This Could Be the Israeli Answer to the Coronavirus Ventilator Shortage

In the basement of a Tel Aviv hospital, seven people joined forces to invent a low-cost, open source ventilator

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Ronen Zilberman, left, and Mordechai Halfon, part of the seven-member team that created the Manshema, an open-source initiative.
Ronen Zilberman, left, and Mordechai Halfon, part of the seven-member team that created the Manshema, an open-source initiative.Credit: Tomer Appelbaum
Roy (Chicky) Arad
Roy Arad
Roy (Chicky) Arad
Roy Arad

“It was like ‘MacGyver.’ In the middle of the night you find yourself on the road and looking for parts,” says the programmer Ronen Zilberman, 40, trying to explain how seven people who had never previously met succeeded within a month, mainly by means of video conferences, in building a device that may turn out to be Israel’s answer to the worldwide shortage of ventilators.

MacGyver, as some will recall, was the resourceful hero of a 1980s television series who constantly found himself in trouble, and would get himself out of it using chewing gum, a fork and shampoo bottle to build a small jet plane. In the present case, a team was able to plan and assemble a ventilator that’s easy to make and very inexpensive – $200 instead of $6,000. The machine is intended for coronavirus patients in a mild to moderate condition, which leaves the expensive, sophisticated ventilators free for treating the more seriously ill.

A spokesman for one of the sponsors of the project tried to persuade me not to visit the lab where the prototype was being built. “It’s a storeroom that looks like a total mess,” they said. Really not impressive; you might be better off meeting on a bench outside.

They were right about the mess. In the rear part of a room in the basement of Assuta Medical Center in Tel Aviv’s Ramat Hahayal neighborhood, in a chamber about 10 square meters in area (100 sq. ft.) and crammed with unidentifiable electrical components, a team huddled next to a small, yellowish cube-like box, which they likened to a “yellow submarine” or a “clumsy Nintendo.” This is the device they call a Manshema (a name that comes from the Hebrew word “to breathe.”)

A plastic tube connects the machine to an oxygen source in the wall, and anyone entering or leaving the chamber has to decide whether to step over the oxygen tube or to pick it up and risk disconnecting it. Not what you might expect from a cutting-edge initiative in the battle against the coronavirus, but maybe it does seem to have a certain Israeli ambiance.

The point of departure for the project was Sprint COVID-19, an open-source initiative that brought together hundreds of people from the technological, military and medical realms, working in teams to devise agile new inventions intended to solve various challenges posed by the pandemic. The project, launched on March 19, has been spearheaded by Assuta Ashdod Hospital, Rafael Advanced Technology and the Weizmann Institute of Science. Some members of the Manshema team are serving in the Israel Defense Forces, in particular, its technological and logistics directorate.

“I didn’t want to sit on my bottom at home and just watch Netflix,” says Stav Bar, 31, a doctoral student in mechanical engineering who works at Rafael Advanced Defense Systems, who lives in Givatayim; he initially had worked remotely but has since returned to work.

“When Bibi [Prime Minister Benjamin Netanyahu] said that 70 percent of the workforce needed to stay home, I asked colleagues from work how I could be of use. A friend sent me the link to Sprint. I immediately thought of a ventilator, even though that’s not part of my everyday routine. Rafael is not in the business of developing medical devices.”

Why not just take advantage of the opportunity to rest a bit?

“When I get to watch the news, which I don’t do often, I look with admiration at the doctors who are coping with the epidemic and I think about the risk a physician takes when he approaches a patient. I felt that this was the least I could do for those people at the front, the doctors.”

It takes about two to three hours to build one device, so hundreds can be manufactured in a week; thus, the hope is that following clinical trials it will be possible to mass produce it. Since most of its parts are basic, low-cost, off-the-shelf products that can easily be bought or made with a 3D printer and the technology is open source, the machine can be made by interested members of the public and companies.

“It’s not a fancy device. Our idea was to come up with something modest, intended only for light and moderately ill coronavirus patients,” says Mordechai Halfon, the project’s young director – he’s 25 and a captain in the army – who looks to be a very practical person, adept with Excel tables.

