About this talk
Krista Donaldson uses design to fight jaundice, create prosthetic limbs, and solve some of the developing world’s most vexing problems. This is why we selected Donaldson as our 2014 ALVA Award winner, a special prize presented by Behance in partnership with GE to recognize remarkable serial inventors.
In this 99U talk, she offers a peek into her team’s design process for getting complicated medical treatments to all corners of the world for a price anyone can afford. Chief among her advice? Talk to your customers. Then talk to them again. And use all that feedback to iterate and, when needed, drastically shift your design process. “We want closure on our projects…but people and society and technologies change. You want to be okay with the ambiguity.”
Krista Donaldson, CEO, D-Rev
Krista Donaldson is the CEO of D-Rev and has worked in international development, product design and engineering for more than 15 years. As D-Rev’s CEO, Krista has led the design and scaling in emerging markets of Brilliance, radically affordable treatment for babies with jaundice, and the ReMotion prosthetic knee, now worn by over 5,500 amputees. She has been recognized by Fast Company as one of the 50 designers shaping the future and the World Economic Forum as a Technology Pioneer.
Prior to D-Rev, Krista was an economic officer at the US Department of State where she worked on economic policy and the reconstruction of Iraq’s electricity sector, and as a design engineer at KickStart in Nairobi, Kenya. A native of Nova Scotia, Krista holds a PhD in Mechanical Engineering from Stanford University.
15 years ago, I worked as part of a Kenyan NGO to design this water pump. And the water pump is pretty revolutionary. It’s for small scale farmers. Before having a pump, farmers would haul buckets from wells or from nearby streams, and this pump enabled them to irrigate a greater amount of acreage. And we’re talking about small scale farms, like maybe one hectare at most. And it enabled them to grow better quality crops. And as a result, you would see tripling in income. And by the way, this works kind of like a stair stepping machine so it’s mechanical. You kind of get a sense of what it looks.
But we really learned one thing, it was about implementation. You can have this great product, but if you can’t get it made properly in a high quality consistent way, then it’s not getting to users. And it’s not having impact. And this picture says it all to me. The pump was just complex enough that it was difficult to make in this high quality consistent way. And this was in Kenya. And my colleagues here, they’re checking every single pump before it goes out. Before it’s painted, before it goes out. Because as you can imagine, if someone spends a lot of money and purchases a pump, but if it doesn’t work, it’s a huge loss of money that otherwise would send children to school. Or put food on the table.
And KickStart had a bit of a problem too because some of the pumps were coming back. And in social impact in general, it’s got not a great history, let’s put it that way. In the ’60s, aid organizations would donate things like tractors to African countries. And these tractors– if you look at Tanzania farms or Kenyan farms, it doesn’t really make sense. The farms are small. They wouldn’t donate enough quote tractors, so people had to like organize cooperatives and had to share. And also there were no spare parts. Later on came the appropriate technology movement. And we’re going from kind of transferring technology now to more thoughtful design. But it was also wrapped up in ideologies. Appropriate technology was often about small is beautiful. Some of you remember E.F. Schumacher. It was intermediate technology, appropriate technology. It also was [? useful ?] to use local materials. And it should be simple. So you’re actually looking at another water pump. But it’s very kludgy. You turn a hand crank and you’re lifting water. So you would see these things, but they really have limited impact. So I’m going to fast forward to where we are now and I’m going to talk about D-Rev, the organization I lead. I’m going to give you a bit of an overview of our philosophy and our two main products ReMotion Knee and Brilliance that Linda and Scott mentioned. Then I’m going to talk to you about three– I’m going to tell you about three lessons learned we’ve had in the whole implementation process in getting products to users to have a kind of impact we want to have. So D-Rev is short for design revolution. And as mentioned, we focus on populations that live on less than $4 a day, and our goal is to increase their income, and improve their health. Three things to know about us, the first is that we design world class products. So that means they perform on par or better than the best products on the market. So no kludgy. No transfer that doesn’t make sense to users. And the photo you’re looking at is actually us doing some user testing in hospitals in East Delhi of the phototherapy device. The second thing is we say we’re user obsessed. So more than just user centric understanding the end users of course, patients with medical devices. It’s patients. It’s doctors. But it’s also purchasing decision makers, because often the purchaser is different than the user in health. It also means understanding everyone who touches the product, whether the manufacturer or the repair person. And it means the context. Many of the hospitals we work in have blackouts. And this matters of course– power blackouts– and it might be up to even 16 hours a day. And this matters if you’re looking at a product that uses electricity. The third thing