialist Store and forward systems provide specialists with attractive opportunities for improve local wellness by creating a job opportunity through a mechanism of Social Business, for otaine a twin goals :reduce costs and improve local incom

Educating with a new, original method The new orginal method for educate low skill and illiterate people

Sharing images by m-phone, together with a two- phase educational method, (phase of relation, with a personal approach to the student, and phase of contextualization, with an approach to local community problems)combined with the use of logical didactic tables, proved to be a phenomenal learning tool, immediately linked to students’ personal perceptions.

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Technical note:

A two-phase approach training (see below) was performed by using structured interviews, didactic tables, m-phones and computers as

didactic tools The two-phase approach.

Phase of relation: the lesson starts with a personal survey handed out to the students: they are requested to answer to questions which

are related to their personal goals, dreams, and personality, focusing on their cognitions, emotions, motivations, behaviours in a variety of

situations. In this phase, the survey is detached from an objective context: students’experiences could virtually be the same everywhere in

the world, being not involved with the local environment

Phase of contextualization: in this second phase, the survey has undertaken the task of deeply analyzing the students’ problems,

concerns and fears which are all linked to their local context

Students are called to answer to several personal questions pertaining to their concerns, fears, the attitude towards health and diseases in their communities, their history as healthy or sick people, their positive or negative experiences and feedback about health care in the local context, their past experiences related to people close to them. At this point, from a personal (universal) context, the students get through a local scenario. Once they are led to the core of their everyday world, the teacher shows how to use the logic to solve their problems with “local remediation kind of” solutions which are familiar.

Use of didactic tables: in this phase the teacher explains with the aid of didactic tables, based on logic and algorithms, and shows how to seek and find all the possible solutions leading to the diagnosis and the management of local diseases. All of the surveys, discussions, meetings, conferences, practical and spoken lessons are focused on local specific concerns and on possible applicable solutions. The topics of the lessons differ from place to place, thus each course is different from the others, because the scenario does change each time. This locally contextualized approach creates a personalization of learning and teaching and produces a strong relationship between trainers and trained, brought in by a condition of complete mutual trust and of feeling comfortable about an easy/practical known action that the students will be capable to handle.

Use of m-phone as didactic tool: in the following lessons, students are quickly shown thousands of images about daily specific lesson topics - i.e. microscope images of malaria positive slides, in the lesson about malaria (learning objective) as well as entero-parasytes, lesson about parasytes) etc -(100-200 images were shown , for a total amount of approximately 30 images per minute, from teacher’s personal data-base) and, just immediately after, without any spoken activities in between, students are asked to recognize the object of the lesson at a real microscope application. In the most recent experience (DRC- October-November 2013) students with different backgrounds and education were asked to identify the main differences between this method and the traditional courses.

As a result, each of them immediately recognizes the “object” in the microscope field. It is then shown how to use the m-phone to take pictures of the microscope field At the end of the lesson, the students are immediately capable to recognize, capture and compare their “objects” with their peers, with the aid of comparative tables or of a remote teacher/colleague/higher reference center. This way, theory becomes an object to be shared.

M-phone impact on practical training: role of m-phone as part of the educative method for training local health workers of rural areas of developing countries-Health and Technology-Springer in press ( DOI: 10.1007/s12553-013-0073-4)

Connecting -Creating a network thanks to m-phone and satellite internet connection for help rural low-resource work forces, also

in the most isolated, underserved areas

The Partnership Scenario: �Global-Local Partnership and Sustainability of the Project.

MobileDiagnosis®works in partnership with local NGOs, by creating a network of local rural health-education posts, linked together and connected to the web platform of MobileDiagnosis- MEDTING - The web platform will share data, images and texts for education and will store the images for creating of a central database for educational and distance-schooling

Tecnical note-MobileDiagnosis methodology is based on the use of mobile phone and mobile connectivity to improve diagnostic quality at the point of service in rural or otherwise remote and disadvantaged settings, thus contributing to better quality of care.

�The m-phone is used both as an educational tool (training health-workers at both health units and community level) as well as tele-diagnostic mean. The full application of MobileDiagnosis methodology includes the redesign of health systems' information flows and reassignment of expert staff in order to assure dedicated distant diagnostic support and advice to remote health units.

