Tarek Loubani & Glia: Saving Lives With Open Medical Hardware

by Chris McGivern & SF Team, 1 April 2020

Tarek is helping doctors all over the world treat patients by reimagining the design, production and distribution of medical devices with the Glia Project.

His fellowship began in March 2017 with an opportunity to explore open hardware processes to create high-quality medical equipment at low cost and improve medical care for patients internationally. As he moves to alumni status, we caught up with Tarek to reflect on what he has achieved and learned, and find out how he has applied openness to create a brand new space ripe with potential for a more equitable future.

“I don’t use the word activist. I’m a doctor. Making sure you have the tools you need is one of the principal roles of the physician. I don’t see what I do as being outside of my medical scope - it’s one and the same.”

Background: Tarek Loubani

Tarek is a Palestinian-Canadian emergency physician, humanitarian, and open source enthusiast. He founded the Glia Project to combine his vocation, interests, and desire to build a better world to develop high-quality, low-cost open medical hardware. There is also a much bigger ambition at its heart: to end asymmetry of care. It’s a subject he understands intimately.

In his home city of London, Ontario, Tarek works as an emergency physician in a spacious, comfortable hospital with everything he needs at his fingertips to treat patients effectively. Here, the highest quality medical devices almost feel part of the scenery.

He thinks it is ridiculous that medics have to pay $300 for a gold-standard stethoscope, a patented device that has changed little in design since its invention 200 years ago. Yet he still feels privileged. Because when his humanitarian work takes him to Gaza, he finds himself in a very different environment.

Confronting the asymmetry of care

During the eight-day war between Israel and Palestine in 2012, Tarek worked at Gaza City’s main hospital where, like every other medical professional in the emergency room, he wanted to give patients every opportunity for the best possible outcome. Instead, his ability to do so was severely hampered: doctors faced dealing with hundreds of seriously injured people with only one stethoscope between them - the one he brought with him from Canada.

In developed nations where modern scanners and ultrasound are readily available and taken for granted, stethoscopes are barely used in emergencies. This is in stark contrast to places like Gaza. Many essential, life-saving tools are in short supply where economic fragility, political isolation, conflict or disaster are part of everyday life. Medics are either impaired by old, low-quality equipment or forced to improvise. Had Tarek and his fellow physicians been able to access a simple stethoscope, they would have made more effective interventions. Instead, they made do with resting ears on their patients’ chests in chaotic, overcrowded conditions.

Tarek’s experience in Gaza encapsulated the need to solve an immediate resource issue, but he also recognised it as a symptom of the underlying, systemic problem. Hospitals and medical agencies lack money and proprietary equipment so make repeated appeals to charity, reliant on the whims of others. Too often, it is politicians and donors dictating who gets what, where and when - if at all.

“In Gaza, our problem was a lack of medical devices,” Tarek explains. “Now, there are many ways you can solve that issue: you can smuggle things in or import equipment. But we wanted to come up with a solution that didn’t increase consumption, overconsumption and dependence on proprietary, patented equipment. And we wanted to solve the problem in a way where no matter what came of the politics down the line, this would still help.”

The Glia Project

Tarek came up with the idea for the Glia Project shortly after arriving home from Gaza. He wanted to reimagine the design, production and distribution of a small range of essential medical devices - stethoscopes, otoscopes, pulse oximeters, and an electrocardiogram - and make them accessible to all.

The humble stethoscope provided an ideal starting point. It took a few years of self-funded work and help from researchers at Western University and the Lawson Health Research Institute to arrive at a significant breakthrough: a 3D-printed stethoscope produced for less than $3 that matches the standards of the top-of-the-range, $300 model.

Glia’s stethoscope is impressive and brilliant in its own right and addresses a serious problem that shouldn’t exist in the world. But Tarek’s real innovation lies in the thinking and methodologies behind it. You can give people stuff, but when stuff runs out, the status quo remains. If you give people the means of building it themselves, however, you can help them move towards self-sufficiency.

Glia’s philosophy combines old, off-patent schematics with affordable 3D-printing techniques to create high-quality, open access, generic models. It enables physicians, engineers and everyday citizens to solve local resource problems, customise designs to meet their needs, and make use of resources they already have in abundance.

“In Gaza, we had lots of expertise and experience,” says Tarek. “We had lots of raw materials. And we had good access to energy. These are all different resource problems I have found in other parts of the world. The difficulty was that all these resources had never been mixed together to create something in Gaza itself.

“Solar power wasn’t popular when we started this project in 2012. Plastic recycling was common, but not for making new technology. And software engineers in Gaza were creating apps that could sell on the market rather than something that could help us. So we wanted to combine the skills, resources and tools we already had to address the clinical problem we had.”

