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The women waited on the prickly grass, their babies hanging from nearby trees in brightly coloured string bags, too-quiet children on their laps. One by one they ascended the veranda steps to the blue Formica table, where the nurse asked them the questions they had heard many times before. “Skin hat?,” “kai kai?,” “Pek pek wara?” “Kus?” Do they have a fever? Have they eaten? Do they have loose stools? Do they have a cough? The women sat rigid on the hard bench and whispered barely audible replies. A thermometer was placed delicately under an armpit. The nurse listened to a child’s breathing with a stethoscope. A clinic book, detailing a child’s previous visits to the clinic was cursorily examined.

What were the options here? Pneumonia, malaria, diarrhea, hopefully not tuberculosis. The nurse was so familiar with the symptoms and the treatment possibilities that she rarely opened the small standard treatment book that sat on the neatly organized table next to her. Most of the children were given antimalarials (chloroquine with Fansidar), antibiotics (amoxicillin) and panadol. The mothers of the very sick ones (bikpela sik) were asked to come back if their child did not improve. They walked away in the blinding sun, carrying their children in their arms and their babies, parceled in their woven string bags, on their heads.

In 2004, when I visited Begasin Health Centre in Usino Bundi district, Papua New Guinea, diagnosis at a rural health clinic meant aligning a patient’s symptoms with available treatments. Some rudimentary diagnostic tools were available: a stethoscope, a thermometer, a sphygmomanometer. But most community health workers and nurses depended on a combination of clinical judgment and syndromic algorithms from standard treatment books to undertake what medical practitioners call “empirical diagnosis.” When the prescribed treatment did not work and patients returned to the health center sicker than when they had left, the health workers would scour the standard treatment book for other possibilities: tuberculosis, meningitis, dengue. There was no laboratory here, no way to test for these diseases, and very sick patients were referred to the general hospital in the coastal capital, several hours walk and a long bus journey away.

There was a microscope at Begasin health centre—possibly a remainder from earlier attempts to extend microscopy services into rural areas, or perhaps a one-off donation from a development agency or NGO—but no one knew how long it had been there or how to use it, and no one had the key to the wooden cabinet in which it was kept. Inside the clinic, a surplus box of microscope slides propped the window open, providing welcome ventilation to the humid, tin-roofed room.

The routine medical protocols I observed on the verandah of Begasin Health Centre in 2004 were a far remove from laboratory-based gold standards for medical diagnosis, yet they did comply with the standards for rural primary health care in low and middle-income countries. At the time, the WHO recommended that anyone presenting with fever in a malaria-endemic area with no access to microscopy services should be treated presumptively with anti-malarials. Empirical diagnosis based on clinical judgement was considered the only way for curative medicine to proceed in places where a lack of technical and transportation infrastructure and expertise precluded the extension of laboratory services.

Yet even as I observed the routine dispensing of antibiotics and antimalarials at Begasn Health Centre, elsewhere the norms for basic care in resource-limited settings were changing. Growing antimicrobial resistance to first-line drugs, such as those for malaria and tuberculosis, and the heightened cost of new drugs were drawing attention to the human and economic cost of empirical diagnosis and the overtreatment it generates. Nonetheless, the technology and expertise necessary for more accurate laboratory diagnosis simply wasn’t present in primary health care settings in many low- and middle-income countries, where the transportation, electrification, communication, and sanitation infrastructure that laboratories depend on did not reach.

A novel solution to this dilemma emerged in the late 1990s, with the development and release to market of a handful of malaria rapid diagnostic tests (MRDTs). These lateral-flow immunochromatographic tests used isolated antibodies to bind with malaria parasite antigens present in a blood sample. A positive test resulted in the appearance of a thin line in the test window where the antigen-antibody interaction occurred. MRDTs were not as accurate as laboratory based microscopy and, as the number of tests available on the market proliferated, concerns about disparity in the quality of devices and a lack of regulation in many low- and middle-income countries also grew. Nonetheless, these small devices had a significant advantage over laboratory-based assays: they were mobile.

Malaria rapid diagnostic test kits were transportable to places with limited road access. They compressed the time between test and result and therefore reduced the risk of losing patients to follow-up. They were affordable (with prices at around $1-$2 per testing kit) and easy to use, meaning they did not require a laboratory technician to read them. MRDTs extended the reach of laboratory medicine in two directions. First, they revealed the presence of pathogens hidden deep in the recesses of the diseased body. Second, they were designed to penetrate the farthest edges of the health system. Global health had entered the age of deep diagnostics.

Public Needs, Private Goods

The excitement that surrounded point-of-care diagnostic devices following the arrival of the MRDT turned on their potential to make the physical extension of laboratory infrastructure unnecessary. But the shift from laboratory to test also brought a wholly different—and equally problematic—infrastructure into view: the market.

The development of MRDTs by biotechnology brought the absence of comparable point-of-care testing devices for other treatable infectious diseases in low-income countries into sharp relief and spurred demands for their development. In 2006, for example, Médecins Sans Frontières (MSF) marked World TB day by calling for the “urgent need for ‘a simple test which yields results almost instantly and can be used by any laboratory technician, nurse or health workers even when far away from a laboratory.’” Campaign groups and public health experts made similar calls for diagnostics for neglected tropical diseases, such as trypanosomiasis and visceral leishmaniosis. Diagnostic devices are commodities, and their nonexistence was explained through the frame of market failure. The WHO focused on disincentives for industry to invest in the technology, including prohibitive R&D costs, a lack of regulation, uncertainty about market size, and concern about the ability of governments to pay for tests (AMS 2009: 9; WHO 2006). They discussed the need “to stimulate and facilitate the diagnostics industry to adapt available technologies to develop new diagnostics” (WHO 1998:2), and to call for partnership and engagement between the public sector and industry. In 1997, in an innovative move, the WHO organized a joint convention with industry to identify feasible TB tests for development. The premise of the convention was that public health experts could identify the tests that were needed, while industry representatives could help identify those that were most feasible (WHO 1997).

