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Summary

When designing Firefly newborn phototherapy with East Meets West Foundation and Vietnamese manufacturing partner MTTS, we used the human-centered design process to create an environmentally friendly product that truly benefits people living in poverty. The resulting Firefly device:

- Lasts for five years, avoiding the medical equipment junkyard seen in so many low resource hospitals.


- Has no disposable or consumable parts, eliminating unaffordable, ongoing costs which put most medical devices out of service.


- Uses twenty times less energy than the most popular LED phototherapy lamp used in the United States, reducing the electricity bill for poor hospitals while using less of the planet's resources.

Human-centered design enabled us to integrate disparate design inputs ranging from user preferences to environmental impact. The resulting device saves lives today while enabling a better tomorrow.

When designing Firefly newborn phototherapy with East Meets West Foundation and Vietnamese manufacturing partner MTTS, we used the human-centered design process to create environmentally friendly products that also benefit people living in poverty. Human-centered design (HCD) is a process in which the needs, wants, and limitations of end users and other stakeholders of a product are given extensive attention at each stage of the design process. During the Firefly design process, Design that Matters used HCD techniques including interviews and observations to understand the needs of healthcare providers, parents and newborns as well as our manufacturing and implementation partners. Especially for entrepreneurs focused on lifting people out of poverty in developing countries, the environment can seem like a luxury consideration in the face of meeting basic necessities like food, water, and energy. We enabled our partners to put saving newborn lives at the center, and in doing so, yielded a device that lasts longer, has no disposable parts, and uses 20 times less energy than the most popular overhead LED phototherapy lamp used in the United States. Our Firefly partners found using human-centered design was a natural process to simultaneously consider many requirements including environmental sustainability.

Avoiding the Medical Equipment Junkyard

Through interviews with healthcare providers and observations of the hospital environments in Vietnam, India, Nepal, Indonesia, and the Philippines, we noticed every hospital had a junkyard of broken medical equipment. Most anyone working in global health has seen this phenomenon.

"At one hospital, a physician may show you a donated anesthesia machine that worked once before it broke (true story); at another, an administrator will open the door to a spare room dedicated to storing broken and inoperable equipment: the 'medical device graveyard' of the hospital." —Mike Meisen, Gradian Health Systems, posted on Why.Dev

In fact, the World Health Organization estimates that up to 80% of donated medical equipment in the developing world is never even turned on. Most equipment that reaches developing countries is designed for a Western context which presupposes air-conditioned facilities, filtered air, no bugs, easy access replacement parts, and surge-protected wall power. Staff we interviewed in low resource hospitals reported the most common phototherapy lamp failures are: burnt-out halogen light bulbs (which are expensive and not locally available), power surges (which fry the electronics), and other unknown malfunctions that render the devices useless. As we began the Firefly design effort, we also used HCD techniques to gather feedback from our manufacturing partner who has over a decade of experience designing, manufacturing, installing, and repairing newborn health equipment in low resource hospitals. We asked them to tell stories from the field while giving us a tour of the inside and outside of their existing equipment, a classic HCD technique that helps people remember past experiences. One of the most striking observations was that the electronic cooling fan is often the first thing to break, causing devices to overheat and burn out.

A typical medical equipment junkyard outside a hospital in Kathmandu, Nepal.

In response, we designed a device that could last as long as possible in the rugged environment of a low resource hospital. The resulting Firefly device has no cooling fan and no other movable parts, which are the first to break. Instead, we designed a novel passive cooling system to keep the electronics running at peak performance. In place of halogen light bulbs that last months, we selected LEDs that last five years without need for replacement. We designed a robust, thick shell for the top light and the bottom light, and used it to seal the device from most dust and bugs. Finally, we added an external power supply that can even out most power surges. To-date Firefly devices have collectively received over thirty-five years of use in Vietnam, Myanmar, Ghana, and four other developing countries without reports of equipment failure. Firefly avoids the junkyard, allowing us to save millions more newborn lives.

From left to right: A mother waits while Firefly treats her newborn in Vietnam; the LED lights inside the bottom of Firefly.

From left to right: Firefly's thick plastic shell; the metal heat sink is the cornerstone of the passive cooling system for the bottom Firefly electronics.

Saving Energy Where It's Scarcest

According to SAPIENS, as of 2009 at least 1.6 billion people—one-fourth of the world's population—currently live without electricity and this number has hardly changed in absolute terms since 1970.

Between 1850 and 2005, overall energy production and use grew more than 50-fold—from a global total of approximately 0.2 billion to 11.4 billion tons of oil equivalents (IEA, 2007). We are simultaneously maxing out our global energy capacity, while billions of people live in poverty because they still lack access to the grid. Design that Matter's mission is to use design and technology to improve the well-being of those living in poverty. The 2006 World Wildlife Federation Footprint and Human Development diagram neatly shows the dichotomy between those who have and those who have not.

