Periodic Reporting for period 5 - DiaDev (Investigating the Design and Use of Diagnostic Devices in Global Health)
Reporting period: 2023-05-01 to 2024-01-31
Point-of-care diagnostic devices are increasingly recognised as critical to meeting global health priorities. A new generation of rapid devices that detect the presence of pathogens and biomarkers in a drop of fluid, open up the possibility of laboratory quality testing reaching under-resourced settings. These devices raise anthropological questions about the contribution of ‘standalone’ technologies to health systems strengthening, the values that are embedded in technological devices, the kinds of knowledge generated by diagnostic technologies, and the social and political relationships entailed in global health innovation.
The DIADEV project, Investigating the Design and Use of Diagnostic Devices in Global Health, addressed these questions through multiple case studies and device ‘biographies’ developed across contexts of disease ‘elimination’, ‘emergency’ epidemic response and routine care ‘integration’. The project developed a common methodological and theoretical framework for exploring the social, cultural and technical processes involved in developing, deploying and using diagnostic devices in resource-limited settings.
DIADEV had two main objectives.
1. To examine how changing relationships of power between governments, donors, and
businesses in global health shape the design and use of diagnostic devices
2. To investigate how diagnostic devices are transforming health systems in resource-poor
Settings
DIADEV helped establish the social study of medical testing as a sub-field that cuts across the disciplines of medical anthropology, science and technology studies and human geography. Through the development of a comparative biographical approach, the project extended studies of medical testing beyond the context of use, to understand the full life-cycle of diagnostic innovation, use and discard as a process of value contestation and generation. Through the establishment of a substantial body of results and publications, the project was able to identify several important lessons for global health policy, including the finding that the current global health innovation ecosystem perpetuates inequalities and often fails to strengthen health systems, and that the prioritisation of access as a value driving the design of technological solutions contributes to global plastic pollution.
The DIADEV project, Investigating the Design and Use of Diagnostic Devices in Global Health, addressed these questions through multiple case studies and device ‘biographies’ developed across contexts of disease ‘elimination’, ‘emergency’ epidemic response and routine care ‘integration’. The project developed a common methodological and theoretical framework for exploring the social, cultural and technical processes involved in developing, deploying and using diagnostic devices in resource-limited settings.
DIADEV had two main objectives.
1. To examine how changing relationships of power between governments, donors, and
businesses in global health shape the design and use of diagnostic devices
2. To investigate how diagnostic devices are transforming health systems in resource-poor
Settings
DIADEV helped establish the social study of medical testing as a sub-field that cuts across the disciplines of medical anthropology, science and technology studies and human geography. Through the development of a comparative biographical approach, the project extended studies of medical testing beyond the context of use, to understand the full life-cycle of diagnostic innovation, use and discard as a process of value contestation and generation. Through the establishment of a substantial body of results and publications, the project was able to identify several important lessons for global health policy, including the finding that the current global health innovation ecosystem perpetuates inequalities and often fails to strengthen health systems, and that the prioritisation of access as a value driving the design of technological solutions contributes to global plastic pollution.
Design: We carried out fieldwork in the USA, Scotland and international conferences, undertook remote interviews, and carried out document analysis of grey literature, and media and online materials. We built up detailed case studies of multiple diagnostic devices, diagnostic laboratories and small start-up companies. We undertook a scoping review and developed and a detailed case study of diagnostics for elimination purposes. We undertook interview and desk-based research relating to the design of plastic devices. Results were presented at academic workshops, seminars, conferences and exhibitions.
Emergency: We conducted a scoping review of laboratory strengthening activities in the country post-Ebola, undertook stakeholder consultation and organised stakeholder and dissemination workshops in Sierra Leone. We undertook extensive ethnographic fieldwork to examine the country’s diagnostic system and pathways. We developed comparative case studies around diagnostics for Zika and Covid-19, including a collaboration with the Mass Observation Project. Results were presented at academic workshops, seminars and conferences, and published in academic journals.
Integration: We mapped the diagnostic system in Telangana, India, conducted a stakeholder consultation, carried out fieldwork in primary health facilities and communities. Key results related to the inequalities built into diagnostic waste management. Complementary research on diagnostic integration in Sierra Leone was carried out through collaborations and partnerships with local researchers. Results have been presented at academic workshops, seminars and conferences and published in academic journals.
Collaboration: We collaborated with colleagues at McGill University in Canada to develop a mixed-methods mapping tool for diagnostic availability and quality. We contributed materials for an exhibition on ‘Parasites: the fight to survive’ at the National Museum of Scotland. We collaborated with Heriot Watt University to develop sustainable prototypes of lateral flow devices made from a variety of recycled plastics. We developed an exhibition about diagnostic waste which we took to ASLM in South Africa. We organised ‘DiaDev Hack’ events and established a ‘Global Frugal Diagnostics Network’.
