Revolutionizing Orthopedic Care in Low-Income Countries, Part 2 of 3
**Note - please excuse the typos. This transcript was automatically generated.**
Hetal Baman (00:00:02) - How do you start a nonprofit medical device company without a single engineer? When Signe fracture care began its journey 25 years ago, Dr. Circle chose to hire his very first employees, none of whom were engineers, especially engineers from the medical device industry. But why? Well, Dr. Circle wanted to hire talent that would think outside of the box. And who didn't have a preconceived notion of how medical devices should be designed and should be manufactured. So today I speak with Gene Milner. One of doctors are the very first employees and now CEO of Sine Fracture Care. Jean Diller started her career as a CPA after graduating from Portland State University. She found her true vocation when she accepted the position of CEO for Assigned Fracture Care International. She joined Dr. Louis Circle Sine founder and orthopedic surgeon in 1999 to create this one of a kind humanitarian organization that is responsible for giving more than 400,000 injured poor patients access to quality orthopedic surgery. She credits her work with the International Atomic Energy Agency office at the United Nations for giving her the foundational skill set to lead the sign team's groundbreaking efforts to equip surgeons in almost 60 low and middle income countries with education and implants.
Hetal Baman (00:01:40) - Jean paints a picture of what Signe looked like in the very beginning and why they decided to go nonprofit versus for profit, who the very first employees were and what their roles were, and the steps that Signe had to take in order to grow over the years. So if you're someone like me who has a background in medical devices or someone who's just very curious as to how this industry works and how a nonprofit medical device company might work, this episode is a really good one. My name is Hetal Baumann and this is the Global Health Pursuit. Yay! Okay. Hey, Jean. How are you today? I'm doing.
Jeanne Dillner (00:02:24) - Really well. How are you today?
Hetal Baman (00:02:26) - I'm doing so good. Look, I'm so excited to be doing this interview with you today. I feel like we've been in talks for, what, like three months already? Exactly. And we had to push. Our last interview because I had I'm pretty sure we had Covid or something. I don't remember. No, it was really bad allergies, so I had to push that back.
Hetal Baman (00:02:49) - But I'm very excited to speak with you today for our audience listening in. This is part two of the Sine Fracture Care podcast series on the Global Health Pursuit podcast. Part one was with Dr. Circle, the founder himself. And in that episode I ask him all about his story and why founding this nonprofit was so important to him. So if you haven't, listen to that part one, I suggest you to go back a week and listen so you have more context of what Jean and I will be speaking about on this episode. So with that being said and out of the way, here is my first question to you, Jean. I want you to talk about the first time you and Dr. Circle have met and what were you up to in life back then?
Jeanne Dillner (00:03:40) - I met Dr. Circle about six months after I had been working with sine fracture care. I had a little consulting business after returning to Richland from living in Vienna for four years, I worked for the International Atomic Energy Agency in business systems. And so when I came back, that was it was natural for me to open up a consultancy to help with that.
Jeanne Dillner (00:04:05) - And so I had heard about Signe from a friend of mine that I met in in Vienna, and his name was Ron Lee, and he had just gotten back from getting his finger fixed at Dr. Circle's orthopedic office. So he said Dr. Circle at that time hadn't really opened up officially the nonprofit. There were people working on it and they needed some business expertise. So I went and met my predecessor, whose name is Dan, and he confirmed that they were going through the process of setting it up as a nonprofit. So I worked with Dan to set up the organization as a nonprofit in the eyes of the IRS, and then also registered them as a business. So about I didn't need to meet Dr. Circle because his energy had been like replicated into Dan Oh, that's so fun. Really cool opportunity. They had to help people walk again in the developing world. And then I got to meet Dr. Circle in his in his office and it was important to me to know that the vision for this was not us swooping in and telling people in the in these hospitals what to do more swooping in and listening to the people and designing what they needed to be able to effectively treat orthopedic patients.
Jeanne Dillner (00:05:34) - And so that's what he told me his plan was, is that he'd been working with surgeons in in particular in Vietnam for many years and realize that they need to have an ongoing supply of relevant implants and training so that they could effectively treat the hundreds of patients that were coming in every week from road traffic accidents. So I was that excited me because that was sustainable, replicable and within a year he was actually able to give them these implants and we just kept going from there.
Hetal Baman (00:06:13) - That is so funny because when you said like it's like a sustainable, replicable process, it kind of triggered the business side of you. Yes. You're like, okay, so this can work actually. Right? The other thing that you mentioned was providing relevant medical equipment, I think key word relevant because I think we often see organizations or companies donating equipment, but it might not be relevant and then it ends up in a closet. So.
