If you hang around the morning meetings for long enough, you start seeing patterns. Diseases that appear, day in and day out, until you’re desensitized to the names.

Malaria, pneumonia, diabetes mellitus.

One of these things is not like the others.

Tuberculosis, cervical cancer, cardiovascular disease.

One of these things just doesn’t belong.

When we think about the nature of illness in the developing world, our mind tends to jump to the so-called ‘diseases of poverty’- things like malaria, TB, and malnutrition. Living in Houston or Chicago or almost anywhere in the US means that you are fortunate enough to have little exposure to these conditions. However, as my experience in morning meeting indicates, that by no means that the poor are exempted from the types of illness that typically hit closer to home. In fact, a 2011 UN report found that non-communicable diseases, such as heart disease, cancer, diabetes, and stroke now make up two thirds of all deaths globally (1). This indicates that a tremendous shift is occurring in the global burden of disease, to the point where the previous label of chronic diseases as “diseases of affluence” is quite the misnomer. Instead, we see that some of the world’s poorest people are increasingly bearing the burden of urbanization and global development.

This is known as the dual burden of disease, a phenomenon in which “noncommunicible diseases are imposing a growing burden upon low- and middle-income countries, which have limited resources and are still struggling to meet the challenges of existing problems with infectious diseases” (2). And what’s even more alarming is the fact that the prevalence of noncommunicable diseases is growing at a faster rate than it initially did in industrialized regions- it’s projected that by 2020, more than 70% of deaths due to ischemic heart disease, stroke, and diabetes will occur in low-income countries! (2)

So what’s going on here? Why are people in Malawi developing these ‘first world diseases’, and how are they treated?

I think that a line from a WHO report on the dual burden of disease is most telling: “Sometimes chronic diseases are considered communicable at the risk factor level”(2). Now, if you’ll allow me to geek out, public health style, for just a moment, I’ll get to the bottom line. But first: EPIDEMIOLOGY APPLIES TO NONCOMMUNICABLE DISEASES. My Epi professor would be proud. Basically, what the WHO is getting at is that social behaviors are transferred from person to person, just like a cough or HIV.

One of the greatest examples of this ‘social contagion’ in Malawi has to do with diet. The introduction of low-cost vegetable oil from industrialized countries (3) has wreaked havoc on the Malawian diet, which up until recently was mostly plant-based. The ready availability of fats has pushed the country into a nutritional transition period, with an ever-increasing percentage of people’s daily calories coming from fat and refined sugar.   Just walking around the market and eating in the hospital cafeteria, you can see the signs of this change: people are selling fried foods (fried potato wedges and ndas, which is basically a deep fried pancake), sugary treats (Fanta, Coke, cookies, and lollipops), and fried meat (don’t worry, Mom and Dad, no street meat for me). Although Nsima, a maize flour starch dish, remains the staple, the influences of processed foods are quite visible. And when that’s what your friends, family, and fellow villagers are eating, you tend to join in, too.

There is also evidence of genetic differences in the ways that various groups of people process calorically dense foods. Some studies suggest that many in Sub-Saharan Africa are better at retaining and storing energy from food, which is great when times are hard (4). However, when the caloric intake goes up, this predisposition backfires.
It seems like the deck is stacked against the average Malawian. Is it any wonder that 80% of cardiovascular-related deaths occur in low- and middle-income countries (4), or that people are developing these disorders at younger ages in comparison to high-income countries?

So how are these problems being handled?

Well, in short, not that well. Chronic conditions tend to take the backseat to the more salient ‘diseases of poverty’. Combatting malaria and malnutrition seem like the first step in increasing the standard for health care. Additionally, such diseases are ‘sexier’ to foreign NGOs and government efforts. Think about it: would you rather say you saved a kid from cerebral malaria, or helped someone manage his diabetes?

