walkitout (walkitout) wrote,

Our Future: Cheap Power and Satellite Internet to Improve Healthcare

I waste a lot of time on the Internet. I have some preferred sites (such as Business Insider and various Nick Denton blogs, such as Jezebel and Gawker), but I also look around at what my friends are excited about and posting links to on FB and I poke around on Google News and so forth. Every little bit, there’s like a supersaturated solution moment, like when you’re making the coconut frosting for German chocolate cake, where the liquid that is … liquid suddenly stops being liquid. BOOM. Suddenly, everyone is all yelling about the same thing.

Currently, it is measles and vaccines.

I have basically the same response every time this happens. If it’s German chocolate cake frosting, I pause, and go, What the Fuck was I thinking making this? I’ll eat the entire thing and gain an outrageous amount of weight. When it is something in the news cycle, the response is more or less: this problem has been around a long time, and it used to be way worse so why are you all excited about this _NOW_. Further, the actual solution can be found _here_, so why are you all screaming about _that thing over there_?

So about those measles vaccines.

Measles vaccines are like a lot of persistently difficult parts of our public health and healthcare systems. They require power, and I don’t mean some psychological or political thing, I mean they require consistent refrigeration, a cold chain. They present an unpleasant tradeoff -- if you deliver this thing to everyone who needs it, someone is going to get sick and maybe die that otherwise would have been fine. You are trading (hopefully more) of one kind of death and disability for (hopefully less and less severe) another variety of death and disability. Measles vaccines -- like a lot of treatments -- is often not a one-and-done, but requires additional doses, which means you have to decide between “over dosing”, but making sure everyone gets enough by overshooting on a lot of people, or you have to take on the additional cost of tracking who got which treatment when and paying attention to the effects.

To sum up: if you want to actually stomp out measles in a population over time, you have to (a) acquire and deliver the vaccine to the people who need it, which means you need a cold chain and transportation infrastructure either for the vaccine or the people or both, (b) documentation of who has received what vaccine when and what the results were. IF YOU DO NOT track the results, you risk an ineffective campaign because people said they vaccinated that village but they didn’t really bother to drive all the way out there and spend hours educating everyone there on what this needle thing was all about. You also risk increasing resistance to all future, similar campaigns, if you are causing some kind of horrible secondary problem (you know, reusing needles and spreading some blood borne disease, type of thing, LIKE WE USED TO DO) that you did not anticipate.

People who actually do this kind of thing for decades at a time have tried virtually every combination of technologies currently in existence to accomplish these goals. Here in the very wealthy United States, our vaccination records are stored in computers and increasingly in the cloud and there’s plenty of reliable transportation and power infrastructure to keep everything cold and track expiration dates and get clients to the shots or vice versa. But it was not always so. There was a time where oral vaccines were important, because syringes were uncommon. The world of our childhood (or our parents’ childhood or our grandparents’ childhood) was a world in which children didn’t get their vaccinations at the doctor, but rather at school. If a record was kept, it was either on the school record, or it was in the memory of the child and their parents, or on a little paper card that must not be lost.

That American world of seemingly so long ago still had far more reliable transportation and power and thus refrigeration than the world of today in rural areas of the developing world. And just like the American world of seemingly so long ago solved communications needs by building landlines everywhere -- which is too expensive to do even today in those same rural areas -- the American solution to delivering power and thus refrigeration everywhere doesn’t work so well in rural areas of the developing world.

Furthermore, the resource availability in rural areas of the developing world is so foreign to anyone who has spent a significant fraction of their formative years in the United States that no matter how bright we are, we cannot come up with viable solutions that will work well in those place. It isn’t just what the developing world _does not have_ or is too expensive to be widespread. It is also what the developing world _does have_, that is unimaginable even when viewed through a historical lens in a United States context. For example, the American experience has always been one of labor shortage. Automation and technology to replace the need for people is almost always cheaper, and if it isn’t now, it will be later. That is so normal to us, and has been throughout our few centuries of history, that we reliably err in focusing on cheap but automated solutions for regions that have plenty of available humans to help out … but no power. Not even enough to recharge the battery. And no way to replace parts including the battery. And a distinct lack of technical expertise to maintain the system or figure out what is needed to fix it. Etc. (My best example of this is an MIT contest from a few years back to develop an inexpensive incubator for developing nations. If at any point in the discussion, anyone at all had said, “for when kangaroo care is inadequate”, I’d have been A-O-Good with the contest. But no one did, and the results of the contest were uniformly worse than kangaroo care. Crazy, hunh?)