Original image source: WWF, Living Planet Report, 2006

While shadowing healthcare providers (an HCD technique), we uncovered attitudes around scarce and expensive electricity that lead to ineffective phototherapy treatment. As we looked over the shoulder of doctors and nurses setting up phototherapy treatment, we noticed most chose the lowest power setting. The American Academy of Pediatrics specifies standard, low power treatment at 10 µW/cm2 per nm, and intensive treatment at 30 µW/cm2 per nm for newborns with severe jaundice. Jaundice presents as a more severe condition in low resource contexts where many families give birth at home and have limited or no follow up visits. By the time a baby is taken to see the doctor, often jaundice has been given more time to progress and is already severe. As phototherapy dims over time, the low power mode is the first to dip below the level of effective therapy. In addition, many more newborns should receive intensive level phototherapy, but were slipping through the cracks. When asked, many providers said they always used the lowest setting because they wanted to save energy.

Luciano Moccia of East Meets West Foundation measures 6.6 µW/cm2/nm irradiance from an overhead halogen bulb phototherapy device in Myanmar. A level of 10 µW/cm2 per nm provides minimal effective phototherapy, while 30 µW/cm2 per nm is intensive level required to treat severe jaundice. Firefly provides 34 µW/cm2/nm from the bottom and 23 µW/cm2/nm from the top. Photos courtesy East Meets West Foundation / Thrive Networks.

Using another HCD technique, we asked our manufacturing and implementation partners to tell us stories and show us pictures from recent visits to the field. Both partners told us stories of visiting yet another hospital that had many light-producing phototherapy devices that, when measured, were so dim as to not provide effective treatment. Unfortunately, the most commonly available overhead phototherapy in low resource hospitals has halogen bulbs which dim in a matter of months while still giving the impression of being able to treat newborns. Unknowing healthcare providers with no time or means to measure the devices, continue to place babies under the lights on low power to save energy.

In response, we sourced state-of-the-art LED lights that provide effective-level phototherapy for five years, and we offer only one power setting: high. Firefly uses twenty times less energy than the most common overhead LED device used in the United States. We not only provide lighting from the top, but also from the bottom, treating newborn jaundice nearly twice as fast! Firefly returns babies more quickly to the safer home environment where they can better bond and breastfeed with their mothers. Our manufacturing and implementation partner has received CE Mark approval for Firefly that enables it to be distributed in Europe and the United States. In 2014, Firefly received the Green Good Design Award in recognition of organizations and products that have forwarded exceptional thinking and inspired greater progress toward a more healthier and more sustainable universe. Using HCD, we found a great opportunity to save energy, save money for hospitals, and save millions of lives!

Building HCD Capacity to Go Green for Low Resource Settings

In June 2014, I facilitated part of the Inventing Green Workshop hosted by the Lemelson Foundation. Over two days I had the opportunity to work side by side with leaders in education and business incubation from India, Indonesia, Peru, and the United States exploring how to equip technology inventors to consider environmental impact in all of their designs. I presented our experience with East Meets West Foundation and MTTS using the HCD process to include environmental concerns while keeping newborn lives as the center. For those focused on improving the well-being of people living in poverty, the Firefly case study generated interest and discussion. How do we convince entrepreneurs working in developing countries, who have big dreams and little financing, to add environmental sustainability to their long list of constraints? How might we create a compelling case for environmentally sustainable technology serving the poor? Once convinced, how might we create non-invasive, uncumbersome tools that bootstrapped entrepreneurs can use to consider the environmental impact during their design process?

For the business incubators from India, Indonesia, and Peru, it's not just about finding the right green design tools, it's about first making the case for environmental sustainability appealing to their entrepreneurs. Indeed, many in international development view environmental movements as being anti-development. For example, coal is often the only source of energy for many living in poverty. In many parts of the world, fossil fuels are still vital and will be for the next few decades, because they are the only means to lift people out of the darkness of energy poverty.

During the Firefly design experience, we didn't have to convince our manufacturing and implementation partners to value environmental design from the outset, we just had to uncover needs together utilizing the HCD process. In this way, following the HCD process simultaneously solved both the why and the how of environmental sustainability for our manufacturing and implementation partners as we created the long-lasting and energy-efficient Firefly design together. How might we build HCD capacity locally so many more entrepreneurs in developing countries can create green designs that lift people out of poverty?

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This "Design Experience that Matters" series is provided courtesy of Timothy Prestero and the team at Design that Matters (DtM). As a nonprofit, DtM collaborates with leading social entrepreneurs and hundreds of volunteers to design new medical technologies for the poor in developing countries. DtM's Firefly infant phototherapy device is treating thousands of newborns in 21 counties from Afghanistan to Zimbabwe. In 2012, DtM was named the winner of the National Design Award.