(Intro)

Before we jump into the SciShow Talk Show with Dr. Rebecca Richards-Kortum, one of this year's MacArthur Genius fellows, we wanted to thank the MacArthur Foundation for helping set up this interview with us.  We also wanna thank Bill and Melinda Gates.  Every year, they put out an annual letter focusing on ways to fight extreme poverty and poor health around the world.  This year's letter comes out this week and focuses on investing in technology that can save children under five who are dying of curable illnesses.  In talking to Rebecca Richards-Kortum, we realized that her work embodies this mission and wanted to share this video the same week that that letter comes out.  You can learn more about Bill and Melinda Gates' annual letter and the MacArthur Foundation in the description below.  Please check 'em out.

H: Hello there, welcome to the SciShow Talk Show times, where I, Hank Green, talk to some interesting person in the world about something interesting.  This is Rebecca Richards-Kortum, a professor at Rice University.  The reason we're talking to you is that you just got the MacArthur Genius grant, so you have officially been bestowed a Genius.  This is, as far as I can tell, the only way that you get to decide that you are objectively a genius, so congratulations and thank you for joining us and how does it feel to be an official genius?

R: Oh, it's obviously, it's a huge honor to get recognized by the MacArthur Foundation.  I don't know that I love the Genius title.  It's really is so wonderful to have the recognition and the platform that comes with that fellowship, but most especially to have access to unrestricted resources that we can use to try and continue our work improving health for women and children in sub-Saharan Africa.  

H: So when you say unrestricted resources, you mean it's just an unlimited amount of money?

R: I wish it was an unlimited amount of money, so the fellowship comes with $625,000 over five years, but there's absolutely no strings on how you use it and so we can do whatever we think will be most helpful.

H: And in research, there often is string that comes along with grant money.

R: Absolutely.  So normally, when we get grant money, we write a proposal that specifies how we'll use those dollars and you know, you just, you have less opportunity to be creative and inventive and try things that you're not sure will work, and if they did work, it could be really exciting.

H: Yeah, and just more opportunity for innovation, changing your path halfway through, so what was the work that you think led to you getting this grant?

R: You know, we've been working over the last ten years to really try and improve health for babies in places like Malawi, which is a small country in sub-Saharan Africa and you know, to sort of put it in perspective, if you look at the rates of newborn death in Malawi, it's really similar to what existed here in Texas more than 100 years ago, so you know, babies are dying of conditions that we absolutely know how to prevent in places like Houston and all over high income countries and so we have been working to try and build technologies that are affordable and that are rugged and robust to work in those environments and we've had some success.  It's been really exciting to see over the last couple of years some of these coming to scale, so you know, I think in part it was a recognition that this approach can work and a belief that it should be expanded.

H: So I'm very interested in medicine and the cost of medicine and obviously we have a good healthcare system here in the US, there's things to complain about but let's be honest, but like, if you look at, you know, if there's a premature baby and you look at the amount of money that goes into the equipment that is going to help keep that baby alive, is gonna help keep that baby healthy, you're looking at a big price tag.  What do you think is the difference between you know, like, a CPAP machine that we create for a baby here in the US that might cost, I don't know--I have no idea, but I'm guessing in the tens of thousands of dollars at least, and like, how do--like, figuring out how to make that accessible, make it, like, usable, make it inexpensive, it isn't necessarily a priority here and that can make it so that it becomes like, a technology that is not available to people who need it.  

How do you think about like, making that technology for a different market?

R: So I would say for me, really, the aha moment was when I went to Malawi and I visited first the newborn intensive care unit and what I saw was, you know, somewhere on the order of 60 babies and just two or three nurses, who were doing everything they could to take care of them, but very little equipment, and then on that same tour, just literally down the hall from that intensive care ward that had no functional equipment, there was this entire room that was full of equipment that people from places like Houston had donated, intending to try and help improve care there, but when that equipment got there, it broke very quickly because we need the line voltage spiked or the air was dusty and so the air filter got clogged or they couldn't get the consumables that they needed and so for me, that was when I realized that it's not just that we need--that places like Malawi need more of what we have, they really need a different kind of technology.  You have to put the focus on making it affordable and making it rugged or it's not going to last.  

H: Interesting.

R: Yeah, so we've really tried to take that, we call it frugal innovation, take that frugal innovation approach and apply it broadly across healthcare units.  

H: So you're looking at creating all sorts of equipment with that focus in mind.  

Like, can you walk me through a little bit of the, like, you know, testing phase, innovation phase, engineering phase, and then also, I'm very interested in like, actually scaling it up and producing these products?

