Unmanned aerial vehicles (UAVs), better known as drones, are on the rise. During the ongoing corona crisis their potential to either monitor curfews or to provide contactless deliveries is increasingly featured in various media outlets and discussed in policy circles.^[1] A focus on health-related issues harkens back to earlier attempts to render drones – a military technology – productive for civil use. Currently, one of the most widely featured companies in this field is the Silicon Valley-based start-up Zipline. In late 2016, Zipline started to deliver blood – and quickly added other essential medicines – for medical emergencies in Rwanda. They expanded to Ghana in 2019. Given that the start-up portrays itself as a robotics company comprising mainly of software and hardware engineers and is located in Silicon Valley, the epicentre of digital innovation, it seems reasonable to ask how Zipline came up with a focus on health. Moreover, what definition of health does Zipline promotes and relies upon? How does the company’s understanding of health relate to other global health priorities? How are ‘end-users’ like doctors and nurses imagined to engage with the new mode of instant airspace delivery of blood and other medical products? Finally, how do African health infrastructures fit into Silicon Valley’s technocratic solutionism (Morozov 2014, Daub 2020)?

What I will call ‘Silicon health’ aims to capture two interrelated aspects of this amalgam. First, I examine Zipline’s digital and logistical imaginations of health for which they claim their technology provides the perfect fit. While we need to understand where these framings originate from and how the affordance between drones and health is operationalized, I also argue that it is actually ‘health’ that helps the technology to take off, earn moral credit and eventually connect African systems to the digital economy and platform capitalism. As a result of the rather unlikely entanglement between Silicon Valley engineers, venture capital, Global Health and African states it seems that ‘health’ has become central in that it both disguises and facilitates the company’s strive for data. In what follows, I briefly summarize Zipline’s origins and outline some of its core operational principles. Against this background I delineate some empirical instances that help to explain the different roles health plays within Zipline’s operations and indicate some of the side effects of Silicon health in Africa. 

Taking off…   

The fact that Zipline commenced its commercial operations on the African continent – and for instance not in the US – is related to regulatory thresholds, as a statement of the company’s CEO Keller Rinaudo indicates: 

“A lot of commercial [drone] operators in the US are waiting to get permission from the FAA [Federal Aviation Authority]. But the FAA is saying we want more data. But no one is actually flying. So, I actually think that […] one of the best ways that we can work together with the FAA to help this technology take off in the US is by operating in a country where we can basically serve a very clear need and get tens of thousands of hours of safe flight data […].“^[2]

During their first three years Zipline conducted their prototype testing without much noise and rather secretly on a large cattle range outside San Francisco.^[3] In early 2016 the company signed a deal with the Rwandan government and Zipline positions itself as a logistical intermediary working between national medical supply chain management and all the health facilities dispersed throughout the territory. Zipline operates out of several distribution centres from where they supply preselected health centres and hospitals in Rwanda and Ghana with blood, vaccines, and other medical products.^[4] The company’s bold mission is “to provide every human on earth with instant access to vital medical supplies.”^[5]

Saving time during medical emergencies by flying above terrestrial hurdles may indeed offer some benefits for the saving a patient’s life. However, the branding of Zipline UAVs as  ‘medical drones’ cannot entirely disguise the contingent nature of this particular use-case. As the CEO’s statement indicates, Zipline’s focus on health and medical emergencies needs to be situated in a broader context of increasing competition for market shares, regulatory thresholds as well as popular scepticism. Currently, drone companies are required to find niches through which they are able to distinguish themselves from competitors and draw public attention, convince regulatory authorities and eventually attract (venture) capital funding. This is also because Zipline’s biggest competitors are monopolistic internet giants like Amazon and Google, which are successfully running their own drone projects but largely focus on profitable consumer goods. Health product logistics appears to be a niche area that is left open for start-ups like Zipline, one that requires they deal with two highly regulated sectors: aviation and health. In addition, public perceptions of drones are suffused both with concerns about their safety (when flying over populated areas) and fears regarding the potential violation of people’s privacy in unpredictable ways. To counter these concerns, drone companies aim to reframe their product from a military technology that has mainly brought destruction, into a device that proves valuable for the saving people’s lives.^[6] Showcasing “good drones” (Sandvik & Jumbert 2018) is assumed to counterbalance fears regarding safety and privacy. Such moralisation, however, is likely to eventually result in pitting privacy concerns against saving lives in emergency situations.

