Saving Lives, One Drone at a Time

When I served as USAID administrator, I had the opportunity to meet a lot of committed and creative people who were working to advance the delivery of humanitarian assistance. Few impressed me as much as Keller Rinaudo Cliffton, a co-founder of Zipline, now the world’s largest autonomous delivery company. I wasn’t sure what to expect when I heard they had launched a fleet of self-flying drones and were delivering blood and medicine across the mountainous Rwandan terrain. Having traversed some of Rwanda’s mountains, it seemed a difficult task to get perishable and vital medical supplies to people in remote rural areas, let alone in time to save lives in an emergency.

I was lucky enough to see their Rwanda operation at work in 2019 when Rinaudo Cliffton’s team offered me a demonstration. I’ve followed Zipline’s progress over the years and watched as they expanded operations in Africa, partnering with governments in Côte d’Ivoire, Ghana, Kenya, and Nigeria. When we decided to focus a Wilson Quarterly issue on humanitarian assistance, I reached out to Rinaudo Cliffton to find out what they’ve been up to over the last five years and what lies ahead. I remain impressed—and even more convinced that innovators like him will help to transform the global humanitarian assistance system to reach its full potential and save more lives.

— Ambassador Mark A. Green

Ambassador Mark A. Green: Let’s start with how and where Zipline got started.

Keller Rinaudo Cliffton: We started building the first version of the system in 2013. Our backgrounds were in robotics, artificial intelligence, and automation. It seemed like it should be possible to build a new logistics system—one that would be 10 times faster, half the cost, and zero emissions. But most importantly, we wanted to build a logistics system that serves all people equally. About 1 billion people have somewhat good access to logistics, which means 7 billion have subpar or no access to daily delivery and logistics and as a result, about 5.5 million kids lose their lives every year. I don’t think we appreciate the implications of not having reliable, working logistic systems. We felt there was this huge opportunity to build something much better. The Rwandan Minister of Health at the time took this big bet on us.

The University of Pennsylvania just published a study showing that we've been able to reduce maternal mortality at the hospitals we serve in Rwanda by 51%. We ran the exact same study in Ghana and we're seeing a 56% reduction in maternal mortality at those hospitals. It turns out logistics are way more important than anyone really appreciates. -Keller Rinaudo Cliffton

We launched with the Rwandan government in 2016 with the goal of delivering blood to 21 different hospitals. For the first nine months it was a real uphill battle and we served just one hospital, but after a year, we were successfully serving 21 hospitals; then we expanded to 50, then 100. We started with only delivering blood then expanded to include more medical products in the health system, and today we are delivering to more than 4,500 hospitals and health facilities. Globally, we've delivered more than 19 million doses of vaccine, including 2.5 million doses of COVID-19 vaccine. We deliver roughly 75% of the national blood supply of Rwanda outside of the capital city. This is done fully autonomously in a way that is 10 times as fast, half the cost, and with zero emissions.

There are now big research institutions doing major studies on Zipline. The University of Pennsylvania just published a study showing that we've been able to reduce maternal mortality at the hospitals we serve in Rwanda by 51%. We ran the exact same study in Ghana and we're seeing a 56% reduction in maternal mortality at those hospitals. It turns out logistics are way more important than anyone really appreciates.

Ambassador Mark A. Green: To be technical for a moment: you're not just a drone company, but rather a logistics business. Could you explain the difference, and do you only use drones—or are you agnostic about the technology?

Keller Rinaudo Cliffton: We learned in Rwanda that the aircraft itself is around 15% of the complexity of the solution. There is a huge amount of software, ground systems, infrastructure, and new human systems that have to exist to make this work. We had to build distribution centers, pre-flight checks, communications architecture, and multi vehicle deconfliction. We had to integrate with the national civil aviation authorities and build our own unmanned traffic management system and provide that to them. We had to build software to integrate with the national health system. And then we had to build warehouses, learn how to store inventory, and how to manage that inventory. Many products have special storage and handling requirements, like platelets, that have to be constantly agitated.

