#HTE

The Challenges of Designing Things that Save Lives: An Interview with Design that Matters, Part 1

As a designer, have you ever had a “What the fuck” moment? Tim Prestero experienced his while working with a group of Special Forces operatives.

A former Peace Corps volunteer and then-PhD-candidate at MIT, Prestero’s original life plan had been “to fix the world as an environmental scientist,” he explains. “Instead, I wound up working on shallow water mine countermeasures” due to funding circumstances. “It’s the middle of the night, I’m 40 miles off the coast of New Jersey with a team of Navy SEALs launching our robot that looked like a torpedo. And I had this moment of clarity like ‘What the fuck? Who are you guys? What am I doing here?’”

“They were really nice guys,” he adds of the SEALs, “but it was weird. I sobered up and started Design that Matters with a gang of guys at the Media Lab. It was just so much more interesting than my thesis.”

A second moment of clarity came during the qualifying exam for his PhD, “a bloodbath that involved a week of deriving sonar equations on the board,” he says. His professors preferred he complete his PhD rather than pursue Design that Matters, which was deemed “weird” and inconsequential. “At the end, they were like 'Don’t you get it? You can be The World Expert in Robot Navigation in Shallow Water…or you can go do this other thing,’” he says. “I was like 'Bye! I’m out of here.’”

Design that Matters has since grown into an impressive organization that helps “make sick people healthy” by harnessing the power of design. Prestero, who learned a hard lesson about the realities of design for social impact with DtM’s stalled incubator project, has since bounced back with the Firefly Infant Phototherapy device, which has treated over 50,000 infants in developing nations and is aiming for 500,000 more. Their in-progress Otter Newborn Warmer is intended to save the lives of over a million babies born prematurely each year. DtM is a grantee of the Autodesk Foundation, which backs innovative design organizations that create social impact. They’ve also got the backing of Lenovo, which provides the high-end CAD hardware for them to realize their designs.

Perhaps most impressive is that Prestero has amassed his own army of over 1,000 troops. They might not be Navy SEALs, but this network of Design that Matters volunteers, students and professionals all donate the crucial time and talent that helps the organization succeed in living up to their name.

At Autodesk University, we caught up with Prestero and Malory Johnson, DtM’s Industrial Design Fellow. Here in Part One of our interview, the pair describe the unusual structure of their company, the importance of designing in context, how to figure out where the money is, and a bunch of eye-opening facts they’ve uncovered during research.

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Core77: Can you introduce yourselves?

Tim Prestero

Tim Prestero: My name is Timothy Prestero. I’m the CEO and Founder of Design that Matters.

Malory Johnson

Malory Johnson: I’m Malory Johnson. I’m the industrial design fellow.

Tim: Together, we represent most of the company right now.

You guys have an unusual structure. Tell us about the company.

Tim: Design that Matters is a nonprofit product design company. Basically, we save newborn lives in developing countries by designing products, medical devices that are a better fit for the context of low-resource hospitals. And we’re a nonprofit because design is kind of a luxury service.

One of the first problems that we had to solve is, “How do we offer design as a service at a fraction of the cost of a commercial design firm?” We saw an opportunity in leveraging volunteers, students and professional volunteers. In the last 10 years, we’ve had 1,200 students and professional volunteers contribute intellectual property to our different projects.

We’re also a nonprofit because of the Van-Gogh-in-the-attic anxiety about intellectual property. What if we accidentally give you the cure for cancer? Well, step one, we’ll freaking cure cancer. How’s that for an outcome? Two is it’s a commitment device. If we, by working with our volunteers, hit on something that has a domestic application, Design that Matters owns the intellectual property so we ask our volunteers to donate their intellectual property to the non-profit. If we do hit on something that has commercial potential, we’ll just plow those revenues back into making lives better for the poor using design. That’s why we’re a non-profit. In every other way, we’re a business and a design firm.

Okay. And what made you decide to focus on medical devices?

Tim: Well, medical devices is a context that eliminates many of the liabilities inherent in social impact work. In other words many do-gooders, particularly those working in low income countries, start with this “Field of Dreams” idea, you build it, they’ll come. I was a Peace Corps volunteer in West Africa a thousand years ago and learned that it’s not the field of dreams. If you build it, people aren’t going to use it unless it solves a problem that they have and more importantly, works within their context.

“Within their context,” what do you mean by that?

Tim: For instance, we’re not going to traditional Chinese medicine practitioners or Ayurvedic doctors in India saying “Drop all that stuff, step into the world of Western medicine.” Instead we’re working with doctors in sub-Saharan Africa, in Southeast Asia who already have a foot in the Western world. They’ve been professionally trained as doctors and they’re trying to apply these techniques in their country. But they’re finding that the tools all suck because none of them were designed for their context.

To clarify, they’re using the same medical practices as Westerners but the equipment that they have access to is inferior?

Tim: No, it’s the same equipment, but it’s inferior for that context. Context is king. It turns out that international medical device standards aren’t. In other words, they’re written for US, European, maybe Japanese applications.

Can you give us some concrete examples?

