about the design of medical technology for low-resource settings.

本日お話するのは

I study health systems in these countries.

資源が乏しい環境での医療技術のデザインについてです

And one of the major gaps in care,

低資源環境国の医療機器を研究しています

almost across the board,

全体的にみて例外なく

is access to safe surgery.

最も大きな差がでる事の一つは

Now one of the major bottlenecks that we've found

安全に手術ができるかどうかです

that's sort of preventing both the access in the first place,

判明した主要なボトルネックのひとつは

and the safety of those surgeries that do happen, is anesthesia.

そもそも手術ができるかどうかと

And actually, it's the model that we expect to work

手術できた場合には手術中に

for delivering anesthesia in these environments.

安全に麻酔がかけられるかどうかです

Here, we have a scene that you would find in any operating room across the US,

そこで 考えたのは

or any other developed country.

厳しい環境で麻酔をかけられる

In the background there

装置の仕組です

is a very sophisticated anesthesia machine.

こちらは米国や他の先進国では

And this machine is able to enable surgery and save lives

よく見る典型的な手術室の光景です

because it was designed with this environment in mind.

奥には非常に高性能な

In order to operate, this machine needs a number of things

麻酔器があります

that this hospital has to offer.

この機械には手術を可能にし

It needs an extremely well-trained anesthesiologist

人命を救う力があります

with years of training with complex machines

先進国の環境を前提にして

to help her monitor the flows of the gas

設計されたので洗練されています

and keep her patients safe and anesthetized

この機械を動作させるには病院側で色々と

throughout the surgery.

準備する必要があります

It's a delicate machine running on computer algorithms,

この複雑な機械の使用には長年に渡る厳しい訓練を

and it needs special care, TLC, to keep it up and running,

受けた麻酔医が必要になります

and it's going to break pretty easily.

手術中ずっとモニターを監視しながら

And when it does, it needs a team of biomedical engineers

患者を安全に麻酔状態に保てる

who understand its complexities, can fix it, can source the parts

麻酔医でなくてはいけません

and keep it saving lives.

麻酔器はコンピュータアルゴリズム制御の非常に繊細な機械で

It's a pretty expensive machine.

簡単に壊れてしまうため長く使用するには

It needs a hospital whose budget can allow it

特別に優しく配慮する必要があります

to support one machine costing upwards of 50 or $100,000.

壊れてしまうと機械の複雑さや壊れる箇所を知っていて

And perhaps most obviously,

修理できて修理部品を調達できて

but also most importantly --

生命を救える状態にできる

and the path to concepts that we've heard about

生物医学技師のチームが必要です

kind of illustrates this --

麻酔器はかなり高くつく機械なのです

it needs infrastructure that can supply an uninterrupted source of electricity,

麻酔器を１台使うのに

of compressed oxygen, and other medical supplies

病院側の予算としては

that are so critical to the functioning of this machine.

5万超か10万ドルは必要になります

In other words, this machine requires a lot of stuff

そして その中でもおそらく

that this hospital cannot offer.

最もはっきりして最も重要なのは

This is the electrical supply for a hospital in rural Malawi.

紹介した機能概念からなんとなく

In this hospital,

お分かりかと思いますが

there is one person qualified to deliver anesthesia,

インフラが必要ということです

and she's qualified

インフラによって

because she has 12, maybe 18 months of training in anesthesia.

絶え間の無い電力供給や 圧縮酸素や

In the hospital and in the entire region

医療用品などの

there's not a single biomedical engineer.

麻酔器の稼働に

So when this machine breaks,

非常に不可欠なものを提供します

the machines that they have to work with break,

言いかえれば 麻酔器は画像の様な病院では支えきれない

they've got to try and figure it out,

多くの資源を必要とします

but most of the time, that's the end of the road.

この画像はマラウイの地方病院に

Those machines go the proverbial junkyard.

電源供給している配電盤です

And the price tag of the machine that I mentioned

この病院には有資格の

could represent maybe a quarter or a third

麻酔科医が一人います

of the annual operating budget for this hospital.

この彼女は 12カ月もしくは18カ月の

And finally, I think you can see that infrastructure is not very strong.

麻酔研修を受けているので

This hospital is connected to a very weak power grid,

資格がありふさわしい人です

one that goes down frequently.

この病院にもこの地域全体としても

So it runs frequently, the entire hospital,

生物医学技師はひとりもいません

just on a generator.

