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"I'm not going to be better than these nurses. What can I do to help these nurses do their job better?"
🌍 Global Perspectives on Digital Health
A podcast unpacking the stories, insights, and innovation shaping health systems and underserved communities.
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Joshua Bress (00:00)
And for people who've ever been to Goma, Goma has like an amazing combination of French Swahili. So there's like expressions like Hakuna problem, you know, no problem. So I met these nurses and I was just like blown away by their commitment. I'll just give the listeners like an example of this commitment, like not uncommonly adopted abandoned children.
Shubhanan Upadhyay (00:10)
That is cool, Hakuna problem nice.
Joshua Bress (00:25)
Okay, that's the level of commitment that these NICU nurses, these neonatal nurses had. So when I came there, I was like, this is not resource constrained. This is an amazing resource. These nurses are just like an amazing source of energy and commitment and passion. And that began like this journey of like, okay, well, I'm not going to be better than these nurses. What can I do to help these nurses do their job better? What can I do to take the best nurse and get them to help other people?
in other settings and other sites. And I will say that as a doctor at this Congolese hospital, I often described it in terms of neonatal medicine as being under the waterfall, like in neonatal mortality. So if you think of like, there's upstream, people always say we need to go upstream. I was like down, down, downstream, getting crushed with acute neonatal cases that are being transferred in extremis, near near death from other hospitals.
So there became this need to say, we got to go upstream or at least like out from under this waterfall. Let's go find the sites that have struggles with neonatal care and train them. That was the beginning of what led to the Novi Guide.
Shubhanan Upadhyay (01:32)
today on Global Perspectives on Digital Health, we have an exploration of arguably, universally, the most underserved.
vulnerable cohort of people that exist.
wherever they are in the world. I'm talking about neonates, your first days, your first hours of life. And when we talk about low resource settings, neonatal mortality has been a difficult problem and challenge to solve, especially
in settings where there are no doctors, there are very limited access to medications.
And so today we're talking to Dr. Josh Bress.
Josh is a a special type of pediatric doctor specializing in these first hours and days of life. And that's called neonatology. we're talking about a digital tool that he has built with his team that has been implemented across many parts of Africa, sometimes in the most difficult or low resource settings So we're hear his story around what it took to build this.
and implement this in these settings. The challenges around building trust and value locally versus scaling and how you apply guidelines in different settings when the context is very different and certain guidelines just might not apply. And some of his challenges and how he's grown things like dealing with rejection,
how to motivate yourself when you're working in a difficult space. And so I'm really, really excited to talk to a fellow clinician and an innovator who has wrestled with a lot of challenges that you might be going through. So let's hear what he has to say.
This is the podcast about people who care about impact in the last mile of healthcare in low resource settings We focus on innovators, implementers, policy, research, funding So our listeners and our guests are across this spectrum.
discussing the challenges, the successes and what it takes to really create true impact for those who need it most. So have a listen, share this with people who you think will find this useful and let's get into this topic.
Shubhanan Upadhyay (03:47)
Josh, welcome to Global Perspectives on Digital Health. What a pleasure it is to have you on the show, welcome.
Joshua Bress (03:54)
Thank you so much. It's a pleasure to be here and I'm a big fan of the podcast.
Shubhanan Upadhyay (03:57)
Thank you.
Tell us a bit about you and your journey. It's really fascinating.
Joshua Bress (04:02)
Sure, I'll tell you little bit about myself. So my name is Joshua Bress. I'm a physician, a pediatrician who specializes in the care of newborns. And I also lead a global nonprofit called Global Strategies. And there I work on a digital project, which brings us together today called NoviGuide A lot of my formative experiences in global health came from time I spent in the Eastern Congo, which ⁓ really shaped what came next for me. So maybe that's a little bit of a lead in.
Shubhanan Upadhyay (04:29)
Yeah, nice. tell us. So in the lead into this, I talked about neonates and your medical specialty as being the most vulnerable people out there, The most vulnerable tiny people out there. Can you tell us about why this group of people, this group of patients,
⁓ is different to others.
Joshua Bress (04:53)
Yes, I I spend my whole life with babies. And as somebody who meets other people in other medical specialties, I'm like, why did you choose not to work with babies? They are some of the most adorable people in the world. And they're also some of the strongest patients in the world. So you said they're vulnerable and they're vulnerable in certain ways, but they're also strong in certain ways. And one of the ways in which they're strong is that they respond to what medical teams do. ⁓ I'll give you an example.
a baby comes out, has trouble breathing, the team gets the baby breathing, within an hour that child may be feeding. It's unimaginable in an adult patient. So for me, one of the things that drew me to newborns was actually their strength. babies and I'm sure we're gonna get into this, but babies are different, okay? And they're different in ways that some people listening to the podcast can probably imagine, right? Like they're physically smaller. They can't talk to you. They eat only one thing.
There are different aspects of babies that are unique. But for me, I'll give you a couple other things that people maybe don't think of as unique to babies. I would say something that's very unique to babies is that they grow. And they grow so rapidly that even during a single hospitalization, they may grow two or three times their size, even four or five times their size before going home for the smallest preterm babies. From the digital side,
Babies don't have medical records, babies don't have names or IDs, like the things that you're gonna need to think about from a digital perspective. From my side, babies are an emergency that can happen anywhere. So every site needs to be prepared for a baby just walking in, whereas other emergencies are gonna get filtered through referral systems. Babies, you know, hopefully are born near where the parents live. So there's so many unique aspects to this. another thing to mention I should say is the connection to the mother.
the mother's story and its influence on the newborn. So you have two people connected together, ⁓ child, new person enters the world without a medical record who can grow rapidly. These are the things I think about from the digital side as we do our work. The next thing I'll mention for global health is just the babies are the poster child for child mortality. If you think in the audience, imagine a low resource setting and a child.
doesn't survive and picture that child. That child is a preterm baby. That's by far the most common cause of death. And that's critical as we think about interventions to help children in resource-constrained settings.
Shubhanan Upadhyay (07:26)
So much of what you said resonates on a personal level in that imminently at the time of recording this I'm gonna be a dad for a third time in a different setting, right? And each time a first two, thank you.
Joshua Bress (07:36)
Okay, congrats.
Shubhanan Upadhyay (07:39)
The second thing in terms of my clinical experience is, which resonates a lot is I remember going through kind of, you know, primary care physician. did pediatric rotations and this notion that, kids are not
just small adults. And I think that also kind of zooms down if you go further down of like neonates or like babies in the first kind of hours and days of life are also different to slightly older babies, if that makes sense, that are kind of like a few months old.
Joshua Bress (08:05)
Yes.
Shubhanan Upadhyay (08:08)
the challenges of taking care of a baby, you know, we, just talked about how they're different, you know, even in different countries, but in a low resource settings, like I'd love to delve into like, what was that really like? Like, what does that look like for a baby in, East Congo that you were in. What was that like?
Joshua Bress (08:27)
Yes.
