The following is a conversation between Dr. Rebecca Richards-Kortum, Founder and Co-director of Rice 360°: Institute for Global Health, and Denver Frederick, Host of The Business of Giving on AM 970 The Answer.
Dr. Rebecca Richards-Kortum
Denver: And we have reached the midpoint of featuring the eight semi-finalists of the MacArthur Foundation’s 100&Change competition. And tonight, it is a great pleasure to have with us Dr. Rebecca Richards-Kortum, the Founder and Co-director of Rice University’s 360°: Institute for Global Health. Good evening, Rebecca, and welcome to The Business of Giving!
Rebecca: Thank you so much.
Denver: Your life was changed forever back in 2006 when you walked into a two-room ward at Queen Elizabeth Central Hospital in Malawi. What did you see there, Rebecca?
Rebecca: You know, it was such a life-changing moment for me to walk into that neonatal unit, and I was struck by, first, just the number of babies that were in a very tiny space. There were probably 50 babies, many of them sharing beds because they didn’t have enough bed space for each baby to have its own bed. And there were just a few nurses, all of whom were really busy trying to take care of babies that were quite ill.
But as an engineer, the other thing that really struck me was the lack of technology. When you walk into a neonatal intensive care unit in the United States, it is just full of big pieces of equipment, and that equipment has made a huge improvement in rates of survival, especially for babies who are born too soon or who born small. In this neonatal unit in Malawi, there was none of that equipment there. And just the contrast of all that made such an impression, and it made an impression both for me as a mom and for me as an engineer.
Denver: And I think what was even more distressing is that when you walked down the hall of that very same facility, you came across the room commonly known as the “equipment graveyard.” What was that?
Rebecca: So, we walked just down the hall and into a room that was full of equipment that had been donated by people like me in places like Houston, hoping to improve care in the newborn ward there. Unfortunately, what happened when that equipment met the harsh environmental conditions at Queen Elizabeth Central Hospital, it didn’t last very long. So a line voltage spike would fry one of the circuit cards, or the dust in the environment would clog a filter in the machine.
And so what you find is that things that are designed to work in high-resource settings often fail very quickly when they get to low-resource settings. In fact, in that room, I remember we counted there were 82 broken oxygen concentrators. And if any one of those oxygen concentrators had been working, it could’ve been saving the lives of babies in that neonatal unit.
Denver: Are a lot of these babies born prematurely in Malawi?
Rebecca: Malawi actually has the highest rate of preterm births in the world. Eighteen percent of babies are born prematurely there. And in some ways, it’s really ironic that a place that has the least ability to deal with the challenges of prematurity suffers one of the highest prematurity rates in the world.
…it is just heartbreaking to watch one of these babies struggle to breathe. You can see their chest; it moves in and it moves out – they call it “indrawing” – and you can just see the effort to breathe.
Denver: Yes. That’s pretty striking. Well, when a baby is born prematurely, their lungs are not fully developed; so they have trouble breathing. What device do we use here in the United States to address that? What did you and your team of students at Rice 360° set out to create?
Rebecca: One of our team members is a wonderful pediatrician named Liz Molyneux who has worked in Malawi at Queen Elizabeth Central Hospital since the early 1970s. She explained to us that about half of babies that are born prematurely have trouble to breathe because their lungs are immature. I have to tell you that it is just heartbreaking to watch one of these babies struggle to breathe. You can see their chest; it moves in and it moves out – they call it “indrawing” – and you can just see the effort to breathe.
Here in the United States, in the early 1970s, there was a technology developed called CPAP. It stands for continuous positive airway pressure. It’s a really simple idea. So the reason that these babies struggle to breathe is that their lungs lack a protein called “surfactant” that reduces surface tension. The analogy that I like to use is: Think about blowing up a balloon. You know how when you blow up a balloon, you put those first few pop of air in… it’s really hard to get it open?
Denver: It sure is.
