On a summer afternoon, Jose Gomez-Marquez stands in the middle of a Family Dollar store, loading up his basket with colorful plastic toys. Down the aisle, two of his MIT students, Valentina Chamorro and Madeline Aby, are rummaging through kitchen supplies, deciding whether to buy an acrylic toothpick holder. “Remember, it’s only a dollar,” Gomez-Marquez says. “You might not know what you’re going to use it for now, but it’ll cost more than a dollar for us to come back here.”
Gomez-Marquez and his students aren’t shopping for goods so much as ideas. As head of MIT’s Little Devices Lab, Gomez-Marquez invents unconventional, affordable medical technologies for communities in need, replicating the functionality of hundred-thousand-dollar laboratory robotics with Lego Mindstorms kits and cheap, open-source Arduino circuits.
On this particular Thursday, he and his students are searching for ways to improve the humble pill bottle. “If we have a pill bottle, what do we care about?” he asks Aby and Chamorro. “We care about alerting people to use it. We care about whether it’s accessible. Can everybody read it? How would you prevent somebody from overdosing? Look around for things that you can hack the bottle with,” he urges. “Imagine we don’t have parts in the lab. If we were in Nicaragua, we might not even have a lab, but we would have a store like this.”
Aby picks up a toy phone that buzzes and beeps when the buttons are pressed, components that might be harvested for an alarm. Chamorro chooses a box of sequins, which can be glued on the bottle to make the labeling braille. Gomez-Marquez selects a pinball-style candy dispenser that might entice a hesitant child to take his medicine.
None of these innovations will individually revolutionize health care in Central America or Africa, but together they amount to a radical departure from the top-down initiatives that the World Health Organization has prescribed for decades. Gomez-Marquez calls it “supply chain arbitrage” — modifying existing materials to improve people’s lives today.
“The gridlock that exists in public health is ridiculous,” he argues. “Do you try to change the whole system, or do you work within the system and try to usurp it with technology?” Gomez-Marquez believes that modifying a pill bottle — and helping locals to do so for themselves — is a powerful way to change the ground rules of health care.
Over the past few years, Gomez-Marquez — without a professorship, doctorate or even a bachelor’s degree — has converted some prominent researchers, including Harvard Medical School virologist Lee Gehrke. “The DIY stuff that Jose does forces us to think that you don’t have to do things expensively,” Gehrke says.
And Gomez-Marquez is having fun doing it on the cheap. “I don’t know many people who can buy a lot of toys with their lab budget,” he says, handing his school credit card to the cashier. “It drives the MIT accountants crazy.”
Born to Build
The unlikely career of Jose Gomez-Marquez began with the distinct likelihood that he would die. Medical technology — or the lack of it — was to blame. In 1976, he was born months ahead of schedule at a hospital in Honduras, prematurely induced because the doctors didn’t have ultrasound and assumed his mother was carrying twins. His intestine collapsed as he took his first breath, requiring immediate surgery. “My family was on the fence about whether to let me live,” he says. “My grandfather was the director of the hospital, and basically said, ‘We’ll bury him in the morning.’ ” They bought the boy a coffin.
The surgery was successful. But his body was fragile, giving him ample opportunity to observe Central American health care firsthand as a child. He became interested in health care gadgets and, eventually, decided to become an engineer. A Rotary Foundation scholarship funded his way to Georgia Tech, Oglethorpe University and then to Louisiana State, where he was studying mechanical engineering when Hurricane Mitch struck in 1998. “The hurricane decimated Honduras,” says Gomez-Marquez. “It also decimated my parents’ finances.” He and his sister (who was also studying in the U.S.) would have had to go home, but the American government offered refugee status to all Hondurans giving them the right to work.
At about the same time, a conversation he had with some Honduran friends provided the impetus to persevere in the U.S. “They were well-off, not in the position we were in,” he recalls. “Their moms and dads ran the country, and they were going to be the captains of industry.” The group was chatting about what technology could do for development, and Gomez-Marquez remarked that simply by installing a CD-ROM in a small village, you could provide a whole library of resources. “They all said, ‘Why would you want to do that? All you’re going to achieve is that they’ll know what they can never have.’ ” As soon as the conversation ended, Gomez-Marquez turned to his sister and remarked, “I knew there was a disparity between the classes, but they really don’t give a shit about the poor.”
Without the family wealth his friends enjoyed, Gomez-Marquez ended up quitting college for a series of marketing jobs, falling back on the computer skills he’d picked up in high school. By 2001, he was earning enough to save a little money. But he was deeply unhappy, frustrated to be drifting ever further away from engineering.
"Do you try to change the whole system, or do you work within the system and try to usurp it with technology?"
