
Cheap and simple medical devices have to overcome deeply rooted biases - theBashShell
https://www.newyorker.com/science/elements/reverse-innovation-could-save-lives-why-isnt-western-medicine-embracing-it
======
myself248
Years ago, a friend of mine was in med school, and headed off for a semester
in the rainforest of Ecuador, performing basic medicine and stuff for people
who rarely got to the city to see a doctor. He called me up, on a Sunday
afternoon, with this question:

"Our dentist in the group just realized she doesn't have a source of suction,
you know, like the vacuum that slurps saliva out of the way during a
procedure. We're in Houston and our flight leaves in 6 hours. Any solution
needs to work off-grid for a month. Got any ideas?"

I thought for a moment, and said "Hit an auto parts store. Get a brake-bleeder
kit. This has a hand-pump vacuum with a clear collection jar. Aim for one with
a glass jar if possible, since it'll be easier to clean. Should set you back
about thirty bucks."

And we didn't speak again for a few months. When he was stateside again, he
said the brake bleeder kit had worked so well and was so simple to operate,
they'd often just hand it to the patient. Not only did this free up a
physician, it also gave the patient something to do during what's often a
nervous and fidgety time, and may have thus decreased the need for sedation in
some procedures.

Sometimes it really is that simple. He had numerous stories of doctors in
hospitals picking the brains of janitors -- they called it a "facilities
consult" \-- to see if they could MacGuyver a solution to a problem that the
medical industry hadn't packaged yet. PTFE plumber's tape apparently comes in
a medical grade too, but sometimes you need to toss around ideas with some
other hands-on maker-fixer sort of people before you figure out how to apply
it.

~~~
WrtCdEvrydy
In a pinch, I've seen third world doctors use super glue to seal cuts.

American culture doesn't allow for anything better than the best outcome in
medicine.

~~~
dotancohen
American culture allows for exactly two possible types of medical care:

1\. The best

2\. None at all

Often the choice between the two is financial.

~~~
jessaustin
Just as true of housing, transportation, education, etc.

~~~
WilliamEdward
This sounds really good to the ear, but it's just not true is it? Americans
have a lot of choice when it comes to these things, at least compared to
healthcare.

~~~
rconti
It's a byproduct of regulation. When you start telling people they can't
consume this substance, or buy a car with fewer than this number of airbags,
or without traction control, or you can't sell an apartment with a size
smaller than this, you create consequences. Maybe people buy used cars instead
of new cars. Maybe they live in illegal units that skirt the regulations not
just on sizing, but on fire safety. And so on. You create black markets.

This is absolutely not to say that regulation is bad! It is just to point out
that it creates unintended consequences you have to be aware of, and place the
slider of regulation in the appropriate place.

After all, we all intuitively know that a minimum wage of $500/hr and a
minimum allowable housing size of 7000sqft won't work! But we also know that
telling a surgeon "just use whatever you find lying around" may not be the
best approach either.

------
subcosmos
I spent the weekend dissassembling a hematology analyzer capable of measuring
17 parameters of the immune system from a large drop of blood. Nabbed it on
ebay for cheap.

Was able to unclog a few of the lines and get it running, learning how it
works by shooting cells past a laserbeam and looking at scatter. Overall, the
complexity of the machine is far simpler than that of a simple laser printer,
but its retail value is $10k as a veterinary instrument. Machines for human
patients are way more expensive.

My dissappointment however was discovering that it refuses to run unless its
barcode scanner can see manufacturer-validated reagent bottles. The chemicals
needed to make it run are simple salt-waters that can be easily made for $10
of various powders, but the manufacturer sells reagent sets for $1000k each.
Now its clear that getting any useful data out of it will require hacking the
ARM embedded system onboard.

Why am I doing this? Certainly not for any kind of regulated medical
treatment, but I personally want to know how my immune system changes on a day
to day basis. Datasets like this dont exist on such a high frequency sampling
rate. What I find however, is that the decades-old tech that powers this
relatively simple machine is being held back by an overly restrictive
regulatory environment and price gouging of chemical reagents.

Why the artificial construction of a $100 lab test, when the actual value to
perform such a test is much much lower? Why can't we live in a world where
such self-experimentation is allowed outside of the strict guidelines of
diagnostics?

~~~
maxander
That's a pretty awesome project. Instead of hacking the ARM, could you just
call up a vet to ask if you can have some of their empty reagent bottles, and
fill those with your homemade reagents? (As a bonus, if you can get it to
work, the vet would probably be interested in knowing the reagent recipe as
well.)

There's a movement towards open-source designs for relatively simple
biological instrumentation- perhaps this sort of machine will be in range of
those efforts someday soon.

~~~
subcosmos
The one neat thing about hacking the ARM (its an at91 system if anyone knows
details) is that I can get access to the raw data underneath. IE, the real-
time cell counting events. I can envisage some neat deep learning on something
like that, if only the dataset existed.

------
tompccs
The answer to the headline is astoundingly obvious yet the article doesn't
mention it once. The reason is regulation: you can't use a medical device that
you've hacked together unless it has been cleared by the relevant authorities
as being safe. Sometimes it's a matter of simply getting a cheaper alternative
through regulatory approval, but other times its just not worth the cost to
prove a cheaper alternative is as safe as the more expensive one. Very
annoying article about an interesting subject.

