btc is over $40,000 again. we are so back.

to commemorate this milestone, let’s talk about a real-life example of a decentralized ledger. we previously explored the bare basics of blockchain and cryptocurrency. one of the concepts we discussed was a decentralized record of transactions.

recently, i learnt about a health system project we have in the state of Yap, a group of islands in the Pacific Ocean and a state in Micronesia. i had never heard of Yap before, so went to read up about the state of 11,000 residents and their culture. i found out that unique to Yap is a bunch of giant limestones that are used as currency!

these limestones, called rai, are up to 4 metres in diameter and requires up to 30 men to move. they were mined from quarries in Palau centuries ago and transported to Yap by the state’s skilled sailors. as mining rai was diffiicult, the stones remained quite rare on the island. despite changing hands over generations, often during significant events like weddings and land sales, the stones themselves are rarely physically moved even if the owners don’t live on the same island.

this is where it gets intriguing. just like bitcoin’s ownership is verified through a distributed ledger, the ownership of rai was also validated, orally though, among villagers present at the point of transaction. this system of distributed oral ledger means that individual villagers cannot lie about their wealth in rai as it can easily be disproved when verified with other nodes (villagers). the collective understanding of ownership is hence largely immutable (!) and mirrors the transparency and resilience of blockchain technology.

however, no sooner did technology and new quarrying methods introduced by western colonizers debase the currency and cause hyperinflation. today, the stones are mainly used ceremonially.

isn’t this fascinating? credits to anthropologists scott fitzpatrick and stephen mckeon for their work on this form of decentralized ledger.

btc always has been.

while every culture has their own cuisine and customs, water is the one food that binds all humans globally.

there are many challenges to water access around the world. even now, 10% of the global population do not have access to a basic drinking water source. nearly 30% do not have access to clean water free from contamination. drinking contaminated water leads to diseases that may kill or prevent people from going to school and work, which can then lead to whole-of-society problems.

all is not lost. there is a beautifully elegant and frugal method of water filtration that reduces diarrheal diseases by 47% in families that use them. the biosand filter is a very simple household water filter — essentially a concrete block with a cocktail of sand within. a layer of biofilm forms on top of the sand mixture. water is poured in from the top. by the time it reaches the bottom, it is free of 99% of harmful bacteria. the filter is cheap to produce, maintenance is easy (essentially just keep the sand wet), and there are no parts that need replacing.

what is more beautiful about this technology is that, since 2001, its canadian founders have made the technology cc0. creative commons zero (cc0) is a public domain dedication that allows creators to waive all their copyright in a work and make it available for unrestricted use by anyone. this means that anyone can build biosand filters without worrying about patents or spending money on buying the rights and technology.

cc0 is a liberating and democratic concept. in the nft space, some projects are cc0. this means anyone (including you!) can take the artwork and create more art, games, your own brand without having to pay royalties, attribute the work, or worry about violating copyright laws. this has allowed for the proliferation of some crypto brands in a quick and completely decentralized way. for example, since its launch just 2 years ago in november 2021, the mfers ecosystem is now global and thriving both online and offline:

if cc0 is so democratizing, how is it that we haven’t achieved clean water for all?

unlike the easy proliferation of a decentralized brand by enterprising web3 degenerates, the spread of vital public health technology is still slow and cumbersome. real change in achieving clean water for all requires money and boots on the ground — from sourcing materials, building the filter cases, testing for quality, to convincing families of their benefit.

also, many in the health innovation space (as in the web3 space) remain skeptical about cc0 solutions. i roll my eyes often at this. as satoshi nakamoto, the founder of bitcoin, famously said: if you don’t believe me or don’t understand — i don’t have time to explain it to you, sorry.

that said, there has been progress in spreading biosand filter technology, with ngos and charities building them in countries such as tanzania, cambodia, and bolivia. however, there are so many other people who can benefit from this technology, especially as water insecurity increases around the world from extreme weather events and changing climate conditions.

i think it is time to harness the enthusiasm and resourcefulness of the web3 cc0 community to create substantial real-world impact. time to build and not leave the potential of a cc0 public good… untapped.

i happened to come across some nursing-focused initiatives in the past few weeks and cannot reconcile the phenomenon of nursing migration.

nurses are undeniably the backbone of healthcare systems worldwide and yet there is a global shortage of nurses. by 2030, we will face a shortage of 13 million nurses around the world. a common strategy of high-income countries is to aggressively recruit nurses from abroad to fill gaps. however, this tactic is counterintuitive, especially in light of global health initiatives aimed at strengthening healthcare systems. while we work to enhance nursing capabilities in regions that are most in need, these very efforts are undermined by the same countries encouraging migration of skilled nurses to wealthier regions, draining resources from areas where they are critically needed.