麻酔器が故障したら 使用する麻酔機械が

And you can imagine, the generator breaks down

壊れたら なんとか問題を突き止めようと

or runs out of fuel.

努力しますがほとんどの場合には なす術がなくなります

And the World Bank sees this

故障した麻酔器は地区の廃棄場に捨てられます

and estimates that a hospital in this setting in a low-income country

この話の麻酔器の価格は

can expect up to 18 power outages per month.

おそらくこの病院の年間予算の

Similarly, compressed oxygen and other medical supplies

4分の1ないし3分の1に

are really a luxury,

匹敵します

and can often be out of stock for months or even a year.

ここまでくれば インフラがそれほど良くないと分かると思います

So it seems crazy, but the model that we have right now

この病院が使用する貧弱な電源網では

is taking those machines that were designed

頻繁に電源供給が停止します

for that first environment that I showed you

病院全体がただひとつの発電機に

and donating or selling them to hospitals in this environment.

依存することが頻繁に起こります

It's not just inappropriate,

想像にやすいですが 発電機が故障したり

it becomes really unsafe.

燃料が無くなったりします

One of our partners at Johns Hopkins

世界銀行の試算によれば

was observing surgeries in Sierra Leone about a year ago.

低所得国のこのような環境の病院では

And the first surgery of the day happened to be an obstetrical case.

ひと月に18に及ぶほどの停電が

A woman came in, she needed an emergency C-section

発生する可能性があります

to save her life and the life of her baby.

同様に圧縮酸素やほかの医療用品は

And everything began pretty auspiciously.

とても高価なもので

The surgeon was on call and scrubbed in.

時には何カ月や一年に渡ってまで

The nurse was there.

手元にないことがありえます

She was able to anesthetize her quickly, and it was important

全くおかしな状況ではありますが

because of the emergency nature of the situation.

現在の援助の仕方では

And everything began well

先進国の環境ようにデザインされた

until the power went out.

麻酔器を乏しい環境にある病院に

And now in the middle of this surgery,

寄付したり販売しているため

the surgeon is racing against the clock to finish his case,

環境適合ができないばかりか

which he can do -- he's got a headlamp.

安全性も著しく損なわれます

But the nurse is literally running around a darkened operating theater

1年ほど前にジョン・ホプキンス大学病院の

trying to find anything she can use to anesthetize her patient,

共同研究者がシエラレオネの

to keep her patient asleep.

外科医を調査しました

Because her machine doesn't work when there's no power.

その日の最初の手術はたまたま産科の手術でした

This routine surgery that many of you have probably experienced,

女性が運ばれてきて母子の命を救う為には

and others are probably the product of, has now become a tragedy.

帝王切開が必要でした

And what's so frustrating is this is not a singular event;

手術はさい先良く始まりました

this happens across the developing world.

外科医は待機して洗浄を済ませ入室しました

35 million surgeries are attempted every year

看護師も待機していました

without safe anesthesia.

麻酔医は迅速に麻酔をかけました

My colleague, Dr. Paul Fenton, was living this reality.

緊急手術を行う性質から考えて迅速さは重要でした

He was the chief of anesthesiology

停電してしまうまでは

in a hospital in Malawi, a teaching hospital.

全てが順調なすべりだしでした

He went to work every day

手術のまっただなかで

in an operating theater like this one,

外科医はこの手術を終わらせるべく一刻を争って駆け続けます

trying to deliver anesthesia and teach others how to do so

頭部の手術灯があるから続けられます

using that same equipment

看護師は真っ暗になった手術室で

that became so unreliable, and frankly unsafe, in his hospital.

患者の麻酔を継続させて患者が麻酔状態を保つように

And after umpteen surgeries

正に駆けまわりながら

and, you can imagine, really unspeakable tragedy,

何かが無いか探します

he just said, "That's it. I'm done. That's enough.

麻酔器は電源が断たれると動作しないからです

There has to be something better."

ここにいる医師の皆さんが日常的に行っている手術 もしくは

He took a walk down the hall

この術式によって誕生できた人もいる手術が

to where they threw all those machines that had just crapped out on them,

悲劇となってしまいました

I think that's the scientific term,

途上国ではこんなことが１回限りの偶然ではなく

and he started tinkering.

日常的に起こっています

He took one part from here and another from there,

安全な麻酔が無い中でのこのような手術が

and he tried to come up with a machine that would work

毎年3500万件も行われています

in the reality that he was facing.