is that we take a market driven approach. So even though we’re a nonprofit, we believe that products should be sold, not donated, not heavily subsidized. This means we design them with a profit margin built in. And we also have to design them though at the same time to be very affordable. The idea is if we’ve designed them well and if D-Rev disappears tomorrow, good products– products that actually provide value to our users will continue to be manufactured, distributed, and sold. And as designers, this holds us accountable to our users. And this is very different than the tractor model. Or even like the appropriate technology model of this is a good enough product for you. So jumping into the ReMotion Knee. The ReMotion Knee project started several years ago when the Jaipur Foot clinic in India, which is the largest fitter of prosthetic limbs to low income populations, decided they needed a better knee. And here you see three amputees in Jaipur. The reality is if you live on less than $4 a day, there are really limited options for what you have. And most amputees lose their limbs, turns out in vehicle accidents. Before that they were working. They were going to school. And now suddenly their lives are very disrupted. And most options they are only able to use a bamboo staff. So how big a problem is this? There’s an unmet need of about $3 million leg systems per year. And to give you a sense of what a leg system is, you have a residual limb, and a socket is fit over top. And then there’s the knee, and the knee is the most expensive and complex component of the leg system. And then there’s a pylon, so like your shin. And then there’s the foot. So what are the options in terms of prosthetic knees? This is a high end, what we would call a smart knee. You can program it to ride a bike. You can program it to drive a car. And this is something, for example, that US vets coming back from war zones would be fit with. This is a low-end titanium polycentric knee. And what polycentric just means is it’s a four bar mechanism, and as it rotates, it’s very stable. So it mimics your natural knee. And this mechanism has been around since the 1960s. it’s certainly not affordable for our target population. And lastly, this is the International Red Cross knee. So where we have affordability, we start to lose out on performance. It’s a single axis knee so it’s just like what it sounds. You have a single axis that rotates, so think like a door hinge. And as your weight shifts over that axis, you lose stability. And I’m going to show you a video because a single axis is what the Jaipur Foot clinic was using when they decided they needed a better knee. And you’re looking at a man named [? Ash, ?] and he’s doing what’s called a 10 meter walk test. And you can see he’s struggling a little bit with his stability. One thing that’s not obvious when you watch a video is how psychologically draining it is to try to prevent yourself from falling. So the first prototype of this project started at Stanford University in a biomechanics class. And then D-Rev, we absorbed those students, and now one of those students is our project manager. And this is the first version of what’s now the ReMotion knee. And this is a 16-year-old named [? Kamal. ?] And he’s doing that same 10 meter walk test. And you can see his stability is much better. So now we’re on the third version. This is the ReMotion knee. It’s a polycentric mechanism, so it’s that four bar mechanism that mimics how you walk. What’s not obvious though, is it’s designed for mass production. So there’s been lots of knees– lots of expensive knees, but really what we’re trying to do is get that highly affordable but high quality product. So it’s priced at $80 retail. And so far we’ve fit in 12 different countries. And this is through a partnership with the Jaipur Foot clinic. And so the ReMotion Knee– the version you’re just seeing, and actually a slight update of that version– will be on the market later this year. Something of interest though, this is the inquiries we’ve gotten for the knee. So we’ve gotten them from over 30 countries. And some of you may have noticed that these actually aren’t even all low income countries. And so what we’ve learned is that there’s a much greater need and even market for this product. I’m going to move on to Brilliance, the phototherapy device, but I’m going to start with giving all of you a quick primer on jaundice. So of all children, about 60%, have some form of jaundice, but only 12%, particularly in high income countries, need to be treated. The number is 17% though, in low income countries. And the reason for this is that there isn’t the same prenatal care. And as a result, you see much higher premature births. The good thing though is jaundice is easy to treat. It’s just blue light. It shines on an infant skin, and it breaks down bilirubin that would otherwise accumulate in the brain, and cause brain damage or even death. So babies are typically treated for two to three days. But the thing to know is that jaundice is time sensitive. So once jaundice has been identified in a child, or severe jaundice, it’s very important that they get treated as soon as possible. So what’s the yearly unmet need for phototherapy? It’s about 7 million babies per year, and we actually estimate that these are fairly conservative numbers. But you can see similar to the knee that the highest need is in sub-Saharan Africa and Asia. What’s the reason for– it’s just blue light. Why is there this great need. Well, I’ve already told you the answer. It’s because phototherapy devices are very expensive. So this is Brilliance. And you see it here