Timothy Prestero
1,081,538 views • 11:05

I've got a great idea that's going to change the world. It's fantastic, it's going to blow your mind. It's my beautiful baby. Here's the thing: everybody loves a beautiful baby. I mean, I was a beautiful baby. Here's me and my dad a couple days after I was born.

So in the world of product design, the beautiful baby's like the concept car. It's the knockout. You see it and you go, "Oh, my God. I'd buy that in a second!" So why is it that this year's new cars look pretty much exactly like last year's new cars?


What went wrong between the design studio and the factory? Today, I don't want to talk about beautiful babies, I want to talk about the awkward adolescence of design — those sort of dorky teenage years where you're trying to figure out how the world works.

I'm going to start with an example from some work that we did on newborn health. So here's a problem: four million babies around the world, mostly in developing countries, die every year before their first birthday, even before their first month of life. It turns out half of those kids, or about 1.8 million newborns around the world, would make it if you could just keep them warm for the first three days, maybe the first week.

So this is a newborn intensive care unit in Kathmandu, Nepal. All of these kids in blankets belong in incubators — something like this. This is a donated Japanese Atom incubator that we found in a NICU in Kathmandu. This is what we want. Probably what happened is a hospital in Japan upgraded their equipment and donated their old stuff to Nepal. The problem is, without technicians, without spare parts, donations like this very quickly turn into junk.

So this seemed like a problem that we could do something about. Keeping a baby warm for a week — that's not rocket science. So we got started. We partnered with a leading medical research institution here in Boston. We conducted months of user research overseas, trying to think like designers, human-centered design — "Let's figure out what people want." We killed thousands of Post-it notes. We made dozens of prototypes to get to this. So this is the NeoNurture infant incubator, and this has a lot of smarts built into it, and we felt great.

So the idea here is, unlike the concept car, we want to marry something beautiful with something that actually works. And our idea is that this design would inspire manufacturers and other people of influence to take this model and run with it.

Here's the bad news: the only baby ever actually put inside the NeoNurture incubator was this kid during a Time magazine photo shoot. So recognition is fantastic. We want design to get out for people to see it. It won lots of awards. But it felt like a booby prize. We wanted to make beautiful things that are going to make the world a better place, and I don't think this kid was even in it long enough to get warm.

So it turns out that design for inspiration doesn't really ... I guess what I would say is, for us, for what I want to do, it's either too slow or it just doesn't work, it's ineffective. So, really, I want to design for outcomes. I don't want to make beautiful stuff; I want to make the world a better place. So when we were designing NeoNurture, we paid a lot of attention to the people who are going to use this thing, for example, poor families, rural doctors, overloaded nurses, even repair technicians. We thought we had all our bases covered, we'd done everything right.

Well, it turns out there's this whole constellation of people who have to be involved in a product for it to be successful: manufacturing, financing, distribution, regulation. Michael Free at PATH says you have to figure out who will "choose, use and pay the dues" for a product like this. And I have to ask the question that VCs always ask: "Sir, what is your business, and who is your customer?"

Who is our customer? Well, here's an example. This is a Bangladeshi hospital director outside his facility. It turns out he doesn't buy any of his equipment. Those decisions are made by the Ministry of Health or by foreign donors, and it just kind of shows up. Similarly, here's a multinational medical-device manufacturer. It turns out they've got to fish where the fish are. So it turns out that in emerging markets — where the fish are — are the emerging middle class of these countries — diseases of affluence: heart disease, infertility. So it turns out that design for outcomes in one aspect really means thinking about design for manufacture and distribution. OK, that was an important lesson.

Second, we took that lesson and tried to push it into our next project. So we started by finding a manufacturer, an organization called MTTS in Vietnam, that manufactures newborn-care technologies for Southeast Asia. Our other partner is East Meets West, an American foundation that distributes that technology to poor hospitals around that region.

So we started with them, saying, "Well, what do you want? What's a problem you want to solve?" And they said, "Let's work on newborn jaundice." So this is another one of these mind-boggling global problems. Jaundice affects two-thirds of newborns around the world. Of those newborns, one in 10 roughly, if it's not treated, the jaundice gets so severe that it leads to either a life-long disability, or the kids could even die. There's one way to treat jaundice, and that's what's called an exchange transfusion. So as you can imagine, that's expensive and a little bit dangerous.

