Here’s a shocking statistic: 2.5 million children under the age of five continue to die each year from vaccine-preventable diseases. Vaccines are available, but lack of infrastructure often prevents them from reaching the remote and impoverished communities that need them most.
A new initiative pioneered by the non-profit organization Energize the Chain could hold the key to reducing this number dramatically and preventing needless deaths. The idea: use electricity from mobile phone masts to run vaccine refrigerators at sites in remote areas. ASAP spoke to the director of Energize the Chain, Dr Harvey Rubin of the University of Pennsylvania.
“Just imagine a kid who’s suffering from a vaccine-preventable disease; just to be able to impact this kid’s life – to keep him or her at home or in school, to keep the mother from worrying about taking her kid to a doctor in a remote health clinic – the day-to-day ripple effect is enormous. These kids are the most vulnerable in the world. To be able to do something for them has really motivated everybody involved in this project,” said Rubin, professor of medicine and director of the Institute for Strategic Threat Analysis and Response at Penn.
The project had its genesis in the aftermath of the 2010 earthquake in Haiti. Rubin received a late-night phone call from an actor-friend and neighbor, David Morse, a veteran of film and television whose credits include The Green Mile, 12 Monkeys and the medical series House. Shocked by the scenes of devastation and suffering circulating in the media – particularly, images of a young boy dying of diphtheria – Morse was compelled to call Rubin and question why children were dying of what is a vaccine-preventable disease.
“I told David that we have the vaccines, but the infrastructure to keep them cold has been destroyed,” recalls Rubin. “It’s something we call the cold chain”. Vaccines remain viable only as long as they are kept refrigerated at the correct temperature. Any break in the ‘cold chain’ – from manufacture all the way through to administration – leaves the vaccines vulnerable to spoliation. Between 25 and 40 percent of vaccines spoil during the transportation process. “David said, ‘So, go solve the cold chain problem’,” chuckles Rubin. “So we started thinking about it”.
The solution that Rubin and his colleagues pioneered is the idea of siphoning electricity from mobile phone masts in order to run vaccine refrigerators. This is made possible by the fact that mobile phone technology is spreading rapidly – there is expected to be 100 percent global coverage by 2015. “There’s plenty of electricity in the developing world because of cell towers,” Rubin said. “In the developing world the [mobile phone] industry is growing even more rapidly than in the developed world because we’re basically saturated here. These are private corporations which are either on the national grid or they have diesel, solar or wind backup, but their whole business model of providing cell phone coverage in the most remote parts of the world depends on having energy.”
Rubin and his colleague Alice Conant published a paper in New Scientist floating the idea. “We wrote that paper, people read it, we got invited to give talks around the world and, lo and behold, it’s actually happening.” From there, the idea snowballed. Rubin was invited to speak at a conference of mobile phone mast owners, operators and suppliers in Kenya. In the audience was Bernard Fernandes, a representative of Econet – a telecoms provider in Zimbabwe – who was so impressed by the idea that on returning home, he took it straight to Econet’s CEO, who greenlighted a pilot project which now runs on sites all across the country:
“Bernard was the local champion, the local hero,” Rubin beams. “He got his engineers to design it, he reached out to the public health service in Zimbabwe and he ran with it — which is exactly how we want it to happen. We want people to take this on as their mission, and Bernard is a perfect example of how this could lead to really wonderful things.” The feedback from the Zimbabwe project is encouraging: “We’ve heard it’s making a huge impact already. We would now love to do an academic study to measure the health impact of this solution, to get the hard data to really prove that this solution is one that can be rolled out globally and really make a health impact.”
Rubin’s ambition is for the initiative to be rolled out across the world via locally owned, locally run programs. There are discussions around launching similar projects in Kenya, Nigeria and Argentina, and an Indian launch is imminent. Karuna Trust, which runs a number of health clinics in the Karnataka region, is committed as the Indian health service partner; Indus Towers, which operates more than one million masts across the country, and Vodafone are on board from the telecoms side. Conant is due to visit India in the summer of 2013 to solidify the arrangements.
While there are plenty of countries interested in implementing this initiative, Rubin acknowledges “our real limitation is the human resource.” As the technology expands in the future, Rubin envisions a super-efficient system made possible by the central connectivity of masts: “Once we put ID tags and remote sensing in the refrigerators, we’ll be able to conduct real-time inventory control – we’ll know which fridge is running low on which vaccines. That way the healthcare worker doesn’t have to carry vaccines that don’t need to be replaced. We’ll be able to say, ‘Go to this location and replenish it with X vaccine.'”
