From Dharavi to Davos: a digital bridge for a fractured world

February 16, 2018 by Steve Davis

In the face of growing inequity, Steve Davis sees opportunities to build on global progress in health and well-being.

The front of a pharmacy on a busy street in Mumbai.

New digital tools in the fight against TB include digital vouchers to pay providers like this pharmacy, an electronic drug system, and an app to manage referrals.

On a hot and humid Sunday afternoon in India last month, I met 21-year-old Ashwini Ghadge at a tiny clinic in Dharavi, a district that’s a little less than a square mile in the center of Mumbai. Home to over a million residents, it is one of the largest slums in the world and one of the most densely populated places on earth.

Ashwini was there to get the regular dose of the drugs she must take to treat her multidrug-resistant tuberculosis (MDR-TB). We both wore masks as she described how painful and frightening this terrible disease is and how her family’s deep poverty had made it impossible to afford effective treatment. As she spoke, we were joined by her general practitioner, a health advocate assigned to her case, the pharmacist at the clinic, and others who work out of that privately run storefront clinic as part of a new approach to providing care for MDR-TB patients in poor urban communities. It’s a pilot program that could be an important breakthrough in the effort to tackle what is one of the world’s most intractable problems in global health, particularly in growing urban centers like Dharavi.

Barely 36 hours later, I was bundled up in a parka in the snowy Swiss ski village of Davos. That night I attended a series of lavish receptions that marked the opening the World Economic Forum, the annual conference that draws many of the world’s richest and most powerful people. The next five days were a whirlwind of speeches, panel discussions, meetings, receptions, and parties as heads of state, CEOs, philanthropists, and other members of the global elite gathered to talk about how to improve the state of the world. It was a very long way from Dharavi—if not geographically, then at least in terms of wealth and power.

I was at Davos in my capacity as the head of PATH. Addressing the spread of MDR-TB was just one of the topics on the agenda at Davos in which PATH is deeply engaged as one of the world’s largest global health nonprofits.

Aerial view of a poor and crowded section of Mumbai.

The Dharavi district of Mumbai. Photo: PATH/Tom Furtwangler.

Bridging a widening chasm

Davos during the World Economic Forum is almost always a place fueled by optimism; this year’s theme was “Creating a Shared Future in a Fractured World.” But given everything that’s going on in the world right now, it’s reasonable to ask whether the chasm that looms between the overwhelming difficulties that Ashwini faces in her day-to-day life and the incredible privilege that many of those who were at Davos enjoy in theirs is unbridgeable.

It’s a chasm that continues to widen. Just before the private jets filled with corporate titans began arriving in Davos, Oxfam published its annual report on income inequality. In 2017, 82 percent of the global wealth went to one percent of the world’s population. Just 42 people now control as much wealth as the 3.7 billion poorest people on the planet. And according to the World Food Programme, more than 800 million people go to bed every night hungry, an increase of 40 million people since 2015.

There are plenty of other reasons to be pessimistic. Authoritarianism and nationalism are on the rise across the globe. Threats from new diseases, climate disruptions, and natural disasters are growing. The manipulation of social media and the danger from cyber threats is increasing. The number of people displaced by conflict and violence is increasing. These trends disproportionately affect the poorest and most vulnerable among us.

So there were moments this year at Davos amid the banquets and high-minded policy and business speeches when the disconnect between “Davos man” and “Dharavi woman” seemed particularly jarring. At times, I found myself wondering whether we were part of the problem or part of the solution—and asking myself if the notion of a shared world is just a convenient fairy tale the privileged tell themselves to avoid the moral implications of the suffering that today’s extreme imbalance in wealth perpetuates.

Nonetheless, I remain an optimist. While my job offers constant reminders of the sheer volume of unfair and unnecessary suffering in the world, I also know that the work PATH and our many partners do has contributed to incredible improvements in health and well-being. Over the last three decades, infant and maternal mortality rates have been cut in half. Hundreds of millions of people have risen from poverty to join the middle class. We are on the verge of controlling—even eliminating—deadly diseases like polio that once sickened and killed millions of people.

In the end, amid the private jets, security details, and tables of gourmet cuisine, I found more reason for hope than cynicism. The reason? The approaches and solutions that people talked about the most at Davos are more aligned than ever with the work that organizations like PATH are doing in places like Dharavi that are truly making a difference.

Unleashing the power of the digital revolution

Two topics in particular were at the forefront of almost every panel discussion and conversation at Davos. I believe they both offer far-reaching opportunities to make significant progress toward a world of greater health equity and less unnecessary suffering.