Tim: Sure. One, we talk about embedded assumptions in design. You can look at a piece of hospital equipment and [realize] by the fact that it’s got little tiny casters, that it was designed with with assumption that all the floors in the hospital are smooth. If it’s very heavy, you just wheel it into an elevator to take it to another floor. Smooth floors and elevators. Well, that’s already a bad assumption.

Two, I was doing background research at the Kanti Children’s Hospital in Kathmandu, Nepal, and asked the biomedical technician “Take me on a tour, show me your favorite gadget.” He took me to the MRI machine, and I thought that was it. But he’s like “No, look at this—” and he opens the back of the machine.

He shows me that inside the box that the power supply is coming through, they’ve attached a surge suppressor. Which he found awesome. It’s a half-million dollar machine and what he cares about is the $10 power strip.

Why? Well, it turns out that 98% of donated medical equipment in developing countries is broken in five years, primarily because power supplies are unreliable. Voltage varies enormously, and so he was excited about a medical device that had this hacked into it. Why doesn’t every piece of medical equipment have that built into it? Because in the U.S., it’s a reasonable assumption that you don’t get voltage spikes.

Three, were working on newborn technologies and asked nursing staff at a Boston hospital “How often do you get mosquitoes in the NICU (Neonatal Intensive Care Unit)?” They’re like, “Never.” The air is filtered to get into the hospital, and then filtered again to get into the NICU.

Meanwhile we’re finding NICUs in, say, Indonesia where they couldn’t stop dust coming in. Everybody’s cooking with coal or charcoal, which generates enormous amounts of dust. All the dust is getting into the equipment and shorting the circuits. That’s what we talk about, poorly adapted to the context.

Besides not thinking about context, where are other areas where a designer can go wrong here?

Tim: By making assumptions about who’s using the equipment. What’s their background, do they have training? We’re dealing with countries where the nurses don’t have six years of college—they have six years of school total. The WHO estimates that only 20% of donated medical equipment in developing countries is ever turned on. That’s a quarter billion dollars of waste, $250 million dollars of unused, donated equipment every year.

Because of lack of infrastructure, electricity?

Tim: It’s a variety of things—imagine a hospital’s given a new piece of equipment, but no training. Who’s going to be the one that figures out that this button here is the one that kills the baby?

And in some of these conservative contexts that a nurse might be operating within, there’s nothing wrong with doing nothing; but trying something new and failing is punished severely. So experimenting with a new piece of equipment is very high stakes, which leads people not to want to use the equipment.

What we designers need to understand is that many of these problems are not technology problems. They’re design problems. The technology exists, but it’s poorly adapted for the context. Unless we do a better job in design, you’re not going to be capable of getting the outcomes that the technology in the medical equipment ought to.

The other advantage of developing medical equipment is that we’re not asking for behavior changes. We’re trying to help doctors in developing countries do the thing they want to do, as opposed to having a gadget that’s going to make them behave differently.

All of these anecdotes you’re talking about speak of hours on the ground.

Tim: It is.

How are you generating all of this intel?

Tim: So, Design that Matters has got three jobs:

One is, “What’s the opportunity?” Meaning where is it that the application of design can take a sick person and make them healthy, or take a device that’s not working and make it a successful device. So needs identification is one. Along with that is, “Where are people spending money?” In other words, understanding which health concerns are priorities such that if we come up with a better solution, the rest of the world is ready. As opposed to us being like “Okay, now we’re going to go on a street corner and try to get people interested in this condition.”

Two is the design research. Not just design research for the design inputs, but also for the evaluation. Malory and I are going to Vietnam in a few weeks with the warmer prototype. What we’ve learned about the hard way is what we call the narrative gap: This difficulty we have in explaining an idea to another person and getting their feedback. A lot of that has to be translated, which is difficult. Then imagine that all of this is in the context of hardware development, and we see people who say “Well, we get great feedback from renderings.” It’s like—really? We find that until we have an alpha prototype, you really can’t trust the feedback, and particularly when working in another country.

Three is having all these partnerships so that the final result gets to treat thousands, hundreds of thousands, millions of people.

Speaking of partnerships, what does Lenovo provide for you? I wasn’t clear.

Tim: Hot shit. Blazing fast machines that are the most incredible things we’ve ever used. Prior to that we were getting by with cheap DIY machines.

We know that Hollywood needs tons of fast machines to produce special effects. The studios farm it out to dozens of FX houses to get the job done quicker, to meet the movie’s release date. What is the urgency for you?

Tim: Well, we’re not in a race to beat our competitors; I’d be thrilled if GE swooped in and saved those babies before us. With us it’s more that if we don’t get this done, more and more kids die unnecessarily.

Like with prototyping, we’ve got time-intensive renderings, then we 3D-print it and it’s like “Oops—how did we miss that this part is not the size of our hand?” That’s all delay. Time is volatility. The fact that we can do stuff so much faster. We have our own fab-lab in Salem with a laser cutter, a couple 3D printers, a vinyl cutter, a little CNC machine, some EE benches. It all sounds very impressive, but unfortunately there is a horsepower gap. And what happens is that if you’ve got slow machines you start to self-edit: If the render takes eight hours, you’re not going to do three of them—you’re going to going to do one, like, “It’s good enough.” Then you take the thing to Africa and find out it’s not good enough.

