Hello from Blantyre! It’s crazy to think that over half the summer is over already. Becky, a Rice alum and current medical student, just left Malawi yesterday after spending a month working at Queen’s. Her departure made realize how much time has gone by.

I’ve spent these past two weeks in Blantyre, working at Queen’s. Although I miss traveling and seeing all the different parts of Malawi, it’s been nice spending time with the people at Queen’s, the other interns, and some other friends we’ve made who are also working in Blantyre. Last weekend we (including our new friends) took an excursion to the beautiful Lake Malawi where we went snorkeling and ate some great food.

But I’ve spent most of my time these past couple weeks in front of a computer, coding. I’m trying to build a program that will generate summary reports from all the CPAP data we’ve been collecting, and while I’ve never programmedd in before, it’s been a fufilling experience learning how to code while working on a meaningful project. All the data we’ve been collecting is stored online in a CSV file. CSV stands for comma separated value, which means that every element of data for each patient (name, hospital, days in hospital, days on oxygen, etc.), is separated from each other by commas. My job is to build a java application that allows the user to parse through this immense amount of data and generate a summary report for each hospital.

As I mentioned in my last blog post, we want to be able to give every district hospital specific information that will help them use CPAP more effectively. By knowing specifically how many babies were put on oxygen or CPAP, the most common diagnoses for those babies, and how many of those babies passed away or were discharged, we think that the hospitals will be able to tailor their practices to be more effective. If there is a large discrepancy in outcome in babies with birth asphyxia who were put on CPAP vs not being put on CPAP, for example, the doctors and nurses will know to place higher emphasis on getting CPAP to asphyxiated babies sooner. As an applied mathematics student, I am a firm believer that good data is an invaluble tool, especially in low-resource settings, because this data can guide the use of limited resources so that they can be the most effective. I think having a program that lets hospitals obtain this data easily can really help improve outcomes.

I’ve also been working with Emily on giving demos of the prototypes we’ve brought with us to the staff at Queen’s. Today we brought an oxygen flow-splitter to the wards. Even though Queen’s already has flow-splitters that work very well, we think that our device can be helpful in other hospitals that can’t afford such nice flow-splitters. Flow-splitters are important because they allow multiple babies to recieve oxygen from one oxygen concentrator by “splitting the flow” and diverting it to multiple tubes. Oxygen concentrators are very expensive and, as we’ve found out, break easily, so the more babies that can benefit from fewer concentrators, the better. Our device allows for up to five babies to recieve oxygen from one concentrator, each being able to get a maximum flow of 2 liters/min. Compared to flow-splitters being used in the US, our device meets the standard for only $5 USD. However, our device isn’t perfect: it leaks and doesn’t regulate the flow very precisely, but the doctors and nurses we’ve shown so far seem excited by the concept.

Well, these past few days certainly have been busy! Since our visit to the dialysis center, Caleb, Jacinta and I have turned our attention to our projects for the Poly, and it has been quite a productive week!

For the past two weeks, Caleb, Jacinta and I have been working on a new, electronic, version of an IV drip. We were given an incomplete senior design project from students at the Poly, and asked to modify their proposal of a 555 timer and a solenoid relay. Assuming a constant flow rate on the IV drip, the timer would count down a preprogrammed time, closing the IV when a certain time, and therefore a certain amount of fluid, had passed through the catheter. Working to improve the model, we found a more advanced programmable timer – able to count up to longer time intervals than the 555 timer. Additionally, Caleb found a mechanical timer, similar to that used on a microwave, which would greatly simplify the proposed circuit. When we presented these designs to Rodwell he seemed pleased – about the new programmable timer. As an electrical engineer, he seemed less impressed with Caleb’s simple, mechanical timer. Though we were initially confused by this, it makes sense. First of all, a mechanical solution is probably not the best thing to come up with for an electrical engineering design project. Secondly, Rodwell explained that mechanical products were easier to break, and they frequently malfunctioned. Meanwhile, programmable circuit boards were more durable, reliable, and broke less often. Moving forward with this design, we have ordered components for our proposed circuit and are looking forward to building a prototype!

