21st century digital medicine will be delivered personally with tracked results. The system will be continuously improved by constant outcome assessments that learn the most effective treatments and deliver them. Infectious disease alerts will be triggered by incidence monitoring of patient diagnoses. The system will “know” the disease burdens and effectively treat both patients and those exposed to them.
At an infrastructure level its global goal will be to identify infectious disease outbreaks while raising medical outcomes to first world standards at a fraction of the per patient cost. Though delivered to the poor, with its systemic and systematic improvements, this “build once, run everywhere” medical system might one day match first world outcomes at the scale of universal networked delivery of high quality care.
Dr. Brian Goldstein closed his eyes tightly and wished it away. When he opened his eyes the report was still there. It was 2025, 10 years after an Ebola vaccine defeated the disease. But this contagious killer had returned.
A new, vaccine resistant strain of Ebola had emerged in Liberia and started spreading around the country before it was discovered. (21)
Brian was the CHE’s Strategic Director of Crisis Preparation and Management. That meant this unexpected crisis was his. He had a great staff but behind his furrowed brow he was choosing the best person he could think of who might know how to stop this quickly.
He turned to the CHE’s First Responder Shared Space and Activated Dr. Richard Chester, one of Harvard’s leading virologists and a specialist in the new Digital Medical Facilities spreading through the less developed countries.
Brian was in Atlanta and Richard in Boston, but their images and sound were as clear as if they were in the same room, separated only by a sheet of glass. Brian was dressed in a business suit and sat at his desk. Richard was in a white doctor’s coat, looking into a hand-held tablet.
“Give me a minute,” Richard said as soon as he saw that Brian was using the CHE’s First Responder Shared Space. He went to his desk and turned to his wall screen.
“Now, in which medical emergency can I help?” Richard said with a smile.
“Are you doing anything big right now?” Brian asked. He bit his lip, looking concerned.
“Hmm. How big do you need to go?”
“What do you think about heading up a new CHE Shared Space on Ebola?” Brian asked.
“I thought we stopped Ebola with a vaccine about 10 years ago.” Richard said.
“A new, vaccine-resistant strain of Ebola just emerged in Liberia. It started near the border of Côte d’Ivoire, among fieldworkers who cross the border to work the cocoa plantations. It was misdiagnosed as other hemorrhagic fevers because no one believed it could be Ebola, but it was figured out when it reached Monrovia and doctors and nurses started dying.”
“How many are infected so far?”
Brian blended a map of Liberia into their screen background. It showed the numbers and locations. The disease was already in almost a dozen places.
“There are over 60 known Ebola patients, with 27 deaths, and we probably only know half of what’s going on.” Brian looked at Richard. “We need to start an Ebola task force right away. It will have its own Shared Spaces, staff and budget. Can you take this on?”
“Interesting timing.” Richard said, “I’ve been thinking about a new way to stop pandemic outbreaks as a normal part of everyday medicine — both in outbreaks and worldwide. Can I make a suggestion?”
Brian’s eyebrows went up. “Definitely. How would you do this?”
“I’ve been doing a lot of virtual patient treatment for Digital Medical Centers throughout the developing world. The best DMC’s are doing a remarkable job of caring for the poor and medically underserved, while producing outcomes as good as first world medical systems — but cost only a tiny fraction of what we spend. Ebola needs prevention more than treatment and modified DMC’s could give us community-based protection from infectious diseases everywhere. Would you consider using DMC’s even though the FDA won’t touch them?”
“For your ears only, the FDA is being forced to consider letting foreign DMC’s provide services in the U.S. Americans who need medical bargains have started using digital tourism to get DMC treatments abroad, even though they’re really at home when they’re being treated. They’ve had such good results they’re making DMC care their first choice. Now they’re pushing the insurance companies to reimburse them. The insurance companies see the the outcomes and costs and want this. They’re pushing the FDA but the FDA doesn’t know how to say yes. The American medical system can’t compete with DMC’s financially, but America’s medical costs have swallowed a quarter of the economy and that’s growing. It’s only a matter of time before the American health system will bankrupt this country. But the medical establishment won’t stand for DMC’s here, out-competing them.”