With machines like what Lenovo’s given us, like the P910 tied to desktop manufacturing, it’s unbelievable. With Firefly, so much of that project was pushing that extra distance and conducting that kind of user-driven feedback and re-design. The better the tools we have, the less likely we are to go “Eh, maybe it’s good enough.”

And how does Autodesk help?

Tim: We use Fusion with the big box [the P910] at our studio to do a lot of the heavy lifting. And this summer we were using Autodesk’s Build Space in Boston for the Otter build. The space is amazing, they’ve got a CNC machine that you could drive a truck inside of. We were doing were molds for vacuum forming this polycarbonate bassinet.

Malory: One of the challenges there is going from CAD to CAM to parts.

Tim: Particularly when you’re committing to something like CNC'ing a mold. It’s like, “Oh, version-V4-final-underscore-copy"—we are going to push a button and four hours later, our thing’s going to come out. If this is not the correct version, we are going to feel really sad because—

Malory: —There is no second chance. But with Fusion it’s all handled in one file, which makes it super easy for version control. Number two, it makes it really easy for the three computers. I mean we have a very small team and even then it’s still complicated to share the sequence of files that it takes to do three other programs. At our shop there isn’t a workstation next to the ShopBot, so I’m using a laptop there. So having the same file that I can manipulate on the giant machine and being able to take that directly into my laptop—I’m using a Yoga—is a big help. The Yoga is the perfect in-field design component because it’s portable but it can still handle the CAD stuff. It can do digital drawing, so then we can be very responsive to our interviews. We can design right after we talk to the experts.

Tim: That doesn’t sound like a big deal but it’s SUCH a big deal.

Malory: We can focus more time on our outcome rather than technological issues.

Let’s back up to something you said earlier, about figuring out where the money is.

Tim: Sure. We’ve found that needs don’t equal markets. There’s a discouraging phenomenon right now of the growth of market-based thinking applied to every corner of human life and every aspect of human industry. Market economy, fantastic. I can support the idea of a market economy. I’m not excited about a market society.

We focus specifically on issues where the market cannot address these problems. There is not a for-profit hospital or a door-to-door care service or subscription model that will answer some of these basic problems like newborn health. Who is investing in newborns? It tends to be governments, bilateral aid agencies, and large foundations. We fish where the fish are. We figure out where the priorities are. Millennium Development Goals was one guide. Now there’s the Sustainable Development Goals. You can look at Saving Lives at Birth as a consortium, a bunch of different funding agencies that put out an RFP almost every year for newborn health related topics. They state what they see as priorities.

We’ll run that through the filter of design for hardware. What’s the opportunity for design for hardware? A good Design that Matters project makes a sound when you drop it.

Why the focus on hardware over, say, service design?

Tim: We work with a lot of volunteers, and it’s very hard to get 1,200 volunteers excited about service design. "Hey, come up with a new logo choice for the banners over our rural hospital to get people to come and get vaccinated.” I do think that those can make a difference, but for us to be able to recruit the kind of philanthropic support and people donating their time, service design is a harder sell.

The sexiness of hardware aside, wrangling the amount of volunteer support and partnerships that you have can’t be easy.

Tim: It’s funny because we’re right now there’s three of us. This summer, there were six. The team fluctuates [cyclically], but there’s also a cast of thousands. We’ve got an amazing board of directors, a fantastic board of advisers, and then this Rolodex of hundreds of people who want to make the world a better place using design. If it’s not obvious by now, my job is to tell stories and to get people excited about what’s over the hill. Okay, I want to run over the hill too.

Then it’s about setting up incentives. We say “Altruism is a good reason to do something once.” But we have to build a system so that people want to participate over and over again. Like with partners like Lenovo, it’s been amazing that it’s reciprocal; I feel like we’re all benefiting from the partnership. That’s the way it’s got to work.

Tim, you mentioned your role as evangelist, among other things. Malory, can you tell us about your role?

Malory: Sure, so we do work with a bunch of student teams, a bunch of designers and engineers. My role as the internal industrial designer, I’m the common thread between all of these different sprints. They happen individually and it’s very easy for things to fall off in between, it’s easy for things to get lost when they’re passed across different projects. I’m involved with them [in this particular manner:] I keep my distance enough from them so that they come up with their own designs independently, but I’m close enough to them that I can take everything that they’ve done and make sure that translates to the next person. I have a hand in every aspect of it, but I focus on the overhead strategy and research part of it.

Do you find the managing part tricky when you’ve got that many people, some of them new?

Malory: There’s always the onboarding process, the technical logistics of making sure they have the right files, the right version of this, and so on. But Tim is a great, inspiring speaking person and everyone seems to be very on board and very sold with the intention of the design. I think that part goes over really easy.

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Stay tuned for Part 2.