Surgery in a backpack

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0:30to make those markets work for you. Follow Merrin Talks Money on Apple Podcasts, Spotify, or wherever you listen. Hello and welcome to the documentary from the BBC World Service. I'm Myra Anubi and I host the People Fixing the World podcast, looking at the common challenges around the world and the creative ways people are trying to tackle them, from eating invasive species as an alternative source of food to saving endangered animals with radioactive material. You can listen and subscribe by searching People Fixing the World wherever you got this podcast.

1:17Welcome to People Fixing the World from the BBC World Service with me, Myra Anubi. This is the program that looks for solutions to some of the world's toughest problems. like the impact of war. Today, we'll hear about innovative ways to get people the medical help and support that they need when their lives are turned upside down. Two billion. That's the number of people that are estimated to be living in areas affected by conflict, according to the UN. Now, that's a quarter of the world's population. And when When fighting starts, a lot of lives are lost and crucially, governments are torn apart.

1:57Conflict can shut down hospitals, cut off power and water, leaving communities without even the most basic health care. But on People Fixing the World, we are all about solutions. In Sudan, we'll find out how communities have created their own emergency response networks. And in Syria, we'll find out how broken hospital equipment is cleverly being repaired. But first, let's talk about an innovation that could revolutionise surgery during war. Our reporter, Craig Langren, went to find out how. We're not in a conflict zone. We're in rural Switzerland, about 20 minutes from the city of Lausanne. There are trees on all sides.

2:40There's just nature, really, for as far as the eye can see. I'm here with Sash Johnalagada, electrical engineer and co-founder of a start-up called Surgebox. We've come to these woods for a reason. Sash wants to show me something that sounds impossible. I am carrying actually what essentially is equivalent to an operating theatre in my backpack. Yes, an operating theatre in a small, ordinary black backpack. We walk deeper into the woods, finding a small clearing. There's mud under fur, pine needles on the ground, nowhere near as bad as a conflict zone, but still not the best place to have an open wound.

3:22So how do you perform potentially life-saving surgery in conditions like this? So here, I'm going to unzip the backpack here. Yeah, so just unzipping the bag and then you've taken out what looks like a large camera battery. Now what's inside looks remarkably ordinary. Just a lightweight plastic sheet, some fiberglass poles and a white box about the size of a shoebox. Sasha's innovation is deceptively simple. If you can't make the whole space clean, just create a protective bubble around the patient. Sasha's asked a colleague to stand in as our patient today. To demonstrate, the patient lies down on the ground as Sash puts what looks like a tent frame around him and then lays some clear plastic over the frame.

4:11So now, let's say a patient has been injured and has been evacuated and now the patient is on the floor. And so the first step is really to prep the patient. Next, he uses a tube to connect the tent frame to the white box which pumps air in to inflate it. and then so now this is where the magic happens i just press it so you just press the silver button two bits of plastic that were touching one another and now sort of moving further and further apart as it inflates exactly yeah and then uh once it's inflated you'll hear it now you can see the fan is at full blow yeah it means that it has not reached the target pressure yet right so we hear it get quieter and that means you've reached the pressure yeah you want to be at exactly the engine noises just dip down it's a lot quieter all of a sudden and that means that we're where we need to be yeah once inflated it creates a transparent bubble that completely seals off the patient's torso from the surrounding environment and sash tells me that this environment is completely sterile.

5:21And now the air quality inside this bubble is as good as it gets. It's as clean as the best operating theatres that you can find in the world. The pump filters the air as it's blown into the bubble. Sash then puts on gloves and opens a flap to insert surgical tools. So as you can see, you're opening the magnetic port. Does that not let any dirt or infection go into the bubble? No, because as you can hear in the background, on, the fan has increased the speed. It's called positive pressure. We hear the pump immediately getting louder, keeping dirty air out and ensuring only clean air can flow in.

6:02It's the same principle hospitals use in operating theatres. The idea came from Sasha's co-founder, Dr Debbie Teodorescu, years ago when she was a medical student in the US. Surgery box has come a long way since then. It's now been used over 60 times in Ukraine and in Myanmar, where a civil war has been raging since 2021. Sash tells me about one patient in Myanmar who was operated on using his inflatable bubble. The patient that was hit by an airstrike. So they had to transport the patient to a hidden building. And then once they're in a hidden building, then they could do the surgery in a clean environment.