The first is digital transformation. Before I went to Davos, I spent a week in India meeting with government officials, health workers, philanthropists, researchers, and NGO partners who are working there to address health challenges such as tuberculosis, malaria, and infant and maternal health. Almost every meeting became a conversation about improving data and digital systems, with the discussion almost inevitably turning to questions like what it would take to build better systems to track diseases in remote communities and detect outbreaks before they spread? Is it possible to measure and assess the outcomes of global health programs on comparative basis? Can digital tools empower patients and health workers to improve how they take care of themselves, their families, and their communities? Will social media accelerate positive behavior change and improve how we mobilize communities?

Dr. Imran Sheikh standing in the doorway of his office.

Clinics like Dr. Imran Sheikh’s two-room consulting office in Dharavi are where the vast majority of local patients receive medical care. Photo: PATH/Tom Furtwangler.

Clearly, the data revolution and technology transformation is beginning to play a role in improving the lives of the poor in India.

Aswhini is a good example. She receives treatment through a program that uses digital vouchers to pay providers, an electronic drug delivery system that tracks whether she takes her medication, and an app to manage referrals. She takes her pills using a simple “smart box” that has a digital connection that records when it is opened so her doctor knows if she is taking her medications and when she needs a refill. The data generated can be analyzed to see what’s working and what can be improved. So far, more than 25,000 TB patients have been treated through this program, including nearly 3,000 with MDR-TB.

The potential to use data, social media, and new digital applications for social good—whether to tackle climate change, eliminate malaria, or increase access to high-quality education—was also central to almost every conversation at Davos. I have been a vocal advocate for exploring how we can use digital tools to strengthen health systems and improve delivery and care in poor communities. While there has been a tendency at recent Davos gatherings to imagine that we’ll cure every ill and solve every problem by building lots of clever apps, that won’t help Ashwini very much because she may never be able to afford a smartphone.

This year, I was encouraged by the tone of the discussions and the thoughtfulness of many of the proposals and ideas that people shared. There are signs of a growing recognition that for digital technology to have a significant positive impact in low-income communities, first we’ll need to build systems that support data collection, management, and analysis that will enable us to understand what’s really going in places like Dharavi so we can create solutions that target the right people with the right interventions in the right way. And while there are also important questions about privacy, access, and affordability, we are closer than ever to unleashing the power of the digital transformation to revolutionize global health.

Engaging the private sector

The second thing everyone was talking about at Davos was the growing involvement of the private sector in global health and development. I quickly lost count of the number of sessions that were devoted to this subject—everything from how to engage the private sector more deeply in innovative financing for global health to the role companies can play in supporting better care for maternal and infant health, helping eliminate diseases like malaria and guinea worm, and preparing for future epidemics.

This is not to suggest that the private sector suddenly has all the answers. Social impact investors and social entrepreneurs are not going to take over the role that governments, traditional philanthropists, and international development agencies play in addressing society’s biggest challenges anytime soon. But increasingly, the private sector is involved in addressing global health challenges that they have mostly have ignored in the past. And it is making a difference.

While I was in India, I saw a number of examples of the positive impact that the private sector is having. There, international companies including GSK, Unilever, and Medtronic are involved in projects to tackle malaria, nutrition, and diabetes. And major Indian technology companies including Tata and Wipro are working on innovations to improve India’s health systems, investing in research to develop new technologies for global health, and exploring how they can adapt effective solutions developed in India to help meet the needs of people in poor communities around the world.

It’s not just large corporations either. The Dharavi tuberculosis initiative was designed specifically to take advantage of the fact that most medical care in the slums of India is provided by private providers—pharmacists, general practitioners, nurses, and traditional street healers. That program was set up to give these private practitioners the information, resources, and financial incentives they need to diagnose and treat people who have TB. The challenge will be to continue to develop innovative ways to provide incentives that encourage private-sector involvement and that support the creation of viable markets in places where traditional business models still aren’t viable.

Creating a shared future

After five days of conversation about how to make the world a better place, it’s not hard to leave Davos feeling optimistic about the prospects for progress. And I was encouraged by some of the high-profile commitments that were made there, such as the announcement that the Bill & Melinda Gates Foundation will contribute $31 million to a new fund aimed at eliminating malaria in Central America.

But ultimately, what’s said at the World Economic Forum matters less than what happens after. Can we really bridge the gap between Dharavi and Davos and create a shared future for all? In the near term, it’s almost certainly too much to hope for. But if we take advantage of the opportunities that the digital transformation and greater involvement by the private sector in global health present, I believe we can at least begin to heal some of the fractures in our world that are caused by persistent poverty and deep health inequity.