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Can Drones Fix Madagascar's Broken Health System?

The home of the world's biggest plague problem has been testing an aggressive pilot program to find out.

Madagascar's healthcare system is a wreck. For decades, officials strove to shift from a colonial-era medical setup concentrated in urban centers to a progressive one with thousands of rural health aides and centers spread across the vast territory. These measures helped to boost life expectancy and nearly eradicated polio by 2008. But still just over half of locals had access to healthcare, with the danger and difficulty of long distance travel barring some and mistrust of modern medicine others from care and local centers facing chronic understaffing and underfunding.

That was before a 2009 coup led to international sanctions and aid cuts that crippled the national economy, leading to a 30 percent slash in health spending in one year alone. Despite heartening political developments over the last two years, the nation remains in a fiscally dark place. And these hits have led to declines in immunizations, surges in malaria and polio, and play a role in a notorious plague epidemic; over half of the world's plague victims since 2010 have been in Madagascar (over nine-tenths in 2015 alone), with dozens dying annually despite the existence of cheap, effective antibiotics, and even an experimental vaccine, which many in outbreak zones just cannot access.

"Everything is difficult," says Matt Bonds of PIVOT, an NGO trying to build a model healthcare system alongside locals near the nation's Ranomafana National Park, of the challenges of working within this brutalized healthcare system. "Even the basics can be difficult."

But about nine months ago there was a flurry of optimism about healthcare in Madagascar in the English-speaking press—after a company called Vayu uploaded a YouTube video depicting the test flight of a medical drone in a rural Malagasy village. The medical community has explored drones before, but mostly in the context of unidirectional systems used to parachute in supplies on a drive-by past a remote community. Vayu, though, showcased drones that autopilot to and from towns, allowing sick locals to send samples for diagnosis to a lab and medical staff to dispatch treatments and directions back as needed. The potential of the system was clear to many: to make it easier to catch and treat isolated illnesses or outbreaks in regions without access to doctors or medicines—especially those that are harder to store or less frequently used. "What it's promising is to take care of one huge issue," says Bonds: "geographic isolation."

The project kicked off in 2015 when Peter Small of Stony Brook University was doing a study on intestinal parasites based out of the Centre ValBio, an ecological and medical station set up near Ronamafana by his university three years prior. Small realized that to collect samples from five villages, his team would have to hike for two weeks through the region's remote and mostly infrastructurally disconnected terrain with a generator, centrifuge, and liquid nitrogen.

"I said, 'why don't we fly these samples back by drone every night?'" recalls Small. "Everyone laughed. [But] I started looking around and realized there was no reason we couldn't."

"It's surprising, given the application of drones in other areas, that it is such early days in terms of their use in health," he says. Part of that, he quickly learned, comes down to the bureaucratic challenges around drones. Not only did he have to get permission from three skeptical Malagasy governmental bodies, but his team had to clear exporting this tech from the US, which has marginal fears about its potential use for military purposes. He also had to make sure that local communities would accept drones. But Small and company eventually persevered because local backers could see their utility.

"At an individual level, everyone [in Madagascar] looks at this and they immediately get it," says Small. "They lean forward in their chair. They get incredibly animated and they say, 'oh my god, this could be such a useful thing for our teams dealing with, say, post-cycle interventions.'"

Rather than repurpose a commercial or military device, as many drone projects do, Small and company collaborated with the Michigan-based Vayu, a company founded in 2014 with the explicit goal of creating low-cost humanitarian drones to provide medical services in isolated regions, especially those hit by sudden, unexpected outbreaks or crises. Their vehicles take off and land vertically, with no need for a runway or launcher, and currently have about a 40-mile range and 4.5-pound carrying capacity, allowing them to deliver lightweight supplies in minutes to regions that might be days away from a medical center by foot. Their test flights over the summer delivered pizzas to Ampitavanana and Torotosy villages, and returned blood and fecal samples to Centre ValBio, effectively proving their return flight ability and diagnostic potential.

Following the buzz created by their video, Small and company have received a grant from TB Reach to test the drone system's efficacy at treating tuberculosis—a disease that is common, but hard to diagnose without a proper lab and still rare enough that it doesn't make sense to put a full facility and expert in every village or even every regional center. Their plan is to train a health worker in every town within drone range of Centre ValBio in how to spot someone who might have TB, then call for a drone when they find someone. On board will be an audio-visual guide on how to collect a medical sample and a container to store it. 

