A recent Ebola outbreak in western Congo is under control — a feat global health leaders have attributed in large part to the apparent success of the experimental Ebola vaccine and the public health campaign that enabled its distribution in a country with few paved roads and an unreliable power supply.
The urgency of the outbreak spurred investment by larger donors, including the Gates Foundation, in products such as high-tech coolers that could maintain the “cold chain” — a refrigerated supply chain necessary to prevent spoilage before vaccines can be administered to patients.
It would be easy to celebrate how the Ebola vaccine and these coolers have solved the pressing health crisis posed by Ebola. But they haven’t. In fact, the turn toward high-tech solutions for distribution of vaccines has overshadowed the more pressing issue: the need to solve the underlying infrastructure problems that make their use necessary. While scaling up systems such as affordable, reliable solar energy and clean drinking water may not attract long-term attention and investment from Western governments and nonprofit organizations, this is the most effective path to preventing future outbreaks and improving basic health care in Congo and other places.
Many countries in Africa have long struggled to maintain access not only to vaccines and medicines, but also to the resources to transport and store them safely. When I visited the Saké/Afya Health Center in the North Kivu province of Congo in 2011, it had few supplies. No drugs, no vaccines, no bandages — though it did have a refrigerator. The fridge had been donated by a large Christian humanitarian relief group to support cold-chain storage for drugs and vaccines, but it had never worked.
Widespread gas shortages meant there was no fuel to operate the generator that powered the refrigerator or even the lights required to treat patients at night. Given this lack of fuel, or an electric grid, the refrigerator did little to preserve the cold chain or further the cause of administering lifesaving vaccines.
Concerns over the vaccine cold chain and technologies developed to overcome limited rural infrastructure can be traced back to the development of the freeze-dried smallpox vaccine in the 1950s. This breakthrough allowed public health officials to vaccinate people in the most remote parts of the world, where refrigerating vaccine vials was impossible. In 1980, smallpox became the first (and so far the only) disease successfully eradicated worldwide.
Inspired by the success of the smallpox vaccine and its effective distribution, as well as an immunization push by the World Health Organization (WHO), the nonprofit Program for Appropriate Technology in Health (PATH) set out to find a solution to the cold-chain woes that plagued childhood immunization campaigns in rural areas. PATH received funding from the U.S. Agency for International Development (USAID).
These efforts had to start at the most basic level: identifying if and when vaccines had spoiled. Using technology from the food industry, PATH developed the vaccine vial monitor (VVM), a small, heat-sensitive label that changes color when the vaccine is exposed to heat. Based on the color of the VVM, health workers know whether a vial is safe to use. VVMs became mandatory on all vaccines quality-controlled by the WHO in the early 1990s, and to date, more than 5 billion vials with VVMs have been distributed.
This worked to reduce vaccine spoilage. After a power outage, for example, health workers would know definitively whether the vial had been exposed to too much heat, rather than throwing out the whole lot. It also expanded the geographic reach of immunization campaigns beyond the limits of the cold chain. Vials could now leave the relative security of their refrigerators and travel with health workers out to remote villages, since they could be used until the VVM turned opaque.
The VVMs were part of a broader movement to create “appropriate technologies” for the developing world during the late 1970s — a corrective to the large-scale modernization projects funded through foreign aid in the 1960s, projects largely seen as benefiting only developing-country elites. It paralleled a campaign by the WHO to foster a broad-based and comprehensive approach to meeting basic health-care needs around the world. These two campaigns were meant to go hand in hand: Small-scale, cost-effective, community-based interventions such as VVMs were meant to complement the provision of primary health care.
But in practice, these technological fixes often forestalled efforts to develop the crucial infrastructure needed to provide health care to people in rural, resource-strapped locales. When the International Monetary Fund and the World Bank imposed strict spending cuts tied to their loans in the 1980s and 1990s, impoverished countries could not afford to develop primary health-care systems or basic infrastructure such as sewage systems and electric grids that reduced disease and improved access to care.
Foreign aid donors were much more inclined to invest in discrete technologies such as VVMs than they were to bankroll primary health-care systems. Easily calculated cost-effectiveness metrics drove donors to focus on “selective” primary health-care practices — growth monitoring, oral rehydration, breast-feeding and immunization (GOBI) — not comprehensive routine care or infrastructure to support it.
As a result, investment in new technologies to improve the GOBI metrics became a key strategy. In an American economic landscape still tottering after stagflation and a major recession, this approach offered the added benefit of keeping many research dollars at home. It also meant that donor governments and organizations could operate and set priorities relatively independently — without the express need to partner with local governments as investment in basic infrastructure would require.
But the consequences of this pattern of investment are clear in Congo today. After four decades and billions of dollars, the need for large-scale health infrastructure remains. If anything, the new Ebola vaccine highlighted this glaring need, because it must remain frozen at far lower temperatures than other vaccines while epidemiologists and health workers travel, sometimes for days, to rural villages to track down contacts of those exposed. Roads and power grids would greatly facilitate vaccine distribution at the correct temperature and enable people to more easily access clinics; clean water and sewage systems would prevent many diseases in the first place.
Today, philanthropic endeavors, not Western governments, dominate global health funding. But these organizations still remain focused on engineering small-scale solutions to overcome infrastructural deficiencies, not large-scale, long-term investments to tackle these problems at their roots.
The Gates Foundation is a major player in this sphere. Among Gates-funded projects are the Arktek cooler, the MetaFridge and the Indigo cooler, all of which enable vaccine storage for substantial periods of time without power. The global vaccine alliance Gavi’s “Got Life” initiative also uses a market-driven approach in partnership with the private sector to fund the acquisition and maintenance of modern cold-chain technology for vaccine storage.
The resultant new technologies provide just enough of a “fix” that the imperative of addressing the underlying infrastructural issues in many of these countries can be avoided.
Except when they can’t.
The Saké/Afya Health Center’s fridge never worked. Today, the center might be given an Indigo cooler instead of a refrigerator in an outbreak. Massive investment in new coolers is exciting and genuinely contributes to immediate outbreak control, but it is not a long-term solution.
Directing that money toward bolstering and maintaining infrastructure and supply chains in developing countries would obviate many of the U.S. tech industry’s humanitarian innovations and build more sustainable, self-sufficient communities around the world. If we are serious about building capacity and self-reliance, we need to learn from history.