Sure. So maybe I'll tell you how I got to Eastern Congo in the first place, because it's not a place that people have a chance to visit. And it's certainly not a place where people spend more than a year commonly who are not from there. I would finish my pediatric training at UCSF. I was actually working in a major medical center as neonatal intensive care. And this opportunity came up to travel there to help a team establish its care system there. ⁓
Shubhanan Upadhyay (08:31)
Yeah.
Joshua Bress (08:52)
And I remember crossing the border there in 2011, 12, this is not a safe place to the world. It's still not a safe place today. And ⁓ showing up and going to this major medical center in the city of Goma. If people who are listening know where that is, it's frequently in the news and telling the team, like I was here and I was ready to help in any way that I could. And they say, great, because ⁓ tomorrow there's going to be triplets that are going to be born. And it's perfect timing.
And I thought, okay, triplets, that's not a common clinical scenario. And so maybe to paint the picture of what it's like in a place like Eastern Congo to be born. And I was fortunate to be working in the major Congolese referral center, but just like what it's like. ⁓ The first thing I always think about in terms of babies is the steps of their transition to being out here, the first minute of life. So in the first minute of life,
a baby will be born and hopefully cry, right? This is what you see in the movies. The baby lets out a cry and there's a team there in case that baby doesn't. One of my family members once described my job as, ⁓ now I see how it works. You press a button and people come. That's what will happen in a place where your child will be born. But in other places, it's like they're there. People are physically there and in case something happens, that team is ready to jump in.
What can happen in the first minute of life? The baby doesn't cry. And that means often that the baby's not breathing and needs help taking those first breaths of life. Minute one. Okay? And I can't tell you how many times I've been that person. Catching the baby and, you know, making sure that that transition happens. After that, the baby needs to get established to life here on the outside. And there's so many things that the baby needs to do. Stay warm, start to learn how to eat, breathe comfortable.
These are the things that the baby learns how to do early in the first hours of life. And I would say from a global health perspective, a lot of the work is focused on that first minute. That was my observation when I was living in Congo, that we're gonna teach people what to do when babies come out and don't breathe. And there's wonderful programs around this topic. But from a clinical side, and this kind of gets to where the Novi guide came in, I knew from my clinical experience, I've met a lot of babies.
And I've not met many babies who only needed help breathing. If you needed help breathing, you needed other things. You needed help in the next hours and days of life. So that was sort of what I observed being in Eastern Congo. The second thing I will tell you is people often talk about these settings as resource constrained. Eastern Congo is one of the most resource constrained. I had an opposite impression. And it was because I was working
in this hospital with these amazing Congolese nurses and nurses would become a huge part of this story. I even remember these nurses names because they're still there. Muka, Nadine, Judith, Elise. These were people who taught me what to do in working in Eastern Congo. They taught me French. They taught me so many things. I remember going to It's like my French going there was not great. The French coming out was serviceable for sure.
Shubhanan Upadhyay (12:05)
I was gonna ask how was your French going there?
Joshua Bress (12:15)
And for people who've ever been to Goma, Goma has like an amazing combination of French Swahili. So there's like expressions like Hakuna problem, you know, no problem. So I met these nurses and I was just like blown away by their commitment. I'll just give the listeners like an example of this commitment, like not uncommonly adopted abandoned children.
Shubhanan Upadhyay (12:25)
That is cool, Hakuna problem nice.
Joshua Bress (12:40)
Okay, that's the level of commitment that these NICU nurses, these neonatal nurses had. So when I came there, I was like, this is not resource constrained. This is an amazing resource. These nurses are just like an amazing source of energy and commitment and passion. And that began like this journey of like, okay, well, I'm not going to be better than these nurses. What can I do to help these nurses do their job better? What can I do to take the best nurse and get them to help other people?
in other settings and other sites. And I will say that as a doctor at this Congolese hospital, I often described it in terms of neonatal medicine as being under the waterfall, like in neonatal mortality. So if you think of like, there's upstream, people always say we need to go upstream. I was like down, down, downstream, getting crushed with acute neonatal cases that are being transferred in extremis, near near death from other hospitals.
So there became this need to say, we got to go upstream or at least like out from under this waterfall. Let's go find the sites that have struggles with neonatal care and train them. That was the beginning of what led to the Novi Guide.
Shubhanan Upadhyay (13:48)
So Goma was like the local equivalent of what we would call a tertiary center. Like, so all the complex or like worrying cases would go to Goma, but they were served by other sites that were in more rural areas, et cetera. Is that, is that an accurate description? Yeah.
Joshua Bress (14:02)
Totally. Okay, so Goma is a city
of between 800,000 and a million people, depending on the refugee situation. And this was a site that got many of the sickest ones, but there was not a clear path to getting them. So it's not like every sick baby made it this far. We knew that many were dying before they ever got a chance to get the highest level of care. But we also knew what people know from the global health data, which is like, had earlier interventions been taken, maybe this baby would never have gotten so sick.
We need to go find the places that are sending us sick babies and we need to help them with the steps beyond just helping them breathe.
Shubhanan Upadhyay (14:40)
So you went out to these sites. What insights did you gather and how does that lead you to saying, hey, this is the problem that we need to solve?
Joshua Bress (14:43)
Yes.
Okay, for people who are in global health, they will know that the next thing you would do is training. Okay, so we're gonna go out and we're gonna train these other sites. And this is where we hit the problem. And that is because there was dilution. I would describe it as like training was like, I'm taking a block of ice and I'm gonna run with it on a hot day to the next place. And it's gonna get smaller and smaller and less and less good the next.
place we go to, we can't sustain this level of excellence at so many sites. That was problem number one. And related to that was something I learned in medical school. So when I was in medical school at Vanderbilt, on the day one, a professor got up there and said, welcome to Vanderbilt School of Medicine, where you will forget more than most people learn. Okay, you will forget more than most people learn. That would be like a comment that would stick with me. Like, okay, we can train people, but they will forget this.
Shubhanan Upadhyay (15:41)
Thank
Joshua Bress (15:49)
and they will forget certain things, certain types of material are forgotten, okay? If I teach you how to breathe for a baby, every time you do that, it's gonna be reinforcing, okay? So it's like riding a bike or driving a car, like you get better at it each time you do it. But drug dosing, okay? Calculating the antibiotics for a baby, calculating the feeds for a preterm baby, managing jaundice, those are not like that. You're gonna forget that.
In addition, in settings like Eastern Congo, there's, and in Uganda, there's high staff rotation. So when we give talks to the medical students here about global health, I'll say, would you ever give a PowerPoint if you knew that 60 % of the audience would be gone in three months? No, you wouldn't do that anymore. You would come up with some new way to do this. And so that became part of the challenge is, okay, we need something that can stay in place, that helps people remember what to do, closer to the point of care.
And then I'll mention one other personal detail, which is I, as a doctor, work nights and nights is two thirds of the day. Okay. Most people say 5 PM. That's the end of the day. A new team comes on and they will stay overnight often until 8 AM. Even if it's 12 and 12, it's at least half of the day. So I had a sense and babies, everybody knows like they often come at night. You know, it's not just like they're born at noon. And so we needed something that could be 24 seven.
that could reach sites and that could account for the fact that the staff was going to change. And this led to ultimately a digital solution.