Defining Silicon Health 

Promoting emergency deliveries of blood (or other medical products) is largely an effect of the company’s focus on their own technology and less the result of an engagement with existing global health priorities. Zipline’s ambitious goal to “provide instant access to all humans on earth” only loosely connects to the aims and objectives of an equally ambitious – and often criticized – Universal Health Coverage campaign (see Prince 2020).^[7] But even within the “Health for all” agendas of international organisations and national Ministries of Health, emergency medicine is not treated as a priority. Risks and fears prevail that an increased focus on emergency medicine would divert resources away from other preventive and curative programs (Raazak & Kellermann 2002). Studies have also indicated that acute medical situations can often be absorbed by a well-functioning and strong primary care service. Many paediatric emergencies in low- and middle-income countries can often be solved with little additional expertise or outside help (Duke & Cheema 2016). In Ghana (though less so in Rwanda) civil and medical organisations have begun to question the value of the contract which their government signed with Zipline guaranteeing the company a payment of 12 million $US over the next four years.^[8] The contention is that this money could have been better used to strengthen other already existing emergency or health supply infrastructures.^[9] Prioritizing high-tech solutions reveals preferences in answer to the question of what kind of health is preferable in a pre-dominantly low-tech context. Here it seems that the buying of Zipline’s services reinforces earlier discussions on the affordance of preventive vs. curative interventions. To put it differently in the words of a commentator during the Vice-President’s inauguration speech of the 4^thdistributions centre of Zipline: “Mr. Vice President congratulations, but remember the people drinking the same unclean water with cattle…I am confident they will appreciate even manual pumped boreholes.”^[10]

But what does the integration of Zipline’s logistics actually mean for health service delivery in Rwanda and Ghana? From a bird’s eye perspective, it seems that Zipline’s promise of instant access to medical products relies, first and foremost, on a significant (re-)centralization of national medical supply logistics. The decentralized health systems of both Ghana and Rwanda usually operate with a mix of push and pull models, depending on the system level and the complexity of respective health facilities (e.g. district hospitals). On a district and hospital level, this allows for a certain degree of independence regarding the whens and wheres of distribution and use of essential medical products. Currently most of the products Zipline delivers are still paralleled by ground-based supplies. However, a stronger shift and reliance on the company’s distributive model is likely to have a substantial impact on the socio-technical significance of remote health facilities. According to Zipline, remote health facilities would no longer “need to maintain thousands of refrigerators”. Such a disconnect from cold chain (and potentially other) infrastructures is not seen as a risky intervention but largely celebrated as some form of liberation. Or as one of Zipline’s employees puts it: “We do guarantee cold chain down to the last mile which frees up a lot of these last mile health facilities from not having to have cold chain storage on site.”^[11]

In addition, Zipline’s pitting of their novel airspace logistics against existing health systems implicates road and transportation infrastructures. By claiming that their drone services “are able to fly over all of these troubles” and thus “doesn’t depend on roads,” Zipline attempts to position airspace logistics and drones as yet another example of a leapfrogging innovation. On the one hand we can certainly understand some of these claims and exaggerations as part of the company’s need to convince investors of the novelty and revolutionizing potential of their innovation. On the other hand, some of these claims distort operational and contextual realties and disguise which technical, legal and infrastructural requirements their services in fact continue to depend on. For instance, Zipline’s distribution centres in Ghana and Rwanda need to be constantly and reliably re-supplied with blood and medical products. That means trucks from national medical stores will still need to use roads to get there. Moreover, visualisations of Zipline’s flight routes show only zig-zagging lines, indicating that their drones are not able to simply fly over ‘ground trouble’ but instead are forced to account for various geographical (e.g. mountains, trees, cell towers), climatic (e.g. wind, rain) and socio-technical formations on the ground (e.g. schools, government buildings). 