In addition to this basic level of ignorance that is insuperable for anyone not living in the target context (and, honestly, should have grown up in that context, or it just doesn’t seem real enough, apparently), well meaning efforts to help in the developing world are hampered by a pair of traits characteristic of charitable endeavors: an insensitivity to feedback and a fundamental lack of awareness and/or respect for the values of the target context. Public policy is driven by visible body count. The visibility part is super important. If everyone has become accustomed to a certain number and kind of deaths (car accidents, heart attack subsequent to decades of smoking), an educational campaign will be necessary to make those deaths visible again. But the count matters, too. You aren’t going to get people to focus on tens of thousands of deaths due to Disease A if they are focused on the hundreds of thousands of deaths due to War B. Other factors matter, too, for example, cigarettes are incredibly effective at managing moment to moment anxiety, which is why so many soldiers survive wartime only to die of the addiction that helped them manage their emotions during that war. While they were being shelled, the cigarette seemed like the least of their concerns, and if you ignore that, they won’t listen to you, either. Why should they?

With this as background, why do certain developing nations, such as the Philippines and some African countries continue to have comparatively high numbers of measles? Because it is ONLY COMPARATIVELY. I want to point out that globally, the number of cases of measles has been dropping for a long time. The last major outbreak in the US in the late 1980s, early 1990s, had something like 30,000 cases. Annual cases of measles around the world are down to less than 10x that figure. It is an almost unimaginable degree of success. With no animal reservoir for measles, eradication is in sight and has been a goal for many globally for over 10 years. At this point, the United States and other nations such as Australia have so few cases of measles that vaccinating the entire population just to deal with a few traveler brought-in cases of measles is increasingly difficult to justify to the population at large.

Vaccines have side effects. Live vaccines have a bunch of risks associated with them that killed vaccines do not, in addition to the cold chain requirement. Any population being vaccinated against a disease which is very rare is going to look at the tradeoff of risks between the vaccine and the odds of catching the disease and start asking some hard questions. With smallpox, we quit vaccinating the population at large before global eradication, to address the horrifying risks associated with that vaccine. With the live polio vaccine, we switched to the killed polio vaccine, when all of the cases of polio in the United States were _side effects of the live vaccine_ and had been for a few years and it was getting to be really embarrassing.

Here’s a nifty little chart comparing some diseases and how we are doing with vaccination vs. the calculated levels needed for herd immunity.


As you can see, pertussis and measles -- the two most objected to parts of the current vaccine schedule in developed nations, due to high rates of “mild” adverse effects -- require incredibly high vaccination rates to develop herd immunity, in part because they are both incredibly transmissible.

As that same page notes, even with herd immunity, you’ll still get outbreaks. EVEN IF we stomped on every person who opted out of immunizations for religious or philosophical reasons -- basically, adopt Mississippi style rules for the whole country. Let’s think about that: Let’s Be More Like Mississippi! Good luck with that slogan. I’m not going to participate -- there would still be a fraction of the population who it would be medically unwise and scientifically pointless to immunize, because the immunization would not “take” and it would further compromise their already poor health (even Mississippi allows for medical exemptions). And this population -- as they know, and as their families know -- would allow outbreaks to recur whenever they encountered a person who had measles.

Since we instituted the school based requirements for vaccinations and the audit trail associated with those requirements (roughly around 1990, associated with the last large outbreak of measles in the US), we have seen a decrease in measles in the United States and other developed nations with similar requirements, to the point where it has been locally eradicated. We have also seen the cases that do occur are in groups (such as a church in Texas) that oppose vaccination. Cases occur in these groups when the group interacts with someone who travels to and/or from a region where measles is still common.

