Social Business: a new model for bringing biomedical technology to communities in need

Although this site is primarily about biomedical technology that address global healthcare needs, I have decided the expand the scope some, to include discussion on the sustainability of such a proposition. Over the next few weeks, I hope to do several updates on what I’ve been learning as I think and read more about this. The motivation for this exercise is quite straightforward: I am not at all sure that I (or anyone else??) have the final word on the best way to bring biomedical technology to communities in need in a sustainable and humanistic fashion.

This blog entry will briefly discuss the model of “Social Business,” as proposed by Professor Muhammad Yunus, the founder of the Grameen Bank in Bangladesh, and the recipient of the 2006 Nobel Peace Prize. Professor Yunus, better known as the Banker to the Poor, is the father of the concept of microcredit, giving tiny loans to very poor people, whom no conventional bank will consider creditworthy. Based on a unique model of social responsibility (group-based credit primarily to poor women without requiring any collateral), Grameen Bank has been able to become a prosperous business entity with a loan repayment rate of over 95%, which according to the Wall Street Journal is “almost miraculous!” Of course, Yunus did not stop with the Grameen Bank, but went on to develop several other institutions, among them the concept and practice of social business.

Until I read Yunus’s book, “Creating a World Without Poverty,” I was only aware of three models by which a technology could be transferred to a community in need. These would include (1) for-profit business, (2) non-profit organizations (NGOs), (3) governmental and inter-governmental agencies. In terms of bringing new technology into a deserving community, I had thought that non-profit might be the best, since making maximum profit for the shareholders seems intrinsically incompatible with bringing maximal benefit to most people at least cost. Governments, although they have access to enormous power and resources, appear unwieldy.

So, among the above-mentioned options, NGOs seemed to be the best bet. However, at the gut level, I have two strong reservations about traditional NGOs. (1) Any nonprofit agency depends on donor money for its survival. Thus, a large proportion of the time of people running a nonprofit goes in fundraising, rather than doing the work itself. (2) Although it is not universally true, it is very easy for an NGO based in a first world country and working in the developing world, to become paternalistic, often without the players themselves being aware of the subtle dynamics.

Social business, as proposed by Yunus, seems to be one way out of this conundrum. What I liked about the book was the very concrete definition of what constitutes a social business. Simply put, an entity qualifies as a social business if either of the following criteria are met. (1) In the first model, the entity functions at least as a non-loss entity, and aspires to make a profit. However, when a profit is made, it is not paid out to the shareholders as dividends; instead, it is either reinvested in the same business, or used to open a new one. (2) In the second model, dividends are paid; however, in this model, majority shareholders have to qualify as “poor,” based on a previously agreed upon, time- and place-dependent set of criteria. In both cases, the model ensures that the entity is a “business” – i.e., it functions in a competitive marketplace, is answerable to its shareholders and has to abide by standard business practice and ethics. Simultaneously, it ensures that it is “social” – where the stated purpose of the entity is social development and change for the poor people in a given geographical area. When running a social business, the people running it do not have to be torn between conflicting priorities of profit maximization and social good. Additionally, it is easier to find investors for such a venture, since they are ensured a return of their principal within an agreed upon time period. This also opens up the possibility of becoming an investor to people who might be otherwise unable or unwilling to give to charity. The people of the local community benefit both by the work being done by the entity, and the possibility of owning shares in the entity itself.

In conclusion, to an economics/business novice like me, the concept of social business seems like the best of all possible worlds. I would love to get feedback from readers.

FrontlineSMS:Medic: Text messages save lives

“Text messages save lives” announces a large red banner on the face page of the website for FrontlineSMS:Medic. True indeed!

The whole project began in the summer of 2008, when Josh Nesbit, a senior in the Human Biology program at Stanford University, with a concentration on International Health and Bioethics, traveled to St. Gabriel’s Hospital in rural Malawi. St. Gabriel’s serves a population of about 250,000 Malawians spread over an area 100 miles in radius. The poorest of the patients have to walk up to 100 miles to get to the hospital; while those with more resources can ride bicycles or oxcarts. Thus, as can be expected, people only come to the hospital when they must. In order to address concerns of peoples’ accessibility to the hospital, St. Gabriel’s has been using an approach that is becoming increasingly popular in similar clinics around the world. The hospital trains and employs volunteer community health workers who travel to the patients’ homes to check on them, deliver medication and serve as conduits of communication with the base hospital.

A problem that is often faced in contexts like this is the fact that the community health workers have to travel to places far from the hospital, and if they see something that might require immediate intervention, their only option is often to physically travel back to the hospital to make the report.