Jeanne Dillner (00:06:42) - Right. What happens still is that people will donate refurbished, expensive equipment like C arms, which are in the ways of getting x rays, movie type x rays of of what's going on beneath the skin.
Jeanne Dillner (00:07:00) - And the unfortunate thing is that these machines aren't supported by any maintenance efforts in in the country. And so, you know, being relevant now is finding funding to give the hospital the money so they can buy an equivalent in country where they'll be the proper maintenance personnel to take care of it. So, yeah, relevancy changes with time. So we're now 25 years later, our product is still relevant, but some of the ways that we help have changed. So because we don't need to travel overseas as much as we did, because the science surgeons are already trained and now they're the trainers for people in for surgeons in their country, but also in their neighboring countries. So if there's a, say, a country in Africa that hasn't had the opportunity to become a sign program yet, surgeons from that country might say go to if it's right next to Ethiopia, go there to get their training. So that's what I said. It was repeatable. It. It's the type of and scalable and scalable is as long as we can get the funding to do the scale of providing the implants, because that's still true.
Jeanne Dillner (00:08:15) - That's what is still true, is that the patient still can't afford to buy it and the hospitals still don't have enough money to buy it. So we still need to give it for free.
Hetal Baman (00:08:25) - Right? Think that's so important. It's so cool that the sign surgeons actually they kind of become your liaisons.
Jeanne Dillner (00:08:34) - Well, they're more than liaisons. They're effectively the future of sign because, you know, in time. Myself and Dr. Zarco won't be at sign. We'll still have people here at Sign that have been trained up to take on the leadership roles for the design and manufacture of the product. But the teaching that's going to be transferred to the side surgeons. So, yeah, it's pretty remarkable that he he didn't he didn't necessarily think out the details. Visionaries usually don't. But he knew that if he did this one thing that it could just keep on going beyond his in my life anyway. Right.
Hetal Baman (00:09:16) - Wow. So could you paint a picture of what sign looked like in the very beginning?
Jeanne Dillner (00:09:23) - Sign was actually the first office that I went to was Dan's, and they were the church that Dr. Circle and Dan went to lended them this office space.
Jeanne Dillner (00:09:35) - And it's really funny because he was the only really employee. I was just a consultant. And then there were other people volunteering to do various aspects, including Dr. Circle, of course, who's been a volunteer the whole time. But once I it sounds kind of silly and, you know, minutia. But once I applied for the business license, then the city of Richland said, you can't be operating out of that office in a church because what you're doing is manufacturing. So you have to get into new a new facility. And we're like, What? We're not manufacturing yet. We don't even have machines. And they said, it doesn't matter. So Dr. Circle had a lot of connections and was able to find a couple thousand square feet in the building that we're still in. And it happened to have a shop and some offices. So Dan quickly moved over there and then set up spot for he and I. And then within a matter of a couple of months, there were several employees that were coming in to re reorganize the facility to allow for machines that were about to come and so they could start learning how to manufacture.
Jeanne Dillner (00:10:44) - So what they did, what he did was he did not hire experienced people, people experienced in manufacturing or in design of orthopedic implants. He wanted fresh ideas. He wanted to look at it from a whole nother way of thinking. And and the reason was the if we were to hire people from the industry, they'd be stuck in the way that people design product for US market. And so he wanted and plus it was probably more fun for him to work with people that are really creative and would just listen and be guided by him to design it for the needs of the situation the owners are in in these countries and still are in in these countries. So a US nail that you know goes through the canal to be fixated to repair your leg is hollow and doesn't require and requires what's called a calm that requires power in the developing world. They don't have they still they have irregular power. So we needed to design a product that could be inserted and then figure out a way to target where to put these screws that go through the holes that are inside the bone.
Jeanne Dillner (00:12:07) - So you can't see you can't see them from the outside where to put them in. So we had to develop a targeting device and then another device that was targeting the specific hole et-cetera, so that the surgeon could be guided properly on where to put that screw. And so a US engineer already experienced at this wouldn't maybe been able to get their arms around that or their mind around that. So anyway, we, we went without engineers for a couple of years and then found a very creative engineer who was able to understand what Dr. Zurcher was saying, visualize it, and then make these incredible, wonderful and manufacturable devices that allowed the surgeons to use our product.
Hetal Baman (00:12:49) - So here's my question to you. I know you guys went the manufacturing route of your own medical devices. Did you ever in the beginning or did Dr. Circle ever in the beginning think, okay, like let me go to some of these big medical device companies and ask them, hey, can we open up a little bit of a small like a small department that will do like engineered, you know, manufacturer engineered devices that are within this need? Like what drove you to actually do your own manufacturing?