There is another cure. It's very technological, it's very complex, a little daunting. You've got to shine blue light on the kid.


Bright blue light on as much of the skin as you can cover. How is this a hard problem? I went to MIT. OK, we'll figure that out.


So here's an example. This is an overhead phototherapy device that's designed for American hospitals, and here's how it's supposed to be used. It's over the baby, illuminating a single patient. Take it out of an American hospital, send it overseas to a crowded facility in Asia, here's how it's actually used. The effectiveness of phototherapy is a function of light intensity. These dark blue squares show you where it's effective phototherapy. Here's what it looks like under actual use. So those kids on the edges aren't actually receiving effective phototherapy. But without training, without some kind of light meter, how would you know?

We see other examples of problems like this. Here's a neonatal intensive care unit, where moms come in to visit their babies. And keep in mind that Mom maybe just had a C-section, so that's already kind of a bummer. Mom's visiting her kid. She sees her baby naked, lying under some blue lights, looking kind of vulnerable. It's not uncommon for Mom to put a blanket over the baby. From a phototherapy standpoint, maybe not the best behavior. In fact, that sounds kind of dumb. Except, what we've learned is that there's no such thing as a dumb user — there are only dumb products.

We have to think like existentialists: it's not the painting we would have painted, it's the painting that we actually painted. It's the use — designed for actual use. How are people actually going to use this?

So, similarly, when we think about our partner MTTS, they've made some amazing technologies for treating newborn illnesses. So here's an overhead warmer and a CPAP. They're inexpensive, really rugged. They've treated 50,000 kids in Vietnam with this technology. But here's the problem: Every doctor in the world, every hospital administrator, has seen TV — curse those "ER" reruns! Turns out they all know what a medical device is supposed to look like. They want Buck Rogers, they don't want effective. It sounds crazy, it sounds dumb, but there are actually hospitals who would rather have no equipment than something that looks cheap and crummy. So again, if we want people to trust a device, it has to look trustworthy.

So thinking about outcomes, it turns out appearances matter. We took all that information together. We tried, this time, to get it right. And here's what we developed. This is the Firefly phototherapy device, except this time, we didn't stop at the concept car. From the very beginning, we started by talking to manufacturers. Our goal is to make a state-of-the-art product that our partner MTTS can actually manufacture. Our goal is to study how they work, the resources they have access to, so that they can make this product.

So that's the design for manufacture question. When we think about actual use, you'll notice that Firefly has a single bassinet. It only fits a single baby, and the idea here is it's obvious how you ought to use this device. If you try to put more than one kid in, you're stacking them on top of each other.


So the idea here is you want to make it hard to use wrong. In other words, you want to make the right way to use it the easiest way to use it. Another example — again, silly Mom. Silly Mom thinks her baby looks cold, wants to put a blanket over the baby. That's why we have lights above and below the baby in Firefly, so if Mom does put a blanket over the baby, it's still receiving effective phototherapy from below.

Last story here: I've got a friend in India who told me that you haven't really tested a piece of electronic technology for distribution in Asia, until you've trained a cockroach to climb in and pee on every single little component on the inside.


You think it's funny. I had a laptop in the Peace Corps, and the screen had all these dead pixels on it. And one day I looked in — they were all dead ants that had gotten into my laptop and perished. Those poor ants.


So with Firefly, what we did is — the problem is electronics get hot, and you have to put in vents or fans to keep them cool — in most products. We decided we can't put a "Do not enter" sign next to the vent. We actually got rid of all that stuff. So Firefly's totally sealed.

These are the kinds of lessons — as awkward as it was to be a pretty goofy teenager, much worse to be a frustrated designer. So I was thinking, "What I really want to do is change the world. I have to pay attention to manufacturing and distribution. I have to pay attention to how people are actually going to use a device. I actually have to pay attention. There's no excuse for failure.

I have to think like an existentialist. I have to accept that there are no dumb users, only dumb products." We have to ask ourselves hard questions. Are we designing for the world that we want? Are we designing for the world that we have? Are we designing for the world that's coming, whether we're ready or not?

I got into this business designing products. I've since learned that if you really want to make a difference in the world, you have to design outcomes. And that's design that matters.

Thank you.