Emphasis on partnership gained momentum in the early 2000s, when the Bill and Melinda Gates Foundation entered the fray, adding diagnostics to its focus on drugs and vaccines within its mission to find technical solutions to global health challenges. The Gates Foundation already had invested in the establishment of novel public-private partnership arrangements for the development of life-saving drugs (DNDi) and vaccines (Gavi). In 2003, they donated $30 million to establish FIND, a nonprofit organization based in Geneva and often referred to as a “product development partnership,” with a remit of helping promising diagnostic developers to overcome development, regulatory, and market challenges. They also gave significant sums to PATH, a Seattle based nonprofit that develops new diagnostic tests, undertakes market research, and builds partnerships with industrial manufacturers.

By the middle of the decade, the global health community widely accepted that “strategic efforts to build laboratory capacity must be pursued urgently by partnerships between public (national and international), private and commercial sectors to address this health care crisis” (Petti et al. 2006: 380). With the articulation of a need for diagnosis segueing into the need for point-of-care diagnostics, work to improve the diagnosis of treatable diseases in resource-limited settings became concomitant with the work of “stimulating” and “shaping” markets for global health. These efforts to incentivize diagnostic development led to the creation of a whole array of market-making techniques, methods and devices, designed to align the necessary with the feasible, which are ancillary to the diagnostic device itself.

Market Devices

So the world needs diagnostics—but which diagnostics? Not only are there multiple candidate diseases for which diagnostics might be developed, there are also multiple possible ways to test for any single disease, from rapid antigen-based assays to molecular-level PCR. Depending on where a test is embedded in a patient care pathway, its infrastructural requirements, what kind of sample is obtained and how (finger-prick, intra-venous blood, saliva, vaginal swab, sputum, urine), and what the test seeks to detect (antigens, antibodies, biomarkers, pathogens) all determine what kind of information a test generates, how accurate that information is, and what can be done with it.

For example, a simple, affordable and easy-to-use test for tuberculosis with high sensitivity (ability to capture positive cases) and low specificity (ability to exclude negative cases) could be used at a peripheral health care setting to triage patients but not to make treatment decisions. Positive cases would need to be sent for confirmatory testing to ensure people are not treated with highly toxic drugs unnecessarily. A point-of-care non-sputum-based biomarker test with high sensitivity and specificity may enable positive diagnosis, but will not necessarily enlighten health workers about drug resistance or susceptibility.

For every disease, a multitude of tests with different performance characteristics are possible. How should diagnostic developers decide in which tests to invest their time and resources? Market logic demands that, if investors are going to invest in diagnostics, and developers are going to embark on lengthy R&D programs, they need to know there will be demand for the end product. Identifying which tests are “needed”—and therefore which tests future customers (bilateral agencies, philanthropic foundations such as the Clinton Foundation, and international organizations such as the Global Fund) are most likely to buy—has therefore become a crucial step in fostering markets for diagnostic devices.

A range of market-making techniques, methods, and devices has been developed or borrowed to help define diagnostic needs and align them with industry-led solutions. Here are three of them:

1. Forecasting

In 2004, in collaboration with the RAND corporation, the Gates Foundation established the Global Diagnostics Forum, an interdisciplinary research group with the goal of identifying which diagnostic tests are likely to have the most health impact and to stimulate interest in such tests among the global health community. As Deborah C.Hay Burgess explained in the forum’s subsequent special supplement of Nature, “An initial step in developing a rational strategy for creating diagnostic technologies for global health is to determine the need for, and the health impact of, potential new tests” (Hay Burgess et al. 2006: 2).

The forum used mathematical modeling techniques to predict the impact (measured in lives saved and disability-adjusted life years [DALYS]) for hypothetical tests in six disease areas (acute lower-respiratory infections, HIV/AIDS, diarrheal diseases, malaria, tuberculosis, and sexually transmitted infections). The GDF models quantified the difference between the status quo—in which empirical diagnosis is the norm in peripheral areas—and a future populated with rapid point-of-care tests.

The chief finding was that higher-accuracy tests, requiring more advanced infrastructure, would have a lower overall impact on disease burden than less-accurate tests that could be used in more peripheral facilities and therefore reach a greater number of people. For instance, a syphilis test requiring minimal laboratory infrastructure was calculated to prevent more than 138,000 congenital syphilis cases and more than 148,000 stillbirths annually. A test that could be performed with no laboratory infrastructure could prevent more than 201,000 congenital syphilis cases and 215,000 stillbirths annually (Urdea et al. 2006: 75; Keeler et al. 2006). Deeper penetration of the health system trumped the scientific penetration of biological matter. The impact of point-of-care diagnostic tests could be greater than that of gold-standard laboratory testing, so long as they were ambitiously distributed.

The scientific calculations that the GDF put forward made a forceful case for global health funders to invest in the development and procurement of rapid, portable, point-of-care diagnostic devices. Yet for all their apparent numerical objectivity, the GDF forecasts also depended on the construction of a compelling story about what global health “impact” looks like.