being used in a hospital– a medical college actually in Tamil Nadu India. And it went on the market about a year and a half ago. We have an interesting business model. Ultimately we’re a small organization, and we recognize that we’re not going to be the ones selling medical devices necessarily, particularly when our target markets are in India and sub-Saharan Africa. We don’t have that kind of expertise. So we licensed it to the biggest maker of neonatal equipment in India, Phoenix Medical Systems. And Phoenix does manufacturing, distribution, sales, marketing, regulatory, all the stuff you need to do to get to market. And this is a picture of the first batch of units. And one other thing we did with Phoenix is that we structured our license with them. First of all, we said we need you to cap the price. And the second thing was is if Phoenix sells to a rural or public hospital, we take less royalties than if they were to sell to a high income hospital. And so what we’re trying to do is financially incentivize sales to where the social need was the greatest. Because if we get our product to market, we get it to hospitals, but those hospitals end up being in Germany or they end up being the high end hospitals in Delhi, we haven’t reached our mission. So where are we now? This is hospitals from the first year and a half. Brilliance is in nine countries. And you can see most of our sales are in India. And this is a very deliberate, and why we chose a partner in India. India has the highest rate of infant mortality. It’s 2 and 1/2 times the next country, which is Nigeria. newborns have been treated. We estimate that 90% of those babies would not have received effective treatment otherwise. So we’ve learned a lot of things about implementation in the last two years with field studies and field trials and product’s going to market. And I thought I would share just three of those. So the first is that it’s a system. You’re designing a system. We think about designing a product, but really what you’re doing is designing a system. Or you have to design a product within a system. And you have to be so aware of that. It’s one thing to get a product made, and of course, I’m talking about hardware because I’m talking about medical devices, but it’s one thing to design it. To get it made. To get it where it needs to go. But then you have to make sure it gets used properly, and that it gets maintained properly. When we started the Brilliance project– well it started actually when an Indian doctor came to one of my colleagues and he said, you know everyone in the global health community is really interested in sepsis, infection, or asphyxia during labor, but one of the biggest problems I see is severe jaundice. And so we thought this was a rural clinic issue because a lot of moms are giving birth at home, and we assume that as babies get sick, they will get referred to urban hospitals where they can get good treatment. But we did something interesting as we went outside of our target market, which was clinics, to these urban hospitals– and here you see one. This is a major public pediatrics hospital in India. And we saw this. What you’re looking at is two children sharing a phototherapy device. But if you look at the bottom, there’s two bulbs. The phototherapy is two bulbs, and three of them are burned out. So the child on the left particularly is not receiving effective treatment. Well it turns out, this is actually pretty par for the course in many urban hospitals where the sickest children are getting referred. We did a study with Stanford University and found that 90% of hospitals in four Indian states, and one Nigerian state did not have effective phototherapy. And it was largely because of the bulbs. We saw a lot of bulbs burned out. We saw blue bulbs replaced by white bulbs. And it was partly a cost issue. If you look at the cost of a single bulb, it can be anywhere from around $25 in Delhi, $50 in Lima, Peru, and over $180 in Kampala, Uganda. So you remember, there’s five or six bulbs. Those bulbs need to be replaced two to three times a year. So that price adds up. And all of a sudden, a product that might have been expensive is now much more expensive. The other thing we learned from talking to doctors and talking to procurement officers is that these bulbs are really hard to replace. So it’s a supply chain issue too, it’s not just a cost issue. In Nigeria, we actually saw white kitchen painted blue and stuck in a phototherapy device, because it was so hard to actually source the blue medical bulbs that you needed. So in designing Brilliance some of you had may have noticed that it uses LEDs. And LEDs are fantastic because And if you’re like me, it’s hard to calculate what does that really mean. It means about eight years of use before the light intensity starts to drop a little bit. They don’t burn out, the intensity starts to drop. So many of you know you can just crank up the current, and you can get the brighter light again. We’re not the first to design phototherapy with LEDs, but we probably are one of the first to use optical modeling to minimize the number of parts. And why do we want to minimize the number of parts? We want to keep the product very affordable, and we also want to minimize maintenance. Less parts, less parts to break. So I thought I would jump out and talk about what we see as our design process. We take a very system approach to design. And many of you being designers will say this is a very over simplified design process, and I agree. But I just want to walk through how we do think about it. The first stage is identify. And this is understanding of course your