the drivers of this global market is complex. nurses in low and middle-income countries are often drawn to the prospect of earning significantly more abroad. a nurse from the philippines can earn as much as ten times the amount at home when they move to the united states. this potential migration, paradoxically, might encourage more people to join the nursing profession at home. however, regulating the emigration of nurses or curtailing foreign demand do not necessarily mean that the source country alleviates their challenges in workforce shortage. without the potential for emigration and associated economic prospects, people might be dissuaded from pursuing nursing at all.

we so often say technology will solve all of these workforce shortage issues. in the past weeks, i have also encountered a tele-consultation model that has been touted as useful and cost-effective. when we delved deeper into the data, we realized that the cost savings were driven by the significant reduction in doctor time, but the workload for nurses increased multi-fold. in the development of innovation, we need to keep in mind the challenges that we are facing as a global healthcare community and nuance our aims. this tele-consultation model, albeit cost effective, is ultimately not a feasible model of care.

the global nursing shortage is more than a simple supply-and-demand issue. It's a reflection of broader global inequities and challenges in healthcare. as i delve deeper into the field of health system innovations and global health, i’m struck by the complexity of these issues. sometimes it can be difficult to reconcile in my head. there are no easy answers, but understanding the various forces at play – economic, ethical, and practical – is maybe a crucial first step.

again, throwing you some food for thought without answers :)

many things have happened in the past weeks since i last wrote, both in my life and in the world. i have been meaning to draw themes and write something nice, deep, and meaningful, but i also remember a friend saying that i should just write about what i think… even if it’s a small and undeveloped thought.

so i thought i might write today on the concept of “i don’t know shit about fuck”. in the web3 circles i run in, we say this a lot. “i don’t know shit about fuck” is often appended with “i’m just a stick figure on the internet”. it means, i might have an opinion, but hey, what do i know, don’t take me too seriously.

we are in the midst of a growing crisis in the middle east, both a geopolitical crisis as well as a humanitarian one. among other tragedies, a hospital has been blown up and many people have died. another tragedy is that everyone and their mother behind their shiny iphones in their reading nook now has an opinion on middle east peace.

and worse, now they have gone so far as to call out people who have not expressed any outrage openly online.

it is outrageous how audacious our opinions have become online and how very, very short-lived our collective memory is. Performative outrage does little to address the complex challenges that trigger persecution and war. Instead, it serves mostly as a social currency, a way for people to loudly proclaim their virtue without taking meaningful action or even deeply understanding the issues at hand.

the ethos of “I don't know shit about fuck” comes across as not only a call for humility but also an admission that our opinions are not definitive judgments. It opens the floor for dialogue and other people’s opinions. It tells us it’s okay to have an opinion (or choose not to express one), it’s ok not to have all the answers, but it’s not okay to let our half-baked opinions stand in for thoughtful engagement.

use it more, that’s what i think. but hey, i don’t know shit about fuck, i’m just a stick figure on the internet.

Yesterday, a colleague asked how I was qualified to speak on a panel about NFTs and healthcare at NFT.NYC earlier this year. The question was quickly appended with “not saying that you are not qualified”.

And this is where the world of global health and web3 diverge.

In the world of academia and global health practice, whether someone has authority on a subject is based on their position (as in the title you append to your email signature), the degrees they have, the work that they have done, and more often than not, their age.

In web3, many people use a pseudonym and control how much of their background to reveal to others in the space. Some might argue that pseudonymity allows for bad actors to run rampant. There are always two sides to a coin. In my experience, pseudonymity equalizes people in a way that I have never experienced anywhere else in the world. Read that sentence again for emphasis. You are not judged by the color of your skin, your age, your wealth, your job, but you are judged by what you say and what you do (owing to transparent and immutable documentation on the blockchain). People are given respect, influence, and at times market-moving power, based on the time and energy they have spent on a topic without necessarily ever revealing who they are.

I am not so silly as to think that speaking at NFT.NYC says anything about my authority in the web3 space. While it is the biggest NFT conference, speaker spots are ultimately not exclusive. It was a platform to share my thoughts with an audience of both supportive friends and critical strangers, and to get more people to think about how we can improve the lives of people around the world with emerging technologies.

So, how are we to decide who is qualified to speak on anything at all?

Is the Harvard professor who has spent 30 years working in rural Indonesia more qualified to speak about dengue than the 16 year old Papuan teenager who has had dengue and seen their little sister die of the disease?

Perhaps the question we should ask is where are the X, the Discord, and the inclusive crypto conference-equivalent in global health, where someone without positional power can also have a platform to amplify their voice.

One of the main tenets of decentralized healthcare is that patients should own and control their own data. Blockchain technology has been proposed as a potential solution, allowing patients to have complete control over their health information. But there’s a caveat: effective use of blockchain relies on internet access, a luxury that half of the world's population still lacks. So, how do we move towards decentralized health records for everyone?