Shubhanan Upadhyay (17:27)
so much of you said of what you said kind of brings me back nostalgic to my days, you know, practicing, ⁓ doing my training, et cetera. Also nights on pediatric and the, and eight awards. ⁓ and, and yeah, absolutely. All of that, all of that resonates, especially the bits that you forget. So, you hit this and you were like, ⁓ and you, you went a couple of.
Joshua Bress (17:40)
Yeah.
Shubhanan Upadhyay (17:50)
layers deep into the problem area to get these insights where you're like, actually, you know, we won't go, we won't just do the first level of, ⁓ could be training like the most scalable way to do this is like a bunch of PowerPoint things that are like, ⁓ actually, there's a new level of understanding of this problem. What did you do next?
Joshua Bress (18:08)
I also mentioned while I was living in Congo, this was a time of ⁓ instability. There was a UN curfew in place. So you would go to the hospital, come back and stay in your apartment until the next day. and I was with a neonatal nurse from San Francisco. And this was like a time of actually like, just focus, focus on trying to solve this problem that was in front of us. was nothing else. And I lived one block from the hospital. So this was like a year of like thinking hard about this.
And this was also 2011-12. So you could get a sense, like I could even get a wifi connection from some restaurant. You know, there was some sense that, that technology was going to come to this place, that there was mobile phones coming. Um, and our idea was that we were going to try to make it easier for people to follow the guidelines. We were going to create a digital tool that walked people through the guidelines at the point of care. And in doing this, we would make a tool that would be available 24 seven.
Shubhanan Upadhyay (18:40)
Yeah.
Joshua Bress (19:07)
that would account for staff turnover. So whoever is there, pick it up. And that would help bring the level of care up in any site that had this 24-7. This was going to be in our original thinking, how we were going to solve some of these problems that we would encounter. And these would be complementary to the things that people are already doing, like hands-on training, technical skills. ⁓ This would be the thing that walks you through the guidelines.
Shubhanan Upadhyay (19:33)
And just to understand, were there guidelines that existed like at least on paper or like posters on the wall or something like that?
Joshua Bress (19:42)
So one thing people maybe not don't realize about low resource settings is printing is extremely expensive. And so if you were lucky, you would find a binder of the guidelines, some guideline or like a book that people dropped off. but there was never like I would often ask, where are the book guidelines? I want to see where you keep them. It's commonly like on a shelf. Like that would be the same thing in my hospital today. Like there are guidelines that are
Shubhanan Upadhyay (19:47)
Okay, yeah.
Joshua Bress (20:09)
on shelves that you could access, maybe on the ethernet, you could access these. But this was not something that was influencing care. OK, this was not something that was driving care forward. A common way we think about our product and the digital work is around maps, OK, because we're going to take people down a road, down a route. And for me, the guidelines are like an atlas. OK.
⁓ they're like an Atlas and in some cases, the guidelines are like Christopher Columbus's diary. Okay. This is not something that someone could read and know what to do to get there. So there is a huge problem with the medium of the guidelines themselves. And I think anybody who works in digital has like their favorite applications. And for me, it is hands down, Google maps. This is the application that drove.
so much of our thinking and seeing how people would use this tool to get from point A to point B. That's what we want. We want people to use our tool to get from point A to point B. I've a sick preterm baby, now I got that baby stabilized all the way home to discharge home.
Shubhanan Upadhyay (21:21)
And in this case, What guidelines did you use? Were they local guidelines?
Joshua Bress (21:28)
Okay, we had to, we had to fast forward a couple of years and I had to find people who could help me. So I would say for people who are medical out there, know, especially in low resource settings, I always tell people the worst applications are made by doctors. Okay. And the second worst are made without doctors. Okay. So you needed to find these technology partners that could see the vision and execute it ⁓ in a way that was, that had like a core tech foundation.
Shubhanan Upadhyay (21:48)
I'm
Joshua Bress (21:57)
So I had to come back to America, take this idea, find the technologists who could help me. I was very fortunate to find my technical partner in this work, Elon Elon Danziger, who led the early development of this, to take this idea and put it into a actual product. Okay, so there's a technical team that comes in. ⁓ The second thing is where are these guidelines? Okay, so they're in different formats, and not to get too in the weeds here, but some of them are narrative.
Some of them are like, they're closer to real-world care, like the kind of thing a doctor would have in the back of their pocket ⁓ when they're working to pull up as a resource, but none of them go into the flow of real-world patient care. Okay, none of them go into the flow. And I'll give you an example of the flow. Okay, an example from pediatrics would be a child that comes in with a cough. Okay, in the guidelines, you can find the treatment for pneumonia.
Shubhanan Upadhyay (22:45)
Yeah, that'd be useful.
Joshua Bress (22:56)
Okay, but it's not going to tell you how to get to that diagnosis of pneumonia. It's going to tell you like flip to page 589 for the guidance on treating and diagnosing pneumonia, where these children have multiple, especially sick preterm babies have multiple parts of their care that have to be done like in a coordinated sequence. And some of that is not written down. I'll give you an example. Preterm baby comes out, maybe weighs
1.3 kilos. Okay. And you ask the team, what should we do first? Check the blood glucose or ask about the maternal HIV status. Okay. Everybody knows the answer is glucose. Okay. But it's not written anywhere That's the first thing you do. So we had to take these kind of materials and make like a synthesis of this into workflows.
that matched what a doctor or nurse would think. And here it was, I'm so grateful for the Congolese nurses, because I knew what they thought. I had spent a year plus with them watching them do this and thinking how they were thinking. And when we eventually made the first Novi guide, which was in newborns, one of the questions we asked people is, is this product asking you the questions you're asking in your head?
That was one of the ways that we were trying to figure out, did we get it right? the first product is a neonatal decision support application that walked nurses and doctors and midwives through the care of a newborn from birth to discharge.
And that included a number of different pathways for new baby being born, a baby coming in from the outside, you're checking on a baby that you're worried about, you're rounding on a baby, you're discharging a baby. What we didn't know then was that this would be used or nearly at a half a million uses. But that was the original vision, was a product that would help nurses follow the guidelines for newborns.
Shubhanan Upadhyay (25:04)
And the other challenge would be that the guidelines themselves have been developed in other places that are not Eastern Congo, usually developed in comfortable, very well resourced establishments with escalation procedures, intensive care units and everything that's available.
work did you have to do to adapt these so that of course you knew a lot of the context because you've worked in eastern Congo for so long you worked in Goma what did you have to do to adapt these how did you think about that
Joshua Bress (25:43)
I would say one of the biggest challenges and surprises of this work is when we started off this work. I want to say, let's say I was pitching this to you, like, hey, we're going to make a neonatal decision support application for Congo. And then we're going to take it to all the countries that have a similar problem with neonatal mortality. The response we got back was you're going have to make that application every country you go to. Okay. That was a common thing that we would get in rejection. You have to remake that application. I never believed that.
