Playing With Toys and Saving Lives

“Apollo 13” is a good movie, but one 95-second stretch is what turned it into it a geek classic. Their Command Module disabled, three astronauts use the Lunar Module as a lifeboat. Carbon dioxide is building up. The Command Module’s filters are available to scrub the air, but they’re square, and the receptacles for them on the Lunar Module are round. “Well, I suggest you gentleman invent a way to put a square peg in a round hole … rapidly,” the flight director Gene Kranz in Houston tells his engineers.

They dump onto a table everything available to the astronauts. Using duct tape, cardboard logbook covers, plastic moon rock bags and a suit hose, they make the filters fit. The astronauts are saved.

That video clip of hacking is widely known, but you may not have seen the one just above. It starts with Yamilet Mendoza Martínez, a nurse shopping in a toy store in Jinotepe, Nicaragua. She needs to make an IV alarm — something that makes noise when a bag of IV fluid is ready to be changed. Having an alarm means the nurse doesn’t have to keep popping in to check every few minutes — an impossibility for severely overworked nurses. The solution? A toy AK-47 — one that buzzes when fired.

Back at the Hospital Escuela Regional Santiago Jinotepe-Carazo, Mendoza Martínez and her colleagues hooked up the gun to an IV pole. As the IV bag empties, a rubber band attached to it compresses, opening one side of a clothespin. That closes the other side, putting the clothespin wire in contact with the electrical contact in the gun trigger. Bag empty = gun buzz.

How do hospitals like this one normally get medical equipment? For the most part, they don’t — some public hospitals can’t even afford IV tubing or gloves. Often, they get donations from rich-country hospitals, which give away last year’s technology. But these machines tend not to last long. They might need parts that are only available a continent away, or no one knows how to repair them. Sometimes it’s just that the electricity has gone out — or there was no electricity to begin with.

Jose Gomez-Marquez demonstrating a MEDIKit Nebulizer.

Nathan Cooke

Equipment destined for a productive life in a third-world hospital is equipment adapted for local circumstances, rugged, fixable locally, with available parts.

That’s often not possible with highly complex machinery. But it is possible with smaller machines and devices. “This market has been neglected,” said Jaspal Sandhu, a co-founder of the Gobee Group, a social innovation and design firm. “There hasn’t been good design for this market. It was: find something from another setting, and we’ll sell it however we can.”

Now, however, frugal design is a booming business. (In India, it is called jugaad, and it’s a major movement.) One of the first companies in the field was the Indian ophthalmic products manufacturer Aurolab, which made kits for cataract surgeries. “Around 10 or 15 years ago people started to pay more attention to it,” said Sandhu. “Companies started to look into those markets not as charity but as a market with real opportunities that needed to be addressed for products designed for them.”

Many different people are inventing health devices for resource-poor settings; so many that the World Health Organization publishes an annual report (pdf) on the ones it likes. Last year’s list includes a nail-and-screw system to set severe fractures that requires no X-ray or electricity, the Embrace infant warmer — a miniature sleeping bag for newborns — and a set of plastic rings that can circumcise men for AIDS prevention safely and painlessly without surgery.

Nurses from Hospital Alfonso Moncada Guillén prototyping with a Drug Delivery MEDIKit in Ocotal, Nicaragua.

Anna Young

Jose Gomez-Marquez goes one step further. He’s the organizer of Mendoza Martínez’s trip to the toy store. Gomez-Marquez, who was born in Honduras, is the director of M.I.T.’s Little Devices group, which builds medical devices that nurses and doctors in very poor settings can adapt themselves — or kits for making their own. (The University of California’s Tekla Labs does the same thing for research scientists who want to build or adapt laboratory equipment.)

There’s nothing new about do-it-yourself — D.I.Y. is how medical products used to be invented. In 1816, Dr. René Laënnec needed a better way to listen to patients’ chests, so he made a cylinder of paper that evolved into the stethoscope. (This article has a good overview of the D.I.Y. field.)

D.I.Y. on a wide scale used to be a contradiction in terms. But it’s less so now that there is a budding Maker movement, which offers tools, advice and support to people who want to create new things. Gomez-Marquez and his colleagues are doing this for health care workers in poor settings. “There were a lot of one-offs,” said Sandhu. “An enterprising physician or local mechanic figured out something local health care needed and didn’t have the resources to get.” (See herefor an interview with the astoundingly creative Nigerian physician Awojobi Oluyombo, whose work is sadly unrecognized and unreplicated, even in Nigeria.) “What Jose is doing is important because it’s a long-term, focused effort.”

