Clinics in the developing world need Devices designed like Land Rovers: rugged, accessible, and easily repairable in the field.
Medical aid is a good story. We’ve all seen articles about well-meaning groups donating X-ray machines and incubators to needy clinics in the developing world. What we don’t see are those same devices when they fail as little as six months later — or even dead on arrival — because they weren’t designed to operate in these environments.
About 90% of medical technology that reaches poor countries is hand-me-down equipment designed for first-world facilities. Expecting it to keep working is like expecting a used Rolls-Royce to survive the Paris-Dakar Rally. And after it malfunctions, it’s usually junked.
In response, some designers have felt that we need to send over cheaper versions of the high-end equipment, the equivalent of economy cars. But what these clinics really need are Land Rovers — devices designed to be rugged, accessible, and easily repairable in the field.
Fortunately, increasing numbers of professionals in the medical equipment industry are becoming interested in applying this different design philosophy to devices aimed at developing countries. My lab at MIT, Innovations in International Health (IIH), is taking this approach even further, by getting everyday makers around the world to design and maintain their own medical technology.
MacGyver Health Care
In developed countries, we rarely think of modifying medical devices. Isn’t that the job of a professional? But in most of the developing world, doctors, nurses, and health care workers tinker with failing medical technology every day to fix it or make it work better.
These health hackers are often secretive about their solutions, however. The first time we saw a medical hack, it took us two hours to convince the nurse, Daniela Urbina, to show us how she had fixed the cracked diaphragm of her stethoscope. A young woman from central Nicaragua, she had experimented with various plastics to replace it, and settled on leftover overhead transparency material cut into a circle and taped inside. It wasn’t pretty, but it worked. We quickly dubbed her a MacGyver nurse.
It’s tragic that Daniela wasn’t proud of her innovation. But in the IIH lab at MIT, we’re developing MEDIKits (Medical Education Design and Invention Kits), construction sets designed to encourage invention among doctors and nurses in the field.
MEDIKits: Designed for Hacking
Our MEDIKits currently come in five flavors: Drug Delivery, Lateral-Flow Diagnostics, Lab-on-Chip, Vital Signs, and Agricultural Prosthetics. The kits started as boxes of parts assembled to familiarize MIT students with medical devices, and evolved to include linear components that you can assemble like Lego bricks into a final device. Through the process, we developed a modular design language to help users see the underlying logic to connecting the parts, and added physical stops to keep some components within safe ranges of operation.
Nothing beats field experimentation to understand whether a kit works. In our case, we would run across the river to the Boston hospitals and share the kits with colleagues, and then fly to Nicaragua, open the box, and see what people would do with them. Each kit provided us with insights into the design of an invention space — which ultimately is what you want.
The Drug Delivery Kit was our first experiment. It’s divided into core devices: syringes, nebulizers, inhalers, transdermal patches, pills, and several other items you might find at your local pharmacy. Then we added modifier elements: color coding, shape coding, couplings, extenders, springs, plungers, compressors, tilt sensors, buzzers, timers, bicycle pumps, and template cutters. These items let users couple and change the functionality of the core devices within specific degrees of freedom. Finally, we added a healthy amount of consumable general-purpose materials: zip ties, velcro, adhesives, paper and plastic sheeting, tubing, needles, and respiratory masks. The last thing you want is for your users to start compromising the modifier’s safety limits because they ran out of tape.
We designed the limits of our early kits carefully, but when users began to snap on, extend, and test their creations, something emerged that we did not anticipate: they hacked our kits. It starts with someone asking permission to simply cut a piece of tubing and bypass our carefully designed coupling. Or taking a part they find in one kit and using it for another, for example, adding diagnostic tubing into a mechanism to disable syringes for safety. As users take ownership of a kit, you as the kit designer become less involved in training people how to use it.
So for the kit to be successful, you have to Design for Hack. And while it’s impossible to predict every type of device a kit can produce, you can start with a core set, add degrees of freedom to that core, and then anticipate and design areas in which those degrees will be hacked.
Our Agricultural Prosthetic MEDIKit is a good example. Some great organizations such as Jaipur Foot provide affordable prosthetics, but if you’re a farmer in the developing world today, and you have the misfortune of losing an arm, you’ll probably be given a plastic hand that’s aimed at looking good but not very functional (and there’s no way you’ll be able to afford a sensor-laden robot hand).
The Agricultural Prosthetic MEDIKit uses a universal gripper made from PVC, bicycle inner tubes, and a soda bottle to attach most farm tools onto the arm or forearm of an amputee farmer. Each part of the kit follows the same three principles: core device, modifier device, and consumables.
Since the price of all three is so small, users have no problem in modifying the core components to make them work better. One person did away with the MIT-designed inner tube, and simply cut a notch in the PVC joints to let the excess tubing out of the way, creating a sling to carry the whole thing. And instead of using the shorter parts provided, they quickly attached long pieces such as broomsticks and telescoping fruit pickers.
