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I'm going to talk to you today

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about the design of medical technology
for low-resource settings.

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I study health systems in these countries.

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And one of the major gaps in care,

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almost across the board,

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is access to safe surgery.

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Now one of the major
bottlenecks that we've found

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that's sort of preventing
both the access in the first place,

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and the safety of those surgeries
that do happen, is anesthesia.

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And actually, it's the model
that we expect to work

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for delivering anesthesia
in these environments.

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Here, we have a scene that you would find
in any operating room across the US,

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or any other developed country.

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In the background there

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is a very sophisticated
anesthesia machine.

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And this machine is able
to enable surgery and save lives

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because it was designed
with this environment in mind.

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In order to operate,
this machine needs a number of things

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that this hospital has to offer.

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It needs an extremely
well-trained anesthesiologist

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with years of training
with complex machines

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to help her monitor the flows of the gas

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and keep her patients
safe and anesthetized

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throughout the surgery.

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It's a delicate machine
running on computer algorithms,

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and it needs special care, TLC,
to keep it up and running,

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and it's going to break pretty easily.

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And when it does, it needs
a team of biomedical engineers

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who understand its complexities,
can fix it, can source the parts

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and keep it saving lives.

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It's a pretty expensive machine.

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It needs a hospital
whose budget can allow it

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to support one machine
costing upwards of 50 or $100,000.

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And perhaps most obviously,

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but also most importantly --

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and the path to concepts
that we've heard about

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kind of illustrates this --

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it needs infrastructure that can supply
an uninterrupted source of electricity,

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of compressed oxygen,
and other medical supplies

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that are so critical
to the functioning of this machine.

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In other words, this machine
requires a lot of stuff

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that this hospital cannot offer.

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This is the electrical supply
for a hospital in rural Malawi.

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In this hospital,

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there is one person qualified
to deliver anesthesia,

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and she's qualified

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because she has 12, maybe 18 months
of training in anesthesia.

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In the hospital and in the entire region

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there's not a single biomedical engineer.

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So when this machine breaks,

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the machines that they have
to work with break,

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they've got to try and figure it out,

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but most of the time,
that's the end of the road.

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Those machines go the proverbial junkyard.

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And the price tag
of the machine that I mentioned

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could represent maybe a quarter or a third

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of the annual operating budget
for this hospital.

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And finally, I think you can see
that infrastructure is not very strong.

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This hospital is connected
to a very weak power grid,

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one that goes down frequently.

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So it runs frequently,
the entire hospital,

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just on a generator.

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And you can imagine,
the generator breaks down

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or runs out of fuel.

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And the World Bank sees this

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and estimates that a hospital
in this setting in a low-income country

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can expect up to
18 power outages per month.

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Similarly, compressed oxygen
and other medical supplies

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are really a luxury,

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and can often be out of stock
for months or even a year.

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So it seems crazy, but the model
that we have right now

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is taking those machines
that were designed

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for that first environment
that I showed you

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and donating or selling them
to hospitals in this environment.

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It's not just inappropriate,

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it becomes really unsafe.

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One of our partners at Johns Hopkins

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was observing surgeries in Sierra Leone
about a year ago.

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And the first surgery of the day
happened to be an obstetrical case.

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A woman came in,
she needed an emergency C-section

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to save her life and the life of her baby.

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And everything began pretty auspiciously.

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The surgeon was on call and scrubbed in.

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The nurse was there.

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She was able to anesthetize her quickly,
and it was important

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because of the emergency
nature of the situation.

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And everything began well

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until the power went out.

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And now in the middle of this surgery,

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the surgeon is racing
against the clock to finish his case,

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which he can do -- he's got a headlamp.

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But the nurse is literally running
around a darkened operating theater

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trying to find anything
she can use to anesthetize her patient,

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to keep her patient asleep.

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Because her machine doesn't work
when there's no power.

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This routine surgery that many of you
have probably experienced,

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and others are probably the product of,
has now become a tragedy.

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And what's so frustrating
is this is not a singular event;

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this happens across the developing world.

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35 million surgeries
are attempted every year

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without safe anesthesia.

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My colleague, Dr. Paul Fenton,
was living this reality.

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He was the chief of anesthesiology

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in a hospital in Malawi,
a teaching hospital.

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He went to work every day

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in an operating theater like this one,

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trying to deliver anesthesia
and teach others how to do so

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using that same equipment

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that became so unreliable,
and frankly unsafe, in his hospital.

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And after umpteen surgeries

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and, you can imagine,
really unspeakable tragedy,

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he just said, "That's it.
I'm done. That's enough.

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There has to be something better."

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He took a walk down the hall

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to where they threw all those machines
that had just crapped out on them,

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I think that's the scientific term,

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and he started tinkering.

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He took one part from here
and another from there,

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and he tried to come up
with a machine that would work

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in the reality that he was facing.

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And what he came up with:

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was this guy.

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The prototype for the Universal
Anesthesia Machine --

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a machine that would work
and anesthetize his patients

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no matter the circumstances
that his hospital had to offer.