The project uses an incremental approach to enabling of health units and training. �The initial interventions will be focused on a limited number of health centers with adequate technical characteristics, medical and laboratory equipment and staffing (traditional lab and

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medical equipment are not provided through the project and their adequacy is a prerequisite for the health units to be included in the project). In those health units health workers will be trained applying MobileDiagnosis training methodology. Training will initially be based on pictures from the microscope and other optical devices

At the same time the existing information flow will be analyzed and redesigned to adapt to m-phone generated information and appropriate feed-back. �A reference center will be identified and assigned staff trained to respond to the requirements of the MobileDiagnosis system (lab and medical equipment, as well as staffing of the reference centre are not provided through the project and their adequacy is a prerequisite for staff training and activation of the Reference center. The Reference Center does not need to be a single physical unit, but must be identified as a defined function. Staff could also be located in different centres (and including at home) as long as they are equipped with computers adequately connected to the internet.

In the following years, the best among trained health workers, will teach to other health workers under the supervision of the chief trainer progressively including all health workers in rural areas. �Results will be regularly monitored and shared widely.

The future of the project- thanks to the satellite-internet and local ITC-provides to creating : -An Open-source training centre, with an images library and an interactive school, to which will be possible to access from the educational page of MobileDiagnosis® site. http://www.mobilediagnosis.net -A Global Referents network – composed by all high-skill excellence specialists operating thanks a mechanism of time banking Tecnical note

This proposal focuses on the first phase: implementation in one Health area (province, district, etc. ) with one reference centre (this could be the core of a future national reference centre). �A second phase is foreseen to consolidate results of the first project area and extend implementation to other health areas in the country. At the same time the transnational network (TN) will be developed.The TN is based on shared knowledge and distant highly qualified support to the national reference centre. The network will be based on a system of accreditation of high level individual experts and or institutions available to provide expert time for free (as part of a social responsibility program). Experts may indicate number and weekly distribution of hours in which they make themselves available to the network. During that time the system will automatically forward them the cases that the national reference centre identifies as requiring second opinion and advice. Their evaluation is then automatically re-conveyed to the Reference Centre, which, in turn will decide the advise to forward the guidance to the originating health unit (eventually translating into local language). Besides technical aspects, this second phase will take into account legal and procedural aspects related to diagnostic and therapeutic liability. Progressive extension of MobileDiagnosis to more countries will require to parallel an increasing number of experts and of a global network of collaborating centers.

Our referents of excellence Jeff Van den Ende Institute of Tropical Medicine Clinical Sciences Antwerp. Francois Nosten, University of Oxford, Nuffield Department of Clinical Medicine, Thailand, Infectious Diseases.

Zeno Bisoffi president of italian society of tropical medicine-Director of Tropical Disease-Verona Negrar Sacro Cuore Centre for Tropical Diseases, Sacro Cuore Hospital of Negrar - Federation of European Societies for Tropical Medicine and International Health

Eduardo Missoni Global Health founder the OISG, has been member of WHO, MAE, world secretary Scout Movement and co-founder of MobileDiagnosis

Alessandro Bartoloni general secretary of italian society of tropical medicine- Director of Department of Infectivology and Tropical medicine Florence Careggi

Marianne Stronhmeyer Professor at-Tropical medicine Florence Careggi

Luigi Gradoni Professor at Istituto Superiore di Sanità, Department of Infectious, Parasitic and Immune-mediated Diseases, Italy, Infectious Diseases

Lawrence B. Faulkner Medical Coordinator Cure2Children Foundation

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MobileDiagnosis -How it works

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The Activities: �1. In developing countries: training local work forces

Creating a local "school” for the health education and training of local rural communities – health workers and non health workers (community representatives). Establishing or strengthening health centers for basic screenings , focused on parasitic diseases, neglected diseases, mother and child care, community health care, etc., and link them with the schools

2. In developed countries: training of trainers

Creating a new generation of trainers by activating courses of MobileDiagnosis and a central referent “office” with high skilled consultants and an open-source training centre, with an images library and an interactive school.

3. Planning a global course of MobileDiagnosis®, equitable care and affordable care, sustainable technologies.

The Project

Creation of a knowledge-centers network based on locally available and not expensive affordable resources and poor technology, and the improving of local health workers that, thanks to a domino effect will improve new health workers. It is operating on three levels:

1) Local level, using the mobile as didactic tool, to educate by showing and comparing the images.

2) National level, thanks to a "mobile to mobile" or “mobile to web” network.

�3) Global level by a network linked to a web technology platform, thanks to collaboration with Medting started in 2011.

This system is operating locally-globally, and contributes to accelerate the Global Health care provision, distance consulting and education, by connecting the “fragile” subjects, especially in the hard contexts (war, migrations, sex discrimination, cast, clan, family) to a solidarity network of highly skilled specialists and to knowledge centers. http://medting.com

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