Okay, I never believed that because babies are not that different around the world. And I had the pleasure of being at births around the world and knew that they weren't that different and that the core elements of the guidelines. So where is the variation? The variation is at the site. The variation is at the level of the site. And that is a sobering reality. And it's sobering. I'll give you an example. Let's say that
Shubhanan Upadhyay (26:38)
Yeah.
Joshua Bress (26:40)
where let's think blood glucose, because I people have a pretty good experience with blood glucose and diabetes. Let's say babies also have glucose problems. So let's say I have two sites and they're both following the same guidelines for glucose, but one has a glucometer. They can measure the glucose and one does not. And they're gonna have to go based on symptoms. Like, does the baby look jittery? the baby... Okay, now imagine there was a video camera in those two places.
and you didn't know anything and you're watching the video camera and you're watching how they're managing the glucose, they look completely different. One person's running around doing blood tests and checking numbers and doing all these other things and the other person is looking at the baby with their eyes and looking at symptoms and though they are following the same guidelines. So this led to a realization that we needed this aligned in context to the site.
People often talk about, we're gonna make a guideline at the World Health Organization, then we're gonna adapt it for Congo. No, you have to make a guideline that's adaptable to every site's potential resource setup. I'll give you some examples from Congo.
Shubhanan Upadhyay (27:44)
subtle nuance,
yeah.
Joshua Bress (27:46)
It's a sobering nuance for us because it was like, now it's not just about when you think of every possible combination. An example of a combination from glucose might be how are going to manage a baby's glucose if we can treat a low glucose but can't measure it? Okay, that is not written down. And so there you rely on the in-country experts and global experts to tell you what you would do in that unique but common situation.
⁓ so I think that was one aspect was realizing. when people open the Novi guide today, the first thing they'll do is it'll ask you, what do you have? What do you have to treat babies? And you can change that at any moment. And that the, under the consequence of that, and maybe we'll get into this is complexity. So anyone listening who involved in technology would be like, okay, well now you have to manage like every possible permutation of equipment and drug availability. And the answer to that for us was yes.
We had to do that.
Shubhanan Upadhyay (28:45)
man, yeah, let's definitely get into like this, guideline principle to take away here my heuristic on guidelines is, especially like having worked in the UK's NHS, each hospital has its own different guidelines on antibiotics. Each has its own guideline on
cancer referral pathways. But as you're saying this, it's a reflection on what the local availability of services are, as well as, what's evidence-based and how do we deal with capacity and et cetera,
Joshua Bress (29:06)
Yeah.
Shubhanan Upadhyay (29:19)
for the antibiotics for example, what antibiotics do we have available? What are the resistance patterns etc? And therefore they then inform what the guidelines look like. Have I taken that away the right thing there? Is there anything I've got missing there?
Joshua Bress (29:32)
No, I mean, I think you're right on. And I think that one of the reasons that guidelines remain on the shelf, right? So why are they on the shelf? Why are people not using them? Like that was a question I started to ask myself. And it's like, one of them is that they can't account for this. They can't account for the fact that I don't have what you're asking me to do. Okay, I don't have what you're asking me to do. That's a very powerless situation and you're gonna leave that guideline there. But within these,
with, but there's an opportunity here. And the opportunity is that when someone can put in, like, this is what I, I'll give you an example as a, as a nurse. Okay. Imagine that you're a nurse and you're taking care of a baby. And I tell you, like, put the oxygen on in the app. Like the app says, like the oxygen is low. Like put, the oxygen on and it's like, I don't have oxygen. Okay. So I have to refer this baby, but imagine keep doing that. You know, we have users in Noviguide who've used it like 5,000 times. Imagine every time you got to say, I don't have that. I don't have that. I don't have that.
That's demoralizing. Okay, so instead we're sitting there thinking like, want to make this so it's going to help you get through this the best you can optimize the care with what you have. Now it's like, okay, this is helping me. It's not pointing things out that I'm lacking. I remember early on in this project, I had an American nurse who was with us who was an adult surgery nurse. Okay.
And we showed him the product and he was playing around with it. And he made this comment saying, you know, if I was like in the NICU for one night, I could probably get through if I had this. Yes, that's what I was going for. Like, you know, to place an IV, can, you know, it's medicine. I knew we were onto something when, when I heard comments like that. And something I was very aware of is, okay, I had these nurses in our head, right? Like these are people I knew well who are friends of
Shubhanan Upadhyay (31:10)
Yeah, nice.
Joshua Bress (31:23)
and I wanted to design something that they really wanted. And I remember when we took the first version of Noviguide out, it was first tested robustly in Uganda. And I remember telling the team in the car, like, okay, here's what I'm looking for from this. I wanna know if the shoe fits, not if the shoe works. I wanna know if this just felt great. Treat the nurses like a true user, that's like a customer. That was such a part of our story. And getting the equipment to align,
Yes, it was necessary medically, but also gave the user this sense of like, these people get me. They understand they don't have everything. I'm trying to do the best I can. It's three in the-
Shubhanan Upadhyay (31:59)
I think.
I really like that. And that's a good principle to take away in the sense that there's like a baseline of, hey, we will deploy this thing and it's being used. And then there's like the next level, which is like, delight the user, like delight the end user. And what are the signals that you get from your users that they are actually delighted rather than, yeah, okay, well, kind of, this is helpful kind of, yeah, to, whoa,
Joshua Bress (32:17)
Delight.
Okay,
that's a great question. I don't think ever been asked that question, but I think about it a lot. Okay, so how do you know someone's like delighted with the thing that you made? Okay, one of one of things we observed early on was people turned it into a verb. Okay, so we knew from the studies that the study researchers had observed people saying, hey, novi guide that kid, put that kid put that baby in the novi guide. Have you done the novi guide?
Shubhanan Upadhyay (32:34)
Yeah. Yeah.
Nice.
Joshua Bress (32:53)
That became like, was like Googling on a much smaller level, obviously, but that was a sign that we were onto something. Okay, but then there was a moment in COVID, which I'll share, which was really, ⁓ for us, COVID was a huge driver. It was such a terrible period, but it was a huge driver of innovation because the product was launching and we were about to expand to other sites. And previously we had gone to those sites in person, tell them what the Noviguide was all about. And we couldn't travel.
So we ⁓ made the decision that we're going to go on Zoom and teach the local midwives who knew how to use Noviguide from the initial studies, how to train other people. And that we were going to be out of the training period because we couldn't get there, but we wanted to keep going. And ⁓ I'll never forget the first time that people talked about Noviguide and I wasn't there.
And we said, okay, go, go to this site. This was in Eastern Uganda, train these people how to train these midwives, how to use the Novi guide and go on zoom and I'll listen in on zoom, but I won't have my video on. I'll just like hear how you're doing it. So can see if you're doing like a good job training people on this product. And I've had some great experiences at global strategies. This was one of the top most surreal moments because I'm here in California in the dark because it's middle of the night.
Shubhanan Upadhyay (34:14)
Yeah.