I came across a company in India, KhushiBaby (perhaps not the only one), that is decentralizing health records offchain and offline. They use Near Field Communication (NFC) chips embedded in cards or a necklace. These chips contain health and vaccination records. Community health workers can scan the chip and read/write on the health records through their mobile device. NFC is the same technology that is used in your Apple Pay or public transport cards. The technology functions without a need to connect to the internet.

Such innovations mean that families no longer have to depend on central health facilities or wade through bureaucratic processes to maintain health records. And as an added bonus, avoiding centralized storage eliminates potential data vulnerabilities of databases stored in a single location.

Yet, like all innovations, NFCs aren’t perfect. They have limited storage capacity, and the risk of loss or damage is real. Introducing blockchain to this model adds a robust layer of security. Even if an NFC chip goes missing, the child's health data remains safe and encrypted, and families can always control the type and amount of information that is shared even with the community health workers. However, in areas where resources to develop and implement interventions are scarce, NFCs are already a step beyond what traditional health systems and paper-based records can offer.

Blockchain and web3 technologies offer an exciting future for decentralization, holding the promise of truly democratizing access and offering self-custody of health data. While they have immense potential, it's important to recognize that the context in which they are applied matters and we can be decentralization maxis without being blockchain maxis. I love the elegance and appropriateness of this NFC health records system and how it offers a digital, decentralized tool that is not dependent on all users having access to the internet.

Kwita Izina, the ceremony where newborn gorillas are given names, is celebrated annually in Rwanda. I have recently symbolically adopted this little gorilla through the Dian Fossey Gorilla Fund, and I can’t wait to learn its name later today.

Several years ago, during their 50th anniversary, I visited the Fossey Fund and had a fantastic time tracking mountain gorillas and learning about the history of the Fund and its Karisoke Research Centre, a legacy of primatologist Dian Fossey.

Helping People, Saving Gorillas

What struck me about the Fossey Fund was its holistic approach to wildlife conservation. Its work goes beyond directly protecting gorillas to uplifting human communities that residing near the gorillas’ natural habitats. Among its human-focused initiatives, the Fund invests in the health of communities in the regions where they work. This effort spans from improving basic infrastructure of rural health clinics, increasing healthcare access for local communities, and holding public health campaigns. This comprehensive approach not only improves human health but also shields gorillas from diseases that can sometimes be transmitted between species.

One Health

The recent COVID-19 pandemic highlighted the links between humans, animal, and the environmental health. This interconnectedness is captured in the concept of One Health, which recognizes that the health of people is closely linked to the health of animals and our shared environment. Beyond infectious disease outbreaks, a One Health lens is important in addressing multifaceted health challenges, from climate change to antimicrobial resistance. Embracing One Health means working collaboratively across sectors including human medicine, veterinary and livestock medicine, agriculture, and public health. Such work is challenging to achieve due to varying priorities, missions, and resources across sectors.

Practical lessons from the ground

Based on recent discussions at the 7th World One Health Congress, it appears that much of the One Health discourse remains focused on policy and science, overlooking the pragmatic facet of work on the ground. As global and public health practitioners, there is much we can learn from groups like the Fossey Fund, that have intuitively practiced a holistic approach to safeguarding the health of animals, humans, and the environment long before the phrase “One Health” was even coined.

I’m super excited about the Kwita Izina and the 23 little mountain gorillas that will be named — a testament to the success of gorilla conservation and the One Health approach.

Check out the Dian Fossey Gorilla Fund here.

First things first, what is a digital wallet?

By “digital wallet”, I mean a blockchain-based cryptocurrency wallet, not a banking app. Essentially, a digital wallet functions much like a bank account. It is managed by a person or a group of people, and holds cryptocurrencies (money) and other digital assets. Money can be transferred in and out.

The main difference between a bank account and a digital wallet is the intermediary bank. To open a bank account, you need to choose a bank and undergo credit checks. When transferring money, you instruct the bank to carry out that transaction on your behalf. You rely on the bank to handle your money safely and transact accurately.

Ironically, a digital wallet is more like holding a physical wallet full of cash. You are free to transact with your money without going through a third-party and without trusting anyone other than yourself to hold and move your money. This is the essence of self-custody.

Self-custody digital wallets can be accessed on any computer with an internet connection through a wide selection of applications. Think of this as signing in to your email accounts — you can access and set up your mailbox through Gmail, Outlook, Apple Mail and many other applications as long as you have your passwords.

So, what happened in the Ukraine war?

In February 2022, at the beginning of the Ukraine conflict, many had to flee the country. Cash machines were overrun and electronic fund transfers frozen. The stability of banks in a country under siege was uncertain.