The challenge of all of this is figuring out how to build a logistics system that is more similar to ordering food off an app in the US. We can just push a button on a phone and have something brought to us in less than an hour. Why don't global logistics systems work more like that? -Keller Rinaudo Cliffton

We also realized none of our customers want to buy drones—that is not what a minister of health wants to do. They want teleportation. They want something to go from point A to point B fast enough to save someone's life, something cheap and reliable that works no matter the time of day, the weather or geography. Zipline pretty quickly realized that we had to take all of this technical complexity and make the service as simple and magical as using FedEx or UPS, while being way faster, less expensive, and able to serve anywhere independent of roads.

Ambassador Mark A. Green: Why did you choose Rwanda as your jump-off point?

Keller Rinaudo Cliffton: We wanted to launch with a national healthcare system because it could show what a drone delivery service looked like on a large scale. We had a sense that this could save a lot of lives, and the Rwandan Minister of Health understood that too. As we were just getting started she told me the best advice we ever got, she said, “Just do blood to one hospital.” That was an incredibly important use case for maternal and child health and really focused us. Half of all blood transfusions in Rwanda go toward moms who experience postpartum hemorrhaging, and 30% are going to kids under the age of five.

Ambassador Mark A. Green: One of the things that I discovered in my humanitarian assistance work is the importance of temperature and climate control elements. You can get blood anywhere you want to get it, but if you don't have climate control storage, it’s not going to work, especially when you’re dealing with a country that is mountainous and not far from the equator.

Keller Rinaudo Cliffton: These are the nuances that make logistics super hard. A lot of the products that we're trying to deliver to the last mile are cold chain dependent. Vaccines, for example, or packed red blood cells, have to be refrigerated. Some COVID vaccines have to be kept in liquid nitrogen cold storage. The challenge is to get products to where people live, which means you're often delivering to a primary care facility that may not have a refrigerator and almost certainly does not have reliable electricity for refrigeration. We’re often trying to figure out if we want to stock products and if so, how many doses. We need to know the chances that half of the supply is going to expire if the facility loses power for hours, which happens all the time. It leads to huge waste in the last mile where you're having to throw things out when they're spoiling, but are also facing large stock outs. For example, there are high percentages of kids showing up at primary care facilities who are not receiving the vaccine they were supposed to get that day because they’re out of stock. We fix that.

The challenge of all of this is figuring out how to build a logistics system that is more similar to ordering food off an app in the US. We can just push a button on a phone and have something brought to us in less than an hour. Why don't global logistics systems work more like that? This was the naive and powerful idea behind everything that we were building for those first eight years; and now that's now happening on a massive scale across more than 4,500 hospitals and health facilities in 8 countries.

Ambassador Mark A. Green: That’s extraordinary. I’d like to hear more about the next generation of drones that you're constructing and what is next for Zipline.

Keller Rinaudo Cliffton: We spent our first six years operating only in Africa and we’re continuing to grow in Africa. We just announced a national memorandum of understanding with the Ministry of Health of Nigeria to build 12 more distribution centers, adding to what we've already built in Nigeria. From there we'll be able to serve more than 60% of the rural population in the entire country. We expect it to save 900,000 lives over 5 years and dramatically reduce costs for the government.

A lot of big companies in the US started taking note of what Zipline was doing and we now have signed contracts with Walmart, Intermountain Health, the Cleveland Clinic, Michigan Medicine, OhioHealth, Memorial Hermann, and many of the largest and most innovative healthcare systems in the world. In the US, there has been an exponential growth in telemedicine in the last few years. It saves money and is critical for rural areas, but it relies on new kinds of logistics that can get medications and prescriptions right to someone’s home.

Our first platform is optimized for those long-range deliveries to rural areas, but we knew we also needed a platform optimized for home delivery to the billions of people living in dense cities and urban areas. We’re launching that new platform later this year and are then going to start rolling it out metro by metro.