Joshua Bress (34:14)
like two in
the morning, listening in to people describing something we had poured our hearts into. That, you know, hours and I can't count the number of hours to make something like this. And I'll never forget hearing the nurses explain it. And they explained it in a way I never would have done. And it was better by a thousand times. And they said something like, have you ever been in a situation where baby died and you thought they didn't need to die? Like that was
that we could have done something better. Have you ever walked away from like a sick baby? Raise your hand, call and response. I never would have been bold enough to do that. It wouldn't have been appropriate. Then they kept saying like, this is a tool that I use and I use it to keep babies safe. This is a tool I use and it helps me do the dosing. You're gonna like the fact that does the dosing for you. And they just explained it. I could see in their words, like the delight that they had in knowing how to teach someone else about this. And then one of the most remarkable moments, this was like,
I'm listening in to my headphones in the dark in my pajamas, and someone finally asked the question, who made this? Who made this thing? And of course, it's a team of us here in America. But the nurse said, ⁓ it's a baby face guy in California. I couldn't believe it. It was like amazing. Like, it didn't have, we didn't have to have any part of this. And it was not.
Shubhanan Upadhyay (35:34)
Ha ha ha ha ha.
Joshua Bress (35:37)
a key aspect of this. Like who made this was like not actually what this was about. It's like, it's who is this for? It's for you. Okay. That was like such a transition moment. And for me, it was just so eye-opening. Just so eye-opening about what our role would become fast forward when we're onboarding our hundredth site. You know, I was telling you earlier that
Something remarkable about NoviGuide is it's been used almost half a million times and most of those have been in Congo and in Uganda. And in person, the number of people I've met who've actually held our product and used it is probably under a dozen. And that's because the local team is the key ingredient for scale. And you have to back off and let those teams who are so talented do their work.
Shubhanan Upadhyay (36:16)
Yeah.
Shubhanan Upadhyay (36:25)
So it's really, really good to get what the signals were for you that showed that people really got it, the value proposition that you're after. you got that communicated into in a way that you were like, this is it. So that's really, really helpful to hear from you.
Do you have any other insights in terms of the challenges you had? know, you initially had this in in Eastern Congo. You said you've scaled this to other parts of the country, but also to Uganda and South Africa. Do you have any aha moments or things that you like, oh, I completely got that wrong and realized, realized something new
Joshua Bress (36:58)
I would say when we first started this, imagine you're our team, right? And you're trying to take some pretty complicated medical guidelines, get them into an application. Naturally, your number one concern is, we get it right? Okay, that was what I was completely focused on. And we didn't have some of the technologies we had now where users can feedback and tell us if we made a mistake or need to change something. What I didn't anticipate was the most common reaction to the product is we want it to do more.
Okay, and that happens even today. So like, where's the guidance for cleft palate? Where's the guidance for X, Y, or Z, skin conditions, other things that are not in the Novi guide. ⁓ And so we felt like we were already delivering like a very big application. You know, the backend of this is enormous and people wanted more. That was an early hint that we would need to learn how to build faster. Okay, now.
I didn't necessarily get that hint when we started it because it came in drips, know, like we need to, I'll give you an example. Like we have lab tests that have both the British and the American units. You know, it's like, okay, fine, we'll tweak that. You know, we'll make these little tweaks, but these started to pile up and up and up. That was a common reaction to the product was like, we wanted to do more than what it's doing already. I would say other.
surprises, I would say, were, and maybe we'll get into this at the end, but just the skepticism, which I still encounter today about digital tools. It's remarkable because everything, even you and I are talking through the medium of an application, but the skepticism about digital tools in medicine, is pervasive and it was definitely pervasive at the time that, an app for that, do we really need an app for that? And just,
lack of curiosity about understanding the differences between the products that were being offered. To me, this was not a casual endeavor, if that makes sense. You can probably tell that from talking to me. This was not something that I was like, oh, let's try this and see if that works. It was like, no, I'm going to pour everything I've learned and everything our team can do into this to make something that's world-class. That was our goal. And so to have it be casually dismissed, that was something I encountered routinely.
Shubhanan Upadhyay (39:02)
Totally.
Joshua Bress (39:17)
and still do today sometimes.
Shubhanan Upadhyay (39:19)
Let's go into your experience of taking this to other settings and your experience of, guess like what we call scaling,
Joshua Bress (39:27)
Okay.
Shubhanan Upadhyay (39:30)
the things that you needed to delight people that were unique to what was happening in Congo, right? Did you find that then when you were and implementing this in Uganda, for example,
it wasn't going to be a copy and paste, right? And so you needed to be able to build fast, but also make sure you were serving the work that you've done and kind of maintaining and having the quality improvement for the Congo context. But now there were this whole bunch of new requirements, both technically, but also maybe from a, you know, a guidelines adaptation perspective, perhaps. How did you,
approach that kind of trade-off between, we have to be valuable locally, but we want to scale this.
Joshua Bress (40:17)
Okay, there's a couple many things to dig into here. The first thing I'll bring up is as you start to scale more and more, the value of the local leadership becomes paramount. people always talk in digital tools and low resource settings of like, must have local leadership. And that's so true. And having done this now myself, I can say at this point and at this specific point and to do these things, I have a real sense of where a local leader can just like really amplify what you're trying to do.
I would say a common problem, and it may be for funders who are listening to this call, is that people often say like, here's a challenge and pitch your solution. And it's like, no, these are not solutions. They are tools. Okay, we are humble tool makers, even if the tool is fancy itself, it is a tool. So then from there, to whom does this tool belong? know, okay, well, one level is the end user. But to get to that scale, we had to find people who are on the road to trying to improve newborn care in their communities.
and this is gonna accelerate them so fast that they're gonna love it and take it and make it their own. And that was a key piece of this. having that right local leader, like we have this amazing local leader in Uganda, her name is Dr. Nakakeeto she is world famous in neonatology. But watching her do things that our team could not dream of doing. And I'll give you like a simple example, is like sometimes she will go out and just train people herself.
how to use the Novi. It's like a real leader in showing people like, see, this matters to me. So if this isn't a perfect fit, you're still gonna use it. You know, you're gonna, that's gonna brush over a lot. Having that just behind it, behind it, the team, the local team, that is just so critical. And that can help you in situations where maybe your tool isn't ideally matched to a specific thing. It's like, it's still being endorsed by the people who are the leaders in that country.
Dr. Nakakeeto has saved more lives than any person I've met. And she continues to do this by taking tools and adapting them for her purposes of scaling newborn care in Uganda. So she's just, that's one aspect of this. The second thing is on the technical side. Okay, so we know we're gonna put this out there. We have it at hundreds of sites now. We're not gonna be able to meet everybody in person and your contact with even the local team is gonna be intermittent. That's when these other
channels come in like WhatsApp. There's also feedback within the app itself. And I'll give you an example that goes back to the delight example. We have NoviGuide Beyond Neonates and one of them is in kids. And this example is we had an application for kids and they had in their paracetamol or in America we call it Tylenol dosing. Every parent knows this, right? You got to measure the liquid medication.