~~~
crankylinuxuser
Yep.

And then you have to breach a very ugly topic most people don't like to
discuss.

When does regulation kill more people by not having the $thing versus having
the $thing? And how many people would suffer complication/dying with the
$thing?

It's a very delicate balance, especially when you consider capitalist forces
that encourage "move fast and break ~things~ people". The FDA is the chopping
block for that... But also FDA overaction also kills people.

~~~
throwaway5752
"Though FDA can trace its origins back to the creation of the Agricultural
Division in the Patent Office in 1848, its origins as a federal consumer
protection agency began with the passage of the 1906 Pure Food and Drugs Act.
This law was the culmination of about 100 bills over a quarter-century that
aimed to rein in long-standing, serious abuses in the consumer product
marketplace."

I have no personal doubt that the FDA has saved millions of lives in the US
and internationally, and the balance of harm/good they have caused would would
make the harm side look infinitesimally small.

Also... I be interested in what cases you know that the FDA caused the deaths
of people by overaction. There are people out there with axes to grind who
thought they were going to get rich with some drug or device, who couldn't
subsequently prove the safety and/or efficacy of their product.

~~~
Symmetry
So, the food regulation side of the FDA's activities have certainly saved
millions of lives and probably swamp what the FDA does in terms of drug
regulations. But generally new drugs tend to be rolled out gradually, doctors
hear about disasters, and I'd be surprised if the FDA saved more than a
thousand lives a year at most. On the other hand a bad call in disallowing new
medicines can have very bad consequences. The FDA only allowed the use of beta
blockers in the US about a decade after they came into use in Europe which
probably cost something on the order of 100,000 excess deaths. Those early
beta blockers did have serious problems and the FDA's decision also probably
saved 1,000 people from liver failure after taking those drugs but I don't
think that justified withholding the category until a liver-safe version was
made. These days the FDA is less strict than it was in the 1960s and has
certainly improved. But we can still do better to move more in the direction
of European style regulation where they have a dozen competing EpiPen
equivalents.

~~~
throwaway5752
You had to go back 60 years. You didn't even mention Fast Track. You are
ignoring device, test, and implant categories.

~~~
Symmetry
I didn't mentioned Fast Track specifically but it was one of the things I was
thinking of when I said the FDA had "certainly improved." A large part of the
credit for that should go to AIDS activists but Reaganite Republicans also
deserve a lot of credit.

I'm not sure the FDA of the 1960s/70s was a net positive in its drug
regulating role on human health. I'm almost certain the FDA of the 2010s is a
good thing on net but I'm pretty sure it's bad on the margin, compared to the
EMA which I think gets things more or less right.

I'm not particularly conversant in how FDA regulatory behavior is different
across product categories but it sure looks like it's the FDA's role as a
device regulator that causes the differences in the market for epinephrine
injectors in the US versus EU.

------
hirundo
Hmm, why would an industry based on profiting from high margin expensive
medical technology not sufficiently promote low margin inexpensive technology?
It's a mystery.

~~~
Consultant32452
A related mystery: what's stopping greedy practitioners from using the cheap
device but still charging the old price increasing their margins even more?

~~~
hirundo
> But cpap machines, the standard device in a country like the U.S., are
> expensive and require uninterrupted electricity. In many countries, Burke
> says, doctors resort to using a makeshift solution: a Coke bottle filled
> with water and attached to some tubing

There's a limit to what you can charge for a coke bottle attached to some
tubing that's much lower than for a machine that blinks and beeps and goes
whirrr with lots of knobs and buttons. Sometimes the solution is to hide the
bottle and tubing in a complicated looking box. Of course not _all_ of it is
theater.

~~~
bsder
Um, please, finish the quote:

> "In many countries, Burke says, doctors resort to using a makeshift
> solution: a Coke bottle filled with water and attached to some tubing. The
> D.I.Y. approach can save an infant’s life but risks causing blindness."

That _NOT_ a better solution, thanks.

The entire article is rife with this.

Ketamine _isn 't_ a better anesthetic--it's acceptable if you don't have
enough anesthesiologists.

The condom with a catherer isn't better, but it is acceptable if you don't
have a real UBT.

It's disappointing to see the fact that the ethics really aren't clear until
the whole way at the end rather than acknowledging it in a much more important
manner earlier in the article.

> "Kass, the bioethicist, is trying to puzzle out the ethics of what might be
> seen as lower-quality solutions."

Doctors are also more likely to use these solutions with lower-socioeconomic
groups--that is the whole point of them being cheaper, after all. And that
opens an even bigger issue in places like the US.

------
gowld
Because people don't keep track of all the buzzwords.

FTA: > “reverse innovation”: taking a technology or solution born of the
resource constraints in developing countries and adopting it in wealthier
ones.

Nothing "reverse" about it; the question is why rich countries don't import
low-cost low-tech solutions from poor countries.

I presume the answer is profit motive.

The classic example that has been hiding in plain sight for decades is "so
many expensive drugs that are about as good as cannabis, and cannabis still
illegal."