Emergency: We conducted a scoping review of laboratory strengthening activities in the country post-Ebola, undertook stakeholder consultation and organised stakeholder and dissemination workshops in Sierra Leone. We undertook extensive ethnographic fieldwork to examine the country’s diagnostic system and pathways. We developed comparative case studies around diagnostics for Zika and Covid-19, including a collaboration with the Mass Observation Project. Results were presented at academic workshops, seminars and conferences, and published in academic journals.
Integration: We mapped the diagnostic system in Telangana, India, conducted a stakeholder consultation, carried out fieldwork in primary health facilities and communities. Key results related to the inequalities built into diagnostic waste management. Complementary research on diagnostic integration in Sierra Leone was carried out through collaborations and partnerships with local researchers. Results have been presented at academic workshops, seminars and conferences and published in academic journals.
Collaboration: We collaborated with colleagues at McGill University in Canada to develop a mixed-methods mapping tool for diagnostic availability and quality. We contributed materials for an exhibition on ‘Parasites: the fight to survive’ at the National Museum of Scotland. We collaborated with Heriot Watt University to develop sustainable prototypes of lateral flow devices made from a variety of recycled plastics. We developed an exhibition about diagnostic waste which we took to ASLM in South Africa. We organised ‘DiaDev Hack’ events and established a ‘Global Frugal Diagnostics Network’.
This project is the first large-scale, comparative and anthropological investigation of point-of-care diagnostic devices and health system strengthening in resource-constrained settings. This project goes beyond the state of the art by bringing together methodologies and theoretical frameworks from anthropology, science and technology studies and geography, to explore the social relationships and value negotiations that determine the life-cycle of specific diagnostic devices. The findings have contributed to new theorisations of global health partnerships, health systems and socio-technical relationships in the social sciences:
Development of ‘social lives of diagnostics’ framework: Overall project contributed to the theorisation of diagnostic devices as objects with ‘social lives’ shaped by value regimes across their life cycle.
Theorising the global innovation ecosystem: Our theorisation of global health innovation as a relational and value-based process revealed: the generation of ‘diagnostic debris’ due to the difficulty of aligning multiple value regimes in the development of global health diagnostics; global health inequities built into a system premised on assumptions that innovation is located in the Global North; marginalisation of voices from users in the global south in innovation processes; valuing ‘access’ results in the design of diagnostic devices that are harmful to the planet.
Theorising test as a verb and health systems as relational infrastructures: We found that diagnostic devices cannot be understood as stand-alone technologies and that test is best understood as a verb rather than a noun. These findings contributed to a critique of the focus on ‘diagnostic availability’ in LMICs and supported the development of a theory of health systems as relational infrastructures. We developed a mixed methods mapping tool that reflects this approach.
Emergency: We developed a theorisation of ‘emergency R&D’ as a new paradigm in global health, and acceleration’ as a paramount value underpinning its activities. We have shown how this has given rise to new kinds of regulatory and innovation institutional architectures and social inequities.
Global Health and Sustainability: Our findings went beyond the existing focus on diagnostic devices as tools of care to focus on the afterlives of diagnostic devices. We found that considerations of sustainability are missing from innovation frameworks in global health.
Development of ‘social lives of diagnostics’ framework: Overall project contributed to the theorisation of diagnostic devices as objects with ‘social lives’ shaped by value regimes across their life cycle.
Theorising the global innovation ecosystem: Our theorisation of global health innovation as a relational and value-based process revealed: the generation of ‘diagnostic debris’ due to the difficulty of aligning multiple value regimes in the development of global health diagnostics; global health inequities built into a system premised on assumptions that innovation is located in the Global North; marginalisation of voices from users in the global south in innovation processes; valuing ‘access’ results in the design of diagnostic devices that are harmful to the planet.
Theorising test as a verb and health systems as relational infrastructures: We found that diagnostic devices cannot be understood as stand-alone technologies and that test is best understood as a verb rather than a noun. These findings contributed to a critique of the focus on ‘diagnostic availability’ in LMICs and supported the development of a theory of health systems as relational infrastructures. We developed a mixed methods mapping tool that reflects this approach.
Emergency: We developed a theorisation of ‘emergency R&D’ as a new paradigm in global health, and acceleration’ as a paramount value underpinning its activities. We have shown how this has given rise to new kinds of regulatory and innovation institutional architectures and social inequities.
Global Health and Sustainability: Our findings went beyond the existing focus on diagnostic devices as tools of care to focus on the afterlives of diagnostic devices. We found that considerations of sustainability are missing from innovation frameworks in global health.