Rebecca: That’s what every breath is like for those little babies because they don’t have this protein that reduces the surface tension. And so what CPAP does is: you just take a soft set of rubber prongs, and you put it in the baby’s nose, and then you blow in a mix of air and oxygen at constant pressure. What that does is it keeps their lungs inflated…like it keeps the balloon inflated. And so the subsequent pops of air, it’s much easier to get them in the balloon. That’s what CPAP does for babies; it just reduces that work of breathing. Typically, it just takes them about a week, or maybe 10 days, until their bodies start to make enough surfactant and they don’t need treatment with CPAP anymore. And literally, it can be the difference between life and death.
When CPAP was introduced in the United States back in the early ‘70s, what we saw was that rates of survival went from 25% to 70%.
Denver: Wow! That’s dramatic.
Rebecca: Yes. And in fact, President Kennedy and his wife had a baby who was born prematurely right about at that time, and that baby was not treated with CPAP, and the baby did not survive. We were at a time when we were making a huge investment in strengthening newborn care and neonatal intensive care in our country, and it really turned the tide on improving newborn survival here. Malawi has been left out of that.
Denver: So the challenge that you faced is to create a CPAP device that would be rugged and robust enough to survive in Malawi, and also be affordable. How did you go about doing that?
Rebecca: So we talked to Liz Molyneux about what she thought was needed, and she showed us actually a CPAP machine that she had invented herself. Even though she’s a pediatrician, she’s secretly an engineer at heart, we think.
She took a vacuum pump that she found, and she reverse-engineered it so that instead of creating a vacuum, it served as a flow driver. But that actually caused the pump to overheat. And so she set up a kitchen fan to blow on the pump so that it wouldn’t overheat, and she made her own CPAP machine. She said, “The nurses are a little afraid of it.” When I saw it, I could see why. It was kind of a scary-looking machine. But it really showed us how necessary that technology was.
So, my colleague, Maria Oden, and I came back, and at that time, Maria was teaching our Capstone Senior Design course. And she assigned in the fall of 2009, a team of senior bioengineering students to come up with a CPAP machine that could be used in Malawi. And that team, they worked over the course of a whole year, and they had a brilliant idea. They thought to themselves: what can we use to deliver flow that’s cheap and that will never break? And their “Aha!” moment was at Petco – an aquarium pump.
Denver: Oh, wow!
Rebecca: Yes. They took two $25 aquarium pumps, and they put it in a little plastic shoebox that they bought at Target, and they made a CPAP device. They were able to take it over to Texas Children’s Hospital right across the street from us here in Houston, and they compared the flow and the pressure that their system delivered to the $8,000 CPAP machines that are used to treat babies here. And they showed that their device delivered an equivalent flow in pressure, and it only costs $160 to make.
Denver: Mighty impressive.
Rebecca: Yes. So they took it to Malawi. One of the student inventors traveled to Malawi the summer after she graduated. I got to see her there when she was demonstrating it to all of the nurses that worked in that very same neonatal unit that I first went to in 2006. And these nurses, they told her everything that was wrong with our device. They said, “Some of the tubes go in the front side; some of the tubes go out the back side; it’s too confusing.” They said, “We want a light so that we know that it’s plugged into an outlet, that the power is actually getting delivered.” They said, “You have made a device that works on 110-volt outlet; that’s not what we have here. And that little step-down transformer that you put on, it’s going to walk away, and then we’re going to fry the pumps. But,” they said, “We’d really like to keep it and try using it.”
So what we did– the student, Jocelyn Brown– she came back to Rice, and she worked over the course of a year to make all the changes that the nurses told her were necessary. And with that, we were able to get a grant from USAID to actually do a clinical evaluation of the CPAP technology. And so we compared it to the use of just low-pressure oxygen, which at the time was all that was available in Malawi to treat preterm babies that had respiratory distress. Jocelyn was able to show that survival went from 25% to 65% for those preterm babies that were treated with her invention.
Denver: Now, as the students like Jocelyn and her fellow students churn out these remarkable innovations, they still have a ways to go, Rebecca, before they can reach the commercial marketplace. You have found an indispensable partner in that effort. Who are they? And what role are they playing?