Jeanne Dillner (00:13:23) - What drove Dr. Urkel to do his own manufacturing is that for probably ten years he did just that.
Jeanne Dillner (00:13:31) - He went to the big companies. He was actually a pretty renowned orthopedic surgeon and had the ear of a lot of the implant companies. But he would he told us that they. Would never say no, but they'd never say yes. They'd all like the idea but couldn't get it through corporate, right? So and then, you know, he could have decided to make this a for profit, but then his time would have been torn between selling in the US and trying to get into that market and serving the patients that were in a really huge need overseas. So he he had the resources to be able to fund, you know, the startup of this organization as a nonprofit and really focus on the design and manufacture of the product so that we could get it out to the patient as fast as possible. The patients that he was targeting or that we're targeting. Otherwise, we would have been spending ten years trying to raise money to do it. Do you see the difference?
Hetal Baman (00:14:33) - So is that like the difference between you going for profit or non profit? Okay.
Hetal Baman (00:14:38) - Can you talk a little bit more about that? Because what I'm hearing is that, you know, what I'm hearing is that you said that if we went the for profit route, then we would have to sell within the US along side, right?
Jeanne Dillner (00:14:56) - And first you'd have to sell if the funding was just if doctors Oracle's start up money was used for a for profit venture, then that money would have been used to keep operations going until we could make a profit, at which time then we could start donating and that and making a profit, making an inroads into the market even 25 years ago would have been very challenging because the nails that we produce are so different from the nails the doctors were used to using. So the, you know, they didn't want they would have maybe felt like they were regressing in technology when in fact they were using a technology that was healthier because they wouldn't be exposed to x ray. And I mean, there were lots of benefits is cheaper and all these other benefits. But, you know, when you're used to doing a thing a certain way, you want to keep doing it that way to minimize learning curve, etcetera.
Jeanne Dillner (00:16:02) - So and really, his goal wasn't to make a profit. His goal was to help patients overseas. Right?
Hetal Baman (00:16:10) - So what challenges did you have to overcome when first when you decided that okay, sign is going to be a non profit? What were the first set of like kind of set of challenges that you had to jump through?
Jeanne Dillner (00:16:24) - Well, from when I look back, other people would have done it differently. Yeah. Not not choosing nonprofit or for profit, but they other people might have spent maybe more time than we had to, you know, build a business plan, build processes and document things and stuff. But we we felt this urgency to get a product out to the patients. And so none of us even had job descriptions, probably for the true startup. I mean, none of us had job descriptions for, I would say a good eight years. But we within that eight years we helped 100,000 people. So and we, you know, didn't we've never really had too many employees, if you know what I mean.
Jeanne Dillner (00:17:15) - You know, we've always been a little bit understaffed. And but because of the mission, people were willing to go the extra miles, you know, to get whatever needed to be done, done. And so, you know, as we've progressed through time, as we are FDA cleared, so we have to comply with a lot of regulatory issues which are getting more there's more demands on that. So we have more employees for that than we did in the beginning. But I guess the challenges were. You know, our focus was because he, Dr. Circle, had the money to allow us to focus on the design and manufacture learning curve. We didn't learn from the early days how to really do an excellent job at fundraising. So and we're still sort of behind that curve because we still spend most of our time focusing in on design and manufacture and in the educational aspect of getting the doctors trained up to use our product to then have the myriad of treatments that they can provide for the patients using our products.
Jeanne Dillner (00:18:22) - Is that helpful?
Hetal Baman (00:18:23) - It is. It is.
Jeanne Dillner (00:18:26) - I don't think we would have changed. I think a lot about should we have done it differently and I mean, we would have had back to them.
Hetal Baman (00:18:34) - Do you think back about that on occasion?
Jeanne Dillner (00:18:36) - I think back or should we have, you know, spent more time in XYZ? And I don't think so because we've helped now we've helped over 400,000 patients. I think what we did was a success. I would like to expand more and treat more types of fractures, but funding limits us for doing that. But yeah, I think we made the right choices.
Hetal Baman (00:19:00) - I mean, I think so too. You guys are doing so great. I from the very beginning you had mentioned that Dr. Jekyll, when he first started hiring people, the first people weren't actually engineers, right. So who are those people?
Jeanne Dillner (00:19:17) - Well, there is Dan, he was a. Lawyer and he you know, he was good at the documentation and, you know, probably good at building sort of a structure for our organization.
Jeanne Dillner (00:19:31) - And then there was me, you know, I'd worked in manufacturing in the summers, but not of metal things. It was a different type of thing. And then.