First, the GDF focused on the potential for point-of-care diagnostics to bring about some improvement, however minimal, for populations with inadequate access to diagnostic technologies: “We consider a new test to represent an improvement if it saves more adjusted lives than would be saved in the status quo” (Girosi et al. 2006: 6). This humanitarian calculus side-stepped tricky ethical questions about global health inequity; including whether it is acceptable for patients at peripheral facilities in low- and middle-income countries (LMICs) to receive a less-accurate diagnostic test than patients with access to laboratory services in wealthier countries or regions (see also Moran, this issue).

Second, the GDF forecasts implicitly abandoned older developmental visions of large-scale infrastructure development, accepting that the electrification and transportation infrastructures necessary for laboratories were unlikely to be extended uniformly across LMICs. In the GDF forecasts, the health centers where point-of-care tests were used would all remain disconnected from centralized electrification, transportation, sanitation, and communication infrastructures into the future. This was acknowledged in an aside made in one of the publications resulting from the project:

Although it is outside the scope of this paper, another method for improving health outcomes that could be approached in parallel to improving diagnostic tests would be enhancing the infrastructure and staffing available at these health-care settings. This approach would, in turn, allow the facilities to adopt better tests that might be available today or in the future. For instance, improving infrastructure and staffing could allow nucleic-acid-based tests for STIs to be adopted in more health-care settings” (Girosi et al., 2006: 8).

The GDF forecasts included calculations about the likely availability and success of treatment at different levels of health facility in different countries, but tenuous links between diagnostic test and treatment were, for the most part, glossed over. For example, the forecasts made no mention of the complexities of rolling out smooth medical supply systems, health-worker training, and treatment protocols in health settings lacking basic infrastructure. As critical global health scholars have shown, whether a test is used, how it is interpreted, and how it is acted on each depend on local institutional histories, relationships and expectations (e.g. Beisel et al. 2016; Chandler et al. 2011). The conflation of test availability with treatment created the impression that diagnostic devices have a direct impact on disease itself, occluding the many contingent steps in the diagnostic process, and focusing attention on the device itself as a worthy investment for global health funders.

Last, the GDF forecasts generated a vision of universal access to point-of-care testing that was, in some respects, no less grand than older developmental schemes. This was a vision in which there are tests for everything and tests everywhere. These tests would not be as accurate as laboratory tests that require carefully calibrated machines, refrigerated reagents, and highly trained technicians, but through sheer ubiquity they would save more lives than the best laboratory tests. This was a vision for a health infrastructure that is modest in quality but ambitious in reach.

Ultimately, the “success” of the GDF forecasts depended less on their scientific accuracy in predicting the future, than on their capacity to convince funders and developers that diagnostics have humanitarian, public health and economic value. The objective was to “articulate the acute need for diagnostic tools” and “encourage technology developers in the public and private sectors to do more to accelerate the development and delivery of new diagnostic solutions” (Hay Burgess et al. 2006: 2).

2. Consensus making

The GDF harnessed mathematical modeling techniques to evidence the need for specific diagnostics and incentivize funders and industry. However, time and again, the accuracy of mathematical forecasting has been shown to vary wildly. In 1967, the RAND Corporation published an influential paper outlining a new forecasting method, based on the generation of consensus among a community of experts. Ultimately, the author stated, mathematical models are only as good as the experts who provide the input values, so why not make this dependence on experts explicit and refine the process? The solution outlined in that paper, called the Delphi method, was first developed to forecast the impact of technological change on warfare. It was underpinned by the idea that groups are better at predicting the future than individuals, and anonymity will encourage flexibility and safeguard against status-based influence. A questionnaire was sent out to selected experts in the field. Their answers were anonymously summarized by a facilitator, who laid out common and conflicting viewpoints and reasoning and asked participants to revise their answers to the questionnaires in these responses. Over several rounds, the group was expected to move towards a consensus about what is most likely to happen.

Since the mid-20th century, the Delphi method has metamorphosed into a facilitation tool for the management of multi-stakeholder projects and is especially popular in global health. In the context of global diagnostics, it is not used to reconcile the predictions of different stakeholders, but to establish which futures—in the form of specific tests—are most desirable. In 2014, for example, the Global TB Programme of the World Health Organisation employed the Delphi method to identify priority diagnostic tests for tuberculosis (WHO 2014). The “experts” consulted in the Delphi Process included 24 participants from technical agencies and researchers (all but one based in the northern hemisphere); seven participants from funding organisations; five participants from supranational TB reference laboratories; five implementers and clinicians (all but one from institutions in the Northern hemisphere); and six representatives from countries with a high burden of TB. The process resulted in agreement on three diagnostic priorities: (i) a point-of care, biomarker-based, non-sputum-based test to detect TB; (ii) a point-of-care test that could be used for triage; (iii) a point-of-care sputum-based test that could be used as a replacement for smear microscopy. These were taken forward to a subsequent meeting with industry, where product profiles for the tests were agreed on.

The use of the Delphi method in this context raises questions about who is included and excluded from processes of defining global health needs. As one WHO representative put it to me, “The process works if you have the right experts.” But who are the “right” experts? Some lines of exclusion were explicit: for example, WHO rules designed to safeguard against the influence of commercial interests dictated that industry representatives were excluded from the process. Others were more opaque: the group was dominated by academics and public-health professionals from funders and global health organizations based in Europe and North America. In an indication of the extent to which the process of identifying needs was driven by market logic, these experts were also key individuals likely to influence their organization’s future procurement policies. Overall, out of 46 invited participants in the Delphi method, twelve were based at institutions in low- and middle-income countries with a high burden of tuberculosis.