Our other big project has been a presentation for faculty at the Poly. For the past week, we have been working on preparing a three-hour lecture, explaining in detail how medical instrumentation labs function at Rice. We will be going over basic goals and objectives of each lab we have taken, as well as presenting some of the materials covered and demonstrating some projects students have completed in the past. Importantly, we hope to showcase the abilities of LabVIEW and work with the faculty, allowing them to see how the materials we brought from Rice could be integrated into their new bioengineering curriculum.

Throughout the busy week, we have also had lots of fun! I would say that the highlight of our evenings has been watching the world cup – the Portugal/Ghana and US/Germany games were particularly exciting, as we were watching in a room filled with us, Germans, and Portuguese spectators! Additionally, this weekend the interns from Namitete visited us! It was nice to see everyone again so soon, and we had fun showing them around Blantyre. In particular, the markets in Blantyre are much bigger than Namitete, so our visitors stocked up on avocado, papaya, pineapple, and other fruit that they had been missing!  Today we will be finalizing our presentation for tomorrow (yikes!) and watching a cricket match in which one of our British housemates is playing – I couldn’t ask for a better weekend, and I’m excited to see how the faculty react to our presentation!

Namitete Interns Visit!

With everyone home from traveling and MK back from the US, the office has been much busier in the past couple days than in weeks prior. I have been working on some more data entry, which is wonderful because it’s helpful for everyone here, but it also doesn’t make for a particularly interesting blog topic. The data I’m looking at is the patient registers and mortality logs for the maternity wards and nurseries of different hospitals. When enough is collected and organized, this data will be used to notice trends in mortality and if there are any patterns in diagnoses that show particularly high death rates. If pneumonia is present and fatal in every hospital but one, then it would be important to see if they have a different means of treatment or if they simply diagnose in a different way. If most neonatal deaths are attributed to sepsis but none to birth asphyxia, it would be helpful for the CPAP team to decide whether there is a problem with the data and the records of the nurses, or if something more subtle is going on. By looking at this kind of information, we can get a lot more valuable feedback on the CPAP and on what kind of difference it is making around each nursery.

Over the weekend the other interns and myself drove north to the coast of Lake Malawi. The lake was beautiful and our lodge was very nice. On Saturday we took a boat around the lake, first to a beach, then to a small island with great snorkeling, and then to some rocks that you could jump off of into the lake. Every stop we made on the boat was incredible. The snorkeling was as good as I’ve done in the ocean, and the rock jumping was exhilarating.

The group at our lodge at Lake Malawi and a lake sunset

Before we went out, we were warned about Schistosomiasis, which is a parasitic worm found along the shores of the lake that can prove fatal. We all got medication from the hospital to take six weeks and twelve weeks after having been to the lake, so that if we happen to get the parasite we can kill it before it does much harm. Even with that medication, we were all a little wary of getting in the water out of fear of the worm. We felt more justified swimming because the sink and shower water was also from the lake, so trying to avoid the water would be a little futile.

We are very fortunate that there is medication available so that we would all be able to have such a fun weekend, but of all the people that get in the lake we are a select few. People who live along the lake wash their clothes and dishes in the water. They bathe in it. The area we were in was not particularly wealthy, and when you hardly have enough money for food you won’t be shelling any out for Schistosomiasis medication. We didn’t have a lot of time to investigate, but I was very curious about how the locals deal with the parasites in the water. I don’t know if they have some sort of immunity, or they know where in the lake not to swim, or if they just get the worm and deal with it. A lot of the children I met were small for their age but had the protruding belly that is a telltale sign of malnutrition; I wondered if some of them were also suffering from Schistosomiasis and their abdomens were swollen because of the parasite.

My friend Sofina that I met at the beach

The lake was a wonderful trip but also a very informative one; and I am very glad for the opportunity both to have such a great weekend and to come to a more enlightened understanding of this country and the way it’s people live.

Rice University puts a lot of emphasis on hands on learning. There are design teams consisting of senior engineers, global health minors, and freshman introductory engineers. These teams are tasked with real-world problems at the beginning of the semester, and are challenged to come up with solutions. Some of these are global health challenges. Coming up with a possible solution may be given the most attention, but the forefront of determining what questions to answer also deserves as much research and thought. How do we determine what technologies are needed for low resource countries? Or even better, how do we ensure that these upcoming technologies have the potential to be implemented  successfully?