In 2004, Gomez-Marquez moved to Boston to study engineering at Worcester Polytechnic Institute. He supplemented his savings by temping. A few businesses wanted to hire him as a full-time marketer, but he resisted. He scoured the city for engineers who shared his ideals. He found them at an MIT meetup in 2005.
It was a gathering for an annual contest then called the MIT IDEAS Competition, in which teams tackled big problems in the developing world. Nonprofit organizations in fields ranging from public health to water management presented problems that might be addressed with technology. Teams could choose any problem, or come up with one of their own based on what they saw in the news. The team Gomez-Marquez joined decided to crack the problem of vaccinating children for measles without a needle. His team’s solution was to nebulize the vaccine with a bicycle pump. Unlike injections, which require more skill to administer, an aerosol system delivers the vaccine through inhalation and can be operated by anyone with minimal training. Their concept won the competition’s Lemelson-MIT Award for International Technology.
Gomez-Marquez entered again in 2006. The new challenge was of a different order: To treat tuberculosis effectively, a daily dose of medication must be administered consistently for at least six months. But the symptoms disappear much sooner, so many patients stop taking their pills midcourse. They then suffer a relapse far more difficult to treat than the initial infection. (As with all bacterial infections, not finishing treatment allows some tuberculosis microbes to survive, evolving resistance.) In many developing countries, the standard solution has been to send community health workers into villages to verify patient compliance. But absenteeism is high. According to a study conducted in India, for example, health workers skip work 43 percent of the time. Another study suggested 88 percent of nurses at some remote clinics were MIA during work hours. The challenge posed to Gomez-Marquez and his colleagues was to ensure that more patients took the full course of meds.
For the non-government organization (NGO) that brought the challenge to MIT, the obvious approach was to improve management of community health workers through some kind of logistical software. Gomez-Marquez was skeptical. “I realized this was no longer the romantic ideal of workers devoted to community health,” he says. “It was people not wanting to do their job.” He and his teammates probed deeper, learning that the medication makes patients’ sweat and urine redden.
“That’s what did it for us,” he recalls. “What if we could remotely track whether people’s sweat or urine was red?” They found reagents that would chemically react with the urine of someone medicated for TB, turning blue on contact. Spots of the substance were selectively applied to a strip of filter paper printed with numbers; medicated urine would highlight some of the digits but not others. Supplied with these cheap paper diagnostics, the patient could text these codes daily to a central database and be rewarded with cell phone minutes for doing so.
The NGO was not pleased — the team essentially created a workaround that made the community health workers they were funding irrelevant. “They took it as an affront,” says Gomez-Marquez. But the judges loved it, giving Gomez-Marquez his second Lemelson award. “To me, that was great because it’s inventing something that challenges the establishment,” he says. “It’s using technology to hack the system.”
At about the same time that Gomez-Marquez was working on the tuberculosis challenge, MIT was developing an Innovations in International Health program (IIH). The fledgling enterprise needed an organizer willing to work as a volunteer and scramble for funding. “Jose was really good at finding strategic partnerships,” recalls Laura Sampath, who was managing MIT’s International Development Initiative at the time. “Also, he’s particularly gifted at problem identification. He sees problems differently from the beginning, and then he’s able to see the problem through to a solution.” With two Lemelson awards behind him, and a willingness to do practically anything, Gomez-Marquez was appointed IIH director and given a lab.
It was actually a small storage space next to a loading dock, but the exposed pipes served as makeshift racks from which he could hang his TB diagnostic filter papers to dry. “The lab was a simulation of the developing world,” he remarks. “I realized that if we could make diagnostics in a place like this, we could make them anywhere.”
Maker Mecca
Gomez-Marquez no longer works in a storage space with exposed water pipes. His lab is situated inside MIT’s International Design Center, equipped with the latest generation of 3-D printers and laser cutters.
He moved into the lab, dubbed Little Devices, to devote himself full time to designing in 2012. Without Gomez-Marquez to run it, IIH was discontinued.
In this clean, modern space, toys, most of them dismantled, are scattered everywhere, along with pregnancy tests (taken apart to see how the diagnostics are packaged), glue guns, soldering irons and a lab robot made largely of multicolored Legos.
The robot was designed and assembled in a couple of days by one of Gomez-Marquez’s students. A foot-tall Lego tower holds a syringe, controlled by some plastic gears, standing astride a homemade plotter powered by motors scavenged from old computer printers. The contraption precisely deposits droplets of chemical reagent onto filter paper. The prepared paper can be used in the field to detect pathogens in blood, meaning that any clinic in the world can make quality paper diagnostics for diseases such as malaria and dengue fever with a few hundred dollars in parts. The professional machine it replaces, called a liquid handler, costs $100,000.
