Looking under the hood and seeing an incubator
By Madeline Drexler
December 16, 2008 - The heat source is a pair of headlights. A car door alarm signals emergencies. An auto air filter and fan provide climate control.
But this contraption has nothing to do with transportation. It is a sturdy, low-cost incubator, designed to keep vulnerable newborns warm during the first fragile days of life.
Unlike the notoriously high-maintenance incubators found in neonatal intensive care units in the United States, it is easily repaired, because all of its operational parts come from cars.
And while incubators can cost $40,000 or more, this one can be built for less than $1,000.
The creators of the car parts incubator — a project being promoted by the Global Health Initiative at the Center for Integration of Medicine and Innovative Technology, or Cimit, a nonprofit consortium of Boston teaching hospitals and engineering schools — say it could prevent millions of newborn deaths in the developing world.
The main causes of newborn death — infections, preterm birth and asphyxiation — are readily treatable with the right expertise and equipment, said Dr. Kristian Olson, principal investigator on the project. He called them the “low-hanging fruit” of global health interventions.
“It’s so frustrating to see these preventable deaths,” he said. “They won’t name babies in Aceh, Indonesia, until they’re two months old. It’s a cultural adaptation to expect a death.”
Mechanically, incubators are simple devices, providing a warm, clean, womblike environment in which a baby can mature (though state-of-the-art models may have accessories like built-in X-ray machines and rotating mattresses). Low birth weight and other problems make it especially difficult for newborns to regulate their body temperature, a condition that can lead to organ failure.
In the car parts incubator, infants born at 32 weeks’ gestation or longer can receive supplemental oxygen while their lungs gain strength, antibiotics if they have infections, and low-lit quiet in which to sleep if their mothers are away or are otherwise unable to hold them. In an emergency, the incubator’s bassinet can be removed and carried to another part of the building or even to another hospital.
In truth, experts say, the developing world doesn’t need more incubators. It needs incubators that work. Over the years, thousands have been donated from rich nations, only to end up in “incubator graveyards” — most broken, some never opened. According to a 2007 study from Duke University, 96 percent of foreign-donated medical equipment fails within five years of donation — mostly because of electrical problems, like voltage surges or brownouts or broken knobs, or because of training problems, like neglecting to send user manuals along with the devices.
To compensate for this philanthropic shortsightedness, medical staffs either crank up the temperature in “incubator rooms” to 100 degrees or more, or swaddle babies in plastic to hold in body heat.
Such makeshift solutions led the Boston team to ask: How can we make an incubator for the developing world that will get fixed?
One person pondering that question in 2006 was Jonathan Rosen, then director of Cimit’s technology implementation program. A proponent of sustainable biomedical technology, Dr. Rosen, now at the Boston University School of Management, uses the term “organic resourcing” to describe the principle of fashioning medical devices from whatever materials were locally abundant.
In his discussions with doctors who practice in impoverished settings, Dr. Rosen learned that no matter how remote the locale, there always seemed to be a Toyota 4Runner in working order.
It was his “Aha!” moment, he recalled later: Why not make the incubator out of new or used car parts, and teach local auto mechanics to be medical technologists?
Cimit then hired Design That Matters, a nonprofit firm in Cambridge, Mass., to design the machine. “The idea was to start with a 4Runner,” said Timothy Prestero, the firm’s founder and chief executive, “and take away all the parts that weren’t an incubator.”
What resulted was a serious-looking gray-blue device that conjures up a cyborg baby buggy, but fits comfortably in hospitals and clinics with few resources. For one thing, the supply of replacement parts is virtually limitless, because the modular prototype can be adapted to any make or model of car.
“Junkyards are great sources for parts,” said Robert Malkin, director of Engineering World Health, a program based at Duke University, who is not affiliated with the incubator project. “We have designs for pumps and a surgical aspirator that are based on car parts.”
And the repair people will be right on the scene. “The future medical technologists in the developing world,” Dr. Malkin said, “are the current car mechanics, HVAC repairmen, bicycle shop repairmen. There is no other good source of technology-savvy individuals to take up the future of medical device repair and maintenance.”
Not everyone agrees that the car parts incubator is the best solution for infant deaths. Skeptics cite a 2005 series of articles in the British journal The Lancet listing proven interventions — including outreach visits during pregnancy, skilled care at delivery and emergency treatment afterward — that could eliminate up to 72 percent of neonatal deaths worldwide.
“Even if we just do what we know now, we could save roughly two-thirds of the infants who are dying,” said Dr. Stephen Wall, a senior research adviser at Save the Children, an independent nonprofit organization.
In his work in resource-poor countries, Dr. Wall has strongly promoted a strategy called kangaroo mother care, in which an infant is placed on the mother’s chest immediately and continuously after birth, ensuring warm skin-to-skin contact and breast-feeding.
The method has been documented to raise survival in low-birth-weight babies who are medically stable, and Dr. Wall says global health practitioners should promote the practice more strongly before endorsing a new device. He notes that most babies in the developing world are born not in hospitals but at home.
“For now,” he said, “there’s an urgent need to provide simple solutions that can be used by families, information that can be shared through community health workers, women’s groups or other community mechanisms.”
But others view the issue differently. “Mothers who are sick and can’t handle their kid, and mothers who can’t nurse, typically don’t take to kangaroo care,” said Dr. Malkin, at Duke. Nor do mothers who have to return to work to support their families, or whose cultures practice carrying infants on the back rather than the chest.
And by itself, the kangaroo method is not enough to help the smallest or sickest babies. Although low-birth-weight infants make up only 14 percent of babies born, they account for 60 percent to 80 percent of neonatal deaths.
“The bottom line is yes, we need more simple technologies in hospitals for the complicated cases,” said Dr. Renée Van de Weerdt, chief of maternal, newborn and child health at Unicef. “At the same time, we need to accelerate efforts to get skin-to-skin care more widely used for the noncomplicated cases.”
The car parts incubator has received $150,000 in initial financing from Cimit. The project team is looking for foundation support to develop a working prototype. Because it does not rely on original products or processes, the incubator will most likely not be patented, though Massachusetts General Hospital (Dr. Olson’s home institution) and Design That Matters will share intellectual property rights.
Meanwhile, the team is refining its business model and solidifying business partnerships abroad. “The technology is the least difficult part of the problem,” Mr. Prestero said. “Manufacturing, financing, distribution, regulatory approval: those are major barriers. There aren’t many examples of a successfully scaled product to serve the poor.”
If international health care bodies like the World Health Organization and the United Nations Population Fund endorse the incubator, he said, it could speed developing countries’ adoption of the device, even without approval of the Food and Drug Administration in the United States.
Dr. Olson says his determination to create a cheap, reliable incubator — and medical training to go with it — was reinforced on a trip this year to Cut Nyak Dhien Hospital, a one-story concrete building in the tsunami-stricken city of Meulaboh, Indonesia.
“When I walked in the incubator room,” he said, “a whole family was sobbing around a crib.” Their 7-day-old baby boy, who was born slightly underweight and suffering from infection, had just died, after lying for hours on a cold cot. With warmth and proper care, he would have survived.
Crowding the room were six donated high-tech incubators from the West. None of them worked.