R: Yeah, so, you know, I tell my students all the time that I think the process starts with listening and I think you need to listen to the people who are in the setting where the technology is going to be used and listen to what is it that they say they need to be able to do their job more effectively.  If you don't do that, I think you're not gonna design the right thing, and the process ends with scaling and again, I tell my students, if it doesn't leave your lab, there isn't really innovation.  So what happens in between is, how do we go through the brainstorming process of coming up with concepts that could work there?  We test them first in the laboratory, then we test them usually at healthcare settings in a high income country, so we'll often test them here in Houston in the Texas Medical Center to be sure that they deliver the right kind of therapeutic effect.  Then we'll go to a place like Malawi and do an actual clinical evaluation with the appropriate ethical approvals, and then you turn that prototype, you're gonna turn it into a product working with the private sector.

H: Okay, so that's a multi-year process, I would imagine?  Like, there's a lot from design and then you have to take it into the field and see how it's going to function?

R: Yeah, so I can give you an example.  So our CPAP device for example, which is designed to help premature babies breathe, that was a need that came to us in the summer of 2009.  We had a prototype by the spring of 2010, got a lot of feedback and improved it and then we took it into clinical evaluation in early 2012. 

It just became a product with international regulatory approval, now it's being used in 23 countries, so from 2009 to now, almost 2017, that's how long it took to go to somebody said that this is what we really need to now you can actually buy it.

H: And that's not a terrible--considering that you're dealing with government regulations, international regulations, you're dealing with you know, testing a pro--like, building a product in one place and testing it across the world.

R: Yeah, I guess I would say it's not a terribly long time on the one hand, on the other hand--

H: Is there a way to speed it up?  Yeah, that's, like, yeah.

R: When you go to Malawi, you know, I go normally four times a year and you go into the newborn unit and you see every single trip babies that need this, it feels like a long time.

H: It feels like a long time, and we are, as a--you know, we are getting much better at innovating and rapidly prototyping and developing technology.  You know, like, it's kind of remarkable that it would take, you know, how long does it take to develop a new mobile phone in China, like, on the order of months these days, and a mobile phone is just a tremendously complicated, much more complicated than a CPAP machine, and of course, like, there's a lot of mobile phone development infrastructure in the world and not a lot of like, rugged, inexpensive CPAP infrastructure, but how can we speed that up?  Is it the regulations that are slowing you down, is it the manufacturing process, is it the testing process?

R: So, you know, I think that this is an area where there's an important need for funding for the development of these technologies, but then, I think even a more important need to think about, how do we guarantee that there's an actual market to purchase them, and you know, there's no question that there's a huge amount of need for these devices.  I can go to any hospital in the developing world, almost any hospital in the developing world, and there's a need for many, many technologies.

That doesn't necessarily mean there's somebody to write a check to purchase those technologies if they're available on the market, and so you know, I think one of the things that's really interesting for medical devices is to look at what the international community did for vaccines.   For vaccines, we have the global alliance for vaccines and immunizations, GAVI, and it basically guaranteed financing so that manufacturers knew that if they made these vaccines, and it helped forecast demand, and it helps countries make a plan for getting access and then ultimately transitioning to paying for it on their own.  We don't really have that in the the medical device area.  I think it's a really important gap.

H: Yeah, that's a fascinating point that, you know, you talked about like, this room full of machines and like, who knows how many of your CPAPs could be bought with one of the ones that was donated, but donations are often machines that have, you know, have been used previously and then you're donating, you're getting a tax write-off, like, there's all kinds of reasons to donate an expensive piece of medical machinery and sort of less reason to just develop a market, which is the thing that is actually needed.  Like, we need people--in like an ideal world, you need that hospital to be able to fund itself and to buy its own rugged inexpensive medical devices, but it's nice that we have the model of the vaccine success to maybe go after that with medical devices.

R: Yeah, and I think there's some other interesting opportunities where a technology can be used both in place like Malawi and in a place like the US, so you have a dual market use, then I think you have some really interesting opportunities, so for example, we're working on a really simple way to measure biliruben in the blood to know if babies suffer from newborn jaundice and we've been developing that in partnership with pediatricians in Malawi and pediatricians in Houston and they actually both want the test when it's finally available, so I think that's a really interesting opportunity, because there's the potential to use the market in a high resource setting to support, in some ways, the markets in low resource settings, but not everything fits that model.

H: Right.  Right, right.  I mean, and my non-science, just frustrated with American healthcare models is aware that there is not a lot of market pressure to make things cheaper in the US.  You know, we have a weird system that just sort of is like, well, you know, let's just have the best possible care regardless of cost and then after the care happens, then we'll talk about how much it costs, but if there is a market pressure for costs somewhere else, maybe that inspires us and activates us to innovate for a lower cost product that we could then turn around and use to disrupt some of the existing, more expensive technologies here in the US.