6:48By hidden building he means operating in a safe place to avoid being targeted. In this case it was a basement. With the bubble protecting the wound they could safely remove the shrapnel. Now Sash was actually able to share some voice notes with me from the surgeon in Myanmar who carried this operation out. For their safety we're not using their name or location and the voice you'll hear is actually that of our translator. With the surgical box, those problems are gone, which makes things much more convenient. For the cases I can handle, I can use this box for injury, like when a hand or arm is pierced by a bullet and a blood vessel is torn.

7:31Fortunately, I can sew the torn muscle on the outside to save the hand from amputation and then transfer the patient to a hospital. It's very convenient. What I want is for the other doctors to use this and to spread the water about it. If you don't have to go to the operating room and you're in the forest, this surgical box is very convenient. I like it and I recommend it. Sash believes it could greatly reduce the chances of things like infections, but he wants to keep expectations realistic. Even today in many operating theaters, patients get infected, right? and you have hospital site infections.

8:14So there is never going to be a guarantee. The practicalities matter too. The bubble itself is single use. With blood and other bodily fluids, you can't risk cross-contamination. But the frame and pump are reused. Sascha's solution currently costs around US$300 per surgery. But he hopes to bring those costs down as they scale up. My vision is that each surgery would be less than$100. $100 per surgery? Yeah. Our vision is big. We want to see a world where all the patients have access to clean environments when they need surgery. And so hopefully in the next couple of three to five years, at least 200 ,000 lives.

8:59That's what we want to kind of save.

9:04I've spent the last three decades trying to better understand money across the boardroom, the newsroom and the trading floor. That's longer than most podcast hosts have been alive. But even though I've got questions, join me, Merrin's Upset Web, every week for my show, Merrin Talks Money from Bloomberg Podcasts, where I have in-depth conversations with fund managers, strategists and experts about how markets really work. And join me for a separate episode where I answer listener questions and how to make those markets work for you. Follow Merrin Talks Money on Apple Podcasts, Spotify or wherever you listen.

9:39You're listening to People Fixing the World from the BBC World Service. Now, we've just heard an account from Myanmar about a clever invention that's basically an operating theatre in a backpack. However, what happens when patients can actually get to a hospital, but when they do, the medical equipment is actually broken. When hospitals have ventilators and incubators sitting idle because they can't get spare parts. Well, Craig Langren, who brought us the previous report, has been investigating this. Craig, you have something else? Yeah, so I've been chatting to an NGO called FieldReady, and they think they've found a clever way to give old equipment a new lease of life.

10:19So I'm Kat Sellers. I'm the executive director of FieldReady. And we are a global humanitarian NGO that specialises in making and repairing aid items in the field. FieldReady works in over 20 countries, including Bangladesh, Uganda and Somalia, as well as several island nations in the Pacific. Conflict closes borders and damages supply chains. So where at one point you would be able to get a replacement piece of kit. I mean, say, for example, your incubator is from Germany. if there's a conflict happening. There's no way you're going to be able to ship in that missing part from Germany. So that item just is no longer usable.

10:56What's the impact of that? We saw a lot of a lack of ventilators in a number of places. You know, we see if there isn't an incubator for a child, that child might die. The solution? Instead of waiting months for medical spare parts to be shipped in from Germany or the US, why not just make them yourself? I spoke to Kat's colleague, Emad, to find out more. My name is Ahmad Nashir al-Nyam. I'm from Aleppo, speaking from Aleppo, northwest Syria. Ahmad runs Field Ready's program in Syria, but he wasn't always fixing hospital equipment. Before the civil war broke out in 2011, he works in business development.

11:36But the war changed everything.

11:43The violence is obviously getting worse as these pictures being sent in by ordinary people from across Syria show. Working with a team of local engineers, one of his early innovations was developing something called rescue airbags for Syria's volunteer rescue force, the White Helmets. These were inflatable devices made from old car tyres that could lift up heavy rubble to search for survivors. But when they took the survivors to hospital, they found another problem. We discovered that after we take these people from under the rubble, when they go to the hospitals, most of the devices, of the medical devices, are broken.

