Defining Success in Appropriate Medical Design


I tweeted this during a lecture from the wonderful Dr. Bob Malkin, who founded Engineering World Health and does some great research identifying actual barriers to use of medical equipment abroad (disclaimer: I may have taken that from his slides, I don’t remember). I’ve worked on a neonatal device that won some big design competitions, so this resonated strongly with me. It got a little bit of traction, so I’m guessing it struck a chord with a lot of other people in this niche, too.

Of his selection of the top 10 or so neonatal devices deliberately designed for resource-poor settings (hospitals with irregular electricity, for example, or clinics that are short-staffed), zero have African manufacturers or distributors. Zero have reached one million treated patients. All won major design competitions. These goals should not be outlandish – try getting VC funding for an app in the Valley without a million projected customers – but it’s been at least three or four years since this type of focused design for hospitals abroad became a Big Thing in university circles, and achieving those goals on this timeline would frankly be small potatoes in the private sector.

If you sit in on any business school competition, you’ll find a Saving Babies Device among the winners. A quick google search will come up with tens of biomedical competitions either specifically for low-resource settings or with a category for the arena. Don’t get me wrong, I’m glad to see the attention – even Y-Combinator opened to nonprofits recently*. But I think they tend to capitalize on the feel-good factor rather than on what can actually get to market.

It’s worth noting that I think the two companies that have gotten the closest to these goals (Embrace and Brilliance) do mimic private-sector distribution channels by selling equipment rather than donating and maintaining strong R&D teams. The less successful products either linger in university tech transfer offices or get shuttled into nonprofit models, where funding is frankly not sufficient to support health research. In fact, overhead costs for most life science companies can reach 50% – far beyond what most donors are willing to stomach. The perception of low overhead costs as the hallmark of a worthy philanthropic venture is beginning to change, but there’s no denying that the type of people capable of designing neat medical equipment have particular skills with a much higher market value than those of other nonprofit employees, and that lab costs are high for quality products. This shouldn’t even out anytime soon.

So, potential next steps:

1) Design competitions are nice but they need to come with more solid backing. Make prize money contingent upon licensing or formation of an LLC, or deliver it in stages based upon patients reached.

2) Focus more on designing efficient back-end systems that support local manufacturing (another gem suggestion from Dr. Malkin – mass paint systems! None in Afria). “Industrial engineering for the developing world” doesn’t sound sexy, but there would be a WHOLE lot of money there.

3) Continue the shift towards low-level prizes contingent upon iteration and scaling (the DIV model**, basically). I’m all for designers patting themselves on the back, but it’s most rewarding when in service of work milestones, anyway.

4) Do. Not. Donate. Devices. Don’t do it. I don’t care who you are or how much money you have or how good it makes you feel or how right you think it is. Donate money to the hospitals, sure, but don’t undermine the economic chain that leads to the creation of better technologies within this sphere.

*I think Watsi is really dumb though, but that’s a post for another time.

**Disclaimer, I intern for them

Defining Success in Appropriate Medical Design

Let’s Talk About Intellectual Property and Global Health

There’s something unique about building and creating in a humanitarian field. Your goal, on one hand, is to work yourself out of a job: you want your inventions to be so contextually appropriate that they remain feasible, so culturally apt that they are used correctly, and so accurate that the results are akin to those in a New York hospital. Your achieve success when you eliminate the health problem you were attempting to stem.

On the other hand, when you design for lower-resource settings you are designing for emerging markets. You hope that the health benefits of your invention will contribute to a cycle of productivity: of lower disease incidence, of more school days for children that would otherwise be ill, and ultimately of economic growth and increased earnings. You are building your work into the fundamentals of a nascent health system, with the hope that your design will flourish within this new system and remain relevant. Stemming a health problem is not the end-all; it is a stepping stone on the way to sustaining access to continued care.

