Saving Babies with Hot Wax

Not all success stories of impact science in this book involve multi-national global agreements over decades, like the cases in previous pages on climate change or the ozone layer. The following successful example is more on the power an individual can have. Thus, in a more personal sense, very inspiring. This is the story of Jane Chen and her company “Embrace.”

In 2007, Jane was attending a new course at her MBA in Stanford titled “Entrepreneurial Design for Extreme Affordability.” The course aims to design solutions to problems that otherwise have very expensive solutions. Jane and her group chose to tackle neonatal mortality. The most common cause of death of infants is preterm birth (defined as babies born prematurely before their 37 weeks after conception). There are around 15 million preterm births globally every year. In the developed world, the survival rate is 90%, while in the developing world it is the staggering opposite, 10% survival rate. It is estimated that up to 75% of these babies could survive if supplied constant warmth, breastfeeding, and protection from infections. In fact, in developed countries, the most common treatment is to put the preterm baby in an incubator with a temperature regulator to keep the baby at constant warmth. These are profoundly sad numbers that reflect a very harsh reality that is essentially exclusive to underdeveloped conditions. In fact, one of the signs of development is how quickly neonatal and child mortality improves as countries evolve and can afford better health facilities, as people—especially women—receive better education and as governments can provide better public services[22]. In essence, what Jane set up to do is to break the dependency of infant survivability and poverty. To try to find a very cheap and easy way to dramatically reduce the preventable deaths of millions of babies across the world. No small task.

One of the critical parts of this problem is that incubators are expensive, difficult to handle, need training to use them, they need constant electricity, and also maintenance servicing. Yet, incubators are precisely one of the key resources the developed world uses to save lives of preterm babies. Unfortunately, these devices are luxuries in themselves and the resources they need to work correctly in many parts of the world, as Jane found on her first fact-finding trip to India. They saw rooms with many babies in need of care. If there were incubators, they were sometimes empty, in the corner of the room, turned off, unused. Maybe there is no electricity, or there is a broken piece they can´t replace, or they just haven’t received the proper training to use it. While preparing for this book, this was exactly my experience when I visited the hospital at Kakuma refugee camp, in Kenya, with 180,000 refugees. The main health facility had two incubators and both were unused already for many months, due to some spare part that was missing. Around the world where incubators are missing or unusable, health facilities resort to use blankets or, when there is electricity, light bulbs for warmth, which is dangerous and very inefficient. Keeping the baby with a constant warm temperature easily and cheaply is much harder than it might appear at first.

In parallel to this life or death challenge, every person who has gone to high school and done basic physics, harbors in their mind the key scientific concept at the core of what Jane and her team built. It is incredibly frustrating to realize, in retrospect, that one has, at the same time, knowledge of such a profound challenge, and knowledge of a solution for it. That´s how I felt when I met Jane a few years ago when I had just told her about this whole idea of impact science. Hopefully, by delaying writing here what that key concept is, I am conveying this very point. There is a key fundamental physical property that all of us know, and that can save the lives of millions of babies. Part of the reason I believe scientists should have a place on the table in seemingly unconnected topics is precisely cases like this one. Although in this case this is a basic one, the tools and factoids of a trained scientist could be applied in very unexpected places.

The foundation of Jane’s solution is knowing that water freezes below 0 degrees Centigrade (32 Fahrenheit). You cannot have water below that freezing temperature, as it becomes ice. In fact, if you place water under very cold conditions, the water will freeze faster. Besides experiencing this many times in our own lives, in high school you might have learned the name of this process, “phase transition.” From liquid to solid, in this case. One of the core observations is that during a transition of phase, the temperature stays constant. The speed of change might differ, but the temperature remains constant throughout the process. Any substance will release energy—temperature—if the surroundings are colder and absorb energy than if the surroundings are hotter. The temperature will change at various speeds, but if the change in temperature crosses a change of phase (like 0C/32F for water) the substance will stay at that temperature until all of it has changed phase. In other words, when it’s hot, ice melts; and if it’s very hot, ice melts quickly. When it’s cold water freezes; when it’s very cold, water freezes quickly. Moreover, it takes much more energy to cross a phase transition than it takes to change the temperature when it doesn´t involve one.

Taking this realization to neonatal mortality, the problem becomes finding a substance that melts/solidifies at the temperature the baby needs. That way physics will ensure a constant temperature. That substance turns out to be a combination of different waxes, although Jane tells the story that they first tried a prototype with butter, making a huge mess of melted butter, plastics, and cloth in the process.

Simplifying it, you heat up a sealed plastic pocket with wax inside in boiling water. Once warm, the plastic holds a warm liquid wax. You put a cloth cover over the pocket of wax that shapes the product as a sleeping bag for the baby. The wax will release constant temperature for a few hours as it cools down to room temperature, and changing phase into solid. After a few hours, when the wax is harder, you can then heat it up again. Compared to the cost of an incubator, this is several orders of magnitude cheaper, and much easier to manufacture, operate, and maintain. The wax is cheap material, as they also are the plastic pockets, the sleeping bag cover, and the process to boil the wax pocket in water.