FrontlineSMS:Medic is poised to change this. FrontlineSMS is a mass text messaging software developed several years ago by software engineer and anthropologist, Ken Banks. It is available free of charge to nonprofits. FrontlineSMS:Medic is a specialized version developed for public health applications similar to one described above in Malawi, by a collaboration set up between Ken Banks, Josh Nesbit and a team of dedicated volunteer software developers and community activists. All it requires is community health workers equipped with the very basic mobile phones, some training in sending and receiving text messages, and one laptop in a central location (such as the local hospital) connected to a GSM modem and running FrontlineSMS:Medic. At very little cost even by local standards, a community health worker can be in instant contact with the base hospital, reporting in their day’s observations and any emergencies that might come up. Not only that, various automated routines can be easily set up. For example, any incoming message from a community health worker containing the name of a drug automatically sends back a response indicating the correct dosage, side effects and common cross-reactivities of that drug.

Further developments are on the horizon. For instance, charging the mobile phones in remote locations where the community health workers function can be challenging. Nesbit and collaborators are exploring several sources of cheap and easily transported solar panels, that can be used to charge the mobile phones when electricity is unavailable or unreliable. With proper planning, these panels can be shared between several community health workers working in a given area.

The team is also exploring the use of camera phones, so greater degree of multimedia use can be implemented.

There are also thoughts of eliminating the laptop altogether, which will further cut costs. One possibility being explored envisages the use of the Android – the new mobile platform from Google – as a hub for several dozen community health workers.

Similar projects based on FrontlineSMS:Medic are now being implemented in other countries such as Bangladesh, Burundi, Uganda and Honduras.

As technology gets further refined and operating procedures better ironed out, there is no doubt that projects using FrontlineSMS and possibly other similar applications will continue to spread to other resource poor areas of the world. One concern that has been raised regarding this approach is that using text messaging requires basic literacy among the health workers, and the ability to use English or a handful of other language scripts. However, as camera phones and other types of multimedia applications become more integrated into cheaper and cheaper cell phones, it is foreseeable in the near future that this type of technology may be within the reach of community health workers who do not have the requisite literacy in the requisite languages. Indeed, it is only human imagination that sets a limit on what is possible!

Solar power to sterilize medical instruments in rural clinics

Here is an inspiring story of a young engineering student from University of Dayton whose summer internship in rural Nicaragua eventually led to the founding of a nonprofit organization with the goal of harnessing solar power to improve healthcare in that community, and possibly, in time, in many others around the world.

It is common knowledge that one of the banes of poor rural clinics anywhere in the world is the unavailability of sterile dressing and surgical instruments. Unlike the large metropolises in affluent countries where the emphasis is on single-use disposable instruments to the extent possible, many poor clinics have only one or two sets of scissors, scalpels and the like. If one operation of an infected carbuncle has just concluded and you walk with a bleeding knee with a piece of bone sticking out… well, you’re just out of luck. The careful doctor or nurse or often a less formally trained healthcare worker will just wash off the instruments with water (which may not be clean to start with) and soap (if available), dab some disinfectant if you’re really lucky, and then off you go under the knife! Autoclaving, defined as the technique for sterilization of clinical equipment and supplies by subjecting them to high-pressure steam at 121° C or more for a certain period of time, is simply a luxury (in terms of power and/or fuel costs) that cannot be indulged in more than once a day or less. The result could be post-surgical infections, which are, in any case, more likely to fester when the patient is malnourished, has poor hygiene, and lives in a place that is hot and humid.

If the new nonprofit, Salud del Sol (Spanish for “Sun Health”), is successful in its mission, this situation may soon start changing, at least in one tiny corner of the world.

It all started with Lori Hanna, then a sophomore in Mechanical Engineering, traveling to Nicaragua in the summer of 2006 for an internship program through her school. There, she was to work with a community group called Las Mujeres Solares (Spanish for “The Solar Women”). This group was started with help from Grupo Fenix, a local organization dedicated to researching, developing and applying appropriate, renewable-energy technologies in Nicaragua. Grupo Fenix taught these women how to build and use the solar cookers. The solar cookers made a big impact in the community, because they save fuel (firewood), are a safe place to store food between meals, and can be used to bring in extra income.

Lori, just like any other intern in her place, was duly impressed by how this simple technology had changed the lives of these rural women, and also by the dedication and energy of these “solar women”. What was unusual, however, was that she did not stop there. Further enquiry revealed a project that involved redesigning these solar cookers to serve as autoclaves to sterilize clinical instruments, which had been initiated and later abandoned as that particular funding source had dried up.