In the case of diabetes (mostly Type 2), the national prevalence is up to 5.6%, a rate that’s often significantly higher in rural areas (5). 85% of Malawi’s population lives in rural areas. And guess what?!? Namitando and the surrounding enclaves are pretty much the definition of rural! A study done by the medical school in Blantyre revealed that the most common causes of diabetes-related hospital visits were complications and poor glycemic control. More than half of patients had trouble obtaining metformin or insulin (common diabetes drugs), and patients from rural areas in particular had trouble accessing refrigeration for their medications (6). Even if they had the right drugs, there is no guarantee that they’ll be able to properly manage their disease- almost 1 in 3 patients who had been receiving treatment didn’t know what diabetes was!!!

With such tasty temptations and lack of infrastructure for chronic conditions, we are well on the way to explaining the dual burden of disease. But the real kicker is that a non-trivial number of patients, some of them extremely sick, don’t even bother to go to the hospital! Poor Economics, an incredible book by Abhijit Banerjee and Ester Duflo, actually does a great job of unwrapping this particular calamity. I don’t want to share everything because 1) spoilers and 2) I’ve rambled for long enough, but one of their points is really unique in its analysis of the union between anthropology, economics, and healthcare. They explain that traditional healing has come to serve alongside modern biomedicine in the lives of the poor. In response to the tremendous economic burden of large health problems or chronic conditions, such diseases are often viewed as problems that require spiritual cleansing (7). Limb pains? Blurred vision? Frequent urination? The rural poor are more likely to consult a traditional healer to get their curse lifted than to visit a clinic and stock up on insulin. I don’t pretend that I know enough about Malawian culture to ascertain the validity of this claim at St. Gabe’s, but it definitely adds another interesting piece to the puzzle of treating patients.

(1). UN News Centre. (13 May, 2011). Countries facing double burden with chronic and infectious diseases-UN report. Retrieved from http://www.un.org/apps/news/story.asp?NewsID=38379#.VZLj7GCJ38E

(2). World Health Organization. (2004). Developing countries face double burden of disease. Bulletin of the WHO, 82 (7), 556.

(3) Caballero, B. (2005). Nutrition Paradox-Underweight and Obesity in Developing Countries. New England Journal of Medicine, 352 (15), 1515-1516.

(4) Gersh, B.J. et all. (2010). The epidemic of cardiovascular disease in the developing world: global implications
. European Heart Journal, 31, 642-648.

(5). Msyamboza, K.P. et all. (2014). Prevalence and correlates of diabetes mellitus in Malawi: population-based national NCD STEPS survey
. BMC Endocrine Disorders, 14 (41).

(6). Cohen, D.B. et all. (2010). A Survey of the Management, Control, and Complications of Diabetes Mellitus in Patients Attending a Diabetes Clinic in Blantyre, Malawi, an Area of High HIV Prevalence. American Journal of Tropical Medicine and Hygiene, 83 (3), 575-581.

(7). Banerjee, A. and Duflo, E. (2011). Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty. New York: PublicAffairs.

(8). Malawi.(2014). [Graph illustrations of age-standardized death rates and proportional mortality]. Data Access from the World Health Organization- Noncommunicable Diseases (NCD) Country Profiles.

Nearly every night after dinner, Sarah, Catherine, Tanya and Karen and I sit for what can sometimes be hours and discuss the work we’re doing and what it means. It is one of my favorite times of day, because the conversation helps direct me to be mindful of the place I’m in and the way we interact with the community.

It appears that the Poly may have a less direct connection to those global health challenges so apparent in Queens, because we’re tucked away in our lab building prototypes instead of witnessing sickness or death firsthand. In reality, our team is working towards solving the same problems that you can see so clearly in the hospital, and therefore the problems and underlying challenges in the clinic are actually very relevant to our work. Even beyond the direct problems of global health, it is important for me to remember that themes of development and outreach are still related to me, even if they don’t always feel entirely tangible in the lab. With that logic, the observations I’ve had about common misperceptions within the development community around Blantyre may not be prevalent in my daily interactions but they are a fibre of my work. Here are the two largest misconceptions I have started thinking about from our dinner conversations and my general observations:

Misconception #1: Sustainability = education.