3. Profiling

Needs must be met with solutions, and while it is sometimes deemed appropriate to exclude industry representatives from the definition of global health needs, their participation in the finding of solutions is presumed to be crucial if those solutions are going to be feasible. In 2014, following the use of the Delphi method to ascertain priority needs, the WHO hosted a meeting in Geneva where industry representatives were invited to help develop performance specifications (sensitivity, specificity, shelf life, infrastructure requirements, cost) for the priority tests. The final specifications were subsequently published in the form of four target product profiles (TPPs).

The TPP was a device originally designed by the FDA in the late 1990s to improve communication with the pharmaceutical industry during the drug-development process. Over the past decade, the TPP has found a new home among global health initiatives as a technique for reconciling needs with solutions, demand with supply. A TPP that has had input from funders, regulators, users, and industry not only describes a goal, in the form of a diagnostic test, but is intended to make its achievement more likely. TPPs, as one WHO representative explained to me, “are aspirational.” They are guidance for the manufacturer on what kind of tests agencies are willing to procure. At the same time, the role of industry in defining those characteristics means they are more likely to be met.

At the 2014 meeting, the writing of TPPs involved negotiations between advocacy groups and industry over the correct pricing of the tests, and between users and industry about the kind of temperature stability that would be required. The TPP convention of recording “minimum” and “optimum” specifications for each of these items meant that some degree of difference between stakeholders could be tolerated in the final profile. The TPP brought the desirable within touching distance of the possible.

Conclusion

The arrival of the malaria rapid diagnostic test fundamentally changed ideas about what kind of medicine was feasible and desirable at the periphery. It became possible to imagine that microbes, parasites, or viruses, which are imperceptible to the human eye, could be identified in bodily fluids by a health worker with basic training in a health facility with no running water, electricity, or laboratory equipment. In changing what was technically possible, the rapid diagnostic test kit also transformed expectations for everyday medicine in resource-limited settings. The human cost of misdiagnosis and unnecessary treatment, which previously had been accepted as the necessary cost of universal access to health care in places without a laboratory, now became an aberration demanding action.

The arrival of mobile point-of-care diagnostics also presaged a shift in the problematization of diagnosis in global health, from how to extend laboratory infrastructure to how to stimulate markets for mobile devices. Once the need for diagnosis in peripheral primary-care settings became commensurate with the need for diagnostic devices, the substantial problem-solving apparatus of global health institutions in Europe and the United States was focused on overcoming the challenge of market failure.

Ironically, given that the “need” for diagnostics in global health was framed as the motivation behind these activities, they also were aimed at specifying those needs. Once identified, needs also had to be articulated with feasible solutions—that is, small, portable, marketable diagnostic devices. The alignment of public needs with private solutions required a fine-tuned array of techniques, methods, and devices that would align the desirable with the feasible at the same time as they kept public and private interests distinct. Whether this has had any impact on the care provided at Begasin Health Centre in Papua New Guinea is another story.

Acknowledgements

This essay is based on research supported by the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme under grant agreement No 715450.

References

Academy of Medical Sciences. 2009. “Global health diagnostics: research, development and regulation. Workshop Report.” Available at: link.

Beisel, Uli.; René Umlauf; Eleanor Hutchinson; and Clare I.R. Chandler. 2016. “The complexities of simple technologies: Re-imagining the role of rapid diagnostic tests in malaria control efforts.” Malaria Journal, 15(1): 64.

Chandler, Clare I. R.; Rachel Hall-Clifford; Turinde Asaph; Magnussen Pascal; Siân Clarke; and Anthony K. Mbonye. 2011. “Introducing malaria rapid diagnostic tests at registered drug shops in Uganda: limitations of diagnostic testing in the reality of diagnosis. Social Science & Medicine (1982), 72(6): 937-44.

Girosi, Federico et al. 2006. “Developing and interpreting models to improve diagnostics in developing countries.” Nature, 444: 3-8.

Hay Burgess, Deborah C.; Jeffrey Wasserman; and Carol A. Dahl. 2006. “Global health diagnostics.” Nature, 444: 1-2.

Keeler, Emett.; Perkins, Mark D.; Small, Peter.; and Hanson, Christy. (2006). Reducing the global burden of tuberculosis: the contribution of improved diagnostics. Nature, 444: 49-57

Petti, Cathy A., Polage, Christopher R., Quinn, Thomas C., Ronald, Allan R., & Sande, Merle A. 2006. Laboratory Medicine in Africa: A Barrier to Effective Health Care. Clinical Infectious Diseases, 42(3): 377–382.

Urdea, Mickey et al. 2006. “Requirements for high impact diagnostics in the developing world.” Nature, 444: 73-79.

World Health Organization. 1997. Workshop report. “WHO tuberculosis diagnostics workshop: Product development guidelines.” Available at: link.

World Health Organization. 1998. “Global tuberculosis programme: The tuberculosis diagnostics initiative.” Available at: link.

World Health Organization. 2006. “Diagnostics for tuberculosis: Global demand and market potential.” Available at: link.

World Health Organization. 2014. Meeting report. “High-priority target product profiles for new tuberculosis diagnostics: Report of a consensus meeting.” Available at: link.

