The Fogarty Institute for Innovation Health
“In health the flesh
is graced, the holy
enters the world.”
–– Wendell Berry
Can technology really make a difference in improving global human health? Half of the world’s population survives on incomes of two dollars per day or less. If they’re fortunate, this might provide for food, water, and shelter. For the desperately poor, healthcare can be an unaffordable luxury. Millions die each year from diseases such as AIDS and malaria, from cancers and toxins, from hunger and malnutrition, violence, and innumerable other bodily insults. Governments of poor nations often have little to spare for healthcare for their people. It isn’t simply a matter of buying drugs and vaccines. The poorest regions of the world are also constrained by a dearth of trained medical personnel, weak infrastructure, and inadequate scientific and educational resources.
Technology cannot eliminate every global inequity in healthcare, but it can––it must––help fill the gaps. The Tech Awards recognize technological innovations that are helping to reduce disease, hunger, thirst, and other pervasive health burdens. This year we reviewed 63 applications from 21 countries in North America, Europe, Africa, and Asia. The five Laureates we honor have developed relatively simple, highly functional, user-friendly technologies. DataDyne, a non-profit organization, developed free, open source software for mobile computing devices to collect and organize public health information. Sanoussi Diakite, a Senegalese engineer and teacher, invented the first machine for de-husking of fonio, a nutritious grain indigenous to West Africa. Star Syringe offers technology to manufacture syringes that automatically disable after a single use, helping to avoid millions of cases of disease transmission from re-use of contaminated syringes. MedMira created extraordinarily fast diagnostic tests for HIV, Hepatitis B, and Hepatitis C infections that can be carried out without sophisticated laboratory equipment. And finally, the Pesticide Action Network of North America, a non-profit organization, developed the Drift Catcher, an instrument that allows communities to monitor exposure to potentially harmful agricultural pesticides being applied to nearby fields and orchards DataDyne –– United States
As we noted in the introduction, the scope of public health problems in developing nations is enormous. Agencies concerned with public health can only effectively address problems if they have accurate and timely information to guide personnel and resources. For example, to deal with a cholera outbreak, medical personnel need to know who is getting sick, where they are, how many people are affected––and they need this information quickly to control the outbreak before more cases appear and more lives are lost. Even in non-crisis situations, the ability to efficiently gather, organize, and interpret data can make the difference between a useful public health system and a cumbersome bureaucracy.
Dr. Joel Selanikio is a practicing pediatrician and epidemiologist. While working as a medical officer with the United States Centers for Disease Control over a decade ago, he recognized the advantages that a system for epidemiological data collection on mobile computing devices would have. Selanikio was thinking beyond laptop computers––which are still relatively uncommon in the developing world––to devices such as personal digital assistants (PDAs) and cell phones, which are becoming ubiquitous even in poor countries. He ultimately left the CDC to join with Rose Donna, an expert in information technology and disaster relief with the American Red Cross, to start DataDyne, a non-profit organization. With funding from the World Bank and other foundations, DataDyne created EpiSurveyor––free, open-source software for public health data collection that runs on PDAs and cell phones. Using EpiSurveyor, anyone with basic computer skills can design surveys and data collection forms on a desktop or laptop computer that can be downloaded to mobile devices. As workers or volunteers in the field collect data on their PDA or cell phone, they upload it to a central database for aggregation and analysis. Compared to paper-based data collection, this approach can speed up by days, months, or even years the ability of an organization to accurately assess conditions in the field, whether it be disease outbreaks, vaccination programs, behavioral patterns, or supply chains.
EpiSurveyor is now used in nearly every country in sub-Saharan Africa to streamline data collection. Zambian health workers have used PDAs to monitor a country-wide measles vaccination program down to the household level, and to survey clinics to identify shortages of anti-malarial drugs. The Ghanaian Red Cross has studied the long-term fate of insecticide-treated bed nets in real households, and used the data to develop better approaches to bed net distribution and installation to combat malaria. The World Health Organization has adopted EpiSurveyor on PDAs as a standard field tool for public health data collection in Africa, and use of EpiSurveyor is spreading to many other parts of the world as well. For more information on DataDyne and EpiSurveyor, see www.datadyne.org. Marc Koska, Star Syringe –– United Kingdom
Every year, at least 16 billion syringe injections are given worldwide in healthcare settings, according to UNICEF statistics. There are thought to be more than 13 million injection drug abusers globally, adding hundreds of millions more illicit drug injections annually. In developing nations, many injections in normal healthcare settings, and nearly all illicit drug injections, are carried out with unsanitary, used syringes. Bloodborne pathogens such as HIV and hepatitis viruses are easily transmitted by these unsafe injections. The scope of the problem is huge – over 20 million new cases of Hepatitis B each year from unsafe injections, 2 million cases of Hepatitis C, and 250,000 new HIV infections. Reuse of contaminated syringes ultimately causes more than a million deaths each year.
