A Simple Cooler Could Help Patients Battle Antibiotic-Resistant Tuberculosis

Main Category: Tuberculosis
Also Included In: Medical Devices / Diagnostics;  Compliance;  MRSA / Drug Resistance
Article Date: 01 Jun 2012 - 0:00 PDT

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Tuberculosis, now largely controlled in the industrialized world, remains a stubbornly persistent killer in most of Africa, as well as parts of Asia and South America. The spread of multidrug-resistant strains of TB has slowed progress against the devastating disease, which is estimated to strike more than 10 million people annually. Now a modified soft-drink cooler, developed by researchers at MIT's D-Lab, could make a dent in the disease's impact.

There are two big issues that physicians confront in trying to tackle drug-resistant TB strains in developing countries. First, the drugs used to treat the disease, which require several doses per day over a course of 18 months, must be kept at a controlled low temperature - in places where the availability of electricity is sparse and unreliable. And second, the drugs must be taken regularly, requiring continuous monitoring by health care workers.

Both issues could potentially be addressed by the cooler developed by researchers in the Little Devices Lab, a team of researchers within D-Lab who work to develop low-cost solutions to pressing medical needs.

D-Lab is a program of classes, workshops and labs at MIT, launched a decade ago by senior lecturer Amy Smith. The program now includes 13 classes on topics in health, mobility and energy, and is devoted to developing appropriate solutions to problems facing low-income people and communities around the world.

José Gómez-Márquez, the D-Lab instructor who runs the Little Devices group, says the team's breadbox-sized cooler was adapted from one designed to keep soft drinks cool. Dubbed "CoolComply," it can run on either plug-in power or solar cells, and contains circuitry to monitor the temperature inside and transmit an alarm if it rises too high. (Higher temperatures cause a gas to be released inside the medicine packets, which can make patients violently ill.)

In addition, to track compliance, each cooler records the exact date and time when the box is opened, which allows a single dose packet to be dispensed. A built-in cellphone transmitter sends information on temperature and cooler activity to a central health facility where the data can be stored and monitored.

The CoolComply team won a $100,000 award last fall as a Vodaphone Americas Foundation Wireless Innovation Project, as well as a $50,000 grant from the Harvard Catalyst. The awards will see the project through initial development and testing.

The idea originated with Kristian Olson and Aya Caldwell, physicians at Massachusetts General Hospital in Boston, who told Gómez-Márquez about the pressing need to keep TB medicines cool and to verify patient compliance with the dosage regime.

At present, since many of the patients entering treatment lack access to refrigerators, they are instead provided with coolers requiring daily deliveries of ice; their compliance with the dosage regime is checked regularly by visiting health workers. Those constraints severely limit the number of patients who can be treated, Gómez-Márquez says. The daily ice deliveries cost $600 a year - about double the cost of the CoolComply system - and "ice doesn't send you a message" to show that medicine has been taken, he says.

Since last September, three prototype devices have undergone field testing in Addis Ababa, Ethiopia; this summer the D-Lab team hopes to deploy at least 10 more there for further testing. Ultimately, the team hopes the devices can be produced locally and distributed by a small for-profit company set up for this purpose, fostering both better health and the creation of local jobs.

The wireless reporting system in the CoolComply device "solves the problem of having to visit the patient every day," Gómez-Márquez says. But getting to that point wasn't easy: The first prototypes built last summer by the team - which also includes D-Lab instructors Anna Young and Amit Ghandi - worked perfectly in the United States, but as soon as they arrived in Addis Ababa for field testing, "none of it worked," Gómez-Márquez says, because of unreliable signals from the local cellphone system. "We had to go back to the drawing board," he says. "We were in despair."

One problem, Ghandi says, was the design of the cooler's antenna. "You couldn't tell what was wrong by looking at it," he says, "but it wouldn't work in certain parts of Ethiopia." Finally, after switching to a different type of antenna and devising some tricks to make up for unexpected gaps in the system (such as the lack of a built-in timestamp on Ethiopian text messages), they were able to get a reliable device up and running.

That's par for the course for such projects, Gómez-Márquez says. "You want, during the first trip, for a lot of things to go wrong," he says. "That's why you go over there." The key thing for this project was enlisting local users to try out a new system under real-world conditions. "We found amazing engineers" at the Addis Ababa Institute of Technology, he says, who "did an enormous amount of work" to help get the system working.

These local engineers, in fact, were delighted to have the chance to work on such a project, which they could see was something that could be built and maintained within the country. Young says one of them told her, looking at an expensive MRI machine in the local hospital, "Nobody I know will ever use this." By contrast, he said of the new cooler, "This is something I can actually see being used by people I know."