R: It's a really interesting way to think about reverse innovation.

H: Yeah, mhmm.

R: You know, if you can show that something works as effectively as more expensive things, then why not bring it back?

H: So you say that you take the product to the private sector to get it manufactured and developed.  Like, what's the process of being like, we have this design, we think that there's a market for it, who do you find to do that?  Do you create your own company, do you--and who do you work with who, like, has the expertise in actually building products?

R: So what we have done is to partner with two different kinds of organizations.  We partnered with industrial design firms, so sometimes we say in our program, we make ugly stuff but it works, and so, you know, it performs the function that you want it to perform to improve somebody's health, but it's not in a very pretty package necessarily, and so then what we'll do is we'll work with an industrial design firm, both to make sure that the design can actually be manufactured in a cost-effective way, but to make it look like a real medical device, to improve its usability--

H: Right.

R:--and, you know, I think it's really important, don't--nurses and clinicians in any setting don't wanna use something that looks like a student project.

H: Yeah.

R: They want it to look like a real medical device and it should, and so we've had great luck working with industrial design firms to do that.

H: It's just like, plug this baby into this toaster oven and then I promise that things will go good.

R: Yeah, you know, one of our collaborators in Malawi who's a pediatrician, she's the one who originally brought us the CPAP project, and even though she's a pediatrician, she's really an engineer at heart so she tried to make her own CPAP machine.

H: Wow.

R: And what she did was she took this giant vacuum pump and she reverse engineered it so that it actually was a flow driver.  That caused it to overheat so then she had to set up a kitchen fan next to it to like, get it cool, and it actually, it worked.  

H: Wow.

R: But everyone was really afraid to use it because it looked so scary.  

H: Yep.

R: Yeah.

H: That's very cool, though.

R: So then, for the next stage where you really want to market a device, you wanna take it through international regulatory approval, what we have chosen to do in our program is we've identified people that want to license the technology and our philosophy as a program is that we license it at no royalty, so at 0 royalty rate for use in low income settings because our goal is to get maximum dissemination and use of the technology and so we're looking for partners that share that, so with our CPAP device, for example, we partnered with a comapny called thirdstone design, they're based in the bay area and they took it through international regulatory approval and now we're doing the distribution worldwide.

H: So what's driving, you know, a manufacturer to develop this and to get it into a place like Malawi?

R: Yeah, so I think there's really two things that are driving their work in this area and one is that they do see a global market for this kind of technology, so if you look at the emerging private healthcare markets in places like Brazil and India and China, that's where we're really seeing a lot of global growth in healthcare, and so I think that there's a very interesting market for companies to go into and to address, but I think the CEO of the company actually traveled to Malawi with us right after they had completed the design of one of the first prototypes and you know, I think that going to the hospital and seeing the technology that they have been working so hard on side by side with us in use really played an important role in their decision to take this technology all the way.  You know, I think it's so frustrating to me to think about the impact, the enormous impact, that very simple technologies can have like, just keeping babies warm, you would not think that so many babies die every year because they're cold, but the impact of hypothermia, like, I think of it as an invisible medical emergency.  Part of my job is to just make it visible.  

H: Yeah.

R: And so, you know, we just have an urgent need for this, but there's also a market there that makes sense in the long term.

H: Right, right.  So I feel like the, you know, the sort of capitalist approach is like, how do we reinforce and create that market?  What, like, who are the organizations that are trying to gather capital?  Where can people donate money to organizations that do care about these invisible crises, that do think like, we did great work with vaccines, now we can do great work with medical devices?

R: Yeah, I mean, I think that there's a very important focus on newborn health right now because 85% of newborns that die, those deaths could be prevented with simple technologies.  USAID, the Bill & Melinda Gates Foundation, through a program called Saving Lives at Birth, has invested a significant amount of resources in trying to bring these innovations forward, but the job is really not done and we need to finish the rest of the technologies that are needed so we can have a NICU Africa.

H: Great, and that's a successful process--project and how many of those have made it out into the world so far?

R: Yeah, I don't know the number, but it's in 23 countries now, so it's--and every government has one in Malawi and then it's in 22 other countries.

H: Great, well, congratulations.  That's very cool.  It's exactly the kind of thing that gets my engines going.  It's got everything I want, it's got science, it's got engineering, it's got passion and compassion and I'm just--yeah.  I'm really, really excited that you're doing such great and I--thanks for teaching a generation of people to do that work and for helping a bunch of people who need that help.  Thank you.

R: Thank you.