“Suppose you have a cut on your finger. Cut a piece of Band-Aid from the strip, pull off the face-cloth and put the bandage over the wound. That’s all there is to it. The bandage will stay right where you place it without tying. Can you imagine anything handier for the household or shop?” — The Red Cross Messenger[1]

“New situations demand new magic.”
(Evans-Pritchard 1937: 513)

The origin of the humble Band-Aid offers enticing material for corporate legend. In 1920, Earle Dickson was a cotton buyer for the medical supply company known as Johnson & Johnson in New Brunswick, New Jersey. Dickson, the story goes, had an accident-prone young wife named Josephine. Concerned about her tendency to acquire small injuries in the course of daily routines, he created an ingenious solution: a prepared set of strips combining sterile gauze, surgical tape and a crinoline fabric cover to keep it clean until use. Now, when his wife needed a dressing, she could simply take a strip, cut it to length, peel off the fabric and apply it herself. Minor wound care moved into the domain of self-treatment, a selling point that eventually convinced Dickson’s employer to begin marketing it the following year. After a slow start, the new bandage caught on. The company displayed enough marketing imagination to distribute it for free to Boy Scout troops across the country, and by 1924 had begun to offer machine-cut Band-Aids in multiple sizes.

BAND-AID® Brand Adhesive Bandage ad from 1920, showing the product as Earle Dickson invented it. Image: Johnson & Johnson Archives.

At the time of Dickson’s innovation, Johnson & Johnson was already a well-established and innovative enterprise. The company derived from the labors of three industrious brothers of that name, the eldest of whom, Robert Wood, had trained as an apothecary. Inspired by the surgeon Joseph Lister’s crusade for the merits of sterile surgery, he had gone into business with a fellow hygiene enthusiast, George Seabury, to create medical plasters and surgical dressings. In 1885 he joined his brothers in manufacturing ready-to-use dressings, and what came to be known as first-aid kits. By 1888, their product list included “accident and emergency cases” for antiseptic treatment, available in several sizes. After surveying railway surgeons across the country about their needs, the company launched a “railway station and factory supply case” containing a set of equipment that would enable station agents to respond to emergencies. In 1898 Johnson & Johnson supplied a “first aid packet” for soldiers fighting for the United States in the Spanish-American War, and in 1901 began producing first-aid instruction manuals. The range of kits on offer only would continue to grow with new transport inventions, like the automobile and airplane.[2] War was good to Johnson & Johnson. If not yet a fully transnational behemoth, it found ample opportunity in the mass suffering of European trenches even before the United States joined the First World War. At the close of the conflict, the company stood poised for new things, and the migration of bandages from battlefield to kitchen offered an expanding domestic front.[3]

Johnson and Johnson Band-Aid® products.

A deeper history of wound care might complicate this story, adding rival accounts and antecedents of packaged dressings and plasters, as well as shifting conceptions of risk. (See Tarr and Tebeau 1997 for more on concern about “accidents” in early 20^th-century America.) Likewise, a wider account of the rise of mass consumption and marketing might situate this particular story within a broad pattern of commodity domestication, such as campaigns to put cigarettes into the hands of women (Brandt 1996). Nonetheless, the corporate arc leading to the trademarked product officially known as the Band-Aid provides key elements for analysis. A simple but ingenious innovation, the adhesive bandage enabled the most ordinary and clumsy citizens to treat minor cuts and abrasions quickly and reliably wherever they found themselves. The early 20^th century housewife and shop operator each gained new assurance in their mechanized environments, freed from worrying about minor hazards contained in the tools of their trade. Standardized and pre-sterilized, the new strip was mobile while packaged and stable once applied. It was easy to use, durable in action and boasted a long shelf-life. A box of them anticipated future accidents and stood prepared for the next minor emergency. An icon of middle-class safety and hygiene was born: children would grow up receiving quick treatment for mishaps, in increasingly colorful forms. The Band-Aid fits neatly into the first-aid kit, a larger and more capacious assemblage of items with similar intent. Deposited around the landscape of everyday industrial life—houses, cars, boats, offices, airplanes—such kits provided a small cache of prepared supplies available for any need that might suddenly arise. Beyond a lucrative business opportunity for corporations like Johnson & Johnson, these little packets enabled a new norm of quick response. One might even describe them as a minor form of medicalization, redefining small problems through anticipated care. At the very moment cries and finger-pointing might begin, a solution now was already at hand, just awaiting application.

1970s Band-Aid® Advertisement.

In and of itself, it is hard to argue with a Band-Aid. As anyone who has used one knows, this little strip of adhesive tape and gauze offers an enchantingly simple and reliable response to a small cut, abrasion, blister, or splinter. Once sealed and padded, a minor injury can heal without further interference, causing less distress. If not fully therapeutic, or particularly effective at keeping a wound moist and sterile, the adhesive bandage would at least offer the advantage of protection as well as palliation. (Current medical consensus favors keeping wounds hydrated and covered; see Sood et al. 2014.) Here, at least, it would seem the overflow of 19^th-century military and industrial production offered some small benefits to civilian society.

Yet the Oxford English Dictionary records a second entry for the term, describing “a temporary or makeshift solution to a problem,” a merely palliative rather than properly curative result.[4] The connotation of this secondary usage is clearly negative, implying insufficiency and disappointment. Whatever the value of palliation for patient comfort, it does not address underlying causes and can appear unsatisfactory from a therapeutic perspective. Ultimately, a Band-Aid is a modest form of care, one that provides minor relief and minimal hygiene. It offers a poor substitute for a health clinic staffed by experts. No one would, or should, mistake it for a hospital. Moreover, a bandage placed over a poorly cleaned wound risks infection, ultimately concealing a festering sore. This second meaning of the term, then, introduces a dimension of critical distance into what would otherwise appear an innocuous, if not irreproachable good. Is a Band-Aid the right tool for the task? Is it enough? Or might it mask a deeper problem while providing false security?