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FBI: IPv6 rollout could hinder police investigations

As the Internet prepares to celebrate World IPv6 Day next Wednesday, law enforcement is worried the transition could hinder legitimate investigations. Some tech companies agree it's a problem.

The FBI tells CNET it may develop "additional tools" for Internet surveillance, depending on how IPv6 is deployed.

(Credit: FBI)

The FBI is worried that an explosion of new Internet numeric addresses scheduled to begin next week may hinder its ability to conduct electronic investigations.

A historic switchover that will give the Internet a nearly inexhaustible supply of network addresses -- up from the current nearly-exhausted total of 4.3 billion -- is planned for next Wednesday. AT&T, Comcast, Facebook, Google, Cisco, and Microsoft are among the companies participating.

Side effects from the transition to Internet Protocol version 6, or IPv6, "could have a profound effect on law enforcement," an FBI spokesman told CNET this week. "Additional tools" may need to be developed to conduct Internet investigations, the spokesman said.

That's one reason the FBI recently formed a new unit, the Domestic Communications Assistance Center in Quantico, Va., which is tasked with devising ways to keep up with "emerging" technologies. CNET was the first to report on the formation of the center in an article last week.

While Wednesday's World IPv6 Day is only one step in the transition to the next-generation system, it's expected to mark the beginning of a gradual decline in popularity of the outgoing IPv4 standard. The participating Internet providers will begin to switch over a fraction of their residential subscribers on Wednesday, and router makers will enable IPv6 by default for their products. (Here's an IPv6 FAQ.)

That's what worries the FBI, which has been meeting quietly with Internet companies to figure out how its agents can maintain their ability to obtain customer records or perform court-authorized surveillance.

"This is a very real concern," says Jason Fesler, Yahoo's IPv6 evangelist. It will "impact a service provider's ability to readily respond to legal requests from law enforcement agencies," according to the Broadband Internet Technical Advisory Group, or BITAG, which counts AT&T, Cisco, Comcast, Time Warner Cable, Google, and Microsoft as members.

D-Link, the Taiwan-based company that's one of the largest makers of routers and networking gear worldwide, agrees. "D-Link is aware of potential issues concerning IPv6 and law enforcement concerns that are currently being assessed," a company spokesman said. "D-Link is committed to IPv6 support and will comply with any future guidelines."

The Internet engineers who recognized the need for more addresses as far back as the 1980s, and began sketching out what became IPv6 over two decades ago, didn't intend to create headaches for police agencies. Instead, it was an unintended consequence of the hybrid technologies that were created to allow IPv4 and IPv6 connections to share one network during the transition.

Once IPv6 is near-universally adopted, it's likely to prove a boon to police, a fact that some law enforcement representatives privately acknowledge. That's because each device -- tablets, phones, refrigerators, lawn-mowing robots, and so on -- will sport its own unique Internet address.

So far, the FBI is taking a wait-and-see approach to the transition, saying that "it is too early to know the extent of the impact of IPv6 upon law enforcement until more providers deploy it."

The bureau's concern about IPv6 is one component of what it calls the "Going Dark" problem, meaning that the surveillance capabilities of police may diminish as technology advances. CNET was the first to report that the FBI is asking Internet companies not to oppose a controversial proposal crafted in response to Going Dark that would extend the Communications Assistance for Law Enforcement Act (CALEA) to the Web.

FBI's GCN problem: the technical details

At the moment, if someone suspected of committing a crime is posting about it on Facebook, for instance, police can obtain a court order to trace an IPv4 Internet address such as 64.30.224.26 back to a single household.

But the exhaustion of IPv4 addresses is prompting many Internet providers to embrace a transitional technology called carrier-grade Network Address Translation, or CGN, that allows a single Internet address to be shared by hundreds of homes, or even an entire town, at the same time. It's common to have 1,000 people share one Internet address.

That means it's no longer enough to know that someone's publicly-visible address is 64.30.224.26.

Facebook and other Web sites that want to trace a network connection back to a person -- for their own anti-abuse purposes or to assist law enforcement -- will need to log the IP address and also what's known as the port number. (Port numbers, such as assigning one household the range 12000-12009, are how a single Internet address can be used simultaneously.)

In addition, an Internet provider using CGN will have to keep logs of which port numbers map to which customer.

"You will need more," Keith O'Brien, a Cisco distinguished engineer, told the High Technology Crime Investigation Association this month. O'Brien said increased use of CGN "will require more information to be gathered in order to accurately identify a subscriber."

O'Brien suggested to his audience that, when conducting investigations, they should ask Web sites for the Internet address address, the exact time, and the source and destination ports that were in use.