The most effective approach to date for preventing re-use has been syringes that are automatically disabled after a single injection. There are several models of auto-disable syringe on the market, but one design stands out for simplicity and low cost. The K1 auto-disable syringe was first conceived by Marc Koska, a British inventor, in the 1980s. K1 is a relatively simple modification in which a tiny locking ring is molded directly in the syringe barrel. When the syringe plunger is fully depressed, it passes the locking ring and can’t be retrieved to re-fill the syringe. The plunger is constructed so that forced extraction from the locking ring breaks it. The K1 design is easily incorporated into injection molds used for plastic syringe manufacturing, so the feature can be added to almost any company’s existing product.
Despite these advantages, Koska spent a frustrating decade trying to interest major syringe manufacturers in the K1 design. He founded his own company, Star Syringe, in 1996, with a new plan to encourage adoption of auto-disable technology. Star grants non-exclusive licenses for the K1 design to manufacturers around the world at minimal cost. As awareness of the problem of syringe re-use has grown, the “Star Alliance” of companies using the K1 design has expanded to include manufacturers in Asia, Africa, and the Middle East. Over 1 billion K1-type syringes have been produced globally, and their use in the developing world has likely prevented millions of new hepatitis and HIV infections. PATH, a non-profit that supports development of healthcare technology for the developing world, strongly encourages the use of auto-disable syringes, and estimates that K1 syringes have saved up to 3 million lives in the past decade. That number will surely increase in the future, since Star recently licensed the technology to Becton Dickinson, the leading syringe manufacturer in the world. For more information on the K1 syringe, see www.starsyringe.com/home.html. MedMira –– Canada
For people who rarely have the opportunity to see a physician or nurse ––a description that includes much of the world’s population––accurate diagnosis and timely treatment of diseases is extremely challenging. Diagnostic tools that enable fast and accurate disease detection are especially important in resource-poor settings, where diagnosing infections during rare visits with a healthcare provider greatly increases the chances that some form of treatment can be initiated. Perhaps equally important, a quick diagnosis also decreases the probability that a patient will unwittingly infect others.
Methods for diagnosing HIV infection have been around since the late 1980s. Until recently, most HIV tests carried out in the United States involved sending a blood sample to a clinical laboratory. The results were communicated to the tested individual several days later. The time lag between testing and communication of results was a serious problem, particularly for people who aren’t part of a well-organized healthcare system. In the United States, for example, studies have found that many homeless or uninsured people tested for HIV infection in public clinics never bother to find out their results if they aren’t provided on the same visit. In the last five years or so, HIV tests have come on the market that can be carried out at the point of care, with little specialized equipment, while retaining the sensitivity and accuracy of laboratory-based diagnostic methods. Rapid, FDA-approved point-of-care HIV tests have been enthusiastically endorsed by the United States. Centers for Disease Control, and will make a huge impact in the resource-poor settings where most HIV infections occur.
Dr. Hermes Chan was still a graduate student when he developed a method for detecting specific antibodies in fluids (such as blood) as they flow over and through a membrane support. Antibodies are proteins produced by our immune systems to defend the body against foreign invaders. The presence of antibodies in the blood that react strongly with a particular microbe (such as HIV) indicate that a person has been infected with that microbe. Dr. Chan founded a company, MedMira, to commercialize diagnostic tests based on this technology. The most remarkable feature of these tests is that someone who isn’t an expert in clinical microbiology can safely and accurately carry them out in minutes. MedMira now markets tests for infection with HIV, Hepatitis B, and Hepatitis C. The RevealTM HIV test is the fastest on the market, requiring only 3 minutes for an answer, but it has the sensitivity and accuracy of competing point-of-care HIV tests, at a comparable cost of less than $20 per unit. MedMira’s most recent product, the MultiploTM HIV/HBV/HBC test, allows simultaneous testing for HIV, Hepatitis B, and Hepatitis C infections within a single test unit, using a single drop of blood. Co-infections by these viruses often occur in risk groups such as injection drug abusers and commercial sex workers. MedMira’s diagnostic devices have been approved by United States and European Union regulatory authorities. The company is pursuing African, Asian, and Latin American markets, and working with international public health agencies to make these tests available globally where they can have the greatest impact. For more information on Multiplo and MedMira, see www.medmira.com. Pesticide Action Network North America –– United States
High-productivity, industrial-scale agriculture often relies heavily on the use of chemical pesticides to reduce damage from insects, and on herbicides to minimize competition from weeds. In large agricultural operations, these chemicals are often applied through aerial spraying. Unfortunately, when released into the air these compounds can drift from their target site, and many pesticides and herbicides are known or suspected to have harmful effects on human health. The low-income communities located next to many agricultural areas suffer the most, but defending these marginalized communities requires data––proof of exposure that can be provided as evidence to confront sprayers, or convince the legal system or regulatory agencies to take action.
Dr. Susan Kegley, a scientist with the Pesticide Action Network of North America (PANNA), invented the Drift Catcher, a user-friendly air-sampling device that can be employed to measure concentrations of airborne pesticides. The Drift Catcher contains a resin bed through which air is pumped at a defined rate. The resin traps chemicals that can be extracted and analyzed in a testing laboratory. Before Drift Catchers are deployed in a community, PANNA thoroughly trains and certifies community members on proper use of the instrument, so that the resulting data reliably documents pesticide concentrations.