users. Understanding your need. Understanding the landscape. What would be the price point for a product like this? What’s the ambient temperatures? Many medical devices that get regulatory approval only have to work up to 35 degrees C. That’s much lower than some of the places where we work. So understanding that whole picture. The next is kind of when we talk about design it is conceptual designing, iteration, getting feedback from your users, all the prototyping and reiteration, and that sort of thing that ends with an embodiment. And then delivery for hardware is manufacturing, distribution, sales, marketing. And then scale is as you move into new markets. Not every product that works in India, for example, is going to make sense in Nigeria or is going to make sense even in Bangladesh right next door. And then because we’re a nonprofit, everybody wants to measure their sales, but we also want to measure our impact. And one interesting thing we did with Brilliance is that we designed in a little counter so that we actually know how long every device has been on. And we can estimate that impact number. They say this is what the design process really looks like. And I love that Seth was talking about the thrashing in the creative process, because it would say this is part of the thrashing. But it’s also if you want to design for impact, if you want to design for any kind of value to your end user, you’re trying to predict as far out in the process. And think about that as early in the design process. So for example, we knew we wanted to measure impact. We needed to make that a product requirement in the very beginning of the process. The other thing I wanted to mention is that we leveraged the heck out of partners. All of these lines on here actually nerdily do respond to different activities in the design process. So you want the implementation, the perspiration, the 99% there. This is it. But we don’t do it all. And in the beginning of the design process because we had an idea of what was coming up, we knew we couldn’t do it all. And we tried to find partners as early in the design process as possible. So what the colors basically mean is orange is what D-Rev did, what we did. Blue is what our partner Phoenix did. And then the other colors are where we had to bring in other experts because neither of us could do it. And the challenge is of course, integrating everything. So our next lesson learned was to keep returning. And of course, that is to keep returning to your users, and to be OK with the relentless iteration. I think many of us, particularly designers, we want to have closure on our projects. We want to see it come to market. We want to see it have impact. But the reality is at least in social impact, like many other fields, is people change. Societies change. Technology changes. And you want to be able to keep moving with that, and to be OK with that. To be OK with the ambiguity of never maybe being perfect closure. So I thought I would talk of a really simple example about how we went from the first version of the knee to– which is the Jaipur knee– to the ReMotion knee. So we would go back to clinics, and we would talk to the processes and visit with amputees who had been wearing our knee for some time– at least six months. And we started to notice something. And that was that there was a little bit of fabric tape or some fabric glued in right here in this joint. You can probably guess why. It was a home made noise dampener. So we learned very quickly– we knew this testing, but we didn’t realize how extensive it was. Nobody wants to click. Particularly in societies where there are social taboo around disability. We saw something else really interesting. Oops, this doesn’t work behind here. And that’s that people would wrap foam around their knees or like an ACE bandage, like you see here with this patient. And that makes sense. If you look at the side of the knee, this is the first version. Admittedly not very elegant. It’s kind of sharp. So you’re wearing it under pants or you are wearing it under your skirt. And again, it’s obvious that you are wearing a prosthetic. It’s not a natural knee. So with the ReMotion knee some of the updates you can see– I know it’s hard to see– but there’s a noise dampener here. Let’s see if I can make it– so much quieter. And also we smoothed the profile so that it looks more like a regular knee under clothing. We made it much thinner because we were also told that kind of regardless of how nice you make it, people are going to wrap things around it. And what’s also not obvious here is that this one is designed for mass production. And that’s where we get that affordability at the high quality. So my last and third lesson learned I wanted to share is that it’s user, user, user. And I know I’m preaching to the choir here, but I think when you talk about users it’s so integral for the whole design process throughout. And everyone at D-Rev, and I believe everyone involved in the design process, even if you’re on the operation side of the office, should interact with users. So we say everyone should do field work. And this is not just good for the design of the product, it’s good for your process. And it’s good for your organizational strategy. So I know I can’t take all of you to go see one of our users so I have a short video clip of one of our users that I’m bringing to you.
And the reason is is at the end of the day you can design a great product, you can do all these things, but the best thing that drives implementation is understanding what you’re doing and why. [MUSIC PLAYING] [NON-ENGLISH SPEECH] [APPLAUSE] Thank you, very much.