The following is an excerpt from Thou Shalt Innovate: How Israeli Ingenuity Repairs the World (Gefen Publishing: March 2018
It started with a coupon in the mail. In 1996, Lily Goffer went to the mall in Nazareth, the largest city in the northern district of Israel; she was buying a pair of jeans for her husband. On a lark, she filled out a form to win a free all-terrain vehicle, and several weeks later, learned she had won.
Her husband, Amit Goffer, had no interest in the machine. When it arrived, he sold it to a neighbor for half of what it was worth. But his children complained so much that he decided to make it up to them. One morning, Goffer rented a few ATVs and set off to ride across a dusty patch of wilderness not far from their home. The kids, he felt, would have a great time.
On the outskirts of Sepporis, an idyllic biblical village, Goffer rode with his daughter, while his son took off on his own, kicking up dirt behind him as the machines growled along the dusty trails. But not long after the ride began, the brakes on Goffer’s vehicle failed. The doctor went careening off the trail and crashed into a tree. His daughter emerged unscathed, but Goffer snapped his neck against the branches.
Lying on the ground, he was terrified. “I couldn’t feel anything,” he says, “and I understood immediately what happened to me.” Prior to his accident, Goffer had founded a company that made MRI devices for operating rooms. So he understood the science behind disability. As his children came running over, he told them to back away. “Don’t touch me,” he said, “I’m a quadriplegic.” He knew he would never walk again.
The next nine months were bleak. Goffer was paralyzed from his upper back down. He had slight movement in his arms, and eventually learned how to use an electronic wheelchair. That helped, but he constantly felt cramped and frustrated. “I couldn’t sit for more than two hours.” Goffer recalls, “It was like being in a very big hole in the dark.”
One of his biggest challenges: going to the bathroom. For many confined to a wheelchair, accidents are common and bowel movements are irregular, which can lead to sepsis or even death. Many paralyzed people are forced to ask someone to insert two fingers into their rectums to stimulate the bowel. The process is painful and can take hours. Some ultimately choose to have surgery that creates a permanent opening between the colon and the surface of the abdomen, where stool collects in a bag.
Despite his frustrations, Goffer was determined to retain some independence. At first, he wasn’t able to brush his teeth. The doctors gave him a contraption to help, but he refused it. He relearned how to brush on his own. For months, Goffer didn’t have enough strength to write, but eventually he relearned that skill, too. “When you’re at the bottom of such a hole,” he says, “there’s only one way to go. Up. You can’t get any lower.”
Mentally, Goffer suffered the most. To help with his recovery, the doctors gave him a heavy regimen of painkillers and other medications. But the side effects clouded his mind. “My IQ went down,” he says. “I felt stupid.”
He didn’t give up. In January 1997, the hospital sent Goffer home, and soon, he stopped taking his medication. It’s one of the best decisions he ever made. As the haze lifted, Goffer began thinking about what he could do about his condition. “I became human again,” he says.
Having regained his ability to think, Goffer began to understand how paralysis stripped him of control. The more he thought about it, the more he became determined to create a way for the disabled to regain a sense of autonomy and dignity. “My motivation,” he says, “was to…give to the disabled individual…a complete device that a person could [use to] go to the movies or theater or restaurant without asking first, ‘Are there stairs?’” He also wanted to help the disabled look their loved ones at eye level—something most people take for granted.
Given his condition, Goffer became obsessed with this dilemma. Life in a wheelchair, he felt, wasn’t enough.
A Revolution Without Wheels
The first wheelchairs weren’t chairs at all; they were wheelbarrows, an invention created in China during the second century A.D. For the next thousand years, there was no other record of a wheelchair outside of the country until an artist sketched King Phillip of Spain (1527–1598) using one to get around. Since then, inventors have tinkered with the idea and added amenities for comfort and mobility. But the basic concept has stayed the same.
One of the few attempts to change the wheelchair occurred in the mid-1990s. That’s when an inventor named Dean Kamen partnered with Johnson & Johnson to create the iBOT, a wheelchair that could purportedly rise up on two wheels, go up and down stairs and navigate over sand, gravel and water. The iBOT never took off. Its $25,000 price tag was too steep, and the invention didn’t live up to its promise: The stairs were too much of a challenge.