That sort of democratization makes all the difference, according to Gomez-Marquez. He contrasts his diagnostics success with his measles vaccination nebulizer experience. Despite winning the Lemelson prize in 2006, the aerosol vaccine was shelved. It has never been used to inoculate a child. “Immunization is a top-down system, where you have to convince the ministries of health,” he says. “With the paper diagnostics and patient monitoring, we can start with a single clinic.”
"I realized that if we could make diagnostics in a place like this, we could make them anywhere."
And because so much of it is DIY, the clinic can take the lead, with Gomez-Marquez playing only a supporting role. “The NGOs come here with a solution, and we don’t need that,” says Miguel Orozco, director of the Center for Research and Health Studies at the National Autonomous University of Nicaragua, one of Gomez-Marquez’s local partners. “We have our own problems. Jose comes here and says, ‘You can solve them, too. You don’t need other people.’ ”
“He’s somebody who really makes innovation accessible to people who wouldn’t think they could be part of the process, particularly in low-resource settings,” adds Massachusetts General Hospital doctor Kristian Olson. A few years ago, Olson built an incubator for infants out of off-the-shelf car parts. Now he and Gomez-Marquez collaborate on a TB compliance system in Ethiopia: a personal low-power refrigerator to keep patients’ meds cool.
The refrigerator uses cell phone technology to alert medical workers when the patient fails to open it on schedule, a simple idea that hasn’t been so easy to implement. When they first went to Ethiopia with a prototype in 2011, nothing worked as planned. Arduino circuits burned out, the mobile network was incompatible with their cellular equipment, and even the red LED, which indicated that the unit was functional, had to be replaced because the color spooked local patients. “You have to break it locally,” Gomez-Marquez reflects. “You only figure out what has to change by having things go wrong.”
The prototype has since been redesigned inside and out, in collaboration with engineers whom Olson and Gomez-Marquez met at Addis Ababa University, a process that’s been fruitful both technically and psychologically. “Jose’s ethos of engaging people in their own solution stimulates people to be invested in it far more than air-dropping some technology,” Olson observes. “There’s something about being engaged with the process that helps with enthusiasm and uptake.”
De-Construction
Up on the tar-papered roof of MIT’s International Design Center, Anna Young struggles against the wind to secure a parabolic mirror to a scaffold of metal pipes. The pipes support a pressure cooker wrapped in refrigerator insulation. The Solarclave is Young’s idea — a sun-heated portable autoclave that can sterilize surgical implements in village clinics — which she first emailed Gomez-Marquez about five years ago. Gomez-Marquez invited her to his lab, and the two of them have been collaborating ever since.
Gomez-Marquez calls the Little Devices Lab an “institutional hackerspace.” Having hacked his way into the MIT system, he now wants to share his resources. “When you’re not a student, it’s really hard to work on a project like this, even if you have a garage,” says Young. Little Devices has plenty of space. Yet the most valuable resource is Gomez-Marquez’s instinct.
Young originally designed the Solarclave for efficiency — working on the optimal system for sterilizing medical instruments without an external power source — but repeated trips to Central America showed that efficiency came at a cost. The more perfectly she insulated the pressure cooker, the less comfortable nurses were in adjusting it to work in their specific environment. “The insulation turned it into a black box,” says Young, using the engineering term for systems that are incomprehensible to outsiders. “Everything becomes a black box very easily for these nurses because they’re not accustomed to being able to modify things.”
“What I’ve tried to add is user hackability,” says Gomez-Marquez. The insulation has been substantially cut back, and the welded support structure has been replaced with one inspired by a box of Tinkertoys. Up on the windy roof, Young is attempting to make the adjustable framework sturdy. It’s a first step toward a kit that can be assembled from local supplies and modified by the individual end user.
Gomez-Marquez has come to believe that the greatest challenge, with the greatest potential impact, is to become a meta-designer. “What if the whole point is not to be the best designers of these devices?” he muses. “What if we make a set of parts and see how people put them together?”
The difficulty of doing so couldn’t be more apparent as he watches Young labor to assemble the Tinkertoy Solarclave. “Ikea furniture is very intuitive to construct, but it’s a very linear construction,” he says. “The harder problem is to design something not knowing how people are going to use it. You have to open up the degrees of freedom, the pathways to different scenarios. You also need some structure, or people get lost.” He pauses to twist a pipe.
“If you open it up just the right amount, though, they’ll follow those pathways and hopefully they’ll hack those pathways as well,” he says. “And then you realize they fully own the technology, because they’re not relying on how you did it.”
[This article originally appeared in print as "Nothing But a Hack."]