Lori took this idea and ran with it. She decided to do her honors thesis on this redesign, and later involved other classmates from different disciplines, until in 2008 she and her friends won an award for their business plan for a nonprofit based on this technology, and the new nonprofit, Salud del Sol, was born. The mission of this new nonprofit is to provide communities in Nicaragua with the opportunity to improve their own healthcare systems by building and selling solar autoclaves, thereby also creating monetary incentives for members of these communities. The founders of Salud del Sol have visions of expanding this project all over Nicaragua, and possibly to other countries. Thankfully, the sun is one resource that is generally abundantly available in most resource-poor places of the world. Interestingly also, the Salud del Sol website provides free access to a detailed design of the solar autoclave, so it is readily available to any nonprofit or social business which wants to utilize it. The website also lists current major challenges in solar autoclave design, and solicits thoughts and ideas from readers to improve them.

A tale of camels, the sun and vaccine refrigeration

Yes, you read it right! There is in fact a thread of logic – very sound logic, if I may add – that connects camels, the sun (or solar panels to be precise), and vaccine refrigeration. Professor Winston (Wolé) Soboyejo, a professor of engineering at Princeton University, and a native of Nigeria, has devised a simple, yet elegant way to refrigerate vaccines as they are transported on camel back to remote places with no road access. In a must-see video, Professor Soboyejo describes the challenge. In these remote places, the only way for children to be vaccinated is for the vaccines to be brought in from the cities first by land rovers and then by camel trains. The roughly week-long journey in the places he studied (Kenya, Ethiopia) is not only arduous, but also wasteful. In current practice, the vaccines are kept refrigerated by ice packs. Once the vaccine container is opened, all the vaccine that is not used up before the ice melts, is wasted. Professor Soboyejo and collaborators thus came up with a simple (apparently!) plan – if Mohammed cannot go to the mountain, then bring the mountain to Mohammed! In other words, they decided that a self-sustained and economical powerpack will travel with the vaccines – on camelback. Deserts have ample sunlight. So, they decided to use solar panels to charge batteries, which would in turn keep the refrigerators cold at all times. They optimized their design on real camels – of all places – in the Bronx Zoo! In the development process, they had to overcome some unanticipated challenges, e.g., the variation in the hump sizes of camels! With exquisite forethought, the solar cells were designed to be lightweight and built with locally available material. For example, the frames are made of bamboo. The vision is that this technology will not only deliver vaccines safely to children in remote desert lands, but also spawn local industry which will manufacture the solar cells. Bravo!

More on disease diagnosis with a mobile phone

This is a quick follow up on an earlier post entitled "Did you say disease diagnosis with a mobile phone?" Newsweek recently did a story on this discovery entitled Dial "D" for Diagnosis. The story, for one, throws a human light on the discovery, by telling us that this potentially socially transforming technology came about from a challenge thrown to a class of Biomedical Engineering graduate students at University of California, Berkeley, by Professor Daniel Fletcher. He apparently asked the students to respond to an imaginary scenario where were hiking in a remote village where an unknown infectious disease was spreading, what could you build with only a camera cell phone and a backpack of lenses that might help identify the disease? This is a quick follow up on an earlier post entitled "Did you say disease diagnosis with a mobile phone?" Newsweek recently did a story on this discovery entitled Dial "D" for Diagnosis. The story, for one, throws a human light on the discovery, by telling us that this potentially socially transforming technology came about from a challenge thrown to a class of Biomedical Engineering graduate students at University of California, Berkeley, by Professor Daniel Fletcher. He apparently asked the students to respond to an imaginary scenario where they were hiking in a remote village where an unknown infectious disease was spreading, and they had to build a device that might help identify the disease, with only a camera cell phone and a backpack of lenses. The product: the Cellscope (please bear with the intro ad). Here is another link to a Youtube video.

Breslauer, D., Maamari, R., Switz, N., Lam, W., & Fletcher, D. (2009). Mobile Phone Based Clinical Microscopy for Global Health Applications PLoS ONE, 4 (7) DOI: 10.1371/journal.pone.0006320

Telemedicine with a twist: cutting costs for state-of-the-art medical imaging

It is not an exaggeration to day that medical imaging has revolutionized western medicine in the past two decades or so, with the frontiers being constantly pushed to allow better, earlier and faster diagnosis for a variety of diseases. The story is quite different, however, in the developing world where, according to recent WHO estimates, over 50% of medical equipment that is available is not being used because it is too sophisticated or in disrepair or because the health personnel are not trained to use it. WHO further estimates that some three quarters of the world population does not have access to medical imaging.