As Goffer researched the history of the wheelchair, he couldn’t believe humans had done so little to change it. Sure, we had found ways to help the paralyzed. We had learned a tremendous amount about the brain and done vital research on stem cells and spinal cord injuries. But neither has helped anyone walk again. Nor has it limited the complications associated with wheelchairs, including poor blood circulation, deteriorating bone density, increased urinary infections, loss of muscle mass and pressure sores.
An accomplished academic who studied electrical and computer engineering in Israel and the United States, Goffer was confident he could invent a new type of device to help the disabled. During the 1990s, the robotics industry witnessed several breakthroughs, including the first truly intelligent robots and the ability to synchronize their motion. Goffer felt these advances could help him create a machine that would help a paraplegic walk again using a lightweight, motorized support suit with rechargeable batteries.
He started his research by determining how much energy it takes a human to walk and climb stairs. “I was afraid that the answer would be a cart full of batteries,” he says, “or some kind of small truck driving behind a person.” But Goffer determined it would only take a small battery.
About a year after his injury, an idea came to him while he was surfing the internet: The disabled could perhaps walk again using a shell or exoskeleton. Some creatures, such as scorpions, do it all the time. “How is it possible that no one ever thought of this?” he wondered. He hurriedly began sketching out prototypes and thinking about how this concept could work.
In 2004, seven years after he first came up with the idea, Goffer finished building his first device: an exoskeleton that hugs users’ legs, along with crutches to stabilize them as they walk. Users wear a remote control on their wrists to control their movement. As they walk, a tilt sensor ensures the chest remains upright and balanced, allowing them to move without falling. The crutches help people go up stairs and stabilize their weight.
Goffer called his innovation ReWalk and decided to test it. He set up the device in his driveway. Two paraplegics and a quadriplegic volunteered to help. His children strapped the first ReWalk on one of the paraplegics and plugged it in. His son stood near the chord, ready to unplug it in case the subject fell. His daughter controlled the tilt sensor. Goffer used his limited arm mobility to fire up the machine. And then it happened: the paraplegic took one step, then another and then a few more. Goffer was so focused on watching the steps that he didn’t notice the paraplegic was crying.
‘It Was So Insulting’
For the next two years, Goffer continued working on the device. He made sure it could work for up to four hours without recharging, far longer than most people walk on a regular basis. And while the initial ReWalk weighed more than 50 pounds, Goffer found a way to make it lighter and more user-friendly.
At first, Goffer paid for everything related to his invention. But in 2006, he was accepted into Israel’s prestigious Technion Incubator, which helps start-up and early-stage companies with funding, mentoring and training, among other things. He also received a grant from an Israeli government program called the Tnufa Incentive Program. If a company is successful, the grant is considered a loan. If the company fails, the state assumes the loss. In both cases, the government doesn’t take a share. The major benefit of the programs is access. Tnufa plugged Goffer into a network of Israel’s best and brightest with whom he could share ideas and receive advice.
Yet the device didn’t take off the way Goffer had hoped. Perhaps because of the failed iBOT, many of his contemporaries felt that ReWalk would never work. His biggest disappointment came in 2006 when he spoke at a robotics conference in Zurich. During his lecture, he showed video clips of a young disabled woman using ReWalk. Many attendees were either skeptical or convinced the clip was fake. Afterward, Goffer sent another video to Dr. Zev Rymer, the chairman of the conference and a professor of physical medicine and rehabilitation at Northwestern University. Rymer sent Goffer back a terse note: “Can I get a video clip of how he [the test subject] walks without the device?”
“It was so insulting,” Goffer says. But he remained undeterred. Four years later, as he continued tweaking the device, Goffer finally gained some traction. In August 2010, he contacted the Veterans Affairs Rehabilitation, Research & Development National Center of Excellence for the Medical Consequences of Spinal Cord Injury in New York. It’s a leader in the field, and he wanted to show ReWalk to Dr. William Bauman and Ann Spungen, some of its top experts. “These things can’t possibly work,” Spungen recalls thinking. “We figured they were overselling their capabilities.” Goffer sensed her reticence, but traveled to New York anyway. He wanted to prove Spungen wrong.