Languages of Design
If you’ve ever tried to explain over the phone something like how to replace a headlamp in a foreign car, you know how frustrating it is to lack a language of design. “The little plastic knob with screws … yes I understand there are four knobs, try the first one….”
We realized that many of the components we included in the kit might be foreign to their users: English-language labels, injection-molded parts, tiny inhaler mechanisms, reagent combinations. To avoid confusion, we created a Language of Design, a way of color-coding each component in a logical manner so that people can identify its function immediately, and share their designs simply by describing the sequence of coded parts, and not the often-intricate mechanisms themselves.
Our PuzzleDx kit does that in a fun way for Lateral Flow Diagnostics, the class of absorbent paper-based diagnostics that includes pregnancy tests. These tests contain three components: a sample, a reagent pad, and a paper pad that collects excess fluid. We knew we couldn’t give users a crash course in chemical diagnostics so they could pipette their own reagent combinations on blank pieces of reagent paper. But we could get them to put together puzzle pieces in a sequence that would make sense.
So we color-coded different puzzle pieces according to the reagent paper contained within and cut slots in the pieces to connect the sample collection and reagent papers when the puzzle pieces were joined. By sharing the types of color combinations and the order in which they’re connected (which can be as easy as snapping a picture on a cellphone), users can easily re-create experiments without having to publish a formal protocol.
By using Languages of Design, you encourage communication across your user communities, facilitate understanding, crowdsource patterns of inventive behavior, and allow recognition of those patterns.
If the Flickr MEDIKit group is getting filled with pictures of prototype combinations with the Yellow, Green, and Blue reagent blocks, it may mean that manufacturing engineers should really start looking at mass-producing glucose, ketones, and human chorionic gonadotropin combinations.
When was the last time your pregnancy test did that?
Toys: Local and Globally Available Materials
A toy helicopter has a rack and pinion mechanism. A toy Ferris wheel turned on its side is an excellent centrifuge. A scrapbooking vinyl cutter is a pretty good CNC machine for making microfluidic channels. Makers have made repurposing materials a competitive sport, and health hacks are no exception. While many of the parts in our kits come prepackaged, we’ve also seen our users find and invent locally available replacements and accessories from toys.
Now, when we go into a toy store, we see a mechanism paradise. Toys make up an amazing supply chain of cheap plastic and electronic mechanisms with fairly good tolerances for most medical applications. Early on, our team was intrigued by what we call the glucometer and the Gameboy paradox. Both of these devices have equally complex electronics and comparable retail price points, but dramatically unequal distribution. I can find a handheld game console almost anywhere around the globe, even in very small towns in the developing world, but in Estelí, Nicaragua, 16 different clinics had to share a single glucometer.
Instead of trying to change the global supply chain for medical devices, we have learned to embrace the existing one for toys. Go to your toy store, and you’ll see the same $2 toy gun that a Nicaraguan nurse spotted and hacked into an alarm for an IV fluid bag, after harvesting the electronics and adding a simple trip mechanism. Lego blocks have very precise tolerances for creating modular microfluidic components. On the way out, toward the bicycle section, pick up a bike foot pump so you can power your nebulizer for $5 instead of paying $75 for the electric compressor sold in medical supply catalogs. Bonus feature: when there’s an asthma emergency in the middle of nowhere, you won’t need electricity to save the patient.
Places like Nicaragua have some of the poorest areas on the continent. But what about Nebraska? What about healthcare at home? For years, health technology has been shielded from tinkering and DIY invention because of the perceived barriers to entry: you’re not a doctor, you’re not a biomedical engineer, you require professional supervision. Health equipment has to be safe and rigorously tested, first and foremost.
All true, but along the way, that message got blurred with professional requirements that are not answering our need to make healthcare affordable. Try to buy a simple pillbox that lets you know when grandma took her pills: some are several hundred dollars. Makers build bird feeders that have the same functionality for a fraction of the cost. A surgical sterilizer costs $1,000–$8,000. But Anna Young got the same functionality by hacking a $30 pressure cooker and adding some DIY solar technology. A $30,000 incubator? Dr. Kris Olson made an incubator out of car parts for about $1,000.
Medical invention kits have the potential to lower many of these barriers and put health hacking back into the hands of users and of patients — the people who have the most to gain from affordable and elegant innovations. As the developing world gets a head start on DIY medical technologies, we’ll see many of those user-generated inventions make their way back to richer countries.
As skyrocketing healthcare costs converge with the democratization of making, many more people will hack health. Whether it’s putting RFID stickers on pill bottles to help patients take their pills on time, or hacking bike pumps and scrapbook cutters, health is filled with fantastic challenges. You can make a difference whether or not you work in healthcare.
Medical devices are very tangible things. One of the reasons I got into the field is because I knew I could create things that you can hold in your hand, give to someone else, and make a positive difference. If you’re a maker thinking about hacking health, or someone in healthcare thinking about creating something tangible, I invite you to try it. Start with a kit or a toy, and you’ll find a community that is eager to embrace your creations. We might even hack them, and we might even heal someone.