The stethoscope, quite rightly, grabbed many headlines after its launch in 2015. But positive press does not always equal success. And it was still only a concept needing validation before being sold or distributed as medical equipment. Tarek was also grappling with the structural direction of Glia as an organisation, and it soon became clear that self-financing wasn’t going to work.

“I failed several times,” he recalls. “I realised you couldn’t spend your way out of the fundamental issues of building an organisation and scaling up gradually.

“I tried a second iteration, which was a purely academic project where I applied for grants from the academy, and that also failed. Nobody would give us money. They said the idea is too crazy, out there and ambitious - they wanted me to scale it down.

“But also, most academic institutions forbid you from putting stuff into the open. You have to patent it if it’s owned by the university - they want all the IP. So we came up with this mixed public-private hybrid, where we were the corporation and able to put the technology, patents and copyrights into the public domain. And that’s where we were before the fellowship.”

Progress and outcomes

Tarek applied to the fellowship programme promising to take significant steps towards addressing the asymmetry of global healthcare in conflict areas needing immediate relief. The opportunity to work with him was intriguing as much as it was exciting. His practical approach tied with innovative, open thinking went way beyond product provision and into the realm of system change, specifically around independence and self-sufficiency.

Additionally, it was clear that openness was an intrinsic component of Tarek’s cause, not just a convenience or advantage to his gameplan. Having invested several years and significant sums of personal money into this project, there was no doubting his commitment. Our support would allow Glia to test and iterate a range of devices on behalf and for the benefit of all, and provide practitioners, technical experts and citizens with an opportunity to collaborate, become makers and improve medical care for patients. He became a Shuttleworth Fellow in 2017.

Over three years, Tarek successfully expanded his pool of designs and tested them in the field to significant effect. Glia’s 3D-printed stethoscope is now medically validated and on sale in Canada: a massive win for Tarek, his community and the open hardware movement, who can celebrate the success of a low-cost, same-quality alternative to a needlessly expensive proprietary tool. It is currently being worn around the necks of doctors in some of the most well-resourced - as well as low-resourced - hospitals in the world.

The Glia otoscope is also released, and there are plans to market it very soon. This device helps identify hearing issues in patients and was previously unaffordable in many areas of the world. Physicians in low-resource areas will be able to diagnose problems. Their patients - particularly young children - will be better placed to manage many of the challenges they face with unidentified hearing loss, such as the impacts it has on their learning development.

Work on the Glia pulse oximeter and electrocardiogram has also taken huge strides forward. Both devices are currently awaiting clinical trial completion. However, of all the medical equipment designed and released by Glia, it is the two simplest that provide Tarek with the highest satisfaction: the stethoscope, and a tourniquet, field-tested on the frontlines of protests in Gaza.

“I think the biggest highlight was the stethoscope,” he explains. “Not because the stethoscope itself is really important. I mean, sure, it’s a great medical tool. But it allowed us to establish the process and establish the viability of the whole project.

“We have taken it from idea to post-marketing, and it means we’ve opened the whole world in front of us. Anybody with a minimal amount of vision will see we did this with a stethoscope, and we can scale it up.

“But the other big highlight is the tourniquet. The stethoscope is really important in the long term, but it isn’t really an emergency device. It doesn’t save lives every single time it’s used. The tourniquet does that.

“The great thing about the tourniquet is that it was 100 percent planned, developed and tested in Gaza. They thought it up, came up with the need, the idea and the engineering. They iterated it, and then they deployed it and tested it. Whereas the stethoscope was almost exclusively devised in Canada and Germany.

“It’s amazing because it doesn’t just prove the devices are attainable, but the culture is attainable. And it’s amazing that something like a pulse oximeter and ECG - which we’re now clinically testing - aren’t the highlights. For most projects, those are the biggest accomplishments they’ll ever reach.”

Personal reflections

Tarek started his fellowship with long-term ambitions for creating an array of devices, including an idea to start work on open source, 3D-printed parts for a dialysis machine. After having the opportunity to support him over the past three years, we have no doubt he will exceed his goals in the not-too-distant future. What he has achieved so far has not only been impressive, but significant.

Under Tarek’s leadership, Glia has developed from a small group of contributors working on a great idea into a professional organisation that has opened up an exciting new space in front of them. He is bringing openness into territory traditionally dominated by proprietary companies and bringing together communities from different walks of life to tackle significant local challenges. In much the same way as the generic drug market works, Glia has done the heavy lifting and taken the necessary risks, while end-users get what they need faster and cheaper, and with quality assurance.