They met in a small room where patients often watch football, play pool, and hang out. About 25 people—research staff, doctors, nurses, and patients—gathered to watch the live demonstration. As a ReWalk test subject walked across the room, up and down a stairwell, and across a long hallway, Spungen watched skeptically. “I was convinced he was not really paralyzed,” she says, “because he was walking so well.” All 25 attendees followed the man down the corridors. As he walked down the hall, everyone— from the patients to the nurses—turned and stared. “It was like watching the Pied Piper,” Spungen says. “Nobody could believe it.”
As the test subject took off the exoskeleton, Spungen saw his feet dangle and become flaccid, a clear sign of paralysis. Goffer’s presentation was no hoax. Once she got over her shock, Spungen turned to Bauman, the center’s director: “We gotta do this,” she said.
A Different Sort of Marathon
Spungen’s endorsement was a major turning point for ReWalk. But what really propelled the device was an extraordinary woman who proved that paraplegics can not only walk, but race, too. Her name is Claire Lomas, and she is a British chiropractor and avid horseback rider.
In May 2007, while competing in the Osberton Horse Trials, a high-level equestrian competition in the United Kingdom, her horse, Rolled Oats, clipped his shoulder on a tree, and Lomas went flying into its branches. As she lay on the ground, Lomas was unable to move her legs. Later, she learned she had fractured her neck, back and ribs and damaged her spinal cord. The doctors inserted titanium rods into her back to try to fix her spine, but the damage was done. She was paralyzed from the waist down. Her doctors told her that she would never walk again.
Yet Lomas, like Goffer, was determined. Looking online, she discovered ReWalk. With the help of friends and family, she raised about $70,000 to purchase one of Goffer’s devices. She practiced with the ReWalk and regularly commuted more than two hours from her home in Leicestershire to East Riding of Yorkshire to learn how to use it properly. After four months, she became so proficient that she focused on a new challenge: the London Marathon.
In May 2012, hundreds of people filled the streets to watch Lomas finish the course. Walking roughly two miles a day, she completed the 26.2-mile race 16 days after she started. As Lomas crossed the finish line, flanked by her husband and year-old toddler, the crowd thundered.
Standing Up and Falling Down
Today, ReWalk has been approved for sale in Europe and in the United States. There are roughly four hundred users around the globe, including a number of U.S. military veterans and law enforcement officials. The company is publicly traded on the New York Stock Exchange, which has provided Goffer with millions of dollars for research and investment. Over the next few years, the Israeli inventor hopes more people like Lomas will be able to use the device. The market’s potential is huge: Goffer estimates there are approximately 6 million wheelchair users in the United States and Europe, about 250,000 of whom would be able to use his device.
Yet ReWalk, and its competitors, still have a number of critics. One reason is safety. It generally takes somewhere between 12 and 15 sessions to learn how to use the exoskeleton. Some patients, depending on their level of paralysis, never master the skill. The device can be risky. Paraplegics have very weak bones, so ReWalk encourages patients not to use the device on slippery, sloped or uneven surfaces. Accidents, of course, happen, and some fear the device’s risks don’t outweigh the rewards. “All it takes is for one or two people to fall and seriously injure themselves for the FDA to shut the whole thing down,” says Arun Jayaraman, a leading exoskeleton expert at the world-renowned Rehabilitation Institute of Chicago. “It has happened previously for other technologies.”
Another challenge is price. Because it costs $69,000 to $85,000, purchasing an exoskeleton isn’t possible for poorer patients. Health insurance providers in the United States have declined to cover it. (Experts say insurance companies are often slow to recognize new and useful technology.)
Some critics claim Goffer’s device isn’t therapeutic, but rather a mobility or performance aide. The difference sounds inconsequential, but it’s not. As a mobility device, the benefits are intuitive, obvious, and universally received. Paraplegics are now able to use this device at home, outside, and at work. But critics say that to have the device recognized as therapeutic, Goffer would need to scientifically prove the medical advantages of the device outweigh the risks. He would also have to prove the benefits cannot be obtained by utilizing other, perhaps safer means. “ReWalk is sold on the basis that it should…help with blood circulation, bladder function, bowel strength,” says Rymer, the Northwestern professor. “There is no hard evidence that demonstrates that it has actually happened.”