A large focus of groups intending to provide medical or public health interventions is to be sustainable in whatever service they supply. Leaving medical supplies is a short-term intervention. People don’t want to simply drop off materials or donations and leave; they want to ensure that the things they bring to the community have impact after they leave. The trouble is when that sustainability is equated wholly to education.

It is often true that educating people about a new health practice or educating healthcare workers about device maintenance can go a long way towards really helping a community. Education often has a long half life, so if you can effectively teach a new skill to someone it is unlikely that their new knowledge will deteriorate much over time. But oftentimes the largest obstacles to an intervention in global health aren’t as straightforward as a lack of education. Maybe it’s not worth teaching a community how important it is to wash their hands if they don’t have consistent access to clean water. Knowing how to repair a device can only go so far if the clinic you work at cannot afford replacement parts. These may seem like obvious examples, but in my experience it is much harder to make these kinds of observations when you aren’t removed from the setting. Sometimes frustration about an unexpected condition or excitement about a new project can impair vision about what the real issues are.

To avoid falling into this misconception it is absolutely essential to have a solid understanding of the environment you are working in. In engineering terms, the process of understanding the problem and forming theoretical design criteria for every educational service or new skill you try to offer is one of the most important steps in the process. In my case, I am lucky to have six other interns that I work with who can help ground my judgement and come to a more complete understanding of the global health problems we are trying to address. Staying conscious about my own perceptions helps me self-regulate and stay diligent about getting all the facts straight.

Misconception #2: There is only one type of solution that works.

This one came mostly from some of the books I’ve been reading on health and economic development interventions in Africa in the past. A lot of experts will argue either entirely in favor or completely against some kind of program- either aid cripples an economy and it must be stopped, or it is necessary to prevent countless deaths and cannot be stopped in the near future. Either hospitals must indefinitely depend on supplies from the US and other foreign entities to keep patients alive, or they should try an immediate reduction in dependance on donations of supplies to stimulate their own medical markets. One article will say that low-resource settings cannot develop without the help of others, and the next will argue that they never can develop while being handicapped by others’ interventions.

In my experience, these macroeconomic assumptions hold less water when tested on the ground. Malawian mortality rates and disease prevalence cannot be attacked with a straightforward, unidimensional approach. The best strategy is different for each circumstance, and it depends on the long-term goals and the urgency of the need being addressed.

As an example, consider the need for pulse oximeters in many of the wards I visited this year and last year. The lack of available pulse oximeters is and has been a large problem in Queens and I’m sure in other healthcare facilities in the area. An all-or-nothing approach from some of the authors I’ve read may be to not intervene in any way in order to supply these devices to the clinics. The lack of adequate technology would spurn the start of a market to locally manufacture or find pulse oximeters. If the need is present, eventually healthcare workers and government officials will find a solution, and because that solution won’t have depended on outside entities it will be much more self-sufficient than any other kind of intervention. However, this kind of sustainability is achieved at the expense of the patients in the wards today, those who are in conditions critical enough to where they cannot wait for the needs to drive the market. There’s no way of knowing how long it would take before the pulse oximeters started appearing sustainably, and in the meantime there is still suffering and mortality.

The other extreme is to look more at the short-term needs in a setting. Pulse oximeters tend to be extremely expensive, especially the type that are small enough to be used on infant patients. They’re also relatively delicate- they require maintenance and repair, as well as a periodical battery change. If an NGO delivered one hundred pulse oximeters to the nurseries at QECH, immediate patient care would improve. However, as those pulse oximeters slowly deteriorated over time, as more and more broke or were lost or ran out of battery power, the intervention would become less effective. In a few years, the hospital may be back in the same situation of not having all the tools necessary to deliver a high standard of care. Therefore the approach of indiscriminate aid or donations is also impractical, because it fails to attack the heart of the problem.