Fesler, Yahoo's IPv6 evangelist, said that in addition to storing IP addresses, his employer is now recording the source port from which its users are connecting. "Only with the combination of time, address, and source port, will any Internet service provider have any chance of checking their logs, and associating that information back to a specific subscriber," he said.

Last summer, engineers from AT&T, Yahoo, and Juniper Networks jointly published "Logging Recommendations for Internet-Facing Servers," which the Internet Engineering Steering Group approved as a best-practices document called RFC 6302. It recommends that anyone operating a Web server record the source port number of inbound connections down to the precise second "to support abuse mitigation or public safety requests."

One inevitable side effect of all this extra logging is the expense: detailed logs consume an extraordinary amount of storage.

CableLabs, a research and development organization founded by the cable industry that counts representatives of Comcast, Rogers Communications, and Time Warner Cable on its board, says the log size is immense. It estimates the average subscriber opens 33,000 connections per day, which means 1.8 petabytes per year per million subscribers just for logging.

But, says Chris Donley, CableLabs' project director for network protocols, there's a way to chop logs sizes. It involves assigning port ranges in advance to specific Internet addresses, which will reduce log volumes in the range of 100,000- to one million-fold, he estimates.

Law enforcement representatives like the idea, Donley says. "It will make it easier for ISPs to respond to public safety requests without requiring onerous infrastructure on either the ISP or public safety part," he said. "We've been meeting with a number of public safety agencies roughly quarterly to discuss this approach."

One caveat is that not all Internet providers are using CGN. Comcast, for instance, has taken a different approach using what's known as a "dual stack," meaning their customers' computers will run IPv4 and IPv6 simultaneously.

Increased logging can also lead to privacy concerns. "We have urged providers not to log information that they don't need for their own provision of services, even if someone else might want the information or they hypothesize that it might be valuable someday," says Seth Schoen, a senior staff technologist at the Electronic Frontier Foundation in San Francisco.

And mandatory logging -- required by an FBI-backed bill that a House of Representatives committee approved last year -- would be especially problematic for smaller Internet providers. "We couldn't retain records" even under the smaller data requirements of IPv4, says Brett Glass, owner of Lariat.net, a local Internet provider in Laramie, Wy. "There would be too much volume."

"There is no doubt that the wiretappers are being left behind and challenged," says one attorney who represents telecommunications providers. "It is just a question of whether you have an always-on storage of everyone's activity for law enforcement's benefit when the Federal Trade Commission is suing you for overcollection in other contexts, and less intrusive measures can be used."

Live IPv6 wiretaps

In theory, intercepting IPv6-only traffic isn't any different from intercepting IPv4 traffic. Even publicly available sniffing tools such as tcpdump, Ethereal, and Wireshark can decode IPv6 packets. In practice, however, some hurdles can arise.

CALEA: The 1994 law called CALEA resulted in industry standards requiring telecommunications companies to make their networks readily wiretappable by police. But those standards, including one element called CACmII (which stands for the awkwardly-titled phrase Content-Associated Communications Identifying Information), are incompatible with IPv6.

During a presentation at a networking conference last fall, AT&T Labs researchers warned (PDF) that "the standards are steps behind the industry evolution" to IPv6.

Encryption: Any computer with IPv6 has built-in encryption called IPsec (which can also be available with IPv4). The New York Times reported in 2010 that the FBI was lobbying for a law requring telecommunications companies offering encryption to build in backdoors for law enforcement, a requirement that would likely cover IPsec, but the bureau distanced itself from that idea a few months later.

"The frequency of use should increase with IPv6," predicts a network engineer at Sonic.net, an Internet provider in Santa Rosa, Calif. "None of this is good news for law enforcement organizations."

But some of the technical details are challenging, and IPsec is still not widely used. Neither are HTTPS encrypted connections; Arbor Networks estimates that only 2 percent of native IPv6 traffic is HTTPS, not counting file sharing traffic.

Tunneling: A technology called Dual-Stack Lite, or DS-Lite, is designed to help with the transition by wrapping an IPv6 packet around an IPv4 packet, which should be faster than other methods.

That, too, can cause problems with wiretaps. An Internet draft published in March by representatives of Telecom Italia and France Telecom acknowledges DS-Lite can hinder eavesdropping. "A single IPv4 address, or some range of ports for each address, might be set aside for monitoring purposes to simplify such procedures," they recommend.

The FBI says it's paying close attention to these aspects of IPv6: "Some of the optional capabilities will determine whether existing law enforcement tools and techniques will continue to support lawfully authorized collections or additional tools will need to be developed."