I’m working at a foundation right now, and the purpose of IP protection for nonprofits and social ventures comes up for debate on what I would hazard is a weekly basis. While both sides propose that such organizations should want their efforts to result in the maximum amount of social good, one argues that the best way to achieve this is to share productive innovations openly – that overriding the egotistical human desire for ownership would result in greater total implementation, and a greater total number of lives saved.

In other words: if you truly want to help people, how dare you attempt to make a career for yourself in this field rather than voluntarily giving away your efforts. I find the degree of guilt-tripping that this mindset perpetuates very short-sighted. “Don’t you want your efforts to go to saving babies/reducing disease rates/increasing crop yields?” Well, yes, of course we do – if we didn’t, we would be working at for-profit engineering firms. But social ventures cannot perpetuate their ability to do good*, and to create new solutions, without receiving living wages and a financial safety net with which to invest in further research and design.

My stance is that this method of operation drives high-talent individuals away from the social sector and forces said ventures to remain beholden to donors.  Being beholden to shareholders (by licensing bottom-of-the-pyramid designs to for-profit companies) is equally limiting: it delays the urgent business of providing such technologies to the locations most in need, rather than middle-income markets.

I maintain that the best way to maintain creators within this space is to provide them with a sense of ownership, and that maintaining high-quality creators is critical to building relationships with end users and clinical partners. In order to accomplish these things, creators need to out-perform other organizations when competing for donor funds or applying for grants. And in order to do this, they need to be able to protect their intellectual capital.

So, where do we go from here?

Peter Haas of the Appropriate Infrastructure Development Group mirrors my thoughts exactly:

“Sorry to break it to you, but this field is one largely of boutique players and very insular boutique operations in large companies. There aren’t many jobs out there to be had, and you need to look hard to find the ones that come up every once and a while. Most people in this field make their own jobs as entrepreneurs and consultants.”

Aside from the opportunities pointed out by Mr. Haas, it’s worth noting that a (relatively) tremendous amount of funding for global health research is channeled through universities. Interest in the field is growing for students of all disciplines, and it’s also worth noting that many low-cost health technologies are prototyped equally cheaply by students.

Stanford provides a particularly successful model for developing new opportunities, in part by honing their openness to student entrepreneurship in the for-profit tech sector. D-Rev, Embrace, and Medic Mobile all have roots here. That is not a coincidence. Stanford’s willingness to allow students to pursue their own inventions, which are unlikely to turn a profit if licensed, has resulted in a transformational impact: the products are life-saving, yes, but more substantial are the hardware and software engineers, the business students and fellows, the executive directors who are now freely and actively working to create more life-saving interventions.

But few seem to have followed suit. Diagnostics for All came out of Harvard, which kindly licensed patterned paper diagnostics from the Whitesides Group to the nonprofit (and I would hazard that Whitesides’ influence played no small role in this decision). But licensing fees are often out of reach of burgeoning nonprofits, and even if that were not the case, I understand that universities would be hesitant to relinquish potential profits. It makes more financial sense for these institutions to keep BoP technologies in-house, where they can be used to bring in grants (see Jhpiego at Johns Hopkins) and where tenured professors can pursue this type of engineering-for-change without worrying about financial security or market viability.

This model is not useless, and it does lead to the continued production of low-cost health technologies, often at the prototype scale. But it is also not transformational. For broader impact, universities need to leave the door open for students to pursue their inventions to market. New product-centric social ventures focused on health design for low-resource settings will broaden the scope of new health interventions, even the financial playing field for these organizations with higher-than-standard overhead, and provide an outlet for students to pursue this field instead of other potentially lucrative options. To summarize that mouthful of a sentence: this combination is what we should aspire to if we want to sustain this field beyond its boutique origins.

*For more thoughts on the application of this line of thinking to the broader nonprofit sector, see Dan Pallotta’s wonderful TED talk from this year.

Let’s Talk About Intellectual Property and Global Health

I got bit by the startup bug this week.

Lots of tangentially related events and happenings floating around as of late. Things are Stewing.