Rebecca: So, we have been working with a commercial partner called 3rd Stone Design. They are absolutely an essential part of our team in helping us go from what is a student prototype to what we call a clinic-ready evaluation unit that we can actually safely introduce in the clinic to evaluate its performance and understand what improvements are needed… and then actually turn it into a medical product which has gone through international regulatory approval, and can actually be sold to begin improving care on a much wider scale.
Denver: How many babies have received treatment from this CPAP device that you all created?
Rebecca: CPAP has been implemented by our program country-wide, all across Malawi. That was done with grant funding from USAID. And so, when you go into any government district or central hospital all across the country, you will find preterm babies are able, if they need it, to receive treatment with CPAP. We’ve treated over 2,200 babies in Malawi with this technology.
But 3rd Stone has been now selling the device throughout low-resource settings. And without any grant support, this device is now being used to save newborn lives in 26 countries. They have over 500 CPAP devices that have been delivered and are being used throughout the world.
Denver: What an uplifting story! Now, how do we know, Rebecca, that this device is not going to end up in the equipment graveyard with so many others?
Rebecca: We have been tracking the performance of this CPAP technology as we’ve rolled this out across Malawi. When we deliver the CPAP machines, we also deliver oxygen concentrators at the same time. We have been supplying the model of oxygen concentrator which is recommended by the WHO. This is supposed to be the best model for a low-resource setting. What we found as we’ve rolled these out, is that we have not seen any failures of the Pumani CPAP devices that couldn’t be repaired locally. In contrast, what we found with those oxygen concentrators is that 63% of them have failed, and the mean time to failure is 413 days.
Denver: Oh my…
Rebecca: So this very expensive piece of equipment just isn’t lasting.
Denver: Well, with CPAP, in a sense as your proof of concept, you begin looking at other things that babies are dying from in Africa. So, in addition to respiratory distress, what are some of those things, Rebecca?
Rebecca: It’s really interesting. What we found as we began rolling CPAP out across Malawi, is we found that the newborn units were missing many technologies, not just technologies to help babies breathe. One of the most important things they were missing is tools to help keep babies warm. We found that if babies were being treated for their respiratory difficulties, if they weren’t warm, the outcomes weren’t as good. So it makes a lot of sense. If you don’t treat all of the needs of these babies, then they aren’t going to do as well as they could. And when we look around the world, what we find is that the leading cause of death for children globally is preterm birth. If we look at the leading killers of newborn babies, there are three leading killers: preterm birth, injury during labor and delivery, and infection.
When we began to look at: what does it take to either treat or prevent those three causes of death– which together account for 85% of newborn deaths, it’s actually not a very long list of technologies. I was kind of surprised. I thought maybe it’s going to be 200 or something, but it turned out to only be 17. And what you need is: you need to be able to keep babies warm. You need to help them breathe if they are struggling to breathe. If they have jaundice, you need to be able to diagnose that and treat it with phototherapy. You need to be able to monitor their vital signs, and you need to do some basic laboratory tests to know if they have infection, if they’re hypoglycemic… and be able to deliver fluids and medications. It’s not a very long list of tools.
Denver: No, it’s not. And that takes us to the proposal that you have made to the MacArthur Foundation 100&Change competition, and you call it NEST. What does that stand for?
Rebecca: NEST stands for Newborn Essential Solutions and Technologies. What it means really is that package of care that we know is necessary for good outcomes for newborn babies, and there’s nothing new or particularly innovative about it. We’ve known how to identify, treat, and prevent these conditions for decades really. We haven’t had the technologies that can withstand these environments, or a really a comprehensive approach to demonstrate what can happen when you put all that together in terms of improving outcomes.
Denver: Are there advantages from, let’s say, a development in commercial perspective of bundling all these technologies together?
Rebecca: Absolutely, there are advantages. And one of the things that we’ve learned as we began to commercialize the CPAP device is what’s possible when you make it available on the commercial market. But also: what are the challenges of trying to introduce a commercially available technology and distribute that in a setting where you just don’t have the ready distribution networks that you would in a place like the United States?
