Jose Gomez-Marquez, bringing maker culture to medicine
...My heart's in Accra 2013-03-05
Jose Gomez-Marquez teaches at MIT’s D-Lab, a remarkable lab focused on the problems of the developing world. He’s a recognized and awarded innovator in the field of health innovation and won Technology Review’s Humanitarian award. Gomez-Marquez’s talk focuses on democratizing innovation and lowering barrier to entry. Titled “Little Devices: Legos, Nebulizers, and Construction Sets for Heath”, Gomez-Marquez explains that we need innovation in health because we spend massively on health and see diminishing returns on much of this spending.
Diseases that used to be reserved for rich countries like diabetes and obesity are now spreading in developing countries. And diseases like dengue, chagas, leprosy and schistosomiasis are now appearing throughout the US, especially in US/Mexico border towns, but also in low-income urban areas.
90% of all developing world medical technologies are the result of donations, and many fail within 6 months. Gomez-Marquez wants to learn how we build better devices for these marketplaces and how we design and build new devices for these environments. We might learn from studying extreme health environments. One example is a Chinese man who needed dialysis and couldn’t afford to travel from a rural area to a hospital to received treatment. For $500, he scavenged parts that allowed him to put himself on dialysis, using a homemade kit.
We might respond to stories like this by saying “Don’t try this at home.” But perhaps we should try this at home. Cook Medical, one of the largest medical device companies in the world, began through experimenting with venous catheters built from guitar strings. Medical innovators solve hard problems through innovating with everyday objects, and these experiments sometimes lead to dramatically positive developments.
We need innovation in health that includes both rigorous research and DIY. Participatory technologists are blessed with creativity and a practical approach to solving problems. There are few case studies of these technologists working within the larger system of healthcare, but when they work together, the stories include an element of magic, of unexpected success. We need to get beyond occasional success stories that feature on CNN and make this a widespread path towards innovation.
He offers three examples of how innovation in extreme health environments can lead to medical successes.
One story starts with a broken stethoscope. Danielle Ordeña, a medical profesional in rural Nicaragua, had to fix her own stethoscope. A stethoscope is a plastic membrane connected to tubes and earpieces. When Ordeña’s stethoscope broke, she searched her hospital for pieces of plastic that might work, and settled on overhead transparency slides. Her stethoscope isn’t pretty, but it works, and it’s a great example of problem-solving. But Ordeña was ashamed of her device and there was no way to share or refine her invention.
Inspired by her example, Gomez-Marquez began building MEDIKit, a construction kit for medical devices. He shows us a $70 electric-powered nebulizer, a tool for aerosolizing medication. It’s pretty simple: a compressor, a set of tubes and some filters. And it’s good that it’s cheap, as it means asthmatics in the developed world can own one and use it in the case of severe attacks. But in the developing world, they’re too expensive and tend to be used mostly in hospitals, in emergency situations. Using the MEDIKit, it’s possible to build a $7 foot-powered nebulizer based on a bicycle pump. The performance is in line with the electric model, but it’s more hackable: versions have been modified to serve two patients at the same time, or to be more comfortable for pediatric patients.
Gomez-Marquez thinks of this work in terms of bringing together core blocks (a compressor or a pump, filters, tubing), modifiers (t-joints to serve multiple people, pediatric adaptations) and local materials to make local innovation possible. That local innovation is particularly important, because people won’t hack devices they’re not comfortable with – when they’ve built the devices themselves, they are comfortable hacking them.
A similar philosophy informs some work he’s done on diagnostic technology using lateral flow systems. If you’ve seen a pregnancy test, you’ve seen lateral flow in action. A bodily fluid sample is put onto a piece of paper and wicks through different compounds to produce a test result as well as a “control line” that shows the tests are working. Gomez-Marquez began designing testing systems as if they were lego pieces, attaching compatible tests together. He describes a “Romanian Flag” test, uniting the red, blue and yellow tests for syphilis, HIV and pregnancy. Doctors can put together sets of tests that are appropriate for a specific market, and that design process suggests what local needs would be for a commercial technology.
In designing microfluidics systems, Gomez-Marquez has literally turned to lego blocks. Manufacturing microfluidics devices is expensive and time consuming, so he began designing a system of color-coded, carefully designed blocks that fit together in other patterns. Soon, he turned to lego blocks, and now can design new microfluidics systems by reassembling blocks and tubes on a lego plate. This beats the crap out of fixing a design in a CAD program, printing it out in Stanford and shipping it back to Central America.
Using toys isn’t just a peculiarity of Gomez-Marquez’s approach: it’s a design strategy. He thinks of it as a form of supply chain arbitrage. It’s hard to get medical devices into many nations, but toys are easy to bring in. If we can find ways to use what’s widely available on the ground, we can build attractive toolkits that build on local availability and capabilities.
He outlines two other projects more briefly.
Adherio is a diagnostic test in which the output was a more complex display than “yes/no”. It was designed as a response to tuberculosis, a disease that affects 9.8 million people a year. It’s highly treatable over 8 months, with $150 of antibiotics. The problem is adherence – people take the medicine while they feel sick, but then stop. That makes TB antibiotic resistant, and suddenly it costs thousands of dollars to fight the disease, and for some people in the developing world, it becomes a death sentence. In wealthy countries, people work for TB adherence by sending health professionals to administer medication. Instead, adhere.io tries to monitor and incentivize positive behavior, rewarding people who stay with the program. Using paper fluidics and lateral flow, adhere.io offers a test strip that detects a metabolite in urine that is a byproduct of taking the TB drugs. When the test trip detects adherence, it uncovers a code that the patient can enter into a mobile phone and report compliance to her doctor. While this system leverages the growing mobile phone network in the developing world, Gomez-Marquez noted that the UN organizations he pitched it to noted it was “creative”, but didn’t actually embrace it.
Gomez-Marquez notes that there are many systems that use distributed sensing to understand weather or traffic. We’re starting to see the beginnings of crowd health monitoring with systems like Google Flu trends, but these systems are in their infancy. Often we only understand epidemics in retrospect: a cholera epidemic in Haiti was traced to Nepali soliders working on relief missions who brought the disease to the country and ended up killing 500 people and infecting more than 7000. We understand epidemics like this well in retrospect, but would be much better off if we could monitor in real-time and intervene earlier.
With a project called Crowdio, Gomez-Marquez is trying to monitor dengue fever in realtime. It’s mosquito-borne and is on the rise now that we’ve stopped using DDT for mosquito control. It’s largely a disease of urbanization, affecting cities with lots of standing water, and it can be very deadly, with the hemorrhagic version killing one in four of those it infects. Testing for Dengue requires very expensive tools, like real-time PCR, and there’s a very small window to diagnose before the disease is dangerous. Crowdio is working to use paper sensors and to collect data from testers so that public health officials can monitor the disease’s spread closer to real time, turning patients into “citizen sensors”.
The goal of all his work, Gomez-Marquez explains, is to move health systems beyond black boxes of engineering to transparent systems people can use to create and innovate. This might include more experiments with construction set science, radically distributed medicine production, interactive diagnostic systems, better systems to monitor and enhance healthy behaviors and techniques to build inventive medical environments.