Proving that ReWalk is therapeutic will be expensive and time consuming, but Goffer remains optimistic. He thinks the device can eventually alleviate symptoms that are common among the wheelchair bound. Dr. Alberto Esquenazi, the chairman and chief medical officer of MossRehab of the Einstein Healthcare Network in Philadelphia, agrees. He screened fourteen subjects, completed training for ten users of ReWalk, and determined that some users reported “improvements in pain, bowel and bladder function, and spasticity.” His study also determined that users “improved their physical endurance” with “no significant adverse side effects” and were willing to use the system on a regular basis.
Based on this study and others, Goffer says insurance providers could save approximately $30,000 annually due to ReWalk’s health benefits. Jayaraman, the Rehabilitation Institute of Chicago expert, estimates the savings might even be higher, as regular exercise using the device could help patients as well. If insurers would cover the device, Goffer and others in his field say, that would lead to more users, and likely more competitors, all of which would push costs down even more.
For all the excitement surrounding the product, however, there was still one person who couldn’t benefit from it: Amit Goffer, the man who invented it.
The Last Man Sitting?
When I meet Goffer near the elevator of his office in northern Israel, he is sitting in an electric wheelchair and has just enough mobility to shake my hand from side to side. He’s spent hundreds of hours on this simple task, not to mention the time it took for him to relearn how to type or answer the phone. But to use ReWalk, patients need full control of their upper bodies, which Goffer doesn’t have.
At 62, he is overweight, in part because he sits all day. But as he ushers me into his office and begins to talk about his invention, his eyes widen with excitement behind his wire-rimmed glasses. Behind his desk, there’s a photo of Goffer and his patients in New York’s Times Square on the day his company went public, their hands raised in a victory pose.
As we speak, a man bursts in, using his ReWalk device to jog across the room. His name is Radi Kaiuf, and he was born in the Arab Druze village of Isfiya. In the spring of 1988, a few months before he was set to finish his service in the Israeli military, Hezbollah guerrillas shot him in the stomach during an operation in the Lebanese village of Maydun. “It’s over,” he recalls thinking before he lost consciousness. “I was shot in the middle of the body, and I am going to die.” Under heavy fire, Kaiuf’s fellow soldiers evacuated him by helicopter to Haifa’s Rambam Hospital. For 19 days, he was unconscious and barely clung to life. When he woke up, he couldn’t move. The doctors told him his walking days were over.
Like Goffer, Kaiuf became depressed. Wheelchair bound, he was often unable to work and tried to kill himself twice. But with the help of friends and family, he decided to look for help. He started going to therapy and physical rehabilitation, which gave him a major psychological boost. And over the next few years, he married, and his wife gave birth to four children.
In 2007, he met Goffer at Tel Hashomer’s rehabilitation center, and the two quickly became friends. During their first conversation, Goffer told Kaiuf that he had developed a device that would help the paralyzed walk again. “I didn’t believe I would be able to stand up,” says Kaiuf. “But after I tried it…I was amazed. My daughter was three years old back then. She looked at me and said: ‘Dad, you are tall!’ That made my day.”
Today, Kaiuf lives with his wife and children outside of Carmiel, in northern Israel, where he’s able to take part in activities he never thought were possible. He’s completed a scuba diving course and once even skied, using a chair-like device. “There’s no question,” he says, “that I am a lot healthier with ReWalk than I would be otherwise.”
As Kaiuf and I say goodbye, Goffer tells me the former soldier often spends more time abroad than in Israel; he’s practically become the face of the device. The idea of an Arab traveling the world praising an Israeli invention sounds like a fantasy. But Kaiuf is one of several Arabs who works for ReWalk, where Goffer says religious Muslims and Jews work side-by-side in peace. Little seems far-fetched in a place where everyone is focused on helping the paralyzed take their first steps in years.
Which is why Goffer hasn’t given up on his dream of walking again. Before I leave his office, he tells me about his latest invention, UpNRide, a Segway-type device that helps quadriplegics move standing up.
Two months later, Goffer used his new device outside his home, in Yokneam. It was the first time he had stood in 18 years.