We think that a package of NEST technology to fully equip the district hospital that serves the community of about 250,000 people, we think ballpark, that cost is on the order of $20,000. And if you multiply: what the market size is all across sub-Saharan Africa for that, you’re looking at roughly a $35 million market. That isn’t the kind of market that is going to bring venture capital out. It’s not the size of market that’s going to get multinational medtech saying “Wow. We really need to go after that.”
So, if you’re trying to subsidize essentially the cost of distribution across only one technology, quickly you take what could’ve been an affordable technology, and you turn it into what’s actually not an affordable technology. And so in having this bundle of technology, that allows spreading that cost of distribution across the whole package– to really make it possible to go in and meet these needs, and do it in a way that is both scalable and sustainable.
Denver: Yes. Real economies and scale there. And as part of this proposal, Rebecca, you’re also looking to create an in-country education program. Share with us your thinking around that.
Rebecca: That’s probably my favorite part of the whole effort. One of the things that has really, I would say, transformed engineering education at Rice is we built a facility here called the Engineering Design Kitchen. It used to be an old kitchen, and it got converted into an engineering design studio that is full of all sorts of rapid prototyping tools. So… laser cutters and 3D printers and hand tools and the PCB mill and all sorts of spare parts– resistors, motors, fasteners. It’s really designed to reduce that activation energy barrier for students who are trying to make a prototype, and quickly do that and put their ideas into practice. We have used that so extensively in helping our students design new technologies to meet needs in nurseries in places like Malawi.
Well, in Malawi, right across the street from Queen Elizabeth Central Hospital, there’s an engineering school called Malawi Polytechnic. The Dean of Engineering is one of our collaborators, a really wonderful woman named Theresa Mkandawire. She came to Rice and she saw our engineering design studio. Together, we decided that we wanted to build exactly the same kind of engineering design studio at Malawi Polytechnic. And we’ve just done that. We did it with support from the Lemelson Foundation.
And in the same way that it transformed engineering education here, it has completely transformed engineering education at Malawi Polytechnic. Students now have access to hands-on tools, and they are working to solve problems that come right across the street from them at Queen Elizabeth Central Hospital. Every time I go to Malawi, my favorite thing to do is go visit that engineering design studio because it is just hopping with energy. It’s amazing!
Denver: Well, one of the things that you’ve done that so many innovators in the West often fail to do is that you really have embedded yourself into the community of Malawi. You have a true spirit of co-creation; and boy, this has really helped inform your work, I bet.
Rebecca: One of the things that we learn the most from is building student teams that are multi-institutional. So every summer, we have students who come from Malawi Tech to Houston, and they work together with Rice students here over the summer. And we do exactly the same in Malawi. It’s been really interesting to see how much they have to teach each other.
I’ll give you an example. The Rice students… they’ve grown up with high-speed internet and unlimited access to information. That’s not true for the students in Malawi. And so, often one of the first things the Rice students will do when they’re given a problem is go to Dr. Google and try and find information that will be helpful. And the Malawian students really needed help to learn how to make use of that kind of information in a setting where information was so widely and freely accessible.
In contrast, when our students go to Malawi, they just can’t get online and order whatever they want from Amazon, and it’s here the next day… or go to Digikey and order what they want. And so they were working with the Malawian students to come up with a way to improve a suction machine, and they wanted an IR light and an IR sensor to incorporate in their design. The Rice students were like, “Oh, we can’t get it on Amazon. We’re stuck. We don’t know what to do.” And the Malawian students said, “Hey, we’re just going to go down to Game, we’re going to buy a TV remote control, and we’re going to have both of those things.” So they’re much better at figuring out: how do you take what you have in your environment and turn it into a solution. And when you get that kind of thinking together, it’s so powerful for the team, and it’s just awesome to watch.
Denver: What have been some of the keys that have made you able to do this? You have created a work environment and corporate culture that really leads this kind of collaboration and innovative thinking. What is the secret sauce in having done that?
