I finally had the chance to visit the Queen Elizabeth Central Hospital in Blantyre, the first pilot place of the bili-lights and the founding place of the incubator design. On their two weeks adventure through Africa visiting all the interns, Dr. Richards-Kortum and Dr. Oden visited us at St.Gabriel’s on the last leg of their journey and then took us with them to Blantyre. It was a wonderful three days with them and they arrived just at the right time: we finished building the incubator that week. I am very grateful to the Namitete Furniture Factory. They had gone beyond professionally to help us every step of the way from woodcraft to wiring. We would walk to the factory every morning to “supervise”—more like stand and watch—as the incubator was assembled. We came to know the managers very well; they were such openly assessable people who we would shake hands with as we entered the factory complex, who every so often personally walked to our station to check on our progress and who offered us coffee during the morning tea break. It was a pleasure to work with these friendly, easy-going people and, especially with Eric, the worker put exclusively in charge to help us with the project. We became such good friends with Eric that he invited us to his wedding on August 1st. I so want to attend, but our plane back to America leaves on the 31st. I hear from Elizabeth that Malawian weddings are quite the experience. Sadly, as friends, we did not make work easy on Eric. We continuously found mistakes in the incubator directions as we built it–the dimensions in centimeters were wrong, the acrylic cover specification, inappropriate, the electrical wiring, unclear. Our progress was continuously delayed by our need to communicate back to the States for confirmation and the daily power outage we experienced. Through it all, Eric was extremely patient, double/triple checking with us on each step and kindly offering his professional opinion like what type of varnish we should use. In fact, I am pleasantly surprised at the professionalism of this small factory in one of the most rural spot on Earth. It is equipped with all the essential, hefty machines and personnel skill to turn questionable wood into elegant, sturdy products. I have to admit I was at first skeptical of the factory when I first saw the pieces of pine wood—multi-colored, irregular, disfigured with holes– that were glued together to meet the various parts’ dimensions. However, I soon stood corrected. The workers sanded, polished and crafted the wood into a beautiful incubator, so strong that we often joke that not even a baby can break it.
What is amazing is that they helped us cut the wood, built the incubator, installed the electronics, and varnished the entire thing. All for about $120. If the incubators were mass-produced, the cost can be sliced even further. That is truly incredible prospect in a country with a fertility rate of 6 children per woman and infant mortality rate of 89 deaths per 1000 live births. However, that is not to say the incubator cannot be improved. The most costly and inaccessible component of the hot cot is the acrylic glass used as the cover lid. There was no way we could get it here in Malawi (we brought it from US) and it was extremely expensive even in an industrial country like Swaziland. I think glass is a more economically suited substitute although it does present the possibility of shattering on the infant. Moreover, the current incubator design doesn’t take into account the prevalent shortage of nurses that we have seen in Swaziland and Malawi. A Holland nurse we meet here is very surprised at the nurse to patient ratio here. Whereas in her country the ratio is 1:6, here the one or two nurses on duty are in charge of the maternity ward, the labor ward, the post-surgical delivery ward and the post-natal ward all at once. At situations like this, nurses want to be able to see in a sweeping glance that babies in the incubators are there and doing well. Unlike the conventional incubators with transparent sides all round, the hot cot’s wooden sides and rather tall height forces the nurses to walk over to each crib to check on the babies from above. The cost would increase substantially if we were to install clear material on all fours sides of the hot cot, but I think at least transparency one side might be a good option.
Or, we could adapt the ingenious method Queen Elizabeth Hospital (Queen’s) at Blantyre used: cutting the height of the incubators to less than half a normal person’s height. Standing at one end of the room in their busy nursery, I could see a row of babies in their hot cots with one sideway glance. I remember my initial puzzlement at the short height of the incubators when I first looked at the original designs from Malawi a year ago. At the time, I attributed the reason to the possible differences in height. Only when I personally saw Queen’s–experience Africa–did I realize the true reason. My astonishment and my admiration of this simple design is only a small reflection of my deep respect for this amazingly creative hospital. I am extremely grateful I had a chance to visit and meet with the pediatricians I had only corresponded through emails. We were introduced with Dr. Elizabeth, a clear-headed Scottish pediatrician with a stern air but a quirky sense of humor, and her great counterpart, Dr.Kirstin Mittermayer, the German pediatrician with an enthusiastic bordering on bubbly disposition. Together, they were obviously two pillars of strength, two great forward-thinkers, in the maternity ward, one of the busiest places I have ever seen.
