Erica Frenkel – TRANSCRIPT
I’m going to talk to that guy, I need one of those bottles for my apartment in Park Slope. Thanks for having me. I’m going to talk to you today about the design of medical technology for low-resource settings. Some of the countries that Arun just highlighted that were dark in that map. I study health systems in these countries. And one of the major gaps in care, almost across the board, is access to safe surgery.
Now one of the major bottlenecks that we’ve found that’s sort of preventing both the access in the first place, and the safety of those surgeries that do happen, is anesthesia. And actually, it’s the model that we expect to work for delivering anesthesia in these environments. Here, we have a scene that you would find in any operating room across the US, or any other developed country.
In the background there is a very sophisticated anesthesia machine. And this machine is able to enable surgery and save lives because it was designed with this environment in mind. In order to operate, this machine needs a number of things that this hospital has to offer. It needs an extremely well-trained anesthesiologist with years of training with complex machines to help her monitor the flows of the gas and keep her patients safe and anesthetized throughout the surgery. It’s a delicate machine running on computer algorithms, and it needs special care, TLC, to keep it up and running, and it’s going to break pretty easily.
And when it does, it needs a team of biomedical engineers who understand its complexities, can fix it, can source the parts and keep it saving lives. It’s a pretty expensive machine. It needs a hospital whose budget can allow it to support one machine costing upwards of 50 or $100,000. And perhaps most obviously, but also most importantly — and the path to concepts that we’ve heard about kind of illustrates this — it needs infrastructure that can supply an uninterrupted source of electricity, of compressed oxygen, and other medical supplies that are so critical to the functioning of this machine.
In other words, this machine requires a lot of stuff that this hospital cannot offer. This is the electrical supply for a hospital in rural Malawi. In this hospital, there is one person qualified to deliver anesthesia, and she’s qualified because she has 12, maybe 18 months of training in anesthesia. In the hospital and in the entire region there’s not a single biomedical engineer.
So when this machine breaks, the machines that they have to work with break, they’ve got to try and figure it out, but most of the time, that’s the end of the road. Those machines go the proverbial junkyard. And the price tag of the machine that I mentioned could represent maybe a quarter or a third of the annual operating budget for this hospital.
And finally, I think you can see that infrastructure is not very strong. This hospital is connected to a very weak power grid, one that goes down frequently. So it runs frequently, the entire hospital, just on a generator. And you can imagine, the generator breaks down or runs out of fuel. And the World Bank sees this and estimates that a hospital in this setting in a low-income country can expect up to 18 power outages per month.
Similarly, compressed oxygen and other medical supplies are really a luxury, and can often be out of stock for months or even a year. So it seems crazy, but the model that we have right now is taking those machines that were designed for that first environment that I showed you and donating or selling them to hospitals in this environment. It’s not just inappropriate, it becomes really unsafe. One of our partners at Johns Hopkins was observing surgeries in Sierra Leone about a year ago.
And the first surgery of the day happened to be an obstetrical case. A woman came in, she needed an emergency C-section to save her life and the life of her baby. And everything began pretty auspiciously. The surgeon was on call and scrubbed in. The nurse was there. She was able to anesthetize her quickly, and it was important because of the emergency nature of the situation. And everything began well until the power went out.
And now in the middle of this surgery, the surgeon is racing against the clock to finish his case, which he can do — he’s got a headlamp. But the nurse is literally running around a darkened operating theater trying to find anything she can use to anesthetize her patient, to keep her patient asleep. Because her machine doesn’t work when there’s no power. This routine surgery that many of you have probably experienced, and others are probably the product of, has now become a tragedy. And what’s so frustrating is this is not a singular event; this happens across the developing world. 35 million surgeries are attempted every year without safe anesthesia.
My colleague, Dr. Paul Fenton, was living this reality. He was the chief of anesthesiology in a hospital in Malawi, a teaching hospital. He went to work every day in an operating theater like this one, trying to deliver anesthesia and teach others how to do so using that same equipment that became so unreliable, and frankly unsafe, in his hospital. And after umpteen surgeries and, you can imagine, really unspeakable tragedy, he just said, “That’s it. I’m done. That’s enough. There has to be something better.” He took a walk down the hall to where they threw all those machines that had just crapped out on them, I think that’s the scientific term, and he started tinkering. He took one part from here and another from there, and he tried to come up with a machine that would work in the reality that he was facing.