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Here it is, back at home

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at that same hospital, developed
a little further, 12 years later,

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working on patients
from pediatrics to geriatrics.

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Let me show you a little bit
about how this machine works.

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Voila!

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Here she is.

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When you have electricity,

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everything in this machine
begins in the base.

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There's a built-in
oxygen concentrator down there.

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Now you've heard me mention
oxygen a few times at this point.

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Essentially, to deliver anesthesia,
you want as pure oxygen as possible,

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because eventually you're going
to dilute it, essentially, with the gas.

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And the mixture that the patient inhales

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needs to be at least
a certain percentage oxygen

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or else it can become dangerous.

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But so in here when there's electricity,

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the oxygen concentrator takes in room air.

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Now we know room air is gloriously free,

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it is abundant,

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and it's already 21 percent oxygen.

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So all this concentrator does
is take that room air in, filter it

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and send 95 percent pure oxygen
up and across here,

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where it mixes with the anesthetic agent.

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Now before that mixture
hits the patient's lungs,

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it's going to pass by here --
you can't see it,

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but there's an oxygen sensor here --

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that's going to read out on this screen
the percentage of oxygen being delivered.

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Now if you don't have power,

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or, God forbid, the power cuts out
in the middle of a surgery,

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this machine transitions automatically,

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without even having to touch it,

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to drawing in room air from this inlet.

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Everything else is the same.

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The only difference is that now

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you're only working
with 21 percent oxygen.

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Now that used to be
a dangerous guessing game,

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because you only knew
if you gave too little oxygen

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once something bad happened.

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But we've put a long-life
battery backup on here.

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This is the only part
that's battery backed up.

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But this gives control to the provider,
whether there's power or not,

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because they can adjust the flows

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based on the percentage of oxygen
they see that they're giving the patient.

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In both cases,
whether you have power or not,

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sometimes the patient
needs help breathing.

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It's just a reality of anesthesia,
the lungs can be paralyzed.

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And so we've just added
this manual bellows.

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We've seen surgeries
for three or four hours

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to ventilate the patient on this.

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So it's a straightforward machine.

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I shudder to say simple;
it's straightforward.

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And it's by design.

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You do not need to be a highly trained,
specialized anesthesiologist

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to use this machine,

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which is good because,
in these rural district hospitals,

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you're not going to get
that level of training.

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It's also designed for the environment
that it will be used in.

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This is an incredibly rugged machine.

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It has to stand up to the heat
and the wear and tear

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that happens in hospitals
in these rural districts.

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And so it's not going
to break very easily,

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but if it does, virtually
every piece in this machine

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can be swapped out and replaced

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with a hex wrench and a screwdriver.

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And finally, it's affordable.

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This machine comes in
at an eighth of the cost

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of the conventional machine
that I showed you earlier.

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So in other words, what we have here
is a machine that can enable surgery

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and save lives,

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because it was designed
for its environment,

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just like the first machine I showed you.

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But we're not content to stop there.

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Is it working?

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Is this the design
that's going to work in place?

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Well, we've seen good results so far.

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This is in 13 hospitals in four countries,

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and since 2010, we've done
well over 2,000 surgeries

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with no clinically adverse events.

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So we're thrilled.

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This really seems like
a cost-effective, scalable solution

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to a problem that's really pervasive.

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But we still want to be sure

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that this is the most effective
and safe device

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that we can be putting into hospitals.

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So to do that, we've launched
a number of partnerships

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with NGOs and universities,

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to gather data on the user interface,

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on the types of surgeries
it's appropriate for,

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and ways we can enhance the device itself.

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One of those partnerships
is with Johns Hopkins

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just here in Baltimore.

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They have a really cool anesthesia
simulation lab out in Baltimore.

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So we're taking this machine

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and recreating some
of the operating theater crises

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that this machine might face

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in one of the hospitals
that it's intended for,

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and in a contained, safe environment,

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evaluating its effectiveness.

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We're then able to compare
the results from that study

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with real-world experience,

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because we're putting
two of these in hospitals

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that Johns Hopkins
works with in Sierra Leone,

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including the hospital
where that emergency C-section happened.

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So I've talked a lot about anesthesia,
and I tend to do that.

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I think it is incredibly fascinating
and an important component of health.

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And it really seems peripheral,
we never think about it,

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until we don't have access to it,

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and then it becomes a gatekeeper.

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Who gets surgery and who doesn't?

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Who gets safe surgery and who doesn't?

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But you know,
it's just one of so many ways

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that design, appropriate design,

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can have an impact on health outcomes.

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If more people
in the health-delivery space

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really working on some of these
challenges in low-income countries

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could start their design process,
their solution search,

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from outside of that proverbial box

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and inside of the hospital --

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In other words, if we could design

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for the environment that exists
in so many parts of the world,

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rather than the one
that we wished existed --

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we might just save a lot of lives.

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Thank you very much.

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(Applause)