“That’s overdue, but it wasn’t my question,” Richard said. “I want to turn Liberia’s DMC’s into a local healthcare medical system that will protect both Ebola and other infectious diseases from spreading, while also giving Liberia one of the best health care systems in the world. If it works, I want to spread this new system to 3 billion poor people around the world.” He paused. “This is about a better way to meet the world’s medical needs. The FDA will sort out how it get American medicine to add these advances.”
Brian pulled up the CIA Factbook summary of Liberia and blended it as the visual background for their Shared Space conversation. (81) “Liberia has 4 million people in about a dozen ethnic groups. They speak about 20 ethnic languages with just 20% speaking English. About 40% live outside the cities and they have major problems with high fertility and infant mortality, and only 59 years life expectancy. They are also one of the least medically served places in the world with far too few doctors and nurses. Are you sure you want Liberia for a demonstration case? Looks unrealistic.”
Richard didn’t hesitate. “Let me say this out loud, and you’re hearing it for the first time. From what I’ve seen, when done right, Digital Medical Centers treat diseases better than our medical system, at much lower costs. The world’s 3 billion poor need us to turn this into a global medical infrastructure that serves them and protects everyone, everywhere.”
“I can’t sell that,” Brian said. “This is about Ebola in Liberia.”
“This medical solution can minimize Ebola and other infectious diseases by stopping them everywhere as soon as they start,” Richard replied. “Besides, a medical infrastructure that prevents infectious disease outbreaks throughout the developing world will protect the United States and the rest of the first world. Let’s start by proving it in the few places in Liberia where there’s Ebola.”
Brian smiled for the first time. “I like taking a disaster and using it to change the world for the better. But be ready to try and do good but face relentless criticism when you go outside what the medical system expects.” (British charity defends management of Ebola center after criticism, http://www.reuters.com/article/2014/12/09/us-health-ebola-leone-idUSKBN0JM28620141209)
“That goes with the territory. Our medical institutions will want to stop a cheaper and better competitor from being turned into a global medical system. But if we make this work we could give billions of poor people real medical care at a cheap price,” Richard said, already reaching for resources from other Shared Spaces and bringing them into this one.
“Got to go,” Brian interrupted, looking at the bottom of his screen. “My staff is working on this and they need me.”
“Give me the map of locations in Liberia and I’ll take you through it later,” Richard said. “Can be any time, including this evening.”
“I’ll be on a plane to Washington tonight,” Brian said. “This has been added to the President’s national security briefing tomorrow. If you want to be in my recommendation, be ready in an hour — and make it good.”
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An hour later Richard began aggressively. ”The last time the CDC fought Ebola in West Africa they did it in the wrong order.”
There were three people in the audience and he saw them all react, but he wanted to kill traditional medical thinking before it took control. “In 2014 the medical community stopped to spend time raising big money to build treatment centers, then they struggled to build and staff them quickly. Only after that eventually slowed Ebola’s rate of growth did they start the containment end-game.”
“That’s funny,” Dr. Brian Goldstein said. “That’s why I invited Dr. Grant Strahan, because that worked the last time and he would run it again.”
Grant was a doctor who was dialed in from his office at CIDRAP, the Center for Infectious Disease Research and Policy at the University of Minnesota. “I was thinking of starting with a 100 bed Ebola treatment facility, and put it where there is enough land to expand to 200 beds. It would be near Monrovia, the capital, where it’s easier to hire staff and services, as well as move foreign supplies and staff in and out of the country.”
“That’s needed,” Richard said, “but there’s a faster and more permanent way to beat Ebola.”
“So what’s your strategy,” asked Nick Flamel. Nick was the President’s National Security Adviser for Healthcare Threats. He was the one who added Dr. Goldstein to the President’s national security briefing the next morning.
“Let’s talk about a digital medical platform that finds, treats and contains infectious diseases instantly, everywhere around the world — and how to start it in Liberia with Ebola,” Richard said, noting that Nick instantly looked interested. “Liberia’s Ebola will be its first test. It will start with just the few locations where Ebola has appeared. If this works it’s a cookie-cutter model.”
He looked at them sharply. “I call this a DMIS — a Digital Medical Immune System platform that identifies infectious disease outbreaks and contains them everywhere. If this platform works, it will make most of your work obsolete. Infectious diseases will remain endemic, but their outbreaks will be caught and treated before they can spread.”
Nick shook his head no. “I don’t see how a digital solution can work when you’re starting with at least 10 locations in Liberia. This country has unreliable electricity, limited communications and a slow Internet!”