Hetal Baman (00:19:41) - Well, what was it? What was your background?
Jeanne Dillner (00:19:43) - I worked for Del Monte and that's where the big money was, you know, in the summer was to work for a cannery, especially graveyard, because you got, you know, an extra $0.10 an hour or whatever. Oh, wow. So that was a lot of money at the time. It was. But and then we had a let's see, Steve and Richard. Richard had taught how to manufacture and he came in, was running one of the machines that we had purchased. And then Shawn got a degree in manufacturing and was running another machine. Dooley was from a refugee from Bosnia, and he was he was an engineer, but he came to us as a machine operator. And then then we learned that he knew how to do drawings and stuff. So he worked with Chris, who was an engineer, but not a he was a mechanical engineer, which is what you need.
Jeanne Dillner (00:20:34) - But he wasn't. He had never designed product for the body before.
Hetal Baman (00:20:37) - For the body.
Jeanne Dillner (00:20:38) - But all these guys were like phenomenal at working together to achieve what was needed. And then we also had like what you might call a benefactor in Randy Huebner, who was the founder of a medical implant company in Portland called Acumen. And they specialized in niche markets that weren't there weren't any products in yet. So one of the things that they had was a nail that fit in your humerus and they were the first, I believe they were the first implant company to manufacture that. And when Dr. Circle talked with him, he and his wife and they were at that time, they had 20 people. He and his wife decided to, you know, donate some of their product to use for Dr. Circle to try out in Vietnam to use in the tibia. So, you know, it was these kinds of people that creative, innovative people that we were in a way so ignorant. We didn't know we couldn't do it.
Jeanne Dillner (00:21:43) - So we just had the faith that we could do it and we did it with the help of Randy, you know? Yeah.
Hetal Baman (00:21:50) - Feel like it's better to have that kind of perspective mindset than the other way around because then you wouldn't even try. Right?
Jeanne Dillner (00:21:56) - Right, exactly. Yeah. And that is and even Randy said, Wow, that's a big idea, Lou, to open up your own manufacturing company, you know? And he didn't tell Lou. No, but he did say, you know, tried to convey what it was going to take. And Lou just said, oh, well, we can do that. You didn't even have any we yet when he said that.
Hetal Baman (00:22:16) - We can do.
Jeanne Dillner (00:22:17) - That, we can do.
Hetal Baman (00:22:17) - That. That was.
Jeanne Dillner (00:22:18) - Too. So that, you know, a remarkable characteristic of Dr. Circle is that immense optimism. And and he found the passion. You know, he had this passion which started when he was a surgeon in Vietnam, of finding a way to equip these surgeons to have, you know, to have what they needed to be able to care for their patients.
Jeanne Dillner (00:22:39) - And so and then his drive really was patient care. I mean, he he needed the the conduit was the surgeons. Right. But really, it's the patients he just thinks so much about. He can empathize with patients he's never met. And it's a lot like the donors we have today. You know, we'd had a donor appreciation event two weekends ago and and the theme was on gratitude and and for their generosity, but also because they're so altruistic, there's no way they're going to meet any of these people that they're helping. They're giving us, you know, tens of thousands of dollars and in some cases, hundreds of thousands of dollars. And because they trust us and believe that we'll use it appropriately so that patients can be healed and and they get some patient stories, but they never get to know the people. You know what I mean? Right. Right. It's a remarkable thing. And I, I was in my talk to them. I just said, you know, lots of people are willing to give to their community, but your community has expanded all the way over to Africa and Asia.
Jeanne Dillner (00:23:44) - And and, you know, you guys are less than 1% of the population. So it's remarkable that in our little town of Richland, there's so many who can think so globally. It's a real blessing and and gift to us.
Hetal Baman (00:23:58) - I think it's a testament to sign for actually allowing these people to I don't want to say blindly trust in the mission because, you know, in that what you were just saying, they're never going to be able to meet all of these patients that you're serving. But through you guys, they're able to see the impact and what.
Jeanne Dillner (00:24:19) - It's the impact is beyond the broken leg. You know, it's like why we talk about staying on the path out of poverty. If they don't get it fixed, they'll drive their family further into poverty. But if they get it fixed, then they have these the future is just as rosy as they can make it, you know. And so they're building communities when they give to us, they're fixing a leg, but they're building up a community, right? Instead of tearing it down by not giving.
Hetal Baman (00:24:49) - So since the beginning of Signe, talk to us about how much sign has grown and, you know, what has needed to happen year after year to really keep up this growth. So outside of fundraising, I mean, I know that's right.