If we would like to completely eliminate measles in the United States, we need to get rid of it in developing nations. (I am tossing out pre-emptively the idea that we could just ban all travel to and from places which have measles and/or requiring a 21 day quarantine for anyone who had been to such a place. If you want to entertain that as an idea, that’s all on you.) We should want to do this anyway (why should they suffer from death and disability from a disease that is so readily avoided?), but even if we don’t care about their children, this is, ultimately, what we need to do if we care about our own children getting measles. And if we are going to meaningfully support developing nations in eradicating measles (and, hopefully, other diseases over time), we are going to have to understand why it is difficult to get even the voluntary vaccination rates which we have here in the United States.

Cost issues were an obstacle for vaccines in the United States up through the early 1990s. California’s late 1980s/early 1990s epidemic of measles was disproportionately in poor, Hispanic communities. Education and school requirements helped, but making the vaccines free to the recipient (and making sure the families knew there would be no appointment cost, either) was important to making sure those vaccines got where they were needed. While vaccines seem very cheap to us in the United States now, that cheapness is relative. Wealthy nations such as the United States must be prepared to meaningfully support the cost of vaccination in developing nations. And I argue that support must be consistent over time if it is to be truly effective.

The cheapest way to increase vaccination rates in a developing nation is to do a mass campaign. This is what the Philippines has been doing. Unfortunately, for a highly transmissible disease such as measles, particularly in a youthful population producing many babies every year, such as the Philippines, the number of unvaccinated people each year _after_ the mass campaign is over grows until it is large enough to support a widespread outbreak. We can see this clearly in the decrease in measles after the 2011 campaign, that then rose again. The 2014 campaign will cause a similar drop, but the implications are concerning. Should they really have to do a mass campaign -- vax everyone from 9 months to 5, regardless of vax status, every 18 months just to prevent further outbreaks? Why is it so hard to do it _there_ the way we do it _here_?

And so I return to the beginning of this very long disquisition! As hard as it is to drive refrigerated trucks to rural locations every few years to deliver vax to all the kiddos, those trucks can have batteries and generators and be kitted out to drive on terrible roads. The population can be informed via radio and other broadcast means of the event well in advance so they can travel to where the trucks will be. And there is much less documentation cost -- just the cost of the trucks, the ads, and all those disposable needles and the people to deploy them and disposing of the sharps appropriately later (if you think about this, I think you’ll see why requiring new gloves for each vax is such a high bar, outside wealthy locations in the United States -- and which is why you don’t necessarily see gloves on the nurse giving Rand Paul a booster in Kentucky). In order to vax kids as they hit certain milestones, you’d have to ensure vaccine supplies and a cold chain and someone with enough expertise to deploy them at much, much more frequent intervals, and you’d need to be able to document what you did and associate that information with the child and access it later on.

I can’t tell you how to make that happen, because I’m a rich person in a rich country. But I can tell you how it _won’t_ happen. It _won’t_ happen by turning the Philippines into 1960s United States, with ribbons of highway everywhere and cheap gas for gas guzzling cars. It _won’t_ happen with miles of poles along those highways, delivering cheap electricity from cheap coal power to households excited to have a modern electric refrigerator to replace the icebox that never really kept the milk cold in the summer time.

Here’s how it might happen. It might happen with tin-roofed, cement block clinics at schools with solar panels on the roof, maybe a wind turbine. Especially if there was a dish on the roof of that clinic that enabled reliable, satellite based internet to store the records for all the kids in town, so that if the family up and moved to the big city, they could still figure out what the kid had and had not received in the way of medical care and vaccination and schooling. But if there is something more important to the people who live in that village, more important than vaccinating their kids against measles, that is going to call on that power from the solar panels and the bandwidth from that satellite based internet, well, we’re fucking going to have to fix _that_ too, if we’re ever going to solve our measles problem. This is the same problem with nutrition support targeted to pregnant and breastfeeding women in desperately poor villages around the world. They share the food you send them with the rest of their family … first. Because those women care about their whole family, just as villages everywhere care about a lot more than just measles.

So the next time you’re sitting there whinging on about bad it is for the climate that developing nations are becoming more like us, well, think about how well that sits with your desire to eliminate measles. And not just measles.

ETA: For that matter, if you want to ever see a world with no measles vaccine in it, the fastest, most effective way to that world is probably the same way we got to a world with no smallpox vaccine in it.
Tags: health, our future economy today, politics
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