LAST MAN ON THE ROPE
There has been a lot of talk about "waves" in the COVID-19 debate lately, but in Switzerland we are more familiar with the mountains than the ocean. Let us imagine mankind as a rope party climbing a mountain. For some climbs we need supplemental oxygen to stay alive.
In hospitals, oxygen is also needed by people who have difficulty breathing. At our latitudes, the provision of oxygen is considered standard treatment and is available in almost every hospital no matter how small or remote. In poorer countries—those on the same rope team—this could not be further from the truth.
Over 2'200 deaths per day. This is not the latest COVID-19 count—it is the number of children who are dying each and every day from pneumonia. The vast majority of these deaths occur in low- and middle-income countries. Most of these deaths could be prevented if children such as Nyanene, pictured opposite, had had access to oxygen. COVID-19 reminds us of the essential role played by this odorless and tasteless molecule.
There is, however, a device that can provide unlimited oxygen at low cost: an oxygen concentrator. This device removes nitrogen from room air, keeping only the oxygen in concentrated form. In richer countries, oxygen concentrators are generally used by the elderly; those suffering from respiratory conditions such as chronic obstructive pulmonary disease. These devices are designed to be both small and quiet, enabling them to be used on the move or at home. They are relatively cheap, but are not well adapted to the context of tropical countries. Indeed they require stable access to electricity, which as in Nyanene's story (below) is not assured; they need regular maintenance by trained personnel, which is problematic in these fragile health systems; they do not tolerate humidity and break down very quickly without little chance of repair. The backyards of many hospitals in low- and middle-income countries are littered with broken oxygen concentrators, many of which were donated by well-meaning people in rich countries.
At dawn, on the day of our alpine ascent, as the rope is getting ready, one thing is clear: Low-income countries are not equipped as we are. Hospitals there are not able to treat all their patients with respiratory problems, be it COVID-19 patients or children with pneumonia. Like mountaineers preparing for an ascent, solutions must be found to ensure that all members of the rope have access to oxygen.
The EssentialTech Centre at EPFL has launched a project in close collaboration with the EssentialMed foundation and the Centre for Public Health and Development in Kenya to develop an oxygen concentrator adapted to the context of these countries. There are two key aspects to the challenge. The technology: minimizing energy consumption; allowing uninterrupted operation during power outages, and ensuring the device can operated in hot, humid and dusty environments. But the technology is nothing without a sustainable business solution. Attention must be paid to user training, maintenance of equipment, supply of consumables such as filters, and local repair in the event of a breakdown. And all this must come at a cost that is affordable. Overburdened health systems in these countries must be able to pay for oxygen over the long term with their limited means.
There are many initiatives underway, supported by caring people, to improvise low-cost medical equipment to deal with the COVID-19 epidemic: a group of enthusiasts is being brought together on a website and online ‘recipes’ for building ventilators and concentrators are being developed. These approaches—while well-intentioned—do not address the fundamental and complex issues faced by health systems in poorer countries where users need high quality training, infrastructure needs to be up and running, maintenance and repair solutions need to be available, spare parts need to be accessible and so on. In addition, there is the ethical issue: many sites offering such recipes are in fact relieving themselves of responsibility in the event of malfunction.
At our center, we have been working to develop essential technologies adapted to the context of poor countries for almost 10 years, including digital X-ray equipment, incubators for premature babies, water treatment equipment - the challenges are immense. In the course of our work, we have learned that, just as in the mountains, there are no shortcuts! It is essential to consider all aspects of the problem, such as manufacturing, transportation, commissioning, user training, maintenance and repair. A holistic approach considers all elements of the product life cycle, as well as the resources actually available locally. We do this by working closely with the key players in the regions concerned.
Let us get back to our team of climbers. The first person on the rope has good equipment, is well trained, well fed and has prepared for the difficult climb. The team members in the middle of the rope— our middle-income countries—are struggling with medium quality equipment. At the back of the rope—the poorest countries—are barefoot and without ice axes or warm clothes. It is clear that not only will our party fail to reach the summit, but the entire rope team is at grave risk.
Now more than ever, and beyond the current crisis, we must mobilize to strengthen the health systems of low- and middle-income countries: oxygen is just one glaring example, highlighted by the current COVID-19 pandemic, of the difficulties these countries face. Supporting these health systems is not only a moral obligation, but also an intelligent investment in the security and progress of our own societies. Innovation can be an extraordinary lever if we take the trouble to enter into a true partnership with the last man on our rope. Robust, modern and cheap solutions developed in partnership with poor countries are also beneficial and attractive in our own countries, where health costs are exploding. The last of the roped party may then be strong and happy companions in our common ascent.
Acknowledgements to Gene Saxon of the EssentialTech Centre and Gerard Escher of EPFL for their help in revising the manuscript.