And we had this app, we released it, we were like, they're gonna love this, they're gonna love the Tylenol paracetamol dosing. And immediately people kept hitting the feedback button. We don't have the liquid. This came into our side like we don't have the liquid, like hundreds of feedbacks. So we deployed the how to cut the pill. And then within the feedback, people clicked, feedback, thanks, got it. It was just remarkable. was like, this was a connection.
to the user that spanned like thousands of miles, but they saw that we were like paying attention. And so the data feedback becomes another way to maintain that personal touch even as you scale. ⁓ That's so critical for us. The local teams are very innovative on this.
Shubhanan Upadhyay (43:48)
Yeah, yeah, absolutely. Short feedback loops.
So I think a couple of principles then like working with local people and not paying lip service to local leadership. I think a big principle, right? And actually listening to them around what's needed so that it kind of elevates their work.
Joshua Bress (44:03)
Yeah.
Shubhanan Upadhyay (44:12)
And then two, yeah, short feedback loops with the end users in terms how are they using this? However, one thing on this then is, you might have got one bunch of, or like one pattern of things that were needed in Congo, right? And to customize in a way towards that from a technical perspective. And then one whole bunch of things that might have been, hey, you need to prioritize these things.
Joshua Bress (44:27)
Yeah, yeah.
Shubhanan Upadhyay (44:38)
How did you prioritize this? do you then, because that becomes a challenge of like, you've got these places that you've got a suddenly create value for, but now there's a trade off, there's prioritization, there's maintainability. How do you think, how did you tackle this, especially with the constraint that you mentioned of like, we still have to ship fast, but now this is all these competing pieces of feedback coming in.
Joshua Bress (45:01)
Okay, this is a key point. I would say it gets at the difference between what people call customization and configuration. And I'll give you a couple of examples of the difference between that. Like customization is like a tailor-made suit. Configuration is like a suit that you buy that fits you okay, that could fit other people okay also. And why is customization great? Because it fits perfectly. Why is customization bad? Because it's so expensive. Okay, so that is like a key piece of this.
of our puzzle. And when we started this, as I mentioned, people told us, you're have to make a new one for Kenya, for Mozambique, for all these different places, and it'll never be the same. We never believed that. And even though people told us that, I didn't believe that. And what we found by doing this work was that the guidelines are way more similar than people think. And a key finding from our work, they differ in predictable ways. Okay, this is like, that has a major implication. They differ in predictable ways.
The example I give to some of our funders is this example. Let's say someone tells me to find the difference between two identical twins. I know where to look. Haircuts, piercings, tattoos. Okay, I know that that's how two twins, identical twins may differ. Similarly with the guidelines. I see two guidelines and I know exactly where to look to see where the differences are.
What you find out is, let's give an example, like the most common antibiotic for newborns, gentamicin. How many ways are there to dose it? I don't know, 20. That's a configuration. I'm to put all 20 into the Novi guide and you tell me how you dose it and we have it. We have it ready to go. ⁓ Another analogy might be a bakery. It's like, okay, we need to be able to make this with chocolate chip cookies without
With chocolate chips or without, we still need to able to mass produce these cookies. So we have to have ways to configure things without needing to go down the road into customization. ⁓ So configuration is actually how you do this. And there's a cost to that. Maybe we'll get into that. But the cost is complexity. So now you have a neonatal application with all the ways to dose Gentamicin
Shubhanan Upadhyay (47:20)
You touched on this birth at the beginning,
Joshua Bress (47:22)
all the different equipment that you could or could not have. How do you manage that complexity? That was a problem that fell to the technologists on our team. And I can go into a little bit about how they solve this.
Shubhanan Upadhyay (47:34)
Yes, please, yes.
Joshua Bress (47:35)
So the way
that, I mean, a lot of this work has analogies and a lot of medicine has food analogies. So I'll give you another food analogy. As the complexity balloons, right? So I'm describing like a neonatal application that could work in most low resource contexts, any equipment you have, any drug strategy you have, the complexity just balloons, okay? And one of the first questions I ask people when they show me their medical applications is this one.
Shubhanan Upadhyay (47:43)
I love it. Go.
Joshua Bress (48:03)
How did you test it? How do you know this is right? Okay? And I'll give you an example from my own kids. Okay, let's say I tell my daughter, make dad a peanut butter and jelly sandwich. Okay, my daughter goes to make the peanut butter and jelly sandwich, but she substitutes mustard for peanut butter. Okay? I can figure that out. I can test that by biting it. And I'll know immediately something was wrong.
And that's how most medical apps are tested in low-resource context. So they make the app, they give it to people, they say, test it out, taste it out. And yeah, does it taste good? Did you bite them? And what you learn early on in this work is that only works for the most simple recipes and medicine is not simple and it's not the strategy. Taking that cooking analogy forward, how did we manage this complexity? The answer was open kitchen.
Shubhanan Upadhyay (48:34)
Mhm. Does it taste nice?
Joshua Bress (48:57)
Okay, so now if I'm watching my daughter make the peanut butter and jelly sandwich, I don't need to taste it. And that works for very complex recipes. So if I'm watching you, you're in France cooking a very fancy meal and I'm watching to make sure you got the exact amount of oregano, I don't need to now taste it to know you got it. I watched you put it in. And what if I brought a thousand people to watch you? Now we're pretty confident you got this recipe right. And a key technology for us,
was making the algorithm so that the ministries of health, so that the key stakeholders could see the back end without needing to taste it. ⁓ And for us, I can't tell you, these applications are large. So you said like how many permutations in the neonatal could there be? Millions. So it's disingenuous to say, it. It's like, we know you will not find everything. You won't find everything that's in there. Some of these are odd cases that don't happen very often.
That was a key piece of our story.
Shubhanan Upadhyay (49:52)
absolutely
Yeah, I love that and I especially love a food analogy. When you were talking about the complexity and configuration part of things, did wonder as well, I was thinking about a food analogy myself in the sense that, like for example, if you are a chef and you're trying to think about, okay, well, you started as a chef who was catering for like a 10 person restaurant, right? I don't know, or a food truck.
You've got kind of controlled, you're doing your three or four dishes that you're famous for, right? And you've got kind of controlled environment and you know how to make it good. It's a different kettle of fish if you suddenly now, okay, you've now got five different restaurants, you've expanded the menu, right? How do you think about that, right? You're not just gonna do, you're not gonna customize in terms of asking people exactly what they want.
Joshua Bress (50:42)
Yeah.
Shubhanan Upadhyay (50:50)
But if you've expanded the menu, you're going to think about, how am I scaling this? And I guess you're thinking about this as a chef of like, ⁓ how do I reconstitute different parts of the meal? So you might have certain bases of sauce or something like that. You might have certain groups or groupings of how you do things. And that to me is a version of like configurability because you're able to meet people's needs in a way that still protects your own
constraints and capacity resources that you have. you're, guess like you're modularizing what you do. So like, for example, I don't know if you, still, you've got one base of sauces for people who really like hot stuff. So you've got one base of sauces that you, that's your go-to for like people who love spicy stuff. Then you've got the more mild dish, or you might have something for a vegan.