This second, critical meaning of the term features prominently in discussions of international aid projects, which include a long history of things that appear superficially beneficial but quickly prove inadequate. Indeed, an entire approach in development and global health might appear cynically insufficient, the smallest palliation in the face of serious need. Such critical, suspicious use of the term invites interrogation, however, given its literal referent in a small, inoffensive adhesive bandage. At what point, and under what conditions, might a Band-Aid transmute from a modest improvement into a deceptive response? When does the inflection shift, from doing “a little good” to “little good”?

To help frame an answer, consider a second metaphorical referent. Like the Band-Aid, the phrase “magic bullet” appears with some frequency in contemporary discussions related to international aid and global health (e.g. Cueto 2013). Frequently, the use in this context is both metaphorical and pejorative, indicating a misguided faith in a would-be technical solution to a socially complex problem. It implies that belief in technology can itself turn into magical thinking, misapprehending the nature of the problem and forgetting larger truths in a quest for simple answers. Indeed, the phrase clearly references European folk tradition, in which a silver bullet might slay a monster such as a werewolf.[5] The silver bullet suggests a fetish of the classic sort, an object thought to possess extraordinary powers by those who believe in it and congealed mystification by those who do not (e.g. Latour 2010; Scott-Smith 2013). At moments of duress, facing a grave threat and the apparent failure of ordinary objects to meet it, magical thinking grows attractive. Surely someone should still act, and “do something”— even when confronting an apparently intractable challenge. The self-appointed task of any critic would then be to dispel fairy tales, unveiling illusions and exposing the false promises of an idol suffused with ontological and epistemological distortions. This is obviously easier to do when occupying a position of certainty and offering an alternative means to deal with whatever lurks beyond the door.

Dr. Ehrlich’s Magic Bullet, 1940. Directed by William Dieterle.

However, in medical history the magic bullet also signals another, positive framing, as a pharmaceutical concept introduced at the outset of the 20^th century by the German Jewish scientist Paul Ehrlich of “drugs that go straight to their intended cell-structural targets” (Strebhardt and Ullrich 2008: 1). Ehrlich’s vision of a charmed projectile suggests an alternative basis for allure: the capacity for specific targeting, as demonstrated by the synthetic drug Salvarsan against syphilis. Although anyone familiar with chemotherapy might recognize shortfalls in the current application of this concept in cancer treatment, an updated, genetically informed version of his dream remains very much alive. Targeting enables a different sort of magic — that of altering scale. Narrowing scope reduces the field of reference from macro to micro, permitting tangible, immediate action within a delimited space of encounter. Targeting nonetheless retains a degree of grand ambition. If the right projectile dispatches its werewolf anywhere, at any time, then a path to universality runs precisely through heightened specificity. Targeting also implies a reduction of waste and a minimization of unintended consequences. The objects it creates lend themselves to regimes of audit, testing, and recursive experimentation, while requiring neither mass labor mobilization nor state-level regulatory systems such as prior development regimes. A specific remedy shines brightly with the promise of efficiency. More might be accomplished with less, simply by concentrating the connection between problem and intervention. The contemporary magic bullet, then, may indeed be a fetish but one whose specific qualities of enchantment exemplify the historical moment. For tangibility clearly inspires those working on humanitarian objects and attracts the interest of influential publics. Rather than abstractly “doing good,” it suggests the possibility of making a specific, located, and measurable difference (Good and Good 2012).

When does a Band-Aid appear deceptive? The question correlates directly with the imagined parameters and scale of expectations that surround it. Scale is an inherently relational concept: a response appears small and attenuated when problems loom large and long. An adhesive bandage might work wonderfully for a superficial cut or abrasion but not a deeper wound. Yet as the legacy of the magic bullet recalls, a delimited scope also could signify precision: the hope that something small might produce a desired effect with fewer secondary consequences. This magic might prove illusory. It might inflate expectations and promise more than it could ever deliver or provide cynical cover for inaction. Nonetheless, the fact of its failure should not wholly displace inadequacy onto the object itself.

Even a cursory historical sketch of Band-Aids and magic bullets, then, can serve to complicate dismissals of small responses to large problems. My intent is not to discount the critical impulse behind these offhand references, which all too often prove painfully accurate about the demonstrable inadequacy of a given intervention, or the exaggerated claims attached to it. Rather, I seek to reorient this critical frame slightly and attend to the assumptions it carries in the moment of its deployment. Is there not another kind of enchantment involved in criticizing interventions with generic demands for “structural change,” whether those voicing the call are critical social scientists, activists, NGO practitioners, or even government ministers? For how is such change imagined? Does this imply the dream of a giant magic bomb, as it were, recalling political movements and revolutions past that upended norms in a complete and satisfyingly ambitious fashion. Or are these visions of expansive modernist planning and the kind of massive projects intent on sweeping, epochal shifts: dams and waterworks, electrical grids, splitting the atom, the dawn of a new age. In their small and flawed utility, little devices can at least open larger questions that otherwise might remain foreclosed. If a welfare state now appears the lost guarantor of security, then how might it be reconceived to include more than a national population? If industrial capitalism ultimately lies at the root of contemporary concerns over inequality and environmental degradation, then what might alternatives to its material norms look like in technical terms?

Recognizing that the problem with Band-Aids is primarily one of scale and application, it follows that a critical response should not simply expose such deficiencies but also explore them in relation to any desired alternative. The concept of scale is complex, suggesting dimensions of both size and level, for which reason some geographers have advocated dispensing with the term and adopting a flatter spatial vocabulary (Marston et al. 2005). But even a less-hierarchal theoretical frame would need to attend to scope and connection, as well as to the sense of a future that Reinhart Koselleck (2004) terms the “horizon of expectation.” Small and delimited interventions seem most inadequate when identified with neglect, cynical calculation or withered ambition. In other words, Band-Aids are most disturbing precisely when another response appears not just more desirable but also fully achievable. Conversely, it is the absence of faith in more comprehensive efforts, or fear of their side effects, that renders the tangibility of a targeted interventions singularly attractive. At moments when modernist utopian projects lose their grip on collective imagination, a cult of micro-interventions grows stronger, and in turn inspires critical nostalgia.