“We didn’t want to compete with the ventilators that cost tens of thousands of dollars,” Halfon says. “A lot of other teams are already working on that. And even if we’d succeeded in designing a ventilator for patients in a serious condition, it’s possible that it would not have been of any use, because we would have needed all kinds of permits, and getting them would have taken a lot of time.

“In the case of a ventilator for someone in a mild condition, there is hardly any risk involved. In the worst case, the patient will decide to disconnect himself. For us, it’s easier to come up with a product like this, and it will also be easier for the physician to order something that doesn’t endanger the patient. The other machines operate in a completely different way. We thought out of the box.”

It actually looks like you’ve created a box.

“Well, it really is about as boxy as you can get.”

According to Ronen Zilberman, “The Manshema is like an electric bicycle. It helps people who are conscious and are breathing on their own but whose lungs aren’t getting enough oxygen. Our goal is to help the body sustain the battle against the virus, to give it more time to fight.”

The Manshema ventilator. The team likens it to a “yellow submarine” or a “clumsy Nintendo.”

Their invention was designed to be a more or less one-time device – use and dispose – so patients wouldn’t be infected by previous users.

“It can be disinfected and reused,” Bar says. “But it was important to make it cheap enough so it wouldn’t be a problem to throw it out after removing the more expensive parts.”

The machine is sophisticated enough to detect when the patient’s condition is deteriorating and independent breathing stops. When that happens, the device signals the medical staff, while at the same time attempting to administer respiration at a steady pace to achieve stabilization.

Halfon relates that a prototype of the Manshema was presented to the directors of the private Assuta hospital chain and to a physician who specializes in treating patients with the coronavirus. Their response was that it looked feasible.

At the moment the team is waiting for final confirmation from the Health Ministry, which they expect to have in the coming days, to run the first clinical tests on actual coronavirus patients. Until then, its members are running experiments with the device on themselves. Each of them has tried the machine out, over extended periods.

“If we had wanted to ventilate seriously ill, sedated patients – those that are ventilated with a tube – we would had to begin with tests on pigs,” Halfon notes. “Fortunately, we can experiment on ourselves and get to know a range of different lungs. That’s a lot simpler.”

No ticket

Everyone is enthusiastic, Zilberman says: “It’s cool to discover that everyone who hears about the initiative wants to help. Suppliers are giving us parts. People just want to make things easier for us. Everyone understands that there’s a crisis and that we are not a startup, but volunteers. They see that we are not out to make a killing, so they don’t have to make a killing, either.

“One evening, when we were just starting out, we had to get some components released from customs. The delivery service said that our things were in a huge container, which they weren’t going to open specially for us, and that it would take a few days for us to get what we needed. But when Gil Bachar, the team’s electrial engineer, told them that we were working on a ventilator, they opened the shipment for us.

“We went to the delivery company’s offices on a Thursday at 10 P.M. Afterward, Gil and I worked all night, and we kept going over the weekend as well. By Sunday we already had a system that more or less worked.”

Something surprising happened, Zilberman continues: “You meet a group of people you didn’t know previously and everyone mobilizes for a single goal. Everyone is charging toward the same goal. Each person brings his expertise and things come together.”

On the other hand, I’ve heard about all sorts of companies that have tried to take advantage of the pressure during this crisis and are demanding higher prices.

“Well, we received different offers. Not all the companies operate the way I told you. But most [potential manufacturing] firms have been ready to give us things for free or at a ‘symbolic’ price. Our difficulties are ‘problems of the rich’ – to choose among the companies.”

Zilberman has already reaped a first benefit from the project. “During the work I went outside for some air,” he relates. “I went to a park about 500 meters from my house in Tel Aviv, and a police car stopped me. The officer was about to give me a ticket [for venturing too far from home]. I told her that she was in the right, but still wanted to tell her why I was there.

“I told her that I was walking in the park so that I could think about the algorithmics of the ventilator, and I showed her a clip of the machine. She told me I was doing essential work and didn’t give me a ticket. Since then I always drive with a ventilation hose in the car, to show what I’m doing.”