You might have a bunch of things for vegan options. I don't know how far I can go with this analogy, but that's how I would think about configuration when you're thinking about this. Otherwise, you're just going to die as a chef because you can't customize for every single type of individual request that there is
Joshua Bress (52:01)
That's a good, mean, to use your analogy, I would say there's certain things I've made many, many times and I can make with my eyes closed. There are some things that our team has in what would call pre-mades, like ready to go, pull it out of the freezer and we can use it. And I think as the Novi Guide grew and especially as we expanded to other medical areas beyond neonates, that experience, I can't tell you how many times I'm now looking at a novel guideline that I've never seen before. I'm working on one now for pediatric epilepsy and saying, I've solved this
Our team has solved this problem before. I know exactly how we solved it and what I'm going to do. So the experience came with time. And there were times when, even as I told our supporters, I couldn't have done this except by learning it. There was no amount of money that could have changed the outcome of this. We had to learn this as a team, how to do this. ⁓ And I think one of the things I'm proud of is that every Noviguide application, I feel, is
high powered and does give that delight that people are looking for, especially in healthcare. I should mention that technology in healthcare has not been a smooth road. And so many of the technologies clinicians have been asked to embrace turned out that we were embracing a cactus. And so to make something that people truly appreciate is one of the things that motivated me. I was here while medical records, electronic medical records are being rolled out. I thought, okay, I definitely don't want to be that.
We want something that people look forward to using.
Shubhanan Upadhyay (53:29)
one of the things I note here in your journey, which I have talked about in a few episodes, I talk about it in conferences where I go and where I speak is there's this challenge and my own mental model is that in this challenge in particularly in digital health is on one side of the spectrum, you have trust, right? And it's a buzzword that's used. People talk about trust, building trust with communities, with end users, et cetera.
And then the other side of the spectrum you have scale and everyone talks about how we need to scale and my observation has been in the industry that to do to be able to build trust you have to do things that don't scale that in your in your own words delight the user you care so much you've been You've lived and breathed That context you understand really deeply what they want and what they don't want and how how that
that resonance you have with the local community. That is hard to scale because it takes time. takes, you know, it's all, it's the antithesis often of like what it takes to scale, which is, you know, expand growth at all costs, be everywhere. You seem to have wrestled with this yourself and been able to do both.
So do you have any lessons to share? First of all, do you see it the same way?
Joshua Bress (54:57)
Well, I think one of things you get at is this idea, I'm very familiar with this here in the States, is something that feels mass produced. Like I know when I'm eating something or I'm using something that just feels mass produced, like there was not care put into the creation of this product. And so I think a lot of this starts with the care you put in to the original design. But another element of mass produced products is I have no way to give my feedback back.
This is just delivered to a store and I purchased it, but there's no way for me to inform its design in any meaningful way. I think designing for healthcare workers, doctors, nurses, and midwives, that has been one of the great joys for me of this work because I am one of them. Our team has deep ties to that community. I was once asked, like, wow, you're not from Uganda. How did you design this thing that Ugandan nurses like? I was like, it's the nurse part.
I know so many nurses and they have so many similar values across the world about why they chose that profession. Like something I always tell our team is the type of people we are working with, these are the type of people, if you ask them in kindergarten, you know, in primary school, what do you want to be when you grow up? They would say the thing that they are. Okay. That is like a deep tie to the work. Okay. I have like, there's nurses here in America, like on their license plate, like Premi RN, you know what mean? It's like,
These are people whose identity is wrapped in this work, especially newborn work, caring for babies. Never forgetting that, I would say, is a part of our success. It's just never forgetting that the people on the other end of our line have dedicated their lives to this. They're not users in that way, right? They're professionals, and we're trying to match something. That made the joy of getting it right all the better.
The other thing I would say, maybe, sure there's other people listening who have different experiences. For me, we made a decision early on that we would never go down a route of forced use. That we weren't gonna try to get like an administrative group or a Ministry of health to force the use of the product. That comes with trade-offs, but it keeps you tied to the user. Now what the user wants, I pay a lot of attention to.
And that's where the design of this, like if a user says they want something, I'm really going to think hard before I say no. These are the people we are trying to please. I think there is a trade-off and I don't think we've always gotten it right, but there are things that I never regret doing something for the users. I sometimes regret doing things like for the system, you know, but for the users, I never regret.
Like I'll give you an example from our world. Like I'm here in California and I go to bed in the evening. And one of the things I'll do before I go to bed is see who used it in the middle of the night in Africa. That's like something I care deeply about. Like who reached for it? Not like they had to, like they reached for it. That has like incredible meaning to us. And it drives us as a team to say like, wow.
like 300 people reached for this in the middle of the night last night. That's a deeply satisfying feeling and inspires you to keep going because the actual work of this, you know, we're talking about really exciting things like babies and saving lives and all of this. The actual work of this is, it can be mundane. The actual work of this can be like playing Sudoku hard for 12 hours. And you have to find inspiration to keep your team going.
Shubhanan Upadhyay (58:39)
You've kind of been on this journey since 2011, creating this, sticking at it, going through ups and downs So I wanted to get into your experience of this and some of the things you've learned founders or leaders listening to this and, you know, caring about this space as well.
Joshua Bress (58:46)
Yes.
Shubhanan Upadhyay (58:57)
What stands out to you in terms of lessons learned? in your journey
Joshua Bress (59:00)
I will say, but this is probably true for any career that anybody may choose. If you watched our team build these applications, ⁓ I hope you would come away with the feeling that this was a labor of love. Like that these people just got into the guidelines in a way that is like four or five dimensional chess and they do it all day long because they think that it's going to help somebody. So finding something that like really drives your passion for me, that was easy. I was already a pediatrician and the idea.
to do this kind of came second. The next thing I would say is that you're working on some novel thing, you don't know if it's right yet or not, and you will solicit feedback about it. One of the things I've learned, and maybe it's because I've been here for so long, is like, I would say a lot of that feedback is great and some of it is completely wrong. And just learning how to sort that feedback out. If I had done everything that people told us to do,
this would never have gotten to the stage that it did. And I'm very aware of that now having reached this point. So for me, something I think a lot about is I need feedback to get this better, but I need feedback from people. I need to sort that out a little bit. I need to know like, are you the type of person who uses our product? And I got to care a lot about this. Are you just giving me a casual advice? And you maybe don't know the context as well. That really matters. For me, I think
our success came in part. I think maybe this podcast will hopefully communicate this is that it came because we knew this problem very well. Okay, so we're in Congo facing this problem alongside Congolese nurses 24 seven for over a year in a place with a curfew. We were living this and that then informed its design. So now when I get feedback, I ask myself, is this helping me understand the problem that I think we're trying to solve? And is there something here that's giving me information about that?
problem. Something I think about a lot from the neonatal side is neonatal mortality, as we mentioned at beginning, is the number one cause of child mortality under five. And if you go to any lecture about this topic, they'll say 2.5 million babies die every year, and most of those babies die from treatable or preventable causes. I've said that line myself, right? You can tell I've said it before to medical students. But what I've learned over time is, yeah, and to reach those 2.5 million, you need to find 100 million. To find those ones,
who may not survive. And 100 million, it's like, well, of course you have to do that digitally because that's the most scalable medium. So tracking, you're keeping on with your instincts, following your instincts, taking advice, but also shelving some advice that maybe is not relevant to your specific case.