Richard rolled up his sleeves. “That’s old thinking. The world has changed and Moore’s law has reached exponential growth on top of exponential growth. By combining tech advances it’s time to operate as a fully digital planet everywhere.”
Brian snickered. “Show us.”
Richard reached for resources he had put at the bottom of their Shared Space. “With four additions we’re going to transform 10 Liberian Digital Medical Centers into a the first local centers in a new Digital Medical Immune System, a DMIS. Each local DMC will use its own solar power, mobile phone communications, fast Internet and clean water to provide real-time medical services.”
“Each of the local DMC’s will involve nearly everyone in each community in finding, treating and containing all kinds of infectious diseases, including Ebola.”
Richard blended into the background of their Shared Space a picture of an example DMC. As he described each of the four components he added that to the picture until the full local DMIS installation emerged.
“The first part of each local DMC is cheap and powerful solar energy. Each DMC will have enough solar power and batteries for all its local and community needs, with some extra electricity it can give away.” In the picture Richard made the house next to the DMC vanish. He replaced the house with a large solar and battery installation. Then the roof of the DMC was instantly covered with solar panels.
“Second, each DMC will deliver free mobile phone service for 2 to 10 km around it from its own cell phone base station. To keep the cost down and the turnaround speed up, we’ll use microcell base stations tied into the local phone network. We’ll compensate the local mobile phone companies as needed.” He added a low mobile phone base station to the roof of the DMC building.5
He saw Grant was puzzled and added, “you use microcell base stations all the time when you’re inside a mall that uses one to give you a strong mobile signal. A strong microcell base station can provide mobile phone services for up to about 2 km.”
“To receive the free mobile phone service each person must wear a cheap disposable wristband that monitors a couple of key vital signs, including temperature. As soon as anyone spikes a fever, the wristband automatically alerts a health monitoring app on their phone. This notifies an Infectious Disease Response System that we run. I’ll tell you more about the system in a minute.”
“Third is high-speed Internet for the DMC’s. This will also connect their mobile phone base stations to the phone network. Half a dozen global companies are building high-speed Internet throughout the developing world to capture those markets. We will choose one of them as our high-speed Internet provider, and give them a medical business model that connects their health services with everyone in all our local communities.” He added a large icon of a lightning bolt in the air above the DMC.
“The last component is free, clean water. Enough solar power will be included to purify water so some can be given away for free.” Inside the DMC a utility closet was replaced with a water purification system with sizable tanks.
“Now let’s put this together into a community medical platform that controls infectious disease.
Staffing: As soon as each location learns Ebola is present, schools will be closed. The school’s teachers and administrators will immediately need jobs. They’re excellent to hire because they’re trusted, they know the people and speak each location’s language. (Five million children out of school in West Africa due to Ebola; http://www.reuters.com/article/2014/12/03/us-west-africa-health-ebola-idUSKCN0JH20920141203 )
Building each location’s medical network: “At the same time we announce the discovery of local Ebola in a location, we will announce a community protection system to keep Ebola from spreading and to keep the people safe — if the community participates. It will include free mobile phone service for everyone, free health screenings, automatic health monitoring through mobile phones, and free access to electricity to keep phones charged and free water during all visits to the DMC.”
Health profiles and community medical mapping: To get free phone service, access to the free electricity and water, each family has to receive free health screenings for all family members. This creates a medical profile of each family. Because Ebola spreads by physical touch and families are the closest relationships, it is essential to focus on families and not individuals.
Containerized DMC offices to begin immediately: “For an overnight start, fully functioning DMC offices will be built into rugged shipping containers. Each DMC set up includes a microcell mobile base station to start free mobile phone service immediately. These DMC offices will be airlifted into all the locations to start the community protection programs immediately.
The full DMC office is built rapidly starting with solar power. The shipping container DMC is stripped with its modules moved into the DMC office as soon as it’s built.
One of the overnight treatment rooms in the full DMC office is an Ebola isolation room with 4 to 6 beds. That room is used to isolate all Ebola patients found while they await transport to the central Ebola treatment facility.
Health screenings: The DMC offices will start mass health screenings immediately. These will be done by rapidly trained local staff who do them as fieldworkers using simplified tablet-based MAS Devices. The screening will include up to 45 medical tests for each person, and the tablet automatically uploads their test results to each person’s medical profile providing a health status inventory of the entire community immediately.