1. Elevator Pitch competition: stellar. Winning things helps, lots; having people who have successfully launched products excited about scoping us out, providing feedback, handing us cards, telling us our project is the one that actually piqued their interest – so, so fantastic. We’re at a great place right now – lots of hustle on multiple fronts (design, IP, FDA, software, conferences).

2. Relevant Forbes article on innovation and profitability.

3. Great video of a Jobs-run (I know, I know) brainstorming session.

I got bit by the startup bug this week.

A Love Letter to the OEDK

I have exhausted the number of places on the Rice campus in which I can expect to productively accomplish any given task. My personal room? Too risky at late hours – things like blankets beckon. Our suite’s common room? Too lush, too classy – good for mindless tasks, including all things involving spreadsheets (BIOE 444, anyone?), that can also be accomplished with wine as an accomplice. Martel commons? Perhaps once upon a time, before it became better suited to hurried lunches and dancing on tables and lots of yelling. Fondren? You’re joking – if sophomore year didn’t ruin that for you, you either weren’t there enough, not hooking up in the stacks, and/or doing something wrong.

So I retreated to the barest block of campus, and became hopelessly enamored. Basic definition: what makes for an effective work space? As far as I’m concerned, the relevant factors can be broken down into several categories, which I’ll describe as follows because, fuck it, it’s 3 a.m. and I love OEDK.

1. It makes you want to work
I am writing this at desk 2D. Should I get up and wander 20 feet, I could play with:

  • A slow-drip IV that operates using mass balance
  • A salad spinner fitted with centrifuge tube inserts
  • An infant pulmonary assist device that operates using water pressure
  • A huge $7,000 check  won by some team last year at the national ASME competition
  • 3 different neonatal incubators

Every single one of those things makes me want to be better – to spend absurd hours creating things on par with what twentyyearoldswhcouldhavebeendrinking have created. More so than this – an inspirational setup – the building itself is raw and spare, uncomfortable. Lights go off when you stop moving. You don’t sleep here. You stay up all fucking night and fiddle and perfect and learn to work for yourself and don’t fucking quit. I napped in the golfcart once last semester, but they’ve since gotten rid of it.

2. It makes you better at working
There is free coffee, so long as you’re one of those people capable of doing dishes. I can reserve a conference room, write on the walls, hook up my music to the room’s speakers and set the display to respond in tune. Did you miss the walls part? Just checking – it’s a real thing. The best is when you’re in the zone and your friends wander past and leave you messages, written on the (glass fishbowl) outside in reverse. That’s part of the point, though – have your privacy within purpose and reason (noise considerations, etc), but don’t fuck around. Instead, we encourage productive distractions in keeping with the larger mission of the space.

Prime example: the magazine rack. I may be the only person who uses these, but particularly when ChromeNanny is up and running, a 20 minute break is fantastically spent flipping through Wired or The Economist or The New Yorker or Foreign Affairs. The mere fact that some of these selections are even available here means the world to me – they imply a larger field of impact for the more tedious aspects of engineering work.

3. It provides a supportive community
I’m watching freshmen play with linked sections of PVC pipes and I honestly have no idea what the fuck they could possibly be doing. A team I bonded with over 4 a.m. coffee sharing is working on a presentation in the computer lab behind me. My orientation week co-advisor spent five nights last week working in the computer lab and I forcibly introduced myself to everyone on his team and two others, and the two BIOEs from my year I didn’t know, and that guy who looked lonely. I hate using “networking”, child of more toolish departments, as the applicable term here. If I see someone making something cool and I don’t know what it is, this is the place to ask – while the doing is happening, while ideas can be exchanged, while they look like they need a break.

Just talked to freshmenz. They’re working out the joint structure for a Strandbeast. YES, absolutely. Perfect.