Health as frontend and its side effects

Reducing the independence of remote health facilities is just one side effect of the company’s overall tendency to disconnect its services from local expertise and engagement. Apart from centralizing commodities at their distribution centres Zipline also operates with a specific framing of their ‘end-user’ or what in the digital world is call the frontend of a service. As the CEO of Zipline puts it: “Although we are taking advantage of a lot of technology on the backend to make that experience possible, the experience for the user, the doctor or the nurse is really, really simple: Push a button, get what you need.”^[12] From the company’s perspective the projection of an idealized ‘user experience’ – like that of an Amazon order in a well-connected (Western) setting – onto rural African health logistics initially offers a substantial operational advantage. If pushing a button constitutes the ideal as well as minimal requirement for engaging with their services, this also means that there is no need to rely on any form of local expertise.^[13] Disengaging end-users from more intense interaction with the technology spares the company from having to provide costly and complex training as well as from relying on non-experts to keep their operations running.

Zipline’s leadership assumes that that this strategy will have only a positive impact on how health staff access and apply medical products. Early indications suggest, however, an actual ‘user experience’ that is somewhat more complex than simply pushing buttons. What the CEO’s image of “pushing a button” currently translates to is the writing of a text message, a WhatsApp message, or phone call in order to place an order at a distribution centre. While there might be back-and-forth communications and the need to clarify between the Zipline pharmacist and the ordering nurse or doctor, Zipline’s system also relies on a mixture of additional social, technical and infrastructural requirements. Sending text or WhatsApp messages requires the availability of either data bundles or credit on a (smart-)phone. This can not always be taken for granted, as many people regularly run out of credit or data bundles. A similar problem concerns the need for a mobile phone that is always charged, which may be difficult in rural regions given the patchy availability of reliable electricity.

On a more practical level, in emergency situations staff often need to choreograph several different tasks at once. The arrival of the blood delivery from outside needs to be integrated with the emergency’s own temporality or with tasks that might have risen after the message had been send. The same applies to Zipline’s announcement of speed and (emergency) temporalities. Storing blood in a decentralized manner in some of the hospitals indicates that Zipline’s services have the potential to actually slow down the availability and applicability of blood. Fetching a pint of blood that is stored in-house might take 5 to 15 minutes, almost half of Zipline’s average delivery time of approximate 30 minutes. This brings us to the final point regarding the availability of blood in remote clinics. In order to showcase their focus on blood, Zipline’s portrayal of the interaction between their services and local clinics does not make any reference to the existence of a local practice called replacement donors. Rural hospitals often only stock small quantities of blood. When demand arises, doctors will use stored blood but in turn will approach caring relatives of the patient and ask for donations to replace the used units (Bates & Hassall 2010). While this system is imperfect when it comes to safety and quality management, the WHO still estimates that in many low-and-middle income countries 50% blood donations depend on on-site replacement donors.^[14] Taking account of the role and relevance of local replacement donations in Zipline’s reductionist framing of the reach of national blood banks, the needs they aim to fulfil suddenly appear more complex and less clear. 

Concluding remarks

Zipline’s focus on speed and acceleration of access to medical products is likely to shine brighter in contexts that are stereotypically not associated with speed and high levels of technologically enabled mobility. While not openly described as such, African health systems, their supply and distribution structures, as well as their ground-based transportation infrastructures, implicitly serve as the slow and sluggish backdrop for Zipline’s privileging of instantaneity and speed. This article was an attempt to understand how Silicon Valley roboticists and (software) engineers come to (re-)define access to medical products and health practices of rural African populations. The aim was to show that, against the company’s claim that their technology constitutes the appropriate solution to the continent’s health needs, it is indeed the other way around: ‘health’ serves the company’s need to showcase their technology and facilitates the collection of flight data. While Zipline claims “that every flight is saving a human life”, it is actually the case is that every flight collects data on the behaviour of drones, often in conditions under which flight would not be allowed in the US. In addition to handing over their safety flight records to the Federal Aviation Authority (FAA) Zipline managed to transport approximately 40 FAA officials to their Rwandan distribution centre in order to demonstrate their features.  