~~~
kiba
Presumably because wealthier nations are cost insensitive. They don't feel the
need to reduce wastes in their healthcare system when they can 'afford' it.

~~~
aetherson
They may also feel that it's not actually lower-cost for them. For example:
say your doctor uses a somewhat lower-tech, kitbashed uterine balloon on your
wife during postpartum bleeding. And say she dies anyway (as someone surely
will).

There is going to be a real temptation to sue the pants off the hospital and
say, "Look, they used some jury-rigged contraption instead of the gold-plated
device that would have cost 10x." And, I mean, that's a bad look for the
hospital in front of a jury, "Yes, well, this might be a little worse, but it
might not, and it cost less money!" Everyone wants healthcare to cost less
until it starts to look like hospitals or doctors are prioritizing "profits"
versus people's lives.

~~~
WrtCdEvrydy
This is why we pay the most of any other country... we try for best outcomes.

If something cheap is used in the UK with a 97% good outcomes, we will spend 3
million to ensure we get closer to 98% outcome.

~~~
TeMPOraL
Depending on the amount of patients, even a 1 percent point increase for $3M
could be a baragin. If, e.g., everyone undergoes such procedure once in their
lifetime, 1% times the population of UK is 660K people that could be saved for
$3M, roughly $4.5 per life saved, which is a no-brainer.

~~~
WrtCdEvrydy
Yes, but we spend on better outcomes for things that aren't remotely critical.

Women in the US have a C-Section rate of 26% compared to the 10 to 15% average
just because doctors want better outcomes.

------
dublo7
I just want to say the title on yc is so much better than the original. Making
something cheaper and simple is innovation. Reverse innovation is ambiguous
and confusing.

------
LoSboccacc
Like Theranos'? Medical science is slow but steady for a reason.

------
TheRealPomax
"People are not necessarily comfortable with the price of medicine dropping?"
Sorry, which planet are you from? Earth, you say? The US even? People in your
country would do anything (and have) for affordable medicine.

~~~
magduf
No, they won't. As comments above pointed out, Americans will sue when
something goes wrong and it's found that the medical provider didn't use the
most expensive option available. And Americans do NOT do what they can to
obtain affordable medicine: if they wanted this, they'd be demanding laws to
rein in costs, to provide socialized medicine, etc., just like most other
developed nations have already done. Instead, we got ObamaCare, and half our
population wants it to be repealed.

------
noobermin
Why would Americans physicians stand for this when they can make loads of
profit off of backroom deals with device manufacturers and their expensive
doctors?

------
toomuchtodo
Entrenched interests, innovator’s dilemma. Orgs and people get addicted to
their revenue stream.

------
BeetleB
I've come across the ORT (ORS in other countries) problem in the US. They're
often hard to find, and incredibly overpriced. In the past, many pharmacies
simply did not carry them. I was sometimes told to buy Gatorade instead.

~~~
titanomachy
Buy them online and keep them on hand just in case?

[https://www.amazon.com/Rehydration-Organization-Poisoning-
El...](https://www.amazon.com/Rehydration-Organization-Poisoning-Electrolyte-
Replacement/dp/B00OG8G9U2/ref=sr_1_5?keywords=oral%2Brehydration&qid=1549915449&s=gateway&sr=8-5&th=1)

------
fxfan
As per my understanding- sophisticated and expensive medical devices have
sophisticated algorithms for processing raw data. I would love it if cheap
devices just exposed raw data and I could use my own algorithms, arguably
newer and better, to process them.

I don't know if cheap devices are much worse as far as raw data is concerned.

------
shanecleveland
> "People in emergency medicine often joke “that you can figure out a solution
> with a couple of popsicle sticks."

But that wouldn't be covered by insurance without a going through a bunch of
red tape. But the approved $1000 alternative is.

------
intrasight
Just don't call it a medical device. Call it a "dietary supplement"

~~~
Symmetry
To be used inside a hospital an innovation needs official blessing. There are
a lots of examples of everyday things like fish oil being rebranded and put
through FDA trials so that they can be used by doctors.

[https://slatestarcodex.com/2014/06/15/fish-now-by-
prescripti...](https://slatestarcodex.com/2014/06/15/fish-now-by-
prescription/)

Something called a dietary supplement just isn't going to be used. Both
because they sound sketchy and because nobody is going to use expensive food
to bribe doctors to sit through a 2 hour training course in some cheap dietary
supplement.

~~~
intrasight
>Something called a dietary supplement just isn't going to be used.

I have more faith in humanity

------
kwhitefoot
This reminds me of Victor Papanek's Design for the Real World.

------
itissid
Root cause analysis:

1\. Developed world: Profit motive(i.e. greed).

2\. Developing world: Profit motive(i.e. greed) and Bureaucracy(greed, but oft
times incompetence).

Greed and incompetence are deeply rooted creations of concentrations of
economic incentives in the hands of a few. Capitalism and Socialism are just
two ways creating those things, just by slightly different routes. One needs
true democratization of technology and its distribution to succeed. Its the
only reason why the internet is so powerful and empowering.

------
kerkeslager
What an awful headline.