A Love Letter to the OEDK

Student Design Projects

I know people who are approaching BIOE 451/452 with the goal of walking out of the Sallyport with a degree in one hand and a patent application in the other. They are, however, vastly outnumbered by those who a) want to attend medical school/some other grad program, b) don’t care enough/wont’t create something good/will burn out or c) don’t know how money/patents work (I go here, and that’s hopefully). But a lot of the projects I’ve seen in previous years are good, and the global health projects in particular have a lot of potential for use at very low development costs (there is NO source of free labor like a graduating senior who wants an A in their capstone course). Here’s the thought process:
– Many engineering schools around the world feature degree programs culminating in design projects, in which the final product is a functional, marketable device.
– Many of these projects focus on global health; for example, bioengineering students at Rice have constructed low-cost automated syringe pumps appropriate for clinics lacking in staff, and cell phone cameras adapters for diagnosis of neonatal jaundice.
– Many students who spend their senior year working on such projects abandon them.

And here are some potential fixes:
– Financial support for students who want to make their class things into real things. USAID is trying to start making small-level grants workable, but it’s not there yet, and a student initiative of this sort would be the perfect place for them to begin.
– DESIGN PROJECT DATABASE. This would allow students from different universities interested in continuing work to interact with one another, rather than the pre-med they got paired with. This year alone I know Rice, Columbia, and Northwestern all had projects developing low-cost autoclaves: a PERFECT scenario where something like this could be useful for both exchange of ideas and potential future investment. A project like this would have to be university-led, as in design teams would need to be urged by a professor to actually submit occasional project updates throughout the year (which wouldn’t be hard for anyone doing regular documentation) (potential lead rice envision grant project, hmmmmmmaybe).

Student Design Projects

Numbers, engineering, and other things people in public policy tend to dislike

Work in international development is a study in constraints.

Work in international health takes this rule and ups the ante by virtue of sheer complexity.

Here’s one example: many vaccines are temperature sensitive, and can be spoiled by fleeting exposure to heat (for instance, 80% of tetanus vials will no longer be potent after 3 hours at 65 degrees Celsius – an entirely achievable temperature in the back of a metal truck). Vaccine vial monitors have by and large minimized the issue of administering ineffective doses, but the primary problem of spoilage remains. This can happen if, say…

  • A drought in Kenya decreases output of hydroelectric dams, resulting in rolling blackouts in the relatively well-developed city of Nairobi that subsequently cut power to refrigerators.
  • Crumbling rural infrastructure and poorly-managed roads slow delivery trucks to a crawling pace, virtually negating cooling systems (if there are any).
  • A health care worker without proper training mishandles the package. This, of course, could happen anywhere, but is much easier to come across in locations with high rates of illiteracy.
  • A flimsy source of funding to a rural clinic is cut, preventing payment of any electrical bill.
  • Et cetera. And the potential impact can be just as varied: a waste of labor, time, physical resources, and money in a setting where none of those things are readily available, not to mention the potential health impact upon a population (worse if the vaccines are administered anyway and a sense of entirely unwarranted protection is developed; worse still if this a HPV vaccine distributed to potential rape victims, or whatever other awful scenario you can think up). Implementing an effective aid program requires very careful and systematic prediction of where things can go wrong, and failsafe plans for when things not-thought-of do. Similarly, post-program analysis can also benefit from more rigorous methodology, such as with use of controlled studies to evaluate the effectiveness of aid (here is a fantastic study on the effectiveness of various methods of HIV prevention among adolescent girls).

    This particular way of framing complex problems in international affairs is not only beneficial but essential to forming strong policy. A thoroughly analytic, numerically focused perspective is invaluable in constructing effective development programs: building a bridge in Nicaragua, a complex of biosand filters in El Salvador, an economic program to support schools in Pakistan. This isn’t a thought process I’ve ever had to implement in a political science or policy studies course, but instead is incredibly reminiscent of the manner in which I’ve had to approach design problems in engineering classes – and I’d like to argue that it places people with this sort of training in a key position in policy agencies. Only so much can be learned from reading case study after case study; students intending to enter high-stakes fields need more trial-and-error, more hands-on practice in program development and design. USAID doesn’t hire systems engineers, but they should if we ever intend to become serious about development.

    Numbers, engineering, and other things people in public policy tend to dislike