Before my internship began, the BTB program directors challenged us to look for problems for future design teams. At the time, I thought of this as a simple goal: of course a low resourced hospital in Malawi will have many problems in desperate need of Rice’s engineers. However, this is surely not the case.

In a previous blog post, I provided a brief summary of the devices that were created by students this past semester. Some of the technologies that we brought over were received with skepticism. It is clear that problems are not uniform throughout every low resource hospital.  St. Gabriel’s does not have a need for every resource or solution that we bring them. This does not mean that these innovations are not welcomed in every hospital. When touring the kangaroo care ward, the doctor lamented on the low number of neonatal patients in the room. Combined with the fact that African babies affected by jaundice are difficult to diagnose because of their darker pigments, only one patient uses the phototherapy treatment per year. Therefore, the phototherapy dosing meter will not provide the potential impact compared to Queen Elizabeth Central Hospital in Blantyre. QECH is a much larger district hospital and sees many patients undergo phototherapy.

After talking to a pediatric doctor, he inquired why one of our showcased devices, the temperature probe,  did not have a way to output the exact temperature.  The probe provides three results: hypothermia, hyperthermia (fever), and normal through three distinct light indicators. To him, simply checking the neonate’s temperature periodically would provide more data. At a busier hospital where constant attention can not be given to neonates in incubators, the three result system would allow mothers to use it as an alert indicator.

We are still gathering feedback from a variety of doctors, clinical officers, and nurses, and hope to return with more useful information for future design teams tasked with the same project.

On another note: This past weekend we traveled to Cape McClear, a small beautiful part of Lake Malawi, and met with the Rice interns from Blantyre. It was an exhausting but very exciting trip. Read Carissa’s blog for a great detailed description of our trip! Even though we were only gone for a weekend, Joao, Jesal and I were very glad to come home to Namitete.

             

 

June 24, 2014

I strongly believe in the importance of context for understanding one’s individual experiences. Therefore, as a helpful exercise, I hope to organize my understanding of Malawian Healthcare from a big picture perspective prior to digging into personal observations. Of course, the description that follows is by no means error-free or truly encompassing; however, I hope you all find it somewhat informative.

Brief Overview of Health Care in Malawi

Healthcare is provided either in government-run settings (62%), missionary hospitals/clinics as part of the Christian Health Association of Malawi (CHAM) (37%) or the private sector (1%). The administration of healthcare occurs at three levels, primary, secondary and tertiary (basic to advanced), which are connected by a referral system. Overall, the first point of contact with the system for most Malawians, involves the primary tier of rural health centers/hospitals. In fact, the vast majority of rural care is provided by CHAM rural hospitals (the category that St. Gabriel’s falls into). In order to provide the above services, healthcare in Malawi is financed through three main methods: government expenditure (21%), foreign aid (60%) and private (19%) – largely out-of-pocket (OOP) – payments (2006 statistics). Overall, while still largely foreign aid dominated, the Malawi gov’t has increased expenditures in health care and private payments (out-of-pocket) as a percentage have decreased (note: private (OOP) was 45% of all financing in 1999).

St. Gabriel’s Hospital Background

St. Gabriel’s Hospital was founded by Luxembourg Carmelite Sisters in 1959 and has been servicing the Namitete area for many years. As mentioned earlier, the church falls under the missionary hospital category. Thus, it charges a fee to inpatient/outpatient services unlike government hospitals that are free of charge upon referral (Note: Many activities are free of charge – ex. outreach vaccination, but not quite sure of other). Check out the picture and website to get a sense of the services provided and amounts of patients served. From what I’ve heard this hospital is definitely above average for rural hospitals in its cleanliness/resources/organization.

Personal Observations on Doctor-Patient Relationship

Compared to the interaction between physician and patient in the States, it felt like a complete different experience at St. Gabriel’s Hospital. There is a more obvious difference in power between the two. This wider gap, dominated by a patient’s greater deference to the physician, may stem from their overall lower educational status and the higher societal position of the doctor. The patients do not speak until spoken to, whether that’s stating their symptoms/complaints or a simple greeting. This phenomenon can also be an extension of the high patient load that physicians face; there may simply be a lack of time to engage in more thorough interactions. However, from what I gather, this silence is not from fear, but respect. I’ve seen multiple instances where the patient provides a gift to the clinician for his therapeutic help. Another interesting aspect I noticed was the limited “host-like” atmosphere of clinical encounters. For example, the physician does not greet the patients at the door during outpatient clinics, instead the patient simply comes to a seated doctor. The emphasis and effort isn’t about providing the patient a good experience, but treatment (except in inpatient palliative care patients, where comfort is highly sought).