Those who don’t have free phone services: Others can visit the DMC and receive a free profile, baseline medical screening and healthcare apps if they have a phone.
Map and inventory endemic diseases: We will immediately inventory all the kinds of infectious diseases endemic throughout the community for immediate treatment. If we’re lucky this finds the Ebola cases and isolates these people before it spreads to others. Regardless, this will map families and kinship for any bio-containment needed in the future.
Infectious disease monitoring: During each person’s health screening their free mobile phone service will be turned on. The health app will be installed on their phone and they will be logged in to it.
Each family member will be given a disposable wristband with a temperature monitor on it, and the health app will collect and send in each family member’s temperature twice a day.
If someone stops running the health app on their phone they receive messages to turn it on or call the DMC if they have an issue. If they don’t comply their phone services can be progressively reduced and then turned off.
If someone just has their own mobile phone without free service, they can still wear a health monitoring wristband and run the health app on their phone.
Fever triggers immediate action: The trigger is simple. An elevated temperature triggers the health app to notify the Infectious Disease Response System. That pulls the person’s medical profile and uses the phone to connect the person with an AI Doc.
The AI Doc runs does a structured interview with its first priority to screen for Ebola.
If it might be an Ebola case the patient is asked to come straight to the DMC for an immediate Ebola blood test, or a field worker is sent to the person’s location to bring them in.
With rapid on-site Ebola blood tests people will be confirmed or cleared right away.
When an Ebola patient is found: If a person has Ebola they will be put in the DMC’s Ebola isolation room immediately. These rooms have 4 to 6 beds. They are used to temporarily hold Ebola patients until they’re safely transported to the central Ebola treatment facility.
All Ebola patients will be upgraded to an advanced wearable health monitoring, to track them minute by minute and provide medical alerts for rapid responsive treatment.
While in the isolation room they will be able to make sure their mobile phone is fully charged, and connect with family members and friends either in visual Shared Spaces or by phone calls. With free electricity and free mobile phone service, they’ll be able to maintain continuous connections.
A safe transportation service will be notified to come and pick them up, to transport them to the central Ebola treatment facility.
The family members of each Ebola patient in the central Ebola facility will be able to access an online daily status report using their phone, so they will be able to stay informed.
All patients able to communicate will be able to be in Shared Spaces with their family and friends.
If it is not Ebola: If it’s not Ebola, the AI Doc requests immediate medical tests with an MAS Device, which can be either at a DMC office or a field location where there is an MAS Device.
The AI Doc’s interactive questions determine if this is an infectious disease or not, and develop a treatment plan. As in any DMC, the sick patient is put on an online, interactive DMC treatment protocol immediately.
Bio-containing Ebola: When an Ebola case is discovered, the mobile phone base station is accessed for its GPS location tracking logs. This tracking includes phones that do not receive free phone service, but connect to the mobile base station.
The phone GPS location records are used to back-track the Ebola patient’s contact history. The people whose phones show they were in contact with the Ebola patient within 24 hours of their temperature starting will be tracked down digitally and bio-contained.
All the prior contacts will be immediately put into a continuous Shared Space where they will be informed about the Ebola patient and started on a bio-containment protocol.
Within hours they will be all upgraded to an advanced wristband with a temperature monitor and other health metrics. Their phone’s health app will be set for minute-by-minute health and geographic monitoring, with continuous individual tracking by the Infectious Disease Response System.
If a prior contact does not have a phone, they will be given a free loaner phone with free service and an advanced health monitoring wristband.
If any of these people’s temperature rises, they will be identified within minutes by the Infectious Disease Response System. Then they will be contacted personally in a private Shared Space for an immediate Ebola blood test. The containment goal is to find and isolate the contagious people immediately, before they can spread Ebola.
Logging, monitoring and improving: Like any DMC, every step in the process will be tracked, reported and continuously improved. Since DMC’s are platform based, when an improvement is made in the DMIS platform that is immediately delivered to the local DMC’s as part of their services. This keeps a Digital Earth’s medical infrastructure at the highest level of healthcare delivery.
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While explaining, Richard had seen an interesting evolution in Nick Flamel’s attitude. He had started nodding and looking interested. By the time he finished, Richard was sure Nick was a supporter. He was puzzled, because he didn’t know why.
He turned to Nick and asked him directly, “What do you think? Is this ready to present to the President or do you want it developed a different way?”