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Clinton: Russian Stalling Could Push Syria into Civil War

U.S. Secretary of State Hillary Clinton says Russia's failure to take decisive action against Syrian President Bashar al-Assad "is going to help contribute" to the very civil war officials in Moscow say they are helping to avoid.

Speaking in Denmark Thursday, Clinton said she rejects the Russians' "vociferous...claim that they are providing a stabilizing influence" in Syria. Instead, she said, Moscow is propping up Mr. Assad as his government continues a brutal crackdown on dissent U.N. estimates say has killed more than 10,000 people.

"We have very strong opposition from Russia and China, but it is primarily Russia," Clinton said, "and that makes it harder to put together an international coalition."

Russia has repeatedly blocked the U.N. Security Council from taking punitive action against the Assad government, a longtime Russian ally.

White House spokesman Jay Carney echoed Clinton's warnings about the danger of Syria's unrest morphing into a proxy war that draws in Iran and other regional powers.

"The longer Assad and his thugs are allowed to brutally murder the Syrian people," he said, "the more likely it becomes a sectarian civil war, the more likely that it spills over Syrian borders.'' Carney warned of a "proxy war" with Iran backing Mr. Assad and other outside nations or forces backing insurgent factions.

Also Thursday, U.S. ambassador to the United Nations Susan Rice condemned as "reprehensible" the latest reported Russian arms delivery to Syria. Media reports and rights groups said a Russian cargo ship heavily laden with weapons docked at the Syrian port of Tartus last week.

Western officials confirmed her comments, adding they understood the ship had been carrying arms for the Syrian government.

Syria is one of Russia's top weapons customers. The U.S. and European Union have suggested the U.N. Security Council should impose an arms embargo and other international sanctions on Syria.

U.S. and European security officials say Iran has also offered Assad extensive support to help him suppress anti-government protests, from high-tech surveillance technology to guns and ammunition.

Last week's massacre of at least 108 people in the Syrian town of Houla - nearly half of them children - has rekindled new urgency into efforts to stem the 15-month-old conflict. The U.N. has said much of the killing was carried out at close range, while activists say pro-government militia known as shabiha were responsible.

Syria Government Explanation

The Syrian government said Thursday a preliminary investigation into the atrocity revealed that hundreds of armed men had attacked families who did not join anti-government protests. Brigadier General Qassem Suleiman said the victims were families that "refused to rise up against the government."

Rice called the Syrian report "another blatant lie."

The head of the Britain-based Syrian Observatory for Human Rights said Thursday that government troops killed three people in overnight shelling near Houla. Rami Abdel Rahman said a 14-year-old boy was later killed by sniper fire.

Damascus-based U.N. spokeswoman Sausan Ghosheh said U.N. monitors based in nearby Homs were traveling to Houla to verify the reports of renewed attacks.

Rebel Deadline

In a statement Thursday, a rebel Free Syrian Army commander gave Assad a deadline of noon Friday local time to start acting on commitments made to international peace envoy Kofi Annan.

Annan was discussing the Syrian crisis with Lebanese officials in Beirut Thursday after talks with Jordanian King Abdullah in Amman.

Rebel Colonel Qassim Saadeddine said his forces would no longer be bound by the Annan peace plan if the Syrian president fails to comply.

The Free Syrian Army is a loosely-organized and lightly-armed rebel group made largely of Syrian military defectors. The Syrian government and the rebels agreed in April to a truce mediated by Annan, but the fighting has continued, with each side accusing the other of violating the deal.

Analyst James Denselow of King's College in London says it would be a mistake for the Free Syrian Army to cut itself off from the U.N.-brokered cease-fire.

"I think they would be falling into a trap if they were to be the ones who unilaterally declared the cease-fire over, because that would allow Assad and the regime to say 'well, they broke it, we still believe in it,' despite the fact that they haven't really been properly observing it," Denselow said.

Cherif Bassiouni of DePaul University said Mr. Assad's government will not in the long run be shielded from prosecution.

"They should know that even though Russia and China are protecting them tomorrow, that if there is a commission that investigates what they're doing and has the evidence, they will not always be immune from prosecution in the future. And this has to be done now while the evidence is fresh,"  Bassiouni said.

U.N. Secretary-General Ban Ki-moon said Thursday he "demands" the Syrian government abide by its peace pledges. Speaking at a forum in Istanbul, Mr. Ban said the almost 300-member U.N. military observer team in Syria is not meant to play the role of "passive observer to unspeakable atrocities."

The U.N. chief also warned that more massacres such as the Houla incident "could plunge Syria into a catastrophic civil war ... from which the country would never recover."

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