Jeanne Dillner (00:25:07) - That's and I don't mean to Harsh Harbor on this fundraising, but that's kind of on my mind right now. So when you hire people that aren't experienced at a thing, you have to give them the time to excel in the thing and the resources. So we for many years relied on Acumen to kind of guide us through how to manufacture X, Y, Z. And then you really at some point, we really needed somebody in our shop who had the expertise to run an experience with running the kinds of machines that we had. So I think it was about 7 or 8 years in that we finally got somebody with that expertise and man, that that make a difference. Maybe at that time we could make enough product to help 7 to 9000 people. But when we hired this one experienced machinist, he was able to tweak the programs and the processes so that we could double within a year.
Jeanne Dillner (00:26:14) - We doubled the amount of product that we could manufacture the nails themselves. And what's interesting is the the supply kind of met what all of a sudden the demand rose up to. It's always sort of been that way where we've gone at maybe making small incremental jumps. But then when we have like a breakthrough for improving manufacturing, then boom, the amount of demand increases. And I don't really know why that is or how that happens, but, you know, we think a lot of providential occurrences. So we think that, you know, the especially the Fab 5 or 6 of us had started signed with Dr. Circle. You know, we just were brought together. There was no really right. There was no ad placed in a newspaper. It was word of mouth and people that were attracted to the mission and willing to take less pay and all those things to be able to help Dr. Circle achieve the prototypes. Let's say for the first 2 or 3 years of of what sign was going to blossom into eventually.
Hetal Baman (00:27:24) - So how many employees do you guys have now?
Jeanne Dillner (00:27:26) - We have 41 now, and we help at least 30,000 people a year now. But we're in the process of raising the funds to buy these other types of machines that will allow us to triple that if the funding and sorry to keep using the word funding, but if the resources come available and the demand rises and we also want to expand into spine care, so that requires more devices per surgery. And so we're working on designs that will be affordable to manufacture and either will manufacture those or will resource it out or will maybe at first have to purchase from somewhere else until such time as we build enough demand to and again, the resources to be able to help set up more programs worldwide in spine.
Hetal Baman (00:28:22) - So interesting because as an engineer, as a biomedical engineer myself, I like to think about doing a spine surgery with no x ray. Or it's like, Right, that's just so innovative on it.
Jeanne Dillner (00:28:38) - Yeah, I remember they used to do that all the time, right? You know, you just have they would probably have a lot bigger incision, but that's how spine surgery started.
Hetal Baman (00:28:50) - So what are you most excited about when it comes to sign in the next coming years?
Jeanne Dillner (00:28:54) - You know, earlier on I mentioned how the it's a repeatable, replicable, sustainable effort and and that kind of ties with in the early days I was frustrated with the colonialism that a lot of the nonprofits had. You know, it's a mindset for that. We're we we're from the developed world. We know how you should do things, and this is what you need to achieve. Dr. Circle went from the complete reverse of that and said, I don't know what it's like working in your situation. We need to hear from you. You have a stake in the success of Sign. He would tell them, and we need your feedback on the product. So, I mean, it was such a fresh way of looking at things. And here we are today. January 29th of 2024 will be our 25th anniversary. And we're looking at the future with different leadership and we're looking at how that leadership could include more, much more representation from the science surgeons, for example, on our board or in other types of leadership within our organization.
Jeanne Dillner (00:30:04) - So I'm excited for that because it really shows that over time we're moving away from us, leading the charge to really giving, let's say, how do I say this a more direct voice from the side surgeons of what's needed and what they see the future is. And and in through the process, we're we're helping guide them to think futuristic. Not when you're in poverty, you're in survival thinking. Right. But as they, you know, are able to move out of the poverty, what I call poverty thinking, then they can, you know, really enjoy the experience of thinking ahead and dreaming big and, you know, thinking about what orthopedics can look like in each of their countries and how how cine can help them achieve that.
Hetal Baman (00:30:55) - I absolutely love that the, you know, moving away from the whole colonialism or colonialist mindset that oftentimes we see. Yeah. I mean, that's that is huge. I would love to see that, you know, in the future of sign. Jean, this is such a great conversation.
Hetal Baman (00:31:15) - Thank you. I loved talking to you and learning from you about sign. I'm just I'm just so excited to keep in touch with you guys and see what happens. Thank you for listening to this episode. If you'd like to learn more about today's topic and guest, head over to the show notes linked in the description of this episode. There you can get access to resources, links and ways you can get involved in the pursuit for global health. And if you love this episode, don't forget to write me a review on Apple Podcasts and rate the podcast on Spotify. It helps me get in front of more people just like you, and continues to elevate the causes we are so passionate about. I'll see you in the next one.