Yanis Ben Amor
Director of Tropical Laboratory Initiative, Earth Institute, Columbia University, Tuberculosis and HIV/AIDS Coordinator, Millennium Villages Project
Breaking the Wall of Tropical Diseases. How the Tropical Laboratory Initiative is Increasing Access to Healthcare in Low Resource Countries
Ladies and gentlemen, I want you to think about the last time you went to a hospital, the last time you had to go see a doctor. Maybe that day you were worried about some diagnostic results that you were waiting for; or maybe that day you went to see the doctor, because you had symptoms that didn’t go away, like a cough or a fever. But one thing is sure, whatever the reason was you went to the hospital, or to see that doctor, you never had to worry about how you got to see the doctor. Now, for a lot of people in low-income countries, just getting access to these diagnostic services, getting access to these hospitals, is a huge barrier.
So, for the next 15 minutes, let me take you away from Berlin, to Sub-Saharan Africa, where I work for the Millennium Villages Project, and more precisely, let me take you to Ghana. I will show you how the Tropical Lab Initiative is trying to break down the wall of access to diagnostics. Lets say today you woke up with a fever that you had for the last three days. Now, if you were living in rural Ghana, most likely you would have to walk on this road for the next five to ten kilometres. You are too poor to own a car. You cannot even afford transport. Now, you think this is bad? Imagine if you had to walk that as a pregnant woman, as an old person, or just you are so sick that you cannot even walk. You think that is bad? That is not a river, ladies and gentlemen, that is a road during the rainy season in Ghana. So, you see, access can be really tricky.
Let me put this into context. This is a map of the cluster of villages, where the Millennium Villages Project works in Ghana. Here, I am showing the seven clinics that are serving the population, and at the top right you can see the district hospital. Now, at the beginning of the project in 2006, none of these clinics had access to diagnostics. So, what that meant was if you were a patient, and you went to one of those clinics and you needed diagnostic services, you would have to go the district hospital that had access to those services. Now, to give you an idea of the distance, if you were to go from the lower clinic to the district hospital, it would take you three hours by car—and this is only 30 kilometres.
What the Tropical Lab Initiative did is we felt that it was unacceptable that people would have to choose between wasting a day of their wage and have to choose between going to a clinic to get access to these life-saving diagnostics or life-saving treatment. So, we did this in three steps. The first one: we added simple diagnostic tools in all of the seven clinics. Now, lets see how this works. Remember this morning you woke with a fever that you had for the last three days, you found your way to our clinic: what would happen to you? Well, first, you would be seen by the lady in green, and she would triage you: she would find out whether you were an emergency case or not. If not, you would be sent to—I cannot show you—there is a diagnostic booth on the right. There, you would be seen by this man. This man is not a doctor; he is not a nurse. He is a health assistant that was trained in using those simple diagnostic tools. What he would do is he would ask for personal information, and then he would ask your symptoms. On the basis of those symptoms, he would then choose what diagnostic test to give you, and you can see one over there.
Because you complained of fever, he would automatically think about malaria. Now, this is the size of this Rapid Diagnostic Test (RDT). Depending on the manufacturer, it costs between 50 cents and a dollar. It requires no training to know how to use it; a child could do it, and it takes 5 to 10 minutes. How does it work? Well, you would put two drops of blood in that little area where you see blood, then you would add a little bit of buffer down below, and within 5 minutes it is a antibody based test; within 5 minutes you have an answer. On the left you can see that there is only a control band that appears: no malaria. On the right, you have an additional band: this person has malaria.
So, just by introducing this simple test, we can now, right there in the clinic, put these patients on treatment without having to ask them to go for a day worth of walk. Now, some tests are a little bit more sensitive, like HIV, because there is a whole stigma associated to it. So those tests we obviously would not do outside in the common waiting room. So, for HIV tests, in this case it would be a nurse who would deliver the test. After she is giving you counselling, you would be given the test, and then, based on the result, you would be given counselling again—all in the privacy of this room.
Now, Rapid Diagnostic Tests are amazing, but they are not the only solution. Why is that? Because right now we have Rapid Diagnostic Tests for HIV. We have Rapid Diagnostic Tests for malaria, for syphilis. We don’t have any Rapid Diagnostic Test for tuberculosis, or for pregnancy-related test that any pregnant woman needs to do when she is pregnant, during the course of what we call “antenatal care”. So, for those tests you need a lab. Incidentally, sometimes to confirm HIV or to confirm malaria or the absence of malaria, you need a lab as well.
So, after having introduced these simple steps within all of the clinics, which was step one, step two was to bring a lab closer to the cluster. Now, if this is all that we had done, we would have just simply shifted the problem, right? Because all these people who live on the periphery, well they would still have to find their way to the lab. So, our solution to that is quite simple. Instead of having the patient travel, we collect the specimen, whether it is blood, sputum, or stool, and we have that specimen travel to the lab, and the patient can stay at the clinic. But even we did only that it wouldn’t be a solution.