As in “Apollo 13,” hacks need to use locally available materials. That often means toys. “Toys have a much better supply chain than other devices,” Gomez-Marquez said. Plastic toys are everywhere, even at open-air markets in remote towns. He encourages health care workers to take them apart and MacGyver the parts.

Lego pieces have been modified to create plug and play modules so that people can assemble their own diagnostic tests, in this case a pregnancy test.

Jose Gomez-Marquez

The blades of a toy helicopter, for example, can be used to kick up a dust cloud — delivering an inhaled asthma drug. The motors from remote-control cars can allow a patient to open or close a prosthetic hand by using his toes, or permit nurses to control machines inside a sterile room without entering. The proximity sensor that keep a toy car from running off the edge of a table can tell you when a pill bottle is opened or when a face is actually in the nebulizer mask.

“Cheap toys today are much nicer than cheap toys of yesterday,” Gomez-Marquez said. “A toy today is really an engineered device. You can harvest these parts.”

Hardware stores are also useful: “You can make a fully functioning asthma nebulizer with a bicycle pump, tubing, some adapters and filters,” he said. “That’s about $10.” And no electricity required.

One of Little Devices’ signature products is the Solarclave for sterilizing instruments. One version uses 140 pocket mirrors glued to an old satellite dish to concentrate the sun’s rays on a pressure cooker. (Another version uses Mylar tape instead of mirrors.) Anna Young, a researcher, is starting a pilot that will put about 50 Solarclave kits into health posts in the Matagalpa area of Nicaragua.

How safe is a medical device made of toy parts and duct tape? Clearly you wouldn’t want one if tested, approved alternatives existed. But hacking is necessary precisely because they don’t. Health care workers build their own because the alternative is no device at all. Patients, too: in China, some kidney patients who can’t afford dialysis construct their own machines — certainly a mark of desperation.

Not every needed part can be found in a toy store or hardware store. To provide stuff unavailable on the ground, the Little Devices lab built MEDIKits — boxes of parts collected for different projects. The MEDIKit for diagnostics, for example, contains components to build lateral flow assays (like pregnancy tests) for all sorts of different conditions, along with reagents and antibodies — health care workers can snap the parts together for the tests they need. There are MEDIKits for building drug delivery devices, prosthetics, microscopy, microfluidics and adherence tools.

MEDIKits are not like new Lego kits — the ones that can be used only to build Hogwarts. These are like the old boxes of Legos, that can construct anything you want. (Some actually contain Legos, which are good connectors.)

“How do they need to use these devices?” Gomez-Marquez asks. “I don’t know. But they know.”

The difference between sending a hospital medical devices and sending it a curated box of parts so it can make its own may seem like a small difference. But it’s part of a major idea shift, one that’s transforming the design of foreign aid.

Projects often fail because we can’t anticipate the issues and problems that play out on the ground. The traditional solution has been to try to make better-informed guesses: when we told you before we knew what you should do we were wrong. But now we really do know!

A new solution is to let people on the ground design the project.

This is changing the way big aid works. Cash on Delivery, pay-for-success, social impact bonds anddevelopment impact bonds are new ideas that set goals, but allow people on the ground to design ways to reach them. With these projects, people aren’t locked in to one strategy. If it doesn’t work — and chances are, it won’t work as conceived (see this blog post by a D-lab fellow about adapting to on-the-ground realities) — they can try something different.

Encouraging local people to innovate is important on a large scale — and it’s important when the idea is just to create an IV alarm. The first step is often just legitimizing hacking. In a hospital in Esteli, Nicaragua, Daniela Urbina, a nurse, fixed her broken stethoscope with a plastic overhead transparency slide. “The tragedy was she was embarrassed — embarrassed to show it to us,” said Gomez-Marquez. “While at M.I.T. we’d say ‘oh, this is such an awesome D.I.Y. hack.’”

How big a difference could this make? Large-scale still seems elusive. It’s not just that the project is new — Gomez-Marquez and his group have so far brought fewer than 50 MEDIKits to Nicaragua. It’s that many problems remain: the product will have to be sold to people who can pay nothing, there’s no distribution chain and, most important, convincing people to do things in a new way takes a lot of door-to-door time.

But if wide is not possible, long is. “Scale is not much without sustainable,” said Sandhu. “Scale can be getting useless crap out to a lot of places that’s not going to be used three months down the line. If it’s done in a way where it can actually be maintained and used effectively, that’s worth a lot. That’s what D.I.Y. has the potential to bring to the table.”

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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”

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