In general, it seems we are better off in understanding Zipline’s focus on health as largely a strategic decision than a path-dependent connection between a medical problem and a technology. During their public presentations over the last couple of years, Zipline’s leadership was repeatedly asked if and when they would consider opening their airspace services for products other than health. In their reactions Zipline continually emphasized that the health logistics market would be large enough for the company to scale up and eventually become profitable. The more recent reality however offered a somewhat different picture. In September 2020, Zipline announced that it will enter a collaboration with the US retail giant Walmart, delivering medical and wellness products into private homes starting in Arkansas. The announcement suggests that the line between lifesaving products for medical emergencies and probably less existential wellness products – and soon other products – is rather thin, suggesting that health may be dropped when other fields of delivery turn out to be (more) profitable.

In the midst of a Q&A at an International Monetary Fund (IMF) meeting Zipline CEO Rindaudo called global health experts that would dare to question the idea and relevance of medical drones in Africa “total hypocrites”^[15]. Despite this criticism, other global health organisations like GAVI and Bill & Melinda Gates Foundation (BMGF) have supported Zipline’s airspace logistics financially and ideologically from early on. This indicates that the kind of Silicon Health that is promoted by digital tech starts-ups like Zipline or Matternet can also be understood as an increase and acceleration of the fragmentation of an already arbitrarily connected global health landscape. How this will play out in the midst of the global pandemic remains to be seen. 

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René Umlauf’s research focuses on conceptual and methodological implications of technological change. In his work on health-, laboratory- and humanitarian-infrastructures he connects this line of inquiry to the broader political, cultural as well as historical encounters between ‘old’ and ‘new’ modes of knowing and doing things. After receiving his PhD in sociology from the University of Bayreuth in 2016 he worked as a post-doc at the Department of Anthropology at Martin-Luther University Halle. In 2020 he joined the Department of Sociology at Leipzig University where he started a project on humanitarian drone infrastructures.

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References:

Bates, Imelda, und Oliver Hassall. 2010. „Should We Neglect or Nurture Replacement Blood Donors in Sub-Saharan Africa?“ Biologicals, Special Section: Advances in Transfusion Safety (pp. 1-104), 38 (1): 65–67. https://doi.org/10.1016/j.biologicals.2009.10.013.

Daub, Adrian. 2020. What Tech Calls Thinking: An Inquiry into the Intellectual Bedrock of Silicon Valley. New York: Farrar, Straus and Giroux.

Duke, Trevor, und Baljit Cheema. 2016. „Paediatric Emergency and Acute Care in Resource Poor Settings“. Journal of Paediatrics and Child Health52 (2): 221–26. https://doi.org/10.1111/jpc.13105.

Morozov, Evgeny. 2014. To Save Everything, Click Here: The Folly Solutionism. London: Pubilc Affairs.

Prince, Ruth. 2020. „Utopian aspirations in a dystopian world: “Health for all” and the Universal Health Coverage agenda – an Introduction“. Somatosphere. 2020. http://somatosphere.net/2020/universal-health-coverage.html/, accessed 21.01.2021. 

Razzak, Junaid, und Arthur Kellermann. 2002. „Emergency medical care in developing countries: is it worthwhile?“, Bulletin of the World Health Organization, 80 (11). http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862002001100011.

Sandvik, Kristin Bergtora, und Maria Gabrielsen Jumbert. 2018. The Good Drone. Routledge. London.

Spicer, Neil, Irene Agyepong, Trygye Ottersen, Albrecht Jahn, und Gorik Ooms. 2020. „‘It’s far too complicated’: why fragmentation persists in global health“. Globalization and Health16 (1): 60. https://doi.org/10.1186/s12992-020-00592-1.