Another facet of this relationship is the patient’s expectation for cure, not treatment. This difference is subtle, but important to recognize. I was often told by health personnel in pediatrics that patients’ guardians strive for discharge as soon as improvement is felt/observed, but if discharged, the patients frequently return with the same illness, possibly worsened. To mothers, an extra day beyond feeling better – “cure” – is more money owed; however, to the physician it is viewed as medically necessary to ensure dose completion and confirmed return to normal health. Mothers often tell their children not to say anything, to put on a show of wellness. There exists a divide on how treatment occurs and what “cure” actually consists of. There are limited initiatives for patient education to bridge this knowledge gap.

Weekend Trip to Cape Maclear (Lake Malawi)

From the car ride surmounting mountains to the pristine, awe-striking beach, Lake Malawi was quite the beauty. Not to mention, the lodging, which was quite cheap, had a resort-like ambience and provided the most pleasant experience. We actually met up with the five other Rice students from Blantyre and their two British physiotherapist friends. (We also happened on two current medical students from Rice! – It was quite the group.) On Saturday, we took a boat and island hopped across the lake and then closed it with some nice dinner, great company and two excellent world cup matches. Though I must say, my personal favorite was simply sitting by the coast with a nice book in hand. By the way, if interested, the next post will revolve around pediatric measurement and Babymetrix. Anyways, enough with the text – enjoy the pictures!

Moni, Muli Bwanji! These past couple of days have gone by in blur! We’ve been working on several projects since arriving, and we’ve been slowly showcasing some of the technologies that we’ve brought along with us. However, when Americans (or other Westerners) proudly bring their new, appropriate medical technologies to a developing country, there’s kind of a hidden assumption that the hospital staff will absolutely love it right away and use it all the time. We’re absolutely no exception to making that sort of assumption, as we learned when demonstrating the oxygen flow splitter last week.

A Need for Oxygen

Many pediatric patients, especially those with respiratory diseases like pneumonia, need to be put on oxygen therapy. However, oftentimes developing world hospitals only have one or two oxygen concentrators (usually giving 5 or 10 L/min) for an entire ward. But most relevant pediatric patients would only need around a maximum of 2 L/min of oxygen, so the oxygen could be split into 2 or more streams. However, current oxygen ‘flow splitters’ that are used in the states are very expensive, and most hospitals in developing regions would not be able to afford them. Therefore, there seemed to be a need to develop cheaper, efficient flow splitters for these hospitals.

Many children that develop pneumonia need to be put on oxygen [1]

The Rice Flow Splitter

A team last semester at Rice was tasked with doing just that—designing a low-cost and effective flow splitter. They came up with a nice, simple design that could split a 10 L/min oxygen concentrator into 5 different ports. Each port could either give .5, 1 or 2 L/min of oxygen to the child, which could be changed by a simple rotating disk.

 

       First Generation Flow Splitter       Flow Splitter 2.0  – several improvements were added,

                                                                        including a locking mechanism

Truce, Jesal and I talked a lot about their design—we thought that it was a good solution—it needed some work, like all of the designs—but it had the potential to turn into a comercializable and accessible product. We even agreed that the flow splitter would have been a really good project to be involved in, as it seemed like such a cool problem that could have such an impact.

Lack of an Actual Need for a Flow Splitter

Given our enthusiasm about the design, it was a bit disappointing when we were told by the St. Gabe’s pediatrician that “[he] would not use the device”. After the initial shock, he explained that the problem was actually quite simple to solve—he already had a well working system that connected the concentrator to copper tubing (which can be kept sterile) attached to cheap flow meters and humidifiers.

 The simple flow meter+ humidifier

The St. Gabe’s system prevents numerous problems that would have arisen with the Rice flow splitter, only a couple of which I will list here:

1) The copper tubing leads directly to patient’s beds, which prevents having tangles of (hard to clean) plastic tubing everywhere in the ward.