同僚のポール・フェントン医師は

And what he came up with:

こんな手術を続けていました

was this guy.

彼はマラウイの病院で麻酔医長をしています

The prototype for the Universal Anesthesia Machine --

この病院は研修指導病院です

a machine that would work and anesthetize his patients

毎日働きに行き病院の

no matter the circumstances that his hospital had to offer.

画面に出ている公開手術室で

Here it is, back at home

毎日麻酔をかけ 研修者が患者に麻酔をかけられるよう指導します

at that same hospital, developed a little further, 12 years later,

彼の病院にある

working on patients from pediatrics to geriatrics.

安定を大きく欠いた 安全性のない

Let me show you a little bit about how this machine works.

同じ種類の麻酔器を使ってです

Voila!

数えくれないくらいの手術をして

Here she is.

語り切れないほどの悲劇を目の当たりにして 彼は言いました

When you have electricity,

「もういい やめだ もうこりごりだ

everything in this machine begins in the base.

何かもっといい方法があるはずだ」

There's a built-in oxygen concentrator down there.

彼は病院の廊下を歩き これまでの手術を

Now you've heard me mention oxygen a few times at this point.

台無しにした壊れた機械の廃棄所に来ました

Essentially, to deliver anesthesia, you want as pure oxygen as possible,

これは科学的な試みの時間と思いました

because eventually you're going to dilute it, essentially, with the gas.

彼はただただ色々いじりはじめました

And the mixture that the patient inhales

彼はここからそこから部品部品を集めて

needs to be at least a certain percentage oxygen

直面している現実環境でも動作する

or else it can become dangerous.

機械を創りだそうとしていました

But so in here when there's electricity,

そして彼が作ったのがこれです

the oxygen concentrator takes in room air.

「どこでも麻酔器」の試作品です

Now we know room air is gloriously free,

どのような病院環境であっても

it is abundant,

動作し患者に

and it's already 21 percent oxygen.

麻酔をかけることができる機械です

So all this concentrator does is take that room air in, filter it

12年間を経て先程の病院に

and send 95 percent pure oxygen up and across here,

多少なりとも発展した麻酔機が帰ってきました

where it mixes with the anesthetic agent.

小児科から老年科の患者に対して使われています

Now before that mixture hits the patient's lungs,

さぁどんな風にしてこの機械が動くのかご紹介します

it's going to pass by here -- you can't see it,

ジャーン

but there's an oxygen sensor here --

これがそうです

that's going to read out on this screen the percentage of oxygen being delivered.

電源がある場合には全ての

Now if you don't have power,

動作は下の方から開始されます

or, God forbid, the power cuts out in the middle of a surgery,

内蔵型酸素圧縮機が下の方についています

this machine transitions automatically,

酸素については既に何度か言及してきましたよね

without even having to touch it,

麻酔をかけるには基本的に

to drawing in room air from this inlet.

できるかぎり純度の高い酸素が必要です

Everything else is the same.

最終的にはその酸素を麻酔ガスと

The only difference is that now

混ぜて使用するからです

you're only working with 21 percent oxygen.

患者が吸入する際には

Now that used to be a dangerous guessing game,

酸素濃度が一定値に達していないと

because you only knew if you gave too little oxygen

患者にとってガスが危険なものにもなります

once something bad happened.

この機械は電源がある場合には

But we've put a long-life battery backup on here.

酸素圧縮機が部屋の空気を取り込みます

This is the only part that's battery backed up.

部屋の空気は見事なほどに無料だと分かっていますし

But this gives control to the provider, whether there's power or not,

豊富にあり しかも必要な

because they can adjust the flows

21パーセントの酸素を既に含んでいます

based on the percentage of oxygen they see that they're giving the patient.

圧縮機が行うのは手術室の空気を取り込み清浄し

In both cases, whether you have power or not,

濃度95パーセントの酸素を

sometimes the patient needs help breathing.

上へ送り ここら辺で

It's just a reality of anesthesia, the lungs can be paralyzed.

麻酔物質と混ぜ合わせます

And so we've just added this manual bellows.

この混合物が

We've seen surgeries for three or four hours

患者の肺に入る前に

to ventilate the patient on this.

この部分を通って

So it's a straightforward machine.

見えませんがここに酸素センサがあり

I shudder to say simple; it's straightforward.