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Notes

^[1]See for instance in Germany where Labor Berlin, one of the biggest laboratories in Europe, entered a collaboration with another Californian drone company called Matternet. The aim is to accelerate transportation of Covid-19 test samples from hospitals to laboratories (https://www.laborberlin.com/wp-content/uploads/2020/11/201117_Pressemitteilung_Drohnen_ENGLISH.pdf, accessed 24.01.2021). Or for instance how some government agencies make use of drones in order to enforce lock-downs and sanitary cordons etc. (https://blog.werobotics.org/2020/04/09/drones-coronavirus-no-sense/, accessed 24.01.2021). 

^[2]See: http://sustainableskies.org/autonomous-drones-air-drop-medical-supplies/, accessed 28.01.2021.

^[3]Both Rwanda and Ghana have their own specific regulatory framework: See Rwanda https://www.droneregulations.info/Rwanda/RW.html#country-searchand for Ghana https://www.droneregulations.info/Ghana/GH.html#country-search, accessed 04.02.2021. 

^[4]In order to get an impression how Zipline drones are actually flying and how they drop their cargo see: https://www.youtube.com/watch?v=nnKnMgWy_tM, accessed 24.01.2021 

^[5]For the company’s self-portrait and mission description see: https://flyzipline.com/. 

^[6]Combating terrorist activities in Afghanistan through drones strikes for instance is ultimately also justified by the narrative of saving people’s life in the US by protecting them from deadly attacks.

^[7]Health (for all) has also been singled out as the 3. Goal of the Sustainable Development Agenda (https://www.un.org/sustainabledevelopment/health/, accessed 09.02.2021). But one can also add that the emergence of Zipline is only another instantiation and expression of a highly fragmented Global Health landscape whose least common nominator constitutes the embrace of technological innovations (Spicer et al. 2020). 

^[8]See https://imaniafrica.org/2019/01/04/a-detailed-evaluation-of-ghanas-drone-purchase-agreement-between-fly-zipline-ghana-ltd-and-the-ministry-of-health-by-kobina-ata-bedu-mcips/accessed 28.01.2021.

^[9]The 12 million $US is however only the fee for the actual delivery services. The set-up of Zipline’s distribution centres (approx. 800.000 $US) have been financially supported by Gavi and Bill & Melinda Gates Foundation among others.  

^[10]See https://www.facebook.com/MBawumia/videos/live-commissioning-of-zipline-medical-drones-project-at-vobsi-walewale/961844704298577/accessed 28.01.2021.

^[11]See https://www.youtube.com/watch?v=z50lBJ4Vsjo, accessed 28.01.2021.

^[12]See https://acecnational.podbean.com/e/zipline-ceo-keller-rinaudo-saving-lives-through-innovation/, accessed 28.01.2021.

^[13]The strong disconnect from end-user’s engagement is also an effect of Zipline’s decision to use fixed-wing drones. Other systems using quadcopters and tilt-rotators can hoover as well as take off and land in different sites both allowing and requiring basic knowledge and training in how to receive or send items. Depending on the context and the actual use case operating systems that are open to end-user engagement have the clear advantage to make use of flying back and force destinations. While Zipline praises itself of being worldwide the first drone delivery system operating at national scale they are also the first to replicate the old logistical problem of returning home empty.

^[14]See https://www.afro.who.int/health-topics/blood-safety, accessed 28.01.2021.

^[15]After being asked whether they talked to other governments before starting their collaboration with the Rwandan government the CEO response was: “[…] to be totally honest the first thousands of conversations I had people told us this was totally stupid and was not gonna work. People also told us … and I am mainly actually speaking about experts in Global Public Health here in the United States, people told us that this actually wasn’t the problem. Based at that the reasons stockouts occur at these hospitals is that doctors aren’t very good at forecasting, doctors are irresponsible and if only doctors would do a better job in forecasting these stockouts wouldn’t happen. And you know I wasn’t an expert in Global Public Health so I heard this and thought: Gosh maybe we are wrong about this and maybe we are being stupid, I mean these guys are experts. And then I kind of looked at the data…[…] and that for me was like a lightbulb moment where I am like all these Global Health experts are total hypocrites […]”  See: https://www.imf.org/external/POS_Meetings/SeminarDetails.aspx?SeminarId=271, accessed 20.05.2021.