Shubhanan Upadhyay (1:01:41)
How do you know when to keep going? I don't know, you must have had downs as well. How did you pass those?
Joshua Bress (1:01:50)
You know, you have to have some thick skin and when you're in voluntary use, yeah, you'll make some things that people never use. You know, that's, that's the facts. You'll make some things that people may never use. And I think what keeps you going are, are the users themselves, you know, like I hear from our, users, even if it's like on a WhatsApp thread or something like that. that really drives me and.
I think also you have to use your imagination and you have to imagine some nurse reaching for this. And that is what really makes you put your effort into it. I think the other thing I should mention is babies themselves. Like, let's say there was a baby on this podcast right now and there were the third box here. That brings out the best in people. That's something that drew me to this field of specifically working with babies.
Shubhanan Upadhyay (1:02:34)
Hehehe.
Joshua Bress (1:02:43)
And I go to deliveries all day long and around the world. And every time I see babies being born and people responding and trying to help that baby. ⁓ And especially the mother-baby connection is like the Sun It's just such a source of energy. And being around that community inspires you. I think of what the Congolese nurses who inspired this tool who now use it. And it's like, yeah, I love those people. Those are the people who I want to...
have everything in the world to help them do what they've dedicated themselves to doing. Those are the people who I wish like the very best for. And you can put that into your design and communicate that through the care that you put into the product.
Shubhanan Upadhyay (1:03:25)
100%. Thank you so much for sharing your, think founders and product teams and people building can take so much from that, your experience there. I've got a couple of other quick questions before we wrap up. What do you from a, you know, there's a lot of policy folk who listen to this. What do you think you need from a health system or government level or like policy level, in the global digital health space?
Joshua Bress (1:03:46)
your sound went out again.
Okay, sure. So I would say for policy makers who are maybe listening to this podcast, you we spend a lot of our work taking paper guidelines and making digital tools. And I think that flows from an assumption that everything you need is in those paper guidelines. And I would just encourage policymakers to think maybe that's not true. That that would be like trying to derive Google Maps from paper maps and you're leaving a lot on the table.
I think policymakers should be thinking at least about digital care pathways for common presenting complaints, fever, cough, preterm birth is of course ours, elevated blood pressure and pregnancy. These should be digital pathways. Not just because paper cannot capture it, but because so much that digital can do that we're not capturing. Sometimes when I look out on the field, I think we have these very, very fancy tools, digital tools, but we're applying them to the paper medium still.
And to me, that's like taking a very fancy video camera and filming an oil painting. There's things that digital can do that paper can't touch. We touched on some of those today, like configurability matching to a site. That's where the future is and it's an exciting place. And I hope guidelines can become digital first. That's kind of how it answered the policy question.
Shubhanan Upadhyay (1:05:06)
Yeah, makes sense. And the other group who listen to this are funders, investors. What would you want, to change in that landscape,
Joshua Bress (1:05:15)
Yeah, maybe I'll take this from the personal journey side of this. When I first graduated and went to Eastern Congo, saw the statistics of the mortality and I thought to myself, why is nobody doing anything about this? Over time with maturity, you realize the actual question is why is everything we're doing not enough? Why is everything, including what we are doing, not enough? I would encourage funders to really, number one, use imagination.
Like think about solutions that maybe are not things that have already been proven and yes, in randomized clinical trials, these are the ways to reduce mortality because otherwise we'll just be using from the same bench of tools. And where I feel like we really need new thinking and new approaches to doing this. The second I would say is to stay true to being quote data-driven. You know, if we're data-driven, then we should be looking at.
neonatal interventions that work in these countries, Nigeria, Congo, Pakistan. Okay, if the solution cannot work in those countries, that's the drivers of the neonatal mortality on a global level. So really keep your imagination true to the data-driven aspect of your mission. I have loved working with our funders, and I think many people who've been part of our organization have enjoyed being part of this journey and learning alongside of us.
Shubhanan Upadhyay (1:06:38)
Amazing. Josh, I could talk to you for hours about this. There's so many things I would have loved to cover and we kind of need to wrap up. But Josh, you've taken us through your journey of kind of creating this from having lived, you had a lived experience of like what it was like to deliver care for neonates in Eastern Congo. You understood deeply the problems that you needed to solve and you of, went a few layers down is what I take away, right?
onto the problem. not thinking about it a superficial level, you had a good handle on like the depth of the problem and the breadth of it. And that then drove you because you cared so much. You you can see it in your, in this discussion with you
that you deeply care about this. And this was really the driver of what's over the last 15 years allowed you to really create impact to, I guess, the health outcomes that you've had in terms of reducing neonatal mortality, but through standardizing care that nurses were delivering through actually delighting them is what I take up here.
That was what it was. wasn't this kind of like top-down mandate of like, we've got to improve training, right? It was what do these people who care deeply about their job need to do that better in this context? So you really understood what it was that they needed. And I think, yeah, that your what were these signals that you really captured the value, like you really delighted them and those examples that you gave.
Joshua Bress (1:07:48)
Yes.
Shubhanan Upadhyay (1:08:06)
was such a great takeaway for me. And I think the other big learning that I take away is like how to think about this thing that I've often wrestled with, which is like trust versus scaling. And how do you do that? And I think the key things were like work with local partners. Don't think about it as customization, but think about it as configurability, like predictable patterns of difference. And that can be much more manageable than like the infinite possibilities of like customization. So I think that was a really, really great learning.
Joshua Bress (1:08:27)
Mm-hmm.
Shubhanan Upadhyay (1:08:36)
And yeah, just your growth, you the way you've thought about and tackled like different types of feedback, rejection and how you've grown and what it takes to build something like this. I've learned so much from you. Is there anything else that you want to share before we go?
Joshua Bress (1:08:51)
The one thing I'll say is, first of all, it's been such a pleasure to talk to you. And it's been fun to revisit, like, just some of my own personal biography and how it relates to this work. But maybe I'll conclude by saying something that I would say to any medical student who's about to join a neonatal unit. This is a team sport. Okay. This is a team sport. And to get the outcomes that we're talking about, like hundreds of sites, round the clock usage, that is a team effort.
neonatal specifically is never done by one person and it's never about one thing. And that's something I would leave the audience with is just, yes, you're meeting me in this podcast and it's such a pleasure. The number of people who've touched this project are too numerous to list. It's been just a real joy and it's so even to see it, so it keeps us going here.
Shubhanan Upadhyay (1:09:40)
That's a good one to end on. think a lot of people will resonate with whatever work they're doing in this space of like, all of this is a team sport and we rely on each other. We rely on the people that we work with to, get into those outcomes. It isn't this kind of lonely linear journey that one person gets to. It's, lots of different types of disciplines working together to work towards that. So yeah, that's a really, really great way to end.
Joshua Bress (1:10:07)
Thanks.
Shubhanan Upadhyay (1:10:08)
Josh, what a pleasure to talk to you. Thank you so much. And I look forward to hearing more about where you guys are expanding towards.