Once stored, the local collector just has to hit a red button. The drone will depart. And if TB is detected at the Centre's lab it will return the next day with a month's worth of medication in a box that flashes and beeps to remind a sick individual to take it everyday and a sensor to monitor their coughing systems when they sleep at night. Every month for the standard half-year treatment, the drone will return with a new round of medication and sensor, collecting the last round to monitor intake and condition. So long as the treatment seems to be taking, the local won't have to leave town to a medical facility. "It's a very cool idea about using drones to forwardly deploy the healthcare system," Small says.

The potential of the Vayu drones go far beyond this TB trial, though. Broadly, Bonds of PIVOT thinks the network could be useful to distribute vital medications to regions that have depleted their stocks (which is all too common due to bureaucratic supply chain problems and unpaid pharmacists), or to detect crises or outbreaks that require a hit of medications it doesn't make sense to keep on hand long-term in a limited facility. That could apply to something like a snakebite, a rare incident requiring a one-time refrigerated antivenom treatment, or even a rural burst of plague, the worst forms of which require quick diagnosis and treatment to control.

Drones have also long been discussed as a means of improving access to more routine treatments like vaccines in remote areas. A study released last June by staff at Johns Hopkins University, modeling supply chains with the help of the Pittsburgh Supercomputing Center, found that drones, even controlling for some failures, could boost availability and reduce supply costs by up to one-fifth in areas like rural Madagascar—figures that may improve as drone tech develops.

Small even thinks one could deliver materials and instructions to help locals carry out more complicated procedures, like collecting ultrasound data to send back to a lab. ("I have an old house and the faucet was leaking the other day," he says. "I go on YouTube and suddenly I'm a plumber. I don't see any reason we can't apply that same principle.") He also floats the idea of using the drones to simultaneously collect ecological data or spot deforestation, poaching, or illegal mining, to help maintain the integrity of ecosystems upon which local health often relies—provided that wouldn't turn too many people against the newly intrusive medical drones.

Yet for all the enthusiasm about drone delivery, Bruce Lee, an associate professor of international health at Johns Hopkins who co-authored the recent study there on drone and vaccine provision, cautions that there will be hard limits to the program's potential. Not only are some pieces of equipment too heavy for drones, but some may be too sensitive or so expensive that the risk of a downed drone makes ground transit more practical—trials have yet to probe those economics and logistics fully. 

Trial runs like the TB application also often fail to predict the challenges of scaling up; different regions may not have a node like Centre ValBio to operate out of, building relations in villages nationwide will be time- and resource-consuming, and it won't always lead to buy-in and good faith. And the wider implementers spread their attentions, the higher the risk that locals trained to perform procedures or manage drones will miss details or won't get enough support to sustain the system properly.

"Pilot studies are of a well-encapsulated, limited area… chosen for a particular reason," Lee says. "You're not necessarily going to choose the most difficult places [or conditions] to deliver."

Even if a successful, versatile drone system can be implemented, it'd be just one link in a wider system—albeit one with great facilitating powers. Despite ambitious plans in the current health ministry, Madagascar remains economically and politically brittle. "Across the spectrum," says Bonds, it "has the lowest per capita spending on healthcare in the world" at the moment.

The continued weakness of the nation's overall economy and healthcare system make it difficult to maintain even the basic healthcare facilities in rural regions, much less to institute the parallel sanitation programs and cultural education drives needed to tackle the causes of diseases like tuberculosis or plague, versus just catching outbreaks and limiting death as drones could do. Drones can't wean those reliant on ineffective traditional healers off of their concerns about Western medicine, nor can they address squalid conditions in urban areas with medial access.

Even Small will admit that people sometimes get a little too gaga over the potential of drones, blinding them to parallel issues: "There are few fields I've been involved in that are as over-hyped as drones," he says. "But that is the nature of innovation: The short-term impact is generally overestimated and the long-term impact is generally underappreciated."

His hope is not that his drones will be a magic bullet, but instead that they will be a useful tool that locals can decide how best to use to address problems and desires they understand better than he does—and as a sort of peg:

"While people get excited about the drone, it's the package of interventions that are critical," he explains. "The drones provide a hook to bring in resources and attention and [additional] innovation. It's a very important enabler." And that, in the end, may be what's truly exciting.