Easy dismissals of “micro” devices simply in terms of their meager size or likely failure, then, run the risk of trading one fetish for another: assuming that the real path to the future always lies in familiar “macro” technologies and planning. In an instant, the very industrial forms that might elicit ridicule from an ecological perspective (if not outright prophecies of doom, when framed by climate change and the Anthropocene), re-emerge as guarantors of social justice. Problems associated with actually existing welfare states and national infrastructural grids vanish—like rabbits from a hat—with the suffering identified in their retreat and inadequate coverage.  Somewhere between such oscillating fantasies lies the harder work of negotiating ambitions around development devices both large and small, and recognizing the significance of older forms without simply projecting them forward.

The Peepoo system. A packet contains a month’s worth of bags. Photo by Peter Redfield.

By way of illustration, let’s leapfrog from Dickson’s Band-Aid and domestic self-care in early 20^th-century America to a contemporary little device, and trace its uncertain career as a magic bullet in international aid. The Peepoo is a “personal single-use toilet” designed for use in poor urban settings and under emergency conditions. Created by a Swedish architect, and subsequently developed and distributed by a small Swedish social enterprise known as the Peepoople, it offers a simple means to dispose of human waste, neutralize its pathogens, and transform it into fertilizer, all in one go. Modeled on the “flying toilet” method of using plastic bags—an all-too real phenomenon of urban slum life—the Peepoo consists of a double-layered sack of biodegradable plastic with a small pouch of urea inside. As explained on the Peepoople website, the addition of this common fertilizer effects a magical transformation:

When the urea in Peepoo comes into contact with feces or urine, a breakdown into ammonia and carbonate takes place, driven by enzymes that naturally occur in feces. As the urea is broken down, the pH-value of the material increases and sanitization begins. Disease-causing microorganisms are inactivated after four weeks. Because dangerous bacteria are inactivated, there is no methane gas development from the feces inside Peepoo.[6]

Since the bag itself is fully biodegradable (“a mixture of aromatic co-polyesters and polylactic acid … with small additives of wax and lime”) and urea is a non-hazardous chemical, the eventual result is a safe and valuable bundle of nutrients for farming. In a miracle of modern alchemy, the Peepoo transforms waste into a potential commodity. Accepting the addition of fluid or toilet paper, it can handle the product of both “washers” and “wipers” equally.

Pee Poo instructions on the back. Photo by Peter Redfield.

However minimalist, it thus holds an eco-utopian promise of closing a circle even as it fulfills a humanitarian ambition of satisfying a vital human need. If incorporated into a micro-enterprise of fertilizer production, it might even offer possibilities for income and a modest means for economic development. At the same time, it requires neither water nor permanent space; it is fully mobile and can adjust to circumstances. The Peepoo is not simply a better plastic bag, then, but a serious engagement with a set of nested problems. Intended as both a humanitarian good and a development device—a caring commodity that also promises improvement—it additionally recognizes ecological concerns about human waste in urban settings. Carefully targeted, it would appear a very magic bullet indeed.

As with many such would-be solutions, however, the Peepoo has struggled to gain traction in practice. Even this admirably simple concept required considerable testing to produce the right technical variation and eventually a set of accompanying accessories. The size of the bag proved a balancing act, since the goal was to be just large enough for a single use; in addition to wasting material and adding to expense, a too-large container might invite reuse, which would counteract its hygienic ambitions. Scale is also a magical concept in market terms, here affecting both manufacture and distribution of everything from the biodegradable material to the potential fertilizer product. Only when amplified to mass production, with offsets of potential revenue, could the Peepoo ever hope to compete with ordinary plastic receptacles. Until then it would require subvention of some sort or another or an extensive marketing campaign to convince potential consumers of its superiority. Moreover, the very logic of its materials gave the Peepoo a relatively short shelf life; since biodegradable material is sensitive and deteriorates by design, the bag requires more durable outer packaging to last even two years. In other words, this product cannot sit and bide its time. To properly function and fulfill its promise, it demands regular use, in sufficient volume.

Fostering a reliable population of Peepoo users has proved elusive, particularly when pursuing Peepoople’s ambition of commercial sustainability. Although potentially valuable in emergency settings (in floods, for example, when sanitation systems are disrupted and it is hard to build latrines), the uncertain frequency of such demand made it hard to translate this potential into a stable consumer base. A set of field trials and experiments in a number of sites, including Bangladesh, Haiti, and Pakistan, finally yielded a couple of community projects in Kenya. But these efforts too soon encountered friction. Sanitation, of course, is more than a technical matter, as it involves an array of intimate and often sensitive social relations and cultural concerns. As a Peepoople representative told me in 2014, “It’s easy to sit from afar and say, ‘Oh, I have a great idea,’ without listening to people or considering the cultural aspect. Once you do then you realize it’s more complicated.” Although encouraged by studies that showed “high user acceptability,” the company still struggled to create durable demand between price, on the one hand, and preference, on the other.  Even a better plastic bag was not the most coveted sanitation device. As the same representative explained, “It’s a product that requires a lot of explanation and so comes with a lot of explanation. It’s not like a mobile phone that everybody wants, no questions asked, but rather needs social marketing for people to understand why this is important.” At the same time Peepoople’s efforts to market human fertilizer ran into cultural resistance and fears over contaminating food. To avoid the stigma of perceived pollution the company refocused on marketing it to tree farmers.