Ukraine is a crypto-friendly nation. In the midst of the crisis, some Ukrainian residents with digital wallets and the ability to access money across borders without being dependent on banks, they were able to execute their evacuation and sustain themselves in the crisis. In Dec 2022, the UN High Commissioner of Refugees (UNHCR) started a program to send displaced people financial aid through their digital wallets. Refugees could then convert this to cash at MoneyGram.

In a world where more than 100 million people are displaced and 1.4 billion adults remain unbanked, digital wallets present a solution. They offer vulnerable populations more than just transactional capability but also offer a layer of security against physical theft compared with carrying large amounts of cash.

Could self-custody of health data be the next frontier?

Beyond finances, there is a huge potential for similar innovation in healthcare. Displaced individuals, refugees moving across jurisdictions, and other vulnerable populations who do not have consistent access to a reliable healthcare system, could benefit from a dependable method to take care of and transfer their own health data.

Perhaps as a health community, this is an instance where we should shift our focus from innovating for incremental improvement in advanced systems of high-income economies to invest in innovating for the most vulnerable who need them most.

Where better to start than to explain what a blockchain is. There are many articles that define and explain what blockchains are. I will attempt in the simplest way I know.

Let’s think about how we send money.

If John wants to give Mary $10, he can do it in a few ways:

John gives Mary $10 in cash.

When John gives Mary cash, there is no middle man and no record. Without a middle man, this transaction is quick. However, without a record, Mary could turn around tomorrow and say that John never gave her the $10.

John transfers $10 to Mary through Venmo, PayPal, PayNow, or a bank transfer.

When John transfers $10 to Mary through a bank or payments service, John gives instructions to the bank (sometimes through the payment service) to take money out of his account and put money into Mary’s account. The bank records this down and the record is called a ledger. A long time ago, banks may keep this record in a physical book. These days, banks keep these records on a server. John and Mary trust that the bank keeps these records safe and tables them accurately. Of course, banks can fail, records can be hacked, and they can also record these transactions inaccurately.

Now, there is a third way:

John sends Mary $10 on the blockchain.

A public blockchain (not all blockchains are public), like Bitcoin or Ethereum, is an open and transparent record of transactions — a ledger. Unlike bank records, copies of this ledger are distributed across many, many computers across the world and are not kept by one bank or company. They are decentralized.

When John transfers $10 to Mary on a blockchain, John flags to these computers on the blockchain that he is making this transaction. This network of computers then work to validate John’s transaction by solving complex mathematical problems. Then, the record of John’s transaction gets written on a ‘block' (think of this like a page of records). When this ‘block’ is filled, it gets added onto a chain (hence, blockchain). Once a block is added to the blockchain, to change it will affect all the subsequent blocks and require the agreement of a majority of computers on this network. This means that a hack or attempt to change transaction data on one or a few of these computers will not result in the blockchain records being altered. This is partly why we say that blockchain data is immutable.

On this very cute visualizer, you can watch in realtime transactions (little people) coming from different apps (buildings) being put on a block (bus) and the blocks being recorded on the blockchain (moving off).

https://txstreet.com/v/eth-btc

Of course, this is a very simplified explanation of blockchain technology and there are many cool and nuanced intricacies to the tech. We also use the blockchain for more than just money transfers. This explanation covers some buzzwords you may have heard of before.

In healthcare, the most discussed potential application of blockchain technology is storing patient medical records on a blockchain. Using decentralized distributed ledger technology to store patient records means that we do not depend on health systems from keeping these records safe or to transfer patient records. This can improve data security and also help patients who cannot depend on a single health system (e.g. displaced refugees) to keep their medical data transferable and secure. There are also challenges in making this possible. We can talk more about this next time!

Remember to subscribe to this blog to get notified of new articles on the intersection of global health and web3. Till next time!

I have finally decided to start writing.

Over the past year, I have been on quite a journey in grad school, diving deep into healthcare and health systems. I have come away with a nuanced understanding of health equity. While many of us are aware of the pervasive inequities present in global health — spanning across nations, genders, socioeconomic backgrounds, and power hierarchies — my time in grad school has helped me understand the underlying drivers of these disparities and got me quite excited to be working towards more equitable systems.

In what seems like a completely different world, I have experienced unparalleled levels of equity in my pseudonymous life in Web3. The principles of decentralized governance, self-custody of assets, and transparent data that underpin this whole ecosystem, could transform the way we interact with the world.

In the past few months, I have immersed myself in discussions with both experts (and dabbling degens) in crypto and blockchain, as well as global health practitioners and academics. My thinking has evolved in this time. Initially I was seeking for a product to build, but now I have realized the importance of building community and bridging conversations between the Web3 and global health world.

This is only the start of that journey of discovery. My understanding of global health and the application of blockchain technology have been growing in parallel and now I hope to find convergence and perhaps even some solutions to the challenges we face in achieving health equity for all.

lfg!