12:26We ask them on what we can do. They say you cannot do anything because since two years, we are not able to bring spare parts in. So it means that all these devices are rubbish, are waste. Aleppo University Hospital had six incubators for newborn babies, but none of them were working. So Ahmad and his team had a lightbulb moment. What if they could make the replacement parts themselves? The baby incubators have to be closed very well. And the doors of these baby incubators are loose. So we cannot close them. So it means that we cannot put a baby in. We said, so what if we bring a new door only for this?

13:12They said, we tried, but we couldn't. We said, what if we design and bring a new one for you? They said, that would be perfect, but we don't know if you can do that. Now, designing a replacement part from scratch isn't exactly simple. It's a bit like doing a jigsaw puzzle where you don't have the box with the picture on it. When Emad showed me pictures and videos of his workshop on a video call, it became clear just how they operate. A workshop equipped with 3D printers, laser cutters and traditional tools that only gets electricity for around two hours a day, running entirely on solar panels.

13:48So we start work at 8.30. We have our coffee, our Syrian coffee with cardamom, and then we start the day.

14:00So we go to the company website and we try to see if there are any sizes or if there are any specific model of this item, of this part. But in most of the cases, we couldn't. So we start the design from zero. The team start working on their desktop, like using different software. and they start working on the drawing to make sure that the sizes are right. Then we use the 3D printer to start printing. It's trial and error, really. A single part might take 12 hours to print, only to discover it needs tweaking and reprinting. But when they finally delivered the repaired incubators back to the hospital, the reaction was immediate.

14:52When we brought them after five days, So they were really shocked. And when they checked them and they are closing very well, they told us that they really look better than the original doors. From six broken incubators, they suddenly had two working ones again. They were very happy because they said that now we have two incubators at our hospital. They had six before, but the sixth are out of service. So they were just trying to refer any babies who need incubators to very far hospitals. And they told us that, unfortunately, many of these babies couldn't survive because of not having these incubators.

15:39And crucially, EMAD's solution is affordable. It costs us about$150 and this baby incubator itself, the cost of it is about from$8 ,000 and more. $150 to give an$8 ,000 piece of equipment a new lease of life. Now EMAD tells me they've got this down to a fine art. Hospitals can report broken equipment through a mobile app And then Emad and his team assess each case, design the parts, print them and train the hospital staff to maintain them. We are working currently with about 13 hospitals. In the last months we have fixed 20 machines. They've seemingly tackled everything from x-ray cooling systems that were wasting thousands of litres of water every day to ventilators, ultrasound machines, any sort of surgical equipment, you name it.

16:35For Ahmad and his team of engineers, there's something deeply personal about this work. Our role here was really different. Like we could save lives through engineering interventions. So what we can do for Syria, like I will tell you, for example, when we print out baby incubators, which is the door of the baby incubator, when we work on it, like when I see them, how they design it, I just imagine how when we are going to fix this incubator, and I just imagine how babies will benefit from these incubators and that we can save their lives. The fall of the Assad regime back in 2024 has opened up new possibilities too.

17:25Suddenly, Ahmed's team can access the whole country, and they're training local engineers to carry this work forward. We could conduct visits to the hospitals and health facilities that we couldn't visit before when they were under the regime control. And we discovered that thousands and thousands of critical machines are again out of service. Ahmad hopes to be able to step up repairs across Syria soon. and in the meantime his designs are available online open source for anyone who might want to have a go at fixing a broken bit of hospital equipment. When he talks about his workshop the smells of iron and wood and melting plastic from the 3D printer he sees something that others simply might not.

18:14For us we smell the future. We smell the hope. So when people come to us and they will tell us that they will say it's bad smell. The bad smell is, for example, the smell of the wood when it's burned using the razor cut. But for us, this is the hope. This is what we feel, that we are doing what we can. Emad and Kat, who we heard from earlier, think this local approach could just be the future of aid work. It's a model that turns traditional aid on its head. They tell me that up to 80 % of humanitarian funding can go on logistics alone. For Emad, working in his beloved hometown of Aleppo, this is about much more than just fixing machines.

