A new Ebola outbreak in the western Congo is under control – an achievement that global health leaders have largely attributed to the obvious success the experimental Ebola vaccine and the public health campaign that allowed for its distribution in a country with few paved roads and an unreliable power supply.
The urgency of the outbreak prompted larger donors such as the Gates Foundation to invest in products such as high-tech coolers that could maintain the "cold chain" – a cold chain necessary to prevent spoilage before delivering vaccines to patients.
It would be easy to celebrate how the Ebola vaccine and these coolers have solved Ebola's urgent health crisis. But they do not have. In fact, the move to high-tech vaccine distribution solutions has blurred the more pressing issue: the need to address the underlying infrastructure issues that make their use necessary. While systems such as affordable, reliable solar energy and clean drinking water can not attract attention in the long term and are being investment by Western governments and non-profit organizations. However, this is the most effective way to prevent future outbreaks and to improve primary health care in Congo and other countries.
Many countries in Africa have long struggled not only to gain access to vaccines and medicines, but also to the resources needed to safely transport and store them. When I visited the Saké / Afya Health Center in the province of North Kivu in the Congo in 2011, there were only a few supplies. No drugs, no vaccines, no bandages – even though it had a fridge. The refrigerator had been donated by a major Christian humanitarian aid group to help store medicines and vaccines in the cold chain, but it never worked.
The widespread gas shortage meant that there was no fuel for the generator that powered the refrigerator, nor the lighting needed to treat patients at night. In view of this lack of fuel or electric grid, the refrigerator has done little to preserve the cold chain or the cause of the delivery of life-saving vaccines.
Concerns about the cold chain of the vaccine and the technologies developed to overcome the limited infrastructure in rural areas are attributed to the development of the freeze-dried smallpox vaccine in the 1950s. This breakthrough enabled public health officials to vaccinate people in the remotest parts of the world where it was impossible to vaccinate vaccines. In 1980, smallpox was the first (and so far only) disease successfully eradicated worldwide.
Inspired by the success of smallpox vaccine and its effective distribution, as well as by a vaccine boost from the World Health Organization (WHO), the non-profit program for Adapted Healthcare Technology (PATH) has found a solution to the cold chain affliction that plagued childhood vaccination campaigns in rural areas. PATH received financial support from U.S. Pat. Agency for International Development (USAID),
These efforts had to begin at the most basic level: identifying if and when vaccines were 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 if a vial is safe to use. VVMs became compulsory for all WHO-controlled vaccines in the early 1990s, and to date more than 5 billion vials have been distributed with VVMs.
This helped to reduce the spoilage of vaccines. For example, after a power outage, health workers would definitely know if the vial was exposed to too much heat instead of discarding the whole lot. In addition, the geographical scope of vaccination campaigns has been extended beyond the boundaries of the cold chain. Vials could now leave the relative safety of their refrigerators and drive with health workers to remote villages, as they could be used until the VVM became opaque.
The VVMs were part of a broader movement to create "suitable technologies" for developing countries in the late 1970s – a corrective to large-scale modernization projects funded by foreign aid in the 1960s, which largely benefit only developing-country elites. This was in parallel with a WHO campaign to promote a broad and comprehensive approach to meeting the need for primary care throughout the world. These two campaigns should go hand in hand: small, cost-effective, community-based interventions such as VVM should complement the provision of primary care.
But in practice, these technological measures often prevent the development of the critical infrastructure needed to provide health care to people in rural areas with limited resources. In the 1980s and 1990s, when the International Monetary Fund and the World Bank imposed strict spending cuts on their loans, the impoverished countries could not afford to develop basic medical care systems or basic infrastructures such as sewer systems and power grids that alleviated disease and improved access to care.
Foreign aid donors were more inclined to invest in discrete technologies such as VVMs than they did in primary health financing. Easy-to-calculate cost-effectiveness metrics prompted donors to focus on "selective" primary health care practices – growth monitoring, oral rehydration, breastfeeding and immunization (GOBI) – no comprehensive routine care or infrastructure to support them.
As a result, investing in new technologies to improve GOBI metrics has become a key strategy. In an American economy that was still stumbling after stagflation and a major recession, this approach offered the additional benefit of keeping many research dollars at home. It also meant that donor governments and organizations could operate relatively independently and prioritize – without the explicit need to partner with local governments as investment in basic infrastructure would require.
But the consequences of this investment pattern are clear in Congo today. After four decades and billions of dollars, the need for a comprehensive health infrastructure remains. The new Ebola vaccine underscored this blatant need by keeping it frozen at far lower temperatures than other vaccines, while epidemiologists and health workers sometimes travel to rural villages for days to find their contacts. Roads and grids would greatly facilitate the distribution of vaccines at the right temperature and facilitate access to clinics; Clean water and sanitation systems would primarily prevent many diseases.
Today, philanthropic efforts, non-Western governments, global health financing dominate. But these organizations continue to focus on developing small solutions to overcome infrastructure deficits, not long-term investments, to tackle these issues at their roots.
The Gates Foundation is a major player in this field. Gates-funded projects include the Arktek cooler, the MetaFridge, and the Indigo cooler, which enable vaccine storage for longer periods of time without power. The global vaccine alliance Gavis "Got Life" initiative also utilizes a market-driven approach in partnership with the private sector to fund the acquisition and maintenance of modern cold chain vaccine storage technology.
The resulting new technologies provide just enough "fix" that the need to tackle underlying infrastructure problems in many of these countries can be avoided.
Except when they can not.
The refrigerator at the Saké / Afya Health Center never worked. Today, the center could be given an indigo cooler instead of a refrigerator during an outbreak. Massive investments in new coolers are exciting and really contribute to the immediate outbreak fight, but it's not a long term solution.
If this money were focused on strengthening and sustaining infrastructure and supply chains in developing countries, many of the humanitarian innovations of the US technology industry would disappear and more sustainable, self-sustaining communities around the world would emerge. If we are serious about building capacity and self-reliance, we have to learn from history.