Ambassador Mark A. Green: Technology is one thing, but you need people on the other end. Tell me a little bit about your human capacity building in the countries and markets where you guys are working.

Keller Rinaudo Cliffton: Hiring and building teams is the most important thing that Zipline does. Zipline’s staff of 1,200 is about half African and half American. We hire entirely local teams of fulfillment operators, flight engineers, flight operators, robotic maintenance professionals. We’re creating high-paying, advanced economy jobs in these countries. We're training young engineers and operations professionals to lead distribution centers and build the business. We’ve been able to hire extraordinary entrepreneurial and technical talent, and level them up into positions of global executive leadership.

Ambassador Mark A. Green: I’ve read that you’ve even partnered with Elton John and the Elton John Foundation. How did that partnership come about, and what does it involve?

Keller Rinaudo Cliffton: The Elton John AIDS Foundation has been a big believer in Zipline. The problem with the battle against HIV is that a lot of it is occurring in very young populations which are often ignored. Teenagers and young adults are often not accessing traditional healthcare systems, so we focused on delivering prophylaxis to where those populations are. We'll deliver to community events, to nightclubs, and directly to homes.

We didn’t design the company to respond to a crisis. What we're doing is building national infrastructure that can operate continuously in a way that all hospitals and primary care facilities, once people are trained, can be relied on. -Keller Rinaudo Cliffton

A lot of the refill rates in the communities we're serving are shockingly low—between 20 and 30% for HIV medications. We wanted to increase the refill rates for our patients because it’s important for people to stay on their medication so they don’t develop resistance. Over the course of a year of working with them, we now have data showing that we've been able to increase refill rates above 80%.

Ambassador Mark A. Green: I’m also curious about Zipline’s work in conflict zones—that's got to be a logistical nightmare.

Keller Rinaudo Cliffton: We didn’t design the company to respond to a crisis. What we're doing is building national infrastructure that can operate continuously in a way that all hospitals and primary care facilities, once people are trained, can be relied on. But once a country has this infrastructure, it becomes vastly more resilient to emergencies, weather events, and even to security challenges. For example, in Ghana, we have a distribution center far to the north in the Tamale region where there is consistently bad flooding. About 70% of the facilities we serve there are unreachable by any other means for three months out of the year. When that happens, Zipline becomes the sole distributor to those facilities. With Zipline, suddenly hundreds of those health facilities are now reachable in a way that is safe and is not endangering any human lives.

Ambassador Mark A. Green: We are living in a time of unpredictability. There is climate volatility, we have 120 million displaced people in the world, and many things are constantly in motion. We can either play catch up, or we can build resilience so that countries are able to turn on a dime and help address some of these challenges as they pop up. You can’t get there if you haven’t invested first in the system.

Keller Rinaudo Cliffton: Exactly.

Ambassador Mark A. Green: What holds you back?

Keller Rinaudo Cliffton: Eight years ago, when we were launching in Rwanda, I would have said that working directly with these different governments was going to be really hard. You don’t know what their incentives are or if are they may not favor innovation. I thought we’d be in good shape because there is so much money from a global public healthcare perspective flowing into these markets, and all of these global public healthcare institutions say they want innovation, and transformation. I couldn't have been more wrong: It’s the countries that have been the innovators. They have signed direct service contracts with Zipline and we have built amazing partnerships with these different countries. On the other hand, only a few donors have been able to put their money where their mouth is. Thankfully those focused on true impact and maximal ROI, like Gavi, the Elton John AIDS Foundation, Pfizer, and UPS Foundation, are committed to supporting governments to scale this, and hopefully other global public health institutions can learn from their model.

Ambassador Mark A. Green is the president and CEO of the Woodrow Wilson International Center for Scholars. He previously served as USAID administrator and US Ambassador to Tanzania. Keller Rinaudo Cliffton is the co-founder of Zipline.

Cover photo: Drone launch over Ghana. Photo by Zipline, used with permission.