Rebecca: I tell my students all the time that innovation begins with listening because I think if you don’t listen, you don’t really understand what are the challenges that users – nurses, physicians – what are the challenges that they face when they’re trying to provide the best possible care for their patients. You need to start with listening and keep listening all the way through because it’s easy to fall in love with your solution and think it’s wonderful when maybe it doesn’t really meet a need… Users don’t think it’s going to help them solve their problem. And you can be depressed by that, or you can just confront that reality and keep going and try and make it better.
I think that building teams and building physical spaces that are permeated with that idea has really helped us be able to bring people together and to move quickly… and hopefully, make a difference at the end of the day.
Every year in Africa, more than a million newborns die, and these deaths can be prevented. And it’s really time to do something about it…
But I think most importantly, what we would do is: we would expand this vision of engineering education from Malawi to Tanzania and to Nigeria, because I think the most important legacy of this will be that next generation of innovators that will take on the challenges of maternal care, the challenges of surgery, the challenges of care for chronic diseases, and really be that engine of innovation to keep this process going.
Denver: That’s a great point you make, and it’s so true – we’re never finished listening. I think a lot of us do it upfront and think we’ve listened, but it never ends, and it never stops. Well, if you should be so fortunate to be declared the winner of 100&Change competition later this year, Rebecca, what would $100 million mean to this initiative? And how would you use it?
Rebecca: It would mean so much to really being able to address the challenge of preventable newborn death. Every year in Africa, more than a million newborns die, and these deaths can be prevented. And it’s really time to do something about it. And I think this $100 million would mean a giant step toward solving that problem in a way that can be sustained.
What we would do with the resources would be to scale up NEST all across Malawi. We would do the same in Southern Tanzania. There we would rigorously evaluate: What is the impact? What is the cost? And what is the cost-effectiveness? That data will be absolutely essential to drive uptake for this concept by WHO, by UNICEF, by other large NGOs that are engaged deeply in newborn care in Africa. We would go to Nigeria to test the business models for being able to deliver and distribute these technologies, to identify and optimize novel ways of financing them.
But I think most importantly, what we would do is: we would expand this vision of engineering education from Malawi to Tanzania and to Nigeria, because I think the most important legacy of this will be that next generation of innovators that will take on the challenges of maternal care, the challenges of surgery, the challenges of care for chronic diseases, and really be that engine of innovation to keep this process going.
I think in many ways for me, the challenge that our team is taking on really is the most important challenge facing the African continent. The reason I believe that is: if we look at history, history shows us that saving newborns is the most powerful key to initiating economic development in poor countries… And so I think that accelerating the progress to improve newborn survival is at the heart of how do we jump-start economic progress there.
Denver: Let me close with this, Rebecca. Each of the 100&Change semi-finalists have so much respect for one another. All of these are truly worthy and extraordinary proposals. But if I were to ask you, and I am, to make the case as to why NEST, the Newborn Essential Solutions and Technologies, will have the greatest impact to address one of the world’s most urgent problems, what would that case be?
Rebecca: I have to say we are just so honored and humbled to be part of an amazing group of eight teams, all of whom are taking on really significant challenges. I think in many ways for me, the challenge that our team is taking on really is the most important challenge facing the African continent. The reason I believe that is if we look at history, history shows us that saving newborns is the most powerful key to initiating economic development in poor countries.
If we look at data from countries across the world, what we see is that when families have more confidence that their babies will live, that’s when they choose to have fewer children. And families who have fewer children, they have more resources to invest in each of their kids; they’re more likely to keep their kids in school, especially their daughters. And as fertility rates fall, then each working adult has fewer dependents to support, and you get economic expansion. And so I think that accelerating the progress to improve newborn survival is at the heart of how do we jump-start economic progress there.
Denver: Well, Dr. Rebecca Richards-Kortum, Founder and Co-director of Rice University’s 360°: Institute for Global Health, I want to thank you so much for sharing this exceptional undertaking with us this evening. Now, for those listening who are interested in learning more about this work, where can they go to find that information?
Rebecca: You can go to rice360.rice.edu.
Denver: Well, great! Thanks, Rebecca, and my very best to you and your colleagues in the MacArthur Foundation’s 100&Change competition.
Rebecca: Thank you so much!
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