By Belinda O’Donnell
I saw my first drone in action this January. I was walking on the sidewalk and there it was, 50 feet above me, a small black dot in the sky. The sound was somewhere between a couple of bees and a motorbike.
Drones are everywhere, it seems, including the conversation about healthcare delivery. UNICEF and the Government of Malawi have teamed up with Silicon Valley start-up Matternet to see if using small quadcopter UAVs (Unmanned Aerial Vehicles) can cut transportation times between clinics and centralized labs. The goal is to speed up HIV testing for infants in remote parts of the country.
In Malawi, where the national prevalence of HIV hovers around 10% and 130,000 children are living with the virus, it’s worth paying attention to anything that could improve early infant diagnosis. The faster infants can be diagnosed, the earlier they can start on Antiretroviral Treatment (ART). Without timely access to ART, only half of infants with the virus will make it to their second birthday. If drones can enable the results of pediatric HIV tests to be returned in a matter of days, rather than weeks or months, it’s easy to see their appeal.
And that appeal extends beyond Malawi. This summer, the Government of Rwanda and the American drone company Zipline will test small fixed-wing UAVs for the distribution of blood samples and emergency medical supplies. The U.S. Department of Defense, Department of State, and USAID are also paying close attention to the use of U.S.-made drones for global health applications. One of the main proposals highlighted at the 2016 Defense, Diplomacy and Development Summit involved using drones specifically tailored for “saving lives at the last mile” in “rural, isolated and conflict ridden areas.” Yet as the use of drones expands, the understanding of how they might fit into a global health context remains largely incomplete.
It’s important to recognize that drones are, at best, a tool for healthcare workers to amplify their ability to provide HIV care and treatment in remote areas. But they are not a complete strategy for improving access to healthcare on their own. According to Madeleine Ballard, a Rhodes Scholar at Oxford with a focus on evaluating global health interventions, there is currently a shortage of about 7.2 million health care workers worldwide. More specifically, African states account for 24% of the global burden of disease, including 91% of the global burden of pediatric HIV, and yet have just 3% of the world’s health workers. In Rwanda, the doctor to patient ratio is 1 to 16,000. In Malawi, the ratio is 1 to 50,000. Supplies don’t treat people, health care workers do, so any discussion of making drones relevant for improving health care in resource-limited states will need to take that into account.
Also, because drone is such a catch-all category, it’s hard to talk about small quadcopters and fixed-wing UAVs designed for global health applications without also thinking of those other drones, the “reaper” and “predator” UAVs used for surveillance operations and lethal strikes.
In many resource-limited settings, it’s completely understandable why people don’t feel safe around drones. Start-ups in the U.S. are making UAVs for improving access to healthcare at the same time that the U.S. military is using them for lethal operations outside of conventional battlefields. Professor Rosa Brooks of the Stimson Task Force on Drones estimates, “there have been hundreds of strikes in multiple countries, [and] our best guess […] is that (they) have killed 4,000 or 5,000 people by now.”
At a time when we lack clear international norms about the use of armed drones, Nigeria, the U.K., Israel, Iraq and Pakistan are also using drones for lethal operations. If I were walking to a clinic in northern Cameroon and saw a drone, my first thought might be “Am I about to be collateral damage in a Nigerian government strike on Boko Haram?” not “Look at that stunning breakthrough in medical logistics.”
Matternet’s founder and CEO Andreas Raptopoulos recognizes this dynamic, describing drones as “a technology that is not only unpopular in the West, but one that has become a very, very unpleasant fact of life for many in poor countries, especially those engaged in conflict.” Against this background, there are going to be layers of political complexity when U.S.-made drones are used for global health interventions in African states.
Most importantly, it’s not clear yet that drone-based interventions are a priority for the people and health systems that are supposed to benefit most from them. Dr. Kim Yi Dionne, a professor of political science at Smith College who has written extensively on public opinion and HIV policy in Malawi, noted that because it’s imperative to improve HIV care and treatment for infants, “it’s very hard for me to come out against a drone, but I still do. Not because I don’t like babies, and not because I think nothing should be done to improve early infant diagnosis; rather, I think that there are other options.” According to Dionne, “nurses would be able to do these tests if there were machines available at rural clinics. You’re bypassing the fact that Malawi needs better road infrastructure. And by improving road infrastructure, you would also be increasing economic productivity for all Malawians, not just for people to get test results.”
Matternet and UNICEF have both described drones as a “leapfrog” technology, implying that drones can bypass roads in resource-limited settings the way that cellphones have bypassed landlines. However, this perspective fails to take into account that people in Malawi are more than patients waiting for test results. They have social and economic needs as well. As Dionne points out, “I’m thinking about the kinds of goods that people deal in. In Malawi, it’s maize in 50-kilo bags. You cannot strap those to a drone … Malawians need roads. They don’t necessarily need [things] to fly in the air.”
Considering country-specific perceptions of drones will be especially important. Dionne adds, “I think there are plenty of middle-class Malawians that have access to the internet and know what a drone is.” Yet, she also notes, “a general vein of conversation in Malawi is about witchcraft. Typically, in these stories, it’s about a basket that you fly in at night.” Clearly, programs that rely on drones for medical logistics have the potential to cause some troubling unintended consequences. Moving forward, people on the ground need to have a say in how and when drones are used for global health applications.
If drones are going to become an effective part of global health initiatives, including the ongoing HIV response, we will have to openly and honestly address the sensitivities caused by drones in conflict environments, their limitations in the context of a significant shortage of healthcare workers, and the possibility that the intended beneficiaries of these programs may not see drones as a priority intervention, or as an acceptable approach at all. Until these concerns are routinely included in the broader conversation on using drones for global health, UAVs risk becoming a donor-driven distraction from the issue at the heart of it all: Far too many people lack access to the health care they need to secure their wellbeing or even survival.
Title photo by UNICEF/Bodole
Belinda O’Donnell (Harvard ’11) is a Washington-based writer and researcher with a focus on US-Africa ties.