“With three changes, it’s a good first draft. If you like the suggestions, I could get you approval to begin tomorrow afternoon at the $30 to $50 million program level,” Nick said. “That program includes your clinics and the first 100 bed Ebola field hospital.”
“That’s a generous amount. It’ll support a fast startup,” Richard said. “What do you suggest?”
“First is the wearable health wristbands. They need to include GPS tracking, and each family’s mobile phone needs to track and report the locations of all the family members, not just the phone’s owner.”
Richard’s eyebrows went up but he didn’t say anything.
“Second is the databases for the personal health profiles and the GPS location tracking logs. These need to be run by the CHE even if the medical services are provided worldwide and administered by Digital Medical Centers based in other countries.”
Richard thought about this, too, but kept quiet.
“Last is the program and technical management. The program management will be done by the CHE. You and any people you want on the project will work for them as independent contractors. The IT technical management will also be done by the CHE and they’ll approve and guide any companies and personnel that provide the technical services. When this is built, the CHE will own it and run it.”
Richard thought for a minute while choosing his words. “So you’re in favor of starting to build a global medical infrastructure that can find and cure both infectious and endemic diseases worldwide, starting with Ebola. To fund this, you want this to include personal GPS tracking of the people helped, with the U.S. government managing the back-end IT systems. I assume that includes managing the personal medical profiles and GPS location tracking data. To insure this medical infrastructure is developed to become what the government wants, any global medical databases will be managed and run by the CHE, the government’s medical agency.”
Brian, the CHE’s Strategic Director of Crisis Preparation and Management, looked Richard in the eye and said, “First, bio-terror makes medicine a semi-branch of the armed forces so U.S. government involvement in a digital medical platform is a requirement. Second, the government learned the hard way that it can create and finance innovations the world needs, but when those are run by non-government organizations they can stop including the U.S. in the future. For these and especially bio-terror reasons, if the U.S. government creates a new medical platform it will want to manage it.”
Again, Richard chose his words carefully. “Companies and NGOs aren’t anti-government. But their customers are all over the world and they’ll insist on privacy or they won’t do business with them,”
“We respect that,” Nick said “but when we help pay for something that will respond to bio-terror attacks, we need to make sure it’s ready to do that.”
“Speaking candidly,” Richard said, “I believe the U.S. government accesses any information it wants, anywhere in the world. This includes everyone’s Electronic Health Records and GPS location tracking data in practically every country, so I don’t think your requests give the government anything new. Still, your suggestions will make everyone’s medical and GPS data immediately accessible, and easy to keep it that way.”
“You have a passionate desire to bring this to the world,” Brian said, returning the focus to medicine. “Do you want to get on the fast-track and literally start at full speed tomorrow, with the funds and deadlines that will build your medical platform right away? The CHE will guarantee immediate availability of the government funds and accelerated support to build and run the DMC’s and back-end DMIS the way you think it should be done. You’ll be in charge.”
On screen, Brian turned to Nick. “What do you think? What would be about the right next stage after Liberia? My guesstimate is a few hundred million dollars to start a global DMIS platform to help — oh, let’s say, DMC’s for 10 to 20 million poor and lower class people — who wouldn’t get much health care otherwise.”
Nick smiled reassuringly and said, “If Liberia goes well, that sounds reasonable — a few hundred million dollars to build out the platform, start serving tens of millions of poor people worldwide and build tight relationships with established DMC’s — that could definitely kick start a digital medical infrastructure for the planet.”
“That’s everything I could hope for,” Richard said. “I assume the U.S. government will continue to manage this and will pick the neighborhoods and communities where DMC’s will be put around the world?”
“Speaking for the CHE,” Brian said, “if it works in Liberia, the best way to grow this will be to try it in a mix of different kinds of neighborhoods and countries. These should include a range from safe places through trouble spots, so we learn on the ground.”
Richard sighed but made himself smile. “The most important thing to say is thank you and I’m looking forward to working with you.” Then he spoke to Nick directly. “It’s not a perfect world so I accept your conditions to have this chance to build a DMIS, a worldwide Digital Medical Immune System with local and virtual Digital Medical Centers. My hope is this will grow to serve billions of poor people with DMC’s that find, cure and prevent infectious disease outbreaks everywhere.”
Richard paused then said with honest conviction, “I’m in all the way.”