In 2004, as HIV treatment programs were rolling out in earnest all over Africa, the terrible shortages of skilled health care professionals in the region – indeed, all over the world – threatened to sink such medically-oriented global health campaigns. There was a dire need for innovations in the training and use of low-end health providers, such as community-based, moderately skilled providers.
Video of the interior of a converted unit
Doc-in-a-box the Rx Film
I was in Geneva at World Health Organization headquarters, waiting to talk to a top official engaged in what was then called the “3 by 5” campaign – getting 3 million HIV+ people living in poor countries on antiretroviral drug treatment before the end of 2005. There was an architecture magazine on the table in the waiting area, and it reminded me of a long article I’d read about shipping containers.
A curious thing happened to trade and shipping in the late 1990s and early 2000’s, as production of goods concentrated in a handful of countries, such as China and India, and the former industrialized nations turned into net consumers, eliminating most manufacturing. Shipping became a one-way process, as billions of dollars-worth of goods were packed into standardized shipping containers in, for example, Hong Kong, and transported to cities like San Pedro, Galveston, Marseilles, Liverpool, Vancouver, Hamburg and New York. By 2004 ports in both very rich and very poor countries were surrounded by enormous stacks of empty steel shipping containers, 
because these areas had no goods to ship back to Shanghai, Mumbai, Singapore or Hong Kong. Designed for maximally efficient transport of goods via train, truck, ship or crane, the abandoned, rusting containers represented a valuable, but lost, resource.
Before I visited Geneva that spring day in 2004 I’d read about artists and architects around the world that were finding fascinating ways to use these abandoned shipping containers for everything from portable housing to classrooms; London apartment complexes made from giant stacks of containers to humble refugee “Future Shack” housing for Kosovo.
In that Geneva waiting room I suddenly had a “light bulb moment,” imagining a way to combine easily-converted, transportable clinics (shipping containers), a franchise model for creation of networks of community health workers, frontline infectious diseases prevention and treatment, and HIV care. In my mind’s eye that day in 2004 the shipping containers could be mass-converted in a developing country port city, distributed all over the poor world, staffed by community health workers that owned their box in a franchise model, and managed via cell phone technology from central hubs staffed by MDs, pharmacists and RNs. The way I imagined it that day, the “Doc-in-a-Box” looked like this:
1.) FRANCHISE
The key element in my scheme was the franchise model. Like a chain of hamburger fast food joints, each Doc-in-a-Box would bear a brand and have standardized appearance and services. The community health worker would be incentivized to provide a high volume of services with quality, and to stay in front of inventory and supplies. As is the case with many fast-food chains, the franchise operator owns his or her “box”, but must adhere to the requirements of the brand. The branded company ensures, with training, supplies and, if need be, penalties that each franchise meets the standards of the overall brand. If the range of services provided by each Doc-in-a-Box were confined to a reasonably finite list of key infectious diseases and primary health issues, and rapid diagnostic equipment were part of the standard brand supplies, I thought much of the global healthcare worker crisis could be solved by minimally trained, entrepreneurially-incentivized community healthcare workers.
2.) CHEAP CONTAINER CONVERSION
If the whole “Doc-in-a-Box” scheme was going to work the containers had to be converted to clinics very cheaply, and function on rainwater-capture, solar power, and other sustainable principles. A critical mass of container clinics would be essential to allow the company to purchase drugs, diagnostics and supplies in high volume, to be dispersed to the franchisees. And the community health workers would need to be able to charge a very modest amount of money for their services, earning back their investment costs, covering supplies and providing the individuals with decent incomes.
3.) DIGNITY AND OWNERSHIP
Community health worker efforts had long floundered in poor countries all over the world because:
• Most programs recruited very poor, semi-literate or illiterate women to serve as community healthcare workers;
• Programs typically offered the recruits very narrow sets of skills, usually focused on a single disease or health issue. Moreover, the skills were rarely transferable to any other work setting or problem;
• The women were expected to work either for free, or at bare subsistence wages;
• Programs were designed by outsiders, often from a foreign country, and then taught to the local workers. There were few ways that the community workers could have fundamental input into the design of the programs, criticism or analysis of program achievements or possible personal advancement into management tiers, at better pay and responsibility;
• Supplies, inventory and logistics were poorly managed, particularly in rural areas. Few incentives existed to encourage community health workers to keep track of supplies and anticipate future needs. When supplies ran out, services simply stopped;
• Theft and corruption were not appropriately offset by effective schemes of pride and ownership, encouraging community health workers to rigidly protect their equipment and supplies and properly process payments for services;
• The most precious resources, bona fide doctors and nurses, were not connected to the community health workers in ways that ultimately improved the quality of work and life for all parties.
In 2005 my then-Research Associate Scott Rosenstein discovered a small company called Box Works, run by New Yorker, Ed Beason. Ed was building classrooms in Haiti out of converted shipping containers, and training Haitians in the process. He had figured out ways to minimize heat problems inside the steel boxes, and convert them very cheaply.
In 2006 Architects Michael Oatman and Carl Soderberg of Rensselaer Polytechnic Institute (RPI) in upstate New York decided to take on the Doc-in-a-Box challenge with their students. Dubbing their converted container RX Box, the RPI team worked with Ed Beason to produce a very cheap prototype made largely with recycled materials. They had Haiti in mind in their design efforts, and with Beason’s help identified materials for use that were readily and cheaply available in that country.
The result was a prototype clinic that RPI hauled down to the Council on Foreign Relations, parking it on 68th Street off Park Avenue for public viewing. A description of the concept was distributed at that time.
The Doc-in-a-Box concept was published in Foreign Affairs in January 2007. And the RPI schematics and plans were posted on the Open Architecture Network.
At a meeting organized by the World Bank I met Scott Hillstrom, a Minnesota lawyer who was interested in developing franchise models of health in Africa. Hillstrom’s group¸ The HealthStore Foundation, was setting up franchised drug store/clinics run by nurses in Kenya. By the end of 2007 the HealthStores in Kenya had half a million patients, mostly women and children.
We heard from many groups around the world expressing interest in the Doc-in-a-Box idea. Some informed us of ingenious ways they were using converted containers to handle health issues. For example, the AIDS-Related TB Project in Lusaka, Zambia uses such clinics to diagnose and treat tuberculosis. GE Healthcare and G-Con Manufacturing of College Station, Texas are developing containers for distribution of vaccines in epidemic emergencies. Most groups, however, were disappointed that the Council on Foreign Relations didn’t have a factory producing thousands of these converted clinics for deployment. Discovering we were idea-developers, not actual manufacturers, drew sighs of disappointment.
One exception was a Bostonian named Elizabeth Sheehan, who grabbed the container-conversion concept with gusto. Sheehan worked with top architects and engineers from MIT and a host of other Boston institutions, developing a very sophisticated version of my admittedly crude concept, which she dubbed Containers to Clinics, or C2C.
Following the devastating January 2010 earthquake in Haiti C2C worked with AmeriCares and USAID, deploying the first of its converted containers to Port-au-Prince for maternal and child health care. A second C2C clinic was deployed to Haiti in the spring of 2011.
We still dream of networks of Doc-in-a-Box franchises, connected via smartphones to central hubs of medical talent. We dream of health insurance or vouchers that cover patient costs, and basic community health workers that provide vaccinations, HIV and TB tests, antiretroviral medicines, malaria bed nets, appropriate antibiotics and a host of other frontline services that can keep people alive, productive and safe.