19:02So I can tell you that Aleppo for me was the home where roots, memories and identity are grounded. Despite the war and the destruction, Aleppo for us represents the possibility of renewal. I can tell you that Aleppo is my story. It's my duty and my hope for a better tomorrow. I think that's something that many of us can really relate to, hoping or wanting a better tomorrow. So we've heard how 3D printers are being used by Ahmed and his team to repair medical equipment in Syria. But what happens when the entire healthcare system collapses, when there's no government infrastructure left at all? Now, since April 2023, Sudan has been torn apart by civil war.

19:47Hospitals have been abandoned, power grids destroyed and millions of people cut off from basic services. But in this chaos, something remarkable has emerged. A network of volunteer-run emergency response rooms coordinating aid across the country. Craig, tell me a bit more about this. Yeah, so it's really interesting, Myra. When the war started and government services collapsed, basically, communities started organising themselves into these volunteer-run coordination centres. They're completely bottom-up in how they work. All of the decisions, crucially, are made by the communities themselves.

20:23And they do pretty much everything from communal kitchens, feeding hundreds of people every day, to health clinics, evacuations, schools, even fixing power grids and digging wells. And most of the coordination happens on WhatsApp. I mean, this sounds, it's good to see people trying to do what they can to find the solutions, but it also sounds incredibly complex to coordinate. How do they keep this active during a conflict? Yeah, it is difficult, Myra. And one of the major issues for a grassroots organisation like this is just getting the funding in to run these projects. So I've been talking to this young tech developer who also happens to go by the name of Young.

21:04Now, he's based in Uganda, but he's originally from Sudan. And he's been working with the emergency response rooms ever since the very first week of the war. In the beginning, in April 15, when the war started, other people started reaching out to me, talking about like, yeah, we need to coordinate. So that was in the first week of the war. Tell me, Craig, what exactly is the solution here? So he's built a chatbot. Essentially, it's a digital system that helps local coordinators to submit funding requests and to track how much money is being spent. So if you're a volunteer and your community, say, need to set up a kitchen to feed people.

21:44You can log into the system, fill out a simple form and submit it. That request then goes straight to the state level coordinators and partner NGOs who can see it in real time and respond. But how does that help build trust with the international funders? Yeah, so that's the key innovation. Instead of expecting volunteers to write up complex monitoring reports, which many just simply won't know how to do. Those things are difficult. Yeah, Exactly. So instead of doing that, they can simply take photos and videos of the projects and upload them through the system in real time. You don't count the people.

22:18You don't do like an attendance list for the people that are just attending in the kitchen. You can just like when people are eating together, you can just take a video and everyone can just say hi. The AI in the system automatically sorts through all of this information. so it pulls data in from documents, photos, even voice notes in Sudanese Arabic and it organises that information so funders can see exactly how their money's being spent and where. Right, right. So in the case we've just heard about, funding was needed for a community kitchen so that's where local people can get together to eat a nutritious meal and the organisers were able to prove that the money had actually been spent putting food on the table.

23:00And you said that this is being done by volunteers in the middle of a war zone, right? How big is this project really? Young told me they've collected over two million US dollars in funding. OK. They're running more than 2000 community kitchens across the country, each feeding around 150 people every day. So they're now operating in 13 of Sudan's 18 states. And Young hopes that the emergency response room's community-led, bottom-up approach to solving problems continues after the war ends too. It's the continuous social movement of the Sudanese people that started in the revolution in 2019. The basic idea is just to have the community as priority number one and no politics, nothing.

23:45Just it's people. It's the power. Like the more you have people with you, the more you have people participating in these activities that is helping our community in Sudan move forward and take matter to their own hands. Yeah, I mean, it's unfortunate to be in this position or situation in the first place, but it does go to show just how much communities can do when they come together. Thank you for all the solutions we've heard today, Craig. Thanks, Mara. I'm afraid that's all we have time for this week but I would love to know what you think about the solutions you've just heard all you need to do is send me an email to peoplefixingtheworld at bbc.co.uk and I do check your WhatsApp messages you can send me either a message or a voice note to the number plus 44 8000 321 721 I'll be back next week with more stories that are changing our world Until then, thank you for listening.

25:10Join me, Merrin's subset web every week for my show Merrin Talks Money from Bloomberg Podcasts, where I have in-depth conversations with fund managers, strategists and experts about how markets really work. And join me for a separate episode where I answer listener questions and how to make those markets work for you. Follow Merrin Talks Money on Apple Podcasts, Spotify or wherever you listen.