One problem that may be at least partially responsible for this discrepancy is that typical medical imaging equipment is large, non-portable, expensive, require multiple components to work in concert (viz., data acquisition, data analysis, image rendering and visual display), and require highly trained personnel to operate them optimally.

A collaborative group of researchers based at the University of California at Berkeley and at the Hebrew University in Jerusalem have come up with an ingenious solution to this intractable problem. These authors propose that one reason why medical imaging equipment are typically so expensive and complicated to use is that they are designed to be self contained units that combine all aspects of imaging, namely: (a) the data acquisition hardware which is in contact with the patient, (b) the imaging processing hardware and software, and (b) the image display unit. This causes substantial duplication in expensive components and places increased demands on operator training.

To make medical imaging feasible in regions of the world with minimal infrastructure, the authors propose to decentralize the different aspects of medical imaging, and generate a new medical imaging system made of two independent components connected through cellular phone technology which, as pointed out earlier in other posts, is quite ubiquitously available even in the remotest parts of the globe. The independent units of this proposed decentralized imaging system are: (a) a data acquisition device (DAD) at a remote patient site that is simple, with limited controls and no image display capability, and (b) an advanced image reconstruction and hardware control multiserver unit at a central site. The vision is that cellular phone technology will transmit unprocessed raw data from the patient site DAD. These will then be processed at a central location, which can have cutting edge image processing and rendering equipment and algorithms. Furthermore, being located at one or a few central site(s), they can be easily upgraded and kept current with the world standards. The final rendered images will then be sent back to the patient site via cell phone, where they can be displayed and reviewed. Of course, this format will also be accessible to real time expert consultation via “conventional” telemedicine.

In this initial report, the authors have confirmed the feasibility of this concept both for diagnostic as well as interventional imaging, by using a laboratory model of human breast cancer.

The next step in the journey, of course, will be to work out the logistics of getting such a system to work in the field. However, it is a great beginning, and this commentator surely hopes that this approach can be translated to real world public health scenarios in the near future.

Mere paper and scotch tape to diagnose disease in the field

It is eminently clear that for diagnostics to work effectively in the developing world, they have to be cheap, rugged, lightweight, portable, and work without needing additional infrastructure. Well, what could be simpler and cheaper than paper and scotch tape?

The laboratory of Professor George Whitesides at Harvard University has generated a prototype “lab-on-a-chip” microfluidic device, made out of water-absorbent paper and water-repellent double sided scotch tape. Microfluidic devices, simply put, are devices composed of channels that conduct fluid from a given point of application to one or more location(s) where some event (e.g., a chemical reaction or an enzymatic action) takes place. These devices are often made from glass or other polymers, and frequently use external pumps to conduct the fluid through the channels.

In this unique new design, the Whitesides group has used the natural absorbance of paper (and its ability to “wick” fluid), along with the water repellent nature of scotch tape to create a diagnostic lab-on-a-chip. Each stamp size device is composed of several alternating layers of paper and tape. The paper is first treated with a photoresist material in a micropatterned fashion using a mask (the photoresist material makes the paper in the treated parts water repellent). This results in the creation of channels that funnel liquid (such as test urine or sputum). Two adjacent micropatterned paper strips are separated by water-repellent scotch tape, where tiny holes punched in the tape serve as conduits for the liquid to flow from one paper strip to the next. Through these microchannels, the liquid is conducted to tiny wells coated with proteins or antibodies, where a color reaction can take place to provide the needed diagnosis (e.g., whether a bacteria or virus is present, or whether the specimen has high, medium or low sugar content).

The prototype (which the authors call 3D microPAD) was recently described in the prestigious journal, Proceedings of the National Academy of Sciences. This particular prototype tests 4 different samples for up to 4 different analytes and displays the results of the assays in a side-by-side configuration for easy comparison. The diagnostic results are color coded for easy reading, and are of a size that can be easily seen by naked eye, and photographed by mobile phones to allow telemedicine.

And the production cost? 3 cents/device!

The Whitesides group has launched a nonprofit, Diagnostics for All (DFA), to commercialize this technology. DFA was recently designated subcontractor in a 5-year grant from the Bill and Melinda Gates Foundation awarded to Harvard University for the invention of a diagnostics platforms for use in developing countries. They also won the Massachusetts Institute of Technology (MIT) $100K Entrepreneurship Competition in 2008, being the competition’s first ever non-profit winner.