Let me introduce you to the concept of ‘turn around time’: Turn around time is the time that it takes from the moment that you, as a patient, give your specimen to the moment that we, as the provider, give you back the result. Now if this turn around time is more than 24 hours, which it is more likely to be, the patient is not going to sit around in the clinic and wait. So, they are going to go home. Now, if it took them already a day to come see you, you can expect that some of them are not going to come back. So, the next day, when we actually had those results available, there is no patient to put on treatment even though we just got a positive result. We thought this was unacceptable.
So, how did we solve this problem? By using one of the most amazing resources available in Africa right now: mobile phones. Did you know that more people in Africa have access to mobile phones than water or electricity? Now, how are we tapping mobile phones to reduce the turn around time? Well, lets take again the example of you having fever. You took an RDT; it was negative, but the nurse, on the basis of your symptoms really suspects that maybe you do have malaria after all; so we need to do microscopy. You would have to provide a blood sample, which she is currently collecting. In the background, you can see there is a health assistant who is prepping the cell phone. For those of you who are familiar with cell phones, you may be thinking: well, how are we tapping this? We are using SMS. Now, an SMS is 166 characters, and for those of you who are using Twitter, it is just a little bit more than a tweet. Now, let me tell you that in just one SMS, in 166 characters, we managed to summarise all the information that is needed from the name of the patient to the test that is required, even to the insurance number.
This is how that works. While the blood specimen is being taken, the health assistant is filling out the simple form. There are a certain number of fields. Now I filled one out for you on today’s date. The syntax, the very simple syntax, that is on this form: if the health assistant is filling the SMS out just like that—so the date, the sample number, the health ID—by the way, in our project, all of the patients have a unique health ID, which already summarises their name, their age; so that is embedded within this code – the lab test required, just by putting two-letter word, and then the specific specimens that are being sent, and finally the health insurance number. Because all of these tests that we are providing are free of charge to all of the patients, but we will then bill the Ghana health insurance. So, just by adding that string of letters, all of this information is sent in one SMS.
Now, this SMS is sent to a server. When that happens, two things happen simultaneously: in the lab, on the computer of the lab, there is a new line that is added with the incoming sample so that any given moment the lab technician can say in real time what samples are coming from which clinic. At the same time, the cell phone that initiated the request gets a confirmation from the server to say: we have received your SMS.
Now, the sample is then being processed, packaged; it is put in a cold chain and sent to the lab, where it is being received by the lab technician. He makes sure that all of the samples that he is expecting that day are in that container and that they are in good condition. Once that is the case, he will send an SMS to the server, and he will close that ticket. If any of the sample is damaged or not there, he could also send a specific text message to the server, and it automatically informs the clinic that sent the sample that they need to take another one.
This is where the action happens. This is the actual laboratory. You see it is nothing fancy; it is a very simple design: a few microscopes, a few machines, and then, in this particular case, we are checking for malaria, so the lab technician will do a microscopy slide. Once the result is known, whether it is positive or negative, all he has to do is to input it into the computer on that line that appeared. You can see that the computer is connected to the phone by a USB and automatically the computer then sends an SMS to the server, which then alerts the phone that originated the request. Now, immediately at that clinic, while the patient is waiting, and you can see it in the background, now the nurse has received confirmation of the result, and if the result is positive, we will be able to treat the patient accordingly—in less than four hours.
So, at this point you are thinking: ok, this is an interesting system, but it only applies to the people who can actually make it to the clinic. I told you earlier that just getting to the clinic can be an issue. Well, we thought about that problem, too. That is our third step: the use of community health workers to go directly to the households. How does that work? Two simple ways: this young lady on the left, either during her monthly visit, or because she just received a phone call from a neighbour or from this old lady, goes to visit this person and finds out that this person has been coughing for three weeks, suspects tuberculosis, and will collect the adequate sputum sample. Very simple, very integrated system.
We have started the project less than a year ago. So, at this point, we are collecting all the information to know what impact this system actually has on the community in terms of mortality, morbidity, or just basic access: do we really see that the people are coming in larger numbers to the clinic, because they don’t have to go to the district hospital anymore? The second step, in order to scale it up, will be to bring it to—because right now it is available only in Ghana—all of the countries, where the Millennium Villages Project works, as you can see on this map.
I would like to thank the amazing team of people who made this project possible in Ghana and in the U.S. But before I finish, let me share a personal story of access. It is really ironic that I almost didn’t make it today because of access. Now you may have heard that New York last week was hit by the super storm Sandy, which destroyed a lot of our infrastructure. Well, Wednesday, when I was about to fly to Berlin from New York, another snow storm hit and cancelled two of the flights that I was on: one and then another one. If it wasn’t for the amazing support from the Falling Walls team and their logistics as well as the amazing support network in New York, I wouldn’t be here. So, if you think about it, if it is possible to fly a speaker half the way around the globe, just in time for a speech in Berlin, I think it should be possible to give local access to diagnostics and treatment to the underserved. Thank you very much.