2) Each port on the system was attached to a humidifier, whereas the Rice flow splitter would have to have the humidified air coming through the input. This increases risk of cross-contamination (as all 5 ports are connected to one humidifier) and could result in yeast/molds/bacteria growing on the inside.

3) The oxygen concentrator at St. Gabe’s is 5 L/min. The Rice flow splitter only works for 10 L/min concentrators (and would thus also not work with less than accurate O2 concentrators), whereas the St. Gabe’s system can adapt to any flow rate.

While the St. Gabe’s system isn’t perfect either, it is relatively low maintenance, works well enough and perhaps most importantly, the doctors and nurses like it.

Needing a Solution to a Different Problem

While there may be a need for flow splitters elsewhere in Malawi, there is certainly no need for one in St. Gabe’s. Even so, the St. Gabe’s system is probably significantly more likely to be useful to other hospitals in the country. However, the doctor did mention that one of their biggest problems is that the O2 concentrators are expensive and fragile, so that if one breaks, its difficult to find someone in the country who can fix it, and buying another would be prohibitively expensive. I’ve even heard similar problems with the O2 concentrators over at QECH from the Blantyre interns.

So what he really wanted was a cheap, durable O2 concentrator. This would be a significantly more difficult challenge, but one that could actually be very useful for hospitals around the country.

 

The O2 concentrator at St. Gabe’s

Working Together for Solutions to Actual Problems

We need to remember that the health-related problems of Malawi—and Africa—are not just one huge homogenous lump that can be fixed in a couple weeks by a few Western engineers in a comfortable office. The people here are already working extremely hard to improve healthcare, and have oftentimes come up with better working solutions to pressing issues.

Now, this doesn’t mean that we should just give up on trying to help develop appropriate technologies because our lack of understanding. Rather, it simply suggests that we listen more to doctors, nurses and community health workers on what problems they have, what they’ve tried in the past, and what they have now; as well as ramping up our efforts to collaborate with health institutions in a diverse array of low resource settings, to get a better idea of the heterogeneity of environments that exist.

Lake Malawi with Blantyre Interns!

On a fun side note, we got to spend the weekend at Lake Malawi with the Blantyre interns! We had a lot of fun going on a boat ride, seeing lots of colorful fish and ‘cliff diving’ (which was really just jumping off some rocks). It was also really cool listening to some of their experiences at QECH, as it seems to be so different than the rural setting of St. Gabe’s. I’d highly encourage everyone to check out their insightful blogs and get a better notion of the diversity of healthcare in Malawi!

The beautiful waters from our boat                      Truce and Emily jumping together                               Jesal refused to go into the water

Quote of the Day

“Pictures just don’t do this place justice” – Truce on Malawi

[1] http://www.drugs.com/health-guide/images/204871.jpg

One of the professors at the Poly, a man named Rodwell, has pitched us a couple of design projects to work on during our time here. Both are projects that have been attempted by Rice design teams, so it feels a little awkward to work on them again. At the same time, if we can come up with an alternative solution we will be able to compare the two and maybe take ideas from both. Also, we have the advantage (and disadvantage) of working with only the materials that can be found here: our solution will be able to be produced locally, but we don’t have as many supplies.

 

Rodwell has worked off of the Rice-designed Bili-lights to create a newer prototype. His perspective is that he has benefited from the information that someone else has compiled, and maybe his work will be able to benefit the next team of Rice engineers who try to improve on the project. Everyone’s goal is to improve the way healthcare is provided, so we might as well work together. For more on Bililights, check out this article (http://news.rice.edu/2009/04/30/bioengineering-sophomore-tweaks-bili-lights-to-cure-babies-of-jaundice/)

 

The first project he gave us is to design a stand for his version of the Bili-lights. The current stand is like a table with a hole in it that rests inside a baby’s crib. His idea was to design an adjustable over-hanging stand so that the lights could be used in a larger variety of settings and crib types. Our challenge is to make our first prototype out of wood, not metal. And there’s no McMaster-Carr.

 

The second project is a timer and shut-off valve for the patient IVs. In the nurseries where we work, the staff cannot be constantly monitoring the IVs to make sure they are not “flooding” the patient. The idea of this design is to allow the user to set a timer, after which, a solenoid valve will automatically close the IV line. We’ve been having to do a lot of research on timer circuits to catch up for our limited Electrical Engineering, but we’ve made progress.