A persistent challenge to implementation, Rubin observes, is cementing successful public-private partnerships between the telecoms industry and ministries of health, which are regulated by local governments. “The hard part is getting the partners to sit down with each other and sign memorandums of understanding,” he said. “The real issue is that the health ministries want to be sure that the cell towers are there for the long term – they don’t want to change their processes and procedures if the cell towers are there only while a particular CEO or champion is there. Likewise, the cell tower companies want to be sure that the health ministry is there for the long term. So this is a lot about educating both sides, so the public-private partnership can work even when we’re not there. And that’s because these are two industries, two segments of the economy that generally don’t speak to each other. When they realise that they both have so much to gain, they generally come together.”
The political component of this initiative is certainly important. There are several issues to consider: who pays for new vaccines? Who pays for distribution? “If we expand the cold chain and make it much more efficient, new polices will have to come into play,” muses Rubin.
So what’s in it for the telecoms companies? “The cell tower operators gain a lot by it: they gain great recognition in the remote villages and [compliance with] corporate social responsibility. They all want to do something that benefits the communities that they serve, and when they are presented with the idea that this could help the communities and in fact doesn’t cost that much – we calculated that in India it costs just [US] 60 cents per day to run one of these refrigerators – I think once the cell tower companies understand the economics, they’re more than willing to be on board, so I’m hoping that this is something that most cell tower companies will embrace. The one thing I really want to do is not put too much burden on the telecoms companies – it’s great that they’re providing the energy, but I don’t think it’s necessarily their job to replace or augment the healthcare industry.”
It might seem strange that very poor communities will have extremely limited public health infrastructures but a highly developed telecoms industry. While Rubin is careful not to pass judgement on the failures of local government when it comes to infrastructure, he concentrates on the fact that this initiative can help to address how to best use the often minimal infrastructure that is in place: “Our solution makes it much more efficient to distribute vaccines, so that even with a less-developed health infrastructure, because the towers are remotely placed – we don’t rely on every step along the cold chain to have somebody responsible for them – we can maximally use the minimal health infrastructure that’s in place. Part of this whole process is educating people. We need to help educate people on how to use the solution, how to use the health infrastructure effectively. How do we really make that balance?”
When quizzed on whether local governments should make it mandatory for the granting of planning permission for telecoms companies to install vaccine fridges at mast sites, Rubin is cautious, but optimistic: “That would be ideal. Wouldn’t that be great if that happened? I don’t know enough about local regulations, but I can certainly see how telecoms companies could get tax or licensing benefits if they agreed to put this in place.”
Regardless of the initial enthusiasm, with so many parties and components involved, there must have been several obstacles in getting the initiative off the ground. “The biggest obstacle is the human interaction. The only obstacle we’ve found is the two different sides – the public and the private – getting comfortable with each other. The technology is very easy – there’s no new technology that we have to put in place; the cost is minimal. The interesting part of this solution is the human relations. Again, once people realise that it’s not going to cost them a lot of money, that the health ministry will be able to use [the resources] very effectively, people say, “Yes, this is a great solution – we all win”. Most importantly, the children win. And that’s really what we’re in it for.”
And what would Rubin say to the skeptics? “A pandemic is not going to start on Broadway and 42nd Street in Manhattan or Piccadilly Circus [London]; a pandemic is going to start somewhere in a remote part of the world. We have to be able to get vaccines to that part of the world. Having the ability to keep vaccines cold and the cold chain in tact is going to protect everybody. We try and make the case that this is good for the developing world, but in fact if you want to step back and look at the global picture, it’s really important to make sure that if something really starts happening in the developing world, that we – as the developed world – can get vaccines and know that they will be delivered effectively, efficiently and safely. This [solution] stands alone: this is good for children under the age of five in the developing world, but when some of the bureaucrats in the developed world say ‘What do I care about that?’ I say, ‘It could be you that’s going to be affected down the line somewhere.’ And then they stop and think maybe that’s important.”
Can Rubin envisage a world free of vaccine-preventable deaths? “No vaccine is 100 percent [effective], but I can foresee many, many, many fewer deaths. Measles and polio are tremendously important diseases to prevent. No vaccine is 100 percent, but even if it’s 80 percent to 90 percent, we’d make an enormous impact.”
Rubin was slated to take part in a UNICEF-hosted meeting in June aimed at bringing together all the partners (including telecoms companies, the pharmaceutical industry, health ministries, courier companies, energy companies and parties from the remote-sensing world) interested in this initiative in order to consider how to roll it out globally. He was hopeful about possibilities from that meeting and moving forward.
He ended on a thought-provoking note: “Who knows? Maybe eventually we’ll have an HIV or malaria vaccine; [using this initiative] they’ll all be able to be given safely across the globe. The impact would be enormous.”