As noted, the Manshema was planned using an open source code (downloadable for free), so that it can be built anywhere in the world where there’s a need for inexpensive ventilators. When I met with the team at the lab, however, they weren’t sure whether they would ultimately stick with the public-domain ideal.

“There is external complexity,” Halfon explained diplomatically, as a representative of the IDF’s Spokesperson’s Unit stood behind him, overseeing the meeting (he also replaced me as a photographer’s assistant, when I almost broke a light bulb).

Mordechai Halfon and Ronen Zilberman.Credit: Tomer Appelbaum

But the issue was cleared up in a conversation afterward. Common sense had prevailed: Halfon said that everyone would be able to download the code and assemble a Manshema.

Zilberman: “It was very important for us to have an open source code. It’s an opportunity to contribute to the global community by releasing knowledge. We will provide the instructions, we will say: Here are the parts required, here is the code, here is what we learned and here’s my email address if you have questions.”

Secret game

“The people here are quick studies,” avers Dr. Elad Grozovski, 66, the oldest member of the group, who’s in charge of the medical side of the project. (Other partners are consultant Ivry Shapira and Roy Darnell, involved in production.) Grozovski was a senior physician in the intensive care unit at Beilinson Hospital in Petah Tikva, so he practically eats ventilators for breakfast, as it were. Since retiring, he has taken up ceramics – but the Sprint initiative has brought Grozovski back to medicine: Indeed, the 30 features he posited as essential for the Manshema were the basis for the invention. “I just had to say a sentence, and right off they knew what I was talking about.”

Will there still be any point to having this device after the crisis is over?

Grozovski: “A device like this can help patients in a milder condition, so they won’t be in need of a ventilator later on. Even if at the moment we haven’t reached a situation in which we need these machines, it’s good to have ideas on the shelf in case the need arises. If so, we will be able to make the Manshema quickly. In normal times, it could take years to obtain the approvals necessary for a device like this.”

For his part, Bar, the engineer, also agrees that in the ideal situation, the Manshema will remain on the shelf. “I hope that these machines will not have to be used. Everyone on the team will tell you that. They will be brought in only if, heaven forbid, there are not enough standard machines available, if masses of people need to be ventilated, as we saw in Europe a month ago.”

If there will be no shortage of ventilators in Israel during the current crisis, are you considering exporting or sending your devices to countries where the situation is worse?

Bar: “Let’s take it stage by stage. But potentially, yes.”

As we are talking, Benny Rahimi, who’s in charge of medical maintenance at Assuta, happens by. “I could see the gears in their brains turning,” he says admiringly. “The team is here every day for lots of hours, even after the rest of us have gone home. They are very passionate about what they’re doing, and we really pamper them. When they need something, we bring it to them.”

Before the outbreak of the pandemic, Halfon, the IDF officer who heads the team, worked in weapons production. I ask him whether it’s not a better feeling to be engaged in health and not build machines designed to kill. He’s not eager to reply: “No comment. It’s a different world. This is technology and that is technology.”

But here it’s “you shall beat your swords into Manshemas.”

“From my point of view, both efforts protect the country and us. In both cases it’s a mission.”

With Bar, too, I try to wax poetic about how good it would be if the brilliant minds of Rafael were involved in creating technologies for the betterment of humanity, and how it’s too bad it took a crisis to make that happen. He doesn’t buy it. As far as he’s concerned, there’s no difference between manufacturing arms and manufacturing ventilators.

“I love my job at Rafael,” he says. “It’s part of me, to participate, to be relevant. From my point of view, in a period like this, it’s catastrophic to sit idly by.”

And you see no difference between the types of work?

“The difference is that here you have to do something fast, at a time of international emergency.”

Toward the end of our conversation, Zilberman spills a deep secret: “One night I was writing a little low-tech game on that can be played on the small monitor of the Manshema. A shooting game where you try not to get run over. In programmers’ jargon it’s known as an ‘Easter egg,’ something you hide in the software. If the patient or the doctor gets bored after hours of ventilating, they can play.”

“It won’t be in the final version of the machine,” Halfon, the more official person, interjects reassuringly. And to conclude, he relates that they have all become friends: “We’ve made a date that after the epidemic, the whole team will come to my place for steaks.”

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