“The fellowship really allowed us to turbocharge our work,” Tarek explains. “Initially, we hired one full-timer in Canada, and eventually three in Gaza. And we were able to make some mistakes, but also do a lot of things right and move forward and push what we’ve accomplished today.

“The way Glia has professionalised has been amazing. I actually can’t keep up with all the activity anymore because it’s like a beehive - you have to learn to stay in your lane and every once in a while get top-level updates from other people who are the experts.

“I’ve had to let go of a lot, which has been difficult as a founder. Decisions are being made that I wouldn’t have made, but I have to remind myself that my choices aren’t necessarily the best, or even correct. This is why founders destroy their companies all the time, right?

“So I’ve tried to move out of that role of founder and become one of the team. It’s much better since I’ve stopped taking responsibility for every last part of the operation, and we have all these pieces falling into place now. I can remember the moment when I realised this thing had outgrown me. My heart was full of joy because, for me, that was always a key part of this whole thing.”

Tarek has been wholehearted in facing his challenges and quite literally put his body on the line for his cause. He took it upon himself to be a human guinea pig and undergo oxygen deprivation while testing the design of Glia’s pulse oximeter. And the dangers of testing tourniquets in the field - in Gaza during the border protests in 2018 - proved all too real. He was shot in both legs while working as an emergency medic to save the lives of injured protestors. While sobering, Tarek is characteristically stoic about the event.

“It’s a fact of my life,” he reflects. “But it doesn’t weigh heavily on me, primarily because I was super lucky. One thousand seven hundred people were shot that day, and 60 people died, including the medic that treated me.

“It did become a significant moment in the project because it reminded us of why we were working. Those engineers making the tourniquets, every one of them had a family member or friend who’d been shot. When it happened to me, it focussed the energy of the group and helped us all remember both the vulnerability and utility of the project. When you’re working on something important, and it’s 3 am, and you’re exhausted, it’s the thing that drives us - the memory of why you’re doing it.

“But I will also say this. When I left Israel, the first place I went to was a Shuttleworth Gathering. It was the best possible place I could be because I was with people that understood, and didn’t push. I wasn’t a spectacle. It was an essential part of my healing, both physically and psychologically.”

Thoughts on the fellowship

“When I started with the fellowship, of course, I needed the money,” says Tarek. “But that’s not what excited me the most. It was Luka Mustafa who told me about the Foundation. I was most intrigued by the fellowship part of it and having those other people you could talk to.”

“The fellowship was the first time that I didn’t feel rudderless. Imagine being on a boat and you can clearly see where you want to go. But you don’t know how to get the boat there. You have the paddles, you’ve got the engine and the steering wheel. But you don’t know what anything is, or how it works, or where the rocks are in the water.

“And I remember right from the start at my first Shuttleworth Gathering, Gavin Weale and a few others gave us these ten commandments about scaling an organisation. I saw these and realised they were teaching me to sail. The fellowship showed me where the rocks are. It showed me how to move and navigate. It showed me how to run an organisation, but also to do it ethically.

“I learned so much from the fellows, and I felt like a sponge soaking up everyone’s experiences. They can clearly see my faults, which is great, and give me kind criticism - they very gently nudge me in the right direction. There’s no judgement, and they are here when I mess up. I’ve got so much out of this experience that I don’t feel I’ve really given anywhere near as much back.

“So, the fellowship strikes that perfect match between being a precious financial and administrative resource, while at the same time providing emotional and professional support. It all comes together really well. In other places, you kind of tolerate them because they give you money, or you do what you can even though they don’t provide money because there are other benefits. With Shuttleworth, it is the perfect combination of both.”

The future path

Tarek moves from Shuttleworth Fellow to Alumni with Glia in good shape for the future. With several devices at or close to the clinical trial stage, the next steps will involve a serious push towards developing tools for a dialysis machine. He still has enormous ambitions for the next decade. Given the vast space he has opened up in front of him, it is exciting to ponder on the other economic problems Glia could turn its hand to solving in the coming years.

“It moves fast from here,” smiles Tarek. “It’s refreshing to see this idea go to the next stage, beyond the startup phase. We’re now a proper company with a proper budget. In terms of sustainability we’ve spent half our budget during the fellowship and divided the other half into the next five years with a taper. We’re actively looking for new funding right now, and our model will break down into three big streams: grants, donations and sales of medical devices.

“We hoped we would dash into the market, but that sales side is growing gradually. Which has its benefits, of course, and means we don’t need to worry about the problems of growing too fast. So, I think the next ten years are going to be incredible, and there will be lots of amazing things along the way. It would not have been possible with Shuttleworth; not just in terms of money but also the people and the advice.”