Taking a walk through the ward, I saw babies everywhere. Lining in rows at the center of one room, small white cubicles–not unlike the stereotypical salesman cubicles–enclosed upon dozens of wiggling babies. All the available machines in an abutting room were in use, some exceeding the limit of one infant at a time. The difference that separate this ward from others I had seen was the wooden incubators lining the edges of the walls—the originals. They were shrunken versions of our modified version, their small size allowing them to capitalize on the scarce resources. As the room was partially heated, the incubators could also afford to have larger slits. I never had the chance to see the original designs when I first worked on the incubator, but seeing it now, it gave me a sharper focus on the project, a sense of definition. It is just amazing to go back to the very beginning with the knowledge of everything that happened afterwards. I saw the need that prompt the modifications that were made to improve efficiency, but at the time, I also felt there were still much to be learned from the first generation. While our version is better from an engineering prospective, the size and bulkiness of the design is a limiting factor in the social and resource circumstances in Africa. I am definitely interested in the hospital’s response if they decide to follow the revised incubator instructions we left them.
Of course, there were the bili-lights, propped on top of the wooden incubators. I felt honored that that the lights I helped made were being used. It was surreal to actually see babies under the bili-lights I made last summer. I thought about it, dreamed about it, but I couldn’t believe I was actually seeing it in a hospital setting rather than in a research lab. I had forgotten how small the old models were. The doctors were definitely glad about the increased size of the new generation, which gives a larger irradiating area for leeway in case the baby moves. The new feature of intensity regulator was a great plus. In the past, the only way they could adjust the intensity was to pluck off different number of LEDs. Now, in addition to the intensity knob, the electrical components were all sturdier. Walking into the ward, Dr.Elizabeth and Dr.Kirstin immediately wanted to compare the new model with the old. It was a furry of movements—measuring, evaluating, experimenting. I love and appreciate the enthusiasm and interest the two doctors showed toward new technological advances. Within three minutes, they were already suggesting practical features that would make the bili-lights even more suitable to their needs. And the needs are great. They have at least two to three infants under phototherapy each day; they are even expecting the number to increase as they switch to a new meningitis medication that increases the likelihood of jaundice. I am looking forward to exploring into the issues they brought up such as a way to lock the intensity knob and the possibility of hanging the device.
It was a mere two hours at Queen’s but it was an amazing experience to see the founding place of the projects that drew me into the realm of global health. Working on the bili-lights and the incubator during my freshman summer was the definite starting point of my interest in how technology can play a role in healthcare of the developing world. Before, I had an interest, an obscure purpose. Now I have faces to relate, stories to associate, and memories to recall that define what I am doing. It was truly a full-filling two hours.
One thing I really hope to look into more after this trip is a transcutaneous bilirubin detector. Queen’s had recently obtained one, but it is a very expensive piece of equipment. Before, Queen’s method of diagnosis for jaundice is much like that of rest of Africa: physical examination. Even for a hospital like St.Gabriel’s that has full chemistry capabilities, it has trouble testing bilirubin levels because the reagents are hard and expensive to obtain. Government hospitals like the one we visited in Zomba have expressed much interest in this addition to the bili-lights.
As a whole, the three days we spent with our professors were unimaginablely busy and insightful. We jumped from meeting to meeting, hurrying from appointments with PEPFAR and UNICEF representatives to touring government hospitals like the centers in Zomba and Blantyre. On one day, we didn’t even have time to eat until late evening. I don’t know how my professors maintained this hectic pace for three weeks. The level of constant activity, tension and excitement is both exhilarating and draining. It was amazing to meet with so many great people, see so much and learn over the shoulders of giants, all in such a short amount of time. I am grateful that the professors shared with us a little of their incredible lives.