供給されている酸素濃度を

And it's by design.

画面に映し出して示します

You do not need to be a highly trained, specialized anesthesiologist

もし電気が使えない場合には また

to use this machine,

起きないと良いですが 手術中に電源が切れた場合でも

which is good because, in these rural district hospitals,

何かを操作する必要も全くなく

you're not going to get that level of training.

自動的にモードを切り替えて

It's also designed for the environment that it will be used in.

部屋の空気をここから取り入れるようになります

This is an incredibly rugged machine.

空気の取入以外は変化しません

It has to stand up to the heat and the wear and tear

その唯一の違いは

that happens in hospitals in these rural districts.

21パーセントの酸素を相手にしていることです

And so it's not going to break very easily,

給気はかつてはあてずっぽうで危険でした なぜなら何かが

but if it does, virtually every piece in this machine

悪化するまで酸素が足りなかったことが分からなかったのです

can be swapped out and replaced

大容量バッテリーをここに入れるようにしました

with a hex wrench and a screwdriver.

ここだけがバッテリを予備電源としています

And finally, it's affordable.

予備で電源を加えましたが濃度計があるので

This machine comes in at an eighth of the cost

電源が有っても無くても

of the conventional machine that I showed you earlier.

手術中に酸素濃度を見て 給気を制御し

So in other words, what we have here is a machine that can enable surgery

患者に与えている酸素濃度を調整できます

and save lives,

患者への人口呼吸は

because it was designed for its environment,

電源の有無に関わらず

just like the first machine I showed you.

必要になることがあります

But we're not content to stop there.

麻酔の問題の一つとして肺を麻痺させてしまうことがあります

Is it working?

この為手動式の ふいご を加えました

Is this the design that's going to work in place?

3時間も4時間も手動ポンプで呼吸させる

Well, we've seen good results so far.

手術も見たことがあります

This is in 13 hospitals in four countries,

これは機構が複雑化されていない機械なのです

and since 2010, we've done well over 2,000 surgeries

単純というとゾッとしますので

with no clinically adverse events.

複雑化されていないと言います

So we're thrilled.

複雑にしないよう意図されたデザインです

This really seems like a cost-effective, scalable solution

こうすれば 麻酔器を使う為の

to a problem that's really pervasive.

高度な研修も 麻酔専門医も不要になります

But we still want to be sure

このことは求められている研修を確保できていない

that this is the most effective and safe device

地方病院にとっては好都合です

that we can be putting into hospitals.

麻酔器は使用される環境に合わせて作られています

So to do that, we've launched a number of partnerships

この麻酔器は考えられないほど頑丈で

with NGOs and universities,

地方の地域病院で

to gather data on the user interface,

熱や摩擦や損傷にも

on the types of surgeries it's appropriate for,

耐えられるようにできています

and ways we can enhance the device itself.

ですからそんなに簡単には壊れません

One of those partnerships is with Johns Hopkins

もし壊れた場合でも事実上どんな部品でも

just here in Baltimore.

6角レンチとドライバーで

They have a really cool anesthesia simulation lab out in Baltimore.

取り替えて備え付けられます

So we're taking this machine

最後に値段は手頃な設定です

and recreating some of the operating theater crises

麻酔器は先程お見せした

that this machine might face

従来の機械の

in one of the hospitals that it's intended for,

8分の1の値段で買うことができます

and in a contained, safe environment,

つまりは ここにある機械は

evaluating its effectiveness.

最初に紹介した従来の麻酔器と同じように

We're then able to compare the results from that study

手術を可能にし生命を救える機械なのです

with real-world experience,

環境に合うように作られたからです

because we're putting two of these in hospitals

でもここまででは満足しませんでした

that Johns Hopkins works with in Sierra Leone,

きちんと動作するでしょうか?

including the hospital where that emergency C-section happened.

現場で思い通りに使えるでしょうか?

So I've talked a lot about anesthesia, and I tend to do that.

ええ これまでは良い結果が出ています

I think it is incredibly fascinating and an important component of health.

この機械は4ヶ国の13の病院にあります

And it really seems peripheral, we never think about it,

そして2010年から 2000件以上の

until we don't have access to it,

手術をしてきていますが

and then it becomes a gatekeeper.

臨床で有害事象は起きていません

Who gets surgery and who doesn't?

大変喜ばしいことです

Who gets safe surgery and who doesn't?