The conceptual breakthrough here, the science fact, is done, but of course this is only a small piece of the solution that later became the company “Embrace”. In the process, Jane and the team had to face many challenges—from finding a sustainable business model to adjusting to cultural differences. The success of the product—both regarding doing all the product development and later manufacturing and distribution—but success also in regards to saving lives, depends on many factors, like any other startup. Some of these challenges could have stronger scientific underpinnings, like the physics of phase transition, and some less so, like figuring out philanthropic or for-profits models that would maximize the impact. Among these challenges, for the context of this book, it’s also worth mentioning the cultural aspects of western numeric accuracy and protocols. As Jane explains on her experience with the first version of the product, it turns out that in India there is a perception of western medicine to be too strong, so there is a tendency to adapt it by weakening it. For example, giving smaller doses of a medicine or shortening the treatment. In the case of Embrace, the wax pockets had temperature indicators with numbers to make sure the temperature was neither too high—hence dangerous—or too cold—and ineffective. This can happen if the pocket is heated too much and the wax is well above the transition phase temperature, so it needs to cool down until the transition phase starts and the temperature becomes constant. If the wax is too cool not all the material has changed phase and it will last too short, or not even get to the right temperature if all the wax is solid. The problem was that caregivers would not heat the pockets properly as they would adjust what they thought was a better temperature number than prescribed. The solution the team found was to replace the numerical indicator of degrees, with a simpler three symbols indicator: too cold, okay temperature, too hot. This was a simple adjustment but a key one, result of a development process iterating quickly as the first users started to use the product. In this case, more data, more “scientific” information was detrimental to the outcome.

The project started as a class assignment, which turned into two years living in India setting up the non-profit and starting to provide the services. The enterprise lived from donations and partners from Gates Foundation, Beyoncé or Mark Benioff, and the awards and praise of the then USA President Obama, the Skoll foundation, the Schwab Social Entrepreneurs of the Year, or Forbes’ Impact 30. The project has since developed a dual operation where one side donates the product to places in most need and without resources, and the other side sells them to governments and private partners that can afford it, at a price that also covers the cost of the donations. In 2016 the company reported having helped more than 200,000 babies across twenty countries.

When you read the story or watch her online videos[23] it´s clear that Embrace is a huge achievement, and that the wax transition phase trick, while being a core scientific key principle, it´s also a tiny part to make it successful. When I met Jane and learned her story, I did, however, wonder what other lifesaving product and services rest upon other basic, or not basic, scientific principles I might already know. I wonder what would happen if we tell more stories like this one, if we motivate more people to connect the dots between a real problem and seemingly unrelated scientific fact or model.

It is also tempting to frame this achievement as the advantage of an “interdisciplinary research.” Innovation usually happens at the interface of different expertise. There is indeed a recent, and needed, push towards removing silos and collaborations researching across domains. The transition of wax phase and neonatal mortality is clearly an enormous success story of connecting domains, but at the same time it seems extremely unlikely at first. No physicist or chemist would answer “neonatal mortality” to the question of why we should research wax, unless they knew about the problem. No public health development expert would find “melting wax” as a potential solution to neonatal mortality unless they realized the link beforehand. One design solution is to maximize interface crossing, creating multidisciplinary teams. But, with how many fields of expertise, how many permutations of how many experts, and with which kinds of networking events would it take to make wax and neonatal mortality a likely match?

Moreover, I worry about the disconnect between the realization of the potential and the actual product. This is a much general entrepreneurship message, but at the same time I firmly believe the process could be eased having an impact scientist that could move back and forth between and across scientific knowledge silos, and pragmatic applications.

An impact scientist is not someone who learns about the connection, neither one that publishes the potential on an academic paper (which can very well do), but someone who helps in the whole process from idea to product, trying to help each step of the way. In the process of writing this book I’ve seen that pipeline, or funnel, in a few cases. First, comes the curious person who discovers the potential (in this case, phase transition could help solve neonatal mortality). Second comes the academic/engineer who puts forward the hypothesis and figures out in more detail how this could (in this case, which waxes, and how the whole thing works). Third comes the impactor who builds the first prototypes, business model, and setup to go for the rest of the way to impact.

Here is another case. Someone plays with image compression and computer file formats and realizes some details of the image get consistently lost or degraded after compression. You realize you can build a program to compare and learn what or how details get lost, what artifacts are created, and how they differ, with different image compressions. A curious person realizes that you can also, given a compressed image with artifacts, train a computer to extrapolate back a possible original image. You can make computers in essence “hallucinate.” The reconstruction will be fake, but likely to be roughly correct (humans do it, a pink-haired person far away looks like a person with a pink hat). This would make a good academic article, and in fact such papers have been written. Now, the impactor also realizes there is a huge application in cases where the exact detailed image is not that important as it is to compress the image a lot (bad internet connections, online games with many players at once …). And so, the impactor builds a solution. That solution, and this story, happens to be a real company called “Magic Pony” that was funded in 2014 and acquired for 150 million dollars in 2016[24].

Thank you for the interest reading this far.

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