In the past five years, PANNA has undertaken 16 projects in nine states using the Drift Catcher to monitor pesticide drift and exposure. In Tulare County in southern California, for example, the community group El Quinto Sol monitored drift of the insecticide chlorpyrifos from orange orchards into homes and yards in the town of Lindsay. Inhaled chlorpyrifos can cause headaches, nausea, dizziness, and even convulsions, and there is particular concern about potential neurological effects on children from prolonged exposure to this chemical. Drift Catcher monitoring in Lindsay in the summers of 2004 and 2005 revealed chlorpyrifos levels several times higher than the concentration limit that the United States Environmental Protection Agency considers acceptable for children. PANNA and El Quinto Sol followed up this data by measuring pesticide residues in the urine of residents of Lindsay, clearly establishing excessive exposure to chlorpyrifos. The publicity and public debate that followed these results contributed greatly to a new law in Tulare County that, as of 2008, bans aerial spraying within a quarter mile of homes and schools. Other Drift Catcher projects in the United States involving chlorpyrifos are building momentum for a ban on this compound. Whether that will, or should, happen will likely be determined by a debate that involves politics and economics as much as science. The use of chemical pesticides is a complex and controversial topic, but the Drift Catcher is allowing marginalized communities to generate solid scientific data on their own pesticide exposure, so they can have a full voice in this debate. For more information on PANNA and the Drift Catcher, see www.panna.org/drift/catcher. Sanoussie Diakite –– Senegal
Farming in the hot, dry climate of West Africa, on the edge of the Sahel, is a precarious way of life. Rain comes just a few months of the year, and soils are often shallow and poor. Few food crops are well suited to these conditions, but fonio is an exception. Fonio is indigenous to the region, and grows prolifically without irrigation or fertilizer. Its grain is nutritious and tasty, and is harvested during the dry season when other food stocks run low. But fonio has drawbacks––the edible grain is extremely small, a millimeter or less, and getting at it requires removing a tough husk. The laborious job of processing the grain by pounding, winnowing, and washing inevitably falls to the women of a household or village.
Sanoussi Diakite, a Senegalese engineer, inventor, and teacher, developed the first machine for mechanical removal of husks from fonio. Since his first prototype in 1993, Diakite has continued to improve the device. The current husker can produce 40 kilograms of high quality grain per hour, a big improvement over the single kilogram or so that a woman can generate by hand in the same time. The mechanized husker allows the production of more healthy food, in less time, and with less physical labor––a major advance for the subsistence farmers of Senegal and neighboring countries.
Mechanical huskers are encouraging more fonio cultivation in West Africa. Fifty of Diakite’s machines are in action in eight countries, helping thousands of farmers to improve their lives. Prepared fonio grain is a valuable cash crop in Africa, and can be exported to Europe. Communities served by mechanical fonio huskers reap significant economic benefits. They can mechanically process more grain than they need for their own consumption, so they sell the surplus, which is more valuable after de-husking. Diakite’s huskers are currently built by students at the Maurice Delafosse industrial high school (Lycée technique industriel Maurice Delafosse) in Dakar. Diakite is working with villages and government ministries to encourage fonio cultivation, and hopes to establish a factory to manufacture mechanized huskers so they can be more widely distributed. Conclusions
The United Nations’ Millennium Development Goals (www.un.org/millenniumgoals) articulate the grave challenges facing billions of people living in economically underdeveloped nations. Several of the goals explicitly focus on health: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria, and other diseases. The deployment of innovative technologies is essential to achieving these goals by 2015, their nominal target. Technology alone can’t achieve the goals, but technological breakthroughs will certainly help prevent and treat diseases, reduce the costs of care, improve services, and bolster the global social and political will necessary to achieve these goals.
I’m writing this article from California’s Silicon Valley, an amazingly creative environment where thousands of bright people are constantly seeking the Next Big Thing in Technology. But achieving the Millennium Development Goals may not take a Next Big Thing––it might just take lots of clever little things that really work. That’s the key idea of appropriate technology––tools that work the best where they are needed the most. Some free software that lets public health workers collect data easily on a cell phone, a machine to crack and sift grain in the dusty villages of Senegal, a simple syringe modification that reduces hepatitis and HIV infections, a little plastic cartridge that can absorb a drop of blood and tell in a few minutes whether a person is infected with HIV, an air-sucking contraption on a pole that tells a town if its children are breathing noxious chemicals… these tools were created by smart, dedicated people who focused intently on what could get the job done. Let’s hope there are more Marc Koska’s out there, more Sanoussi Diakite’s, another Hermes Chan, some Joel Selanikio’s, and a few more Susan Kegley’s––we’ll need them all if we’re going to accomplish the Millennium Development Goals, and deliver the blessings of good health to all the world’s people.