The gate at PeePoople, Kenya. Photo by Peter Redfield.

Production likewise proved a problem. After beginning as an enterprise in Kenya with semi-manual production, the Peepoople then sought to automate and lower costs by shifting manufacture to Germany, since the requisite materials were not available in Kenya and costly to import.  They also experimented with automated machinery, built by a German company that made diaper machines. Subsequently they moved production to Sweden to consolidate near their headquarters. But the actual demand never reached a level sufficient to justify the enterprise, and in late 2015 the Swedish office closed. The Nairobi branch remained open, if relatively somnolent when I visited in the following year, and the experiment appeared to have stalled awaiting resumption of local manufacture. However, in October 2016 a Stockholm-based Christian NGO called International Aid Services (IAS) acquired the Peepoople brand, vowing to keep the dream alive. At the time the user base consisted of some 20,000 people living in the Kibera slum in Nairobi, a market subvented by charitable donations.

The Peepoo, then, would seem a classic magic bullet, its earnest charms wavering while seeking an imagined target. From a critical perspective it appears a mere Band-Aid, a minimal improvement that fails to address the underlying factors that might drive someone to resort to a plastic bag in the first place. Some people I’ve discussed this with find the very concept offensive, and many raise trenchant concerns about its viability as a development device.[7] Such evaluations, however, should not overlook larger questions exposed by this simple sack with eco-utopian sensibilities. For the flush toilet, whether enveloped in middle class privacy or arrayed in a public block, may itself not offer a viable alternative, particularly when viewed from arid settings or at a planetary scale (Redfield and Robins 2016). An environmental perspective would suggest that water-based sanitation begs for reinvention, not further mass diffusion. In its own, humble way, the Peepoo opens this urban norm, calls attention to an exceptional violation—the plastic bag—and serves as a reminder of the deeper problem of waste. In this light, its shortcomings might yield not the end of the story but rather another beginning.

References

Brandt, Allan M. 1996. Recruiting women smokers: The engineering of consent. Journal of the American Medical Women’s Association, 51(1-2): 63-66.

Cueto, Marcos. 2013. “A Return to the Magic Bullet? Malaria and Global Health in the Twenty-First Century.” In When People Come First: Critical Studies in Global Health, Biehl and Petryna eds. Princeton: Princeton University Press,: 30-53.

Evans-Pritchard, E.E. 1937. Witchcraft, Oracles and Magic among the Azande. Oxford: Claredon Press.

Good, Byron J. and Mary-Jo DelVecchio Good. 2012. “‘To make a difference ….’: Narrative Desire in Global Medicine.” Narrative Inquiry in Bioethics, 2(2): 121–124.

Koselleck, Reinhart. 2004. Futures Past: On the Semantics of Historical Time. New York: Columbia University Press.

Latour, Bruno. 2010. On the Modern Cult of the Factish Gods. Durham, NC: Duke University Press.

Marston, Sallie A.; John Paul Jones III; Keith Woodward. 2005. “Human Geography without Scale,” Transactions of the Institute of British Geographers, New Series, 30(4): 416-432.

Redfield, Peter and Steven Robins. 2016. “An Index of Waste: Humanitarian Design, ‘Dignified Living’ and the Politics of Infrastructure in Cape Town.” Anthropology Southern Africa, 39(2): 145-162.

Scott-Smith, Tom. 2013. “The Fetishism of Humanitarian Objects and the Management of Malnutrition in Emergencies.” Third World Quarterly 34(5): 913-928.

Sood, Aditya; Mark S. Granick; and Nancy L. Tomaselli. 2014. “Wound Dressings and Comparative Effectiveness Data.” Advances in Wound Care, 3(8): 511-529. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121107/

Strebhardt, Klaus and Axel Ullrich. 2008. “Paul Ehrlich’s magic bullet concept: 100 years of progress.” Nature Reviews Cancer 8(6): 473-480.

Tarr, Joel and Mark Tebeau. 1997. “Housewives as Home Safety Managers: The Changing Perception of the Home as a Place of Hazard and Risk, 1870-1940.” In Accidents in History: Injuries, Fatalities and Social Relations, Cooter and Luckin eds . Amsterdam: Rodopi: 196-233.

[1] Quoted in http://www.kilmerhouse.com/2008/09/how-to-use-a-Band-Aid-brand-adhesive-bandage/

[2] http://www.kilmerhouse.com/2013/06/from-1888-to-2013-celebrating-the-125th-birthday-of-the-first-aid-kit/

and http://www.kilmerhouse.com/2011/05/how-a-conversation-led-to-first-aid-kits/

[3] http://www.kilmerhouse.com/2014/08/world-war-i-centennial-how-the-great-war-changed-johnson-johnson/

[4] See OED entries under “Band-Aid” and “sticking plaster”; whereas the first only dates this secondary meaning to 1968, the latter traces it back to 1877. Since the generic term “plaster” describes a shifting lineage of therapeutic devices, from medicated pastes to industrial plastics, this secondary sense of inadequate treatment appears to well predate Dickson’s iconic product.

[5] A belief that obviously post-dates the invention and diffusion of firearms. See http://www.jurn.org/ejournal/Wettstein-Werewolf.pdf

[6] http://www.peepoople.com/information/faq/

[7] for commentary see, e.g. https://saniblog.org/2010/04/30/the-peepoo-bag-system-top-or-flop/

Feature Image: The werewolves of Ossory. A priest administers the Eucharist to the dying wife of a werewolf he meets in the woods.