Pulse oximetry is a unique example because it highlights an area where neither method of international involvement is ideal. Other strategies like BTB’s to deliver pulse oximeters that are affordable by the hospitals try to straddle the opposing issues of providing a service while also encouraging local sustainability. There are also many other areas where one side of the argument may be better for the community than the other. The point I want to make is that the underlying issues faced in global health are multifaceted, dynamic and deeply rooted in history, economics, culture, and geography. Because of their complexity, it is impossible to make blanket statements about whether or not interventions in low-resource settings are good or bad. Each circumstance must be observed with respect to the unique setting and context that defines it.

As I briefly mentioned in my post about the Poly interns, we were excited to meet with the Physical Assets Management (PAM) engineers to better understand their role in the hospital system as well as to see if there was a potential for collaboration between the PAM office and the Poly. In the process, I learned much more about the challenges PAM engineers face on a daily basis as they try to repair and maintain all of the equipment across Queens and 6 surrounding district hospitals.

Walking into PAM is a bit of an overwhelming scene. Outside their warehouse sit 9 or 10 hospital bed frames broken and awaiting repair. Upon entering the building, we were greeted with hundreds of boxes of donated neck collars that the hospital had no space or use for, so they had been sent to PAM for storage indefinitely.

Boxes of 4,000 soft neck collars fill the entryway to PAM. These collars were donated from India in 2011, but PAM was the only spot that had enough space to store them while the hospital tried to identify a use for them.

Suction pumps, ventilators, heat lamps, and autoclaves in need of servicing fill the warehouse shelves, and an army of nonfunctioning oxygen concentrators cover about a fifth of the floor space:

We met with one of the head engineers in the office, and he gave us a tour of the workspace. Since we were with the Poly interns, this tour was incredibly helpful for better understanding the common breaks that PAM sees in the hospital’s most-used equipment.

For example, Queens already runs on a limited supply of suction pumps due to lack of availability, but these machines are also subject to frequent breaks because they lack an alarm system to alert nurses that the container is filled with fluids and must be emptied. The machine then continues to suction, the container overflows, and the fluids flood the motor. For a nurse whose attention must be split across patients and procedures, something as simple as an audible alert when the container is reaching its capacity could be the difference that avoids the machine needing 2-month repair stint at PAM. In addition, a shut-off mechanism could provide a fail-safe in case the nurse is unable to attend to the overfilled container in time. These types of design ideas gave the Poly interns great material with which to start a design project that would fill a real-world need at Queens, not only helping clinicians get more out of their machines, but also reducing some of the repair load that falls on PAM.

Francis, Christina, and Sarah look on as Joseph explains how radiant warmers in the nursery use temperature to regulate a baby’s body temperature. If the probe malfunctions and misreads ambient temperature, the warmer can under or overheat the infant. 

In an ideal world, PAM would be able to perform quarterly checks on all hospital equipment both at Queens and at the 6 district hospitals it services. However, these checks would take 4-5 staff members about 3-4 days per hospital, per quarter. In terms of funding and staff availability, these standards are oftentimes impossible, so the challenge then becomes how to get the most out of preventative maintenance by the in-hospital maintenance departments.

Another approach could be more useful instruction for clinicians and nurses on day-to-day care for the machines. While engineers must have an in-depth knowledge of a technology, the user requires a much more basic understanding of key points to extend viability and proper functioning of a device. For example, understanding that running an autoclave (used to sterilize surgical or other procedural equipment between patients) without water covering the heating element can permanently ruin the heating element is one instance where user knowledge prolongs the lifetime of a machine and keeps PAM from having to perform a costly, time-intensive repair.

An autoclave with a damaged heating element sits in PAM for the foreseeable future until they are able to acquire a replacement element from the procurement office.

So while the procurement of repair parts and availability of trained engineers present very real constraints for PAM, having an understanding of the upstream causes of machine breakdown can provide options that in the long run can work within these limitations to increase PAM’s ability to serve Queens and its surrounding district hospitals.

hello…..

SUCTION PUMP

first of all i would like to introduce to you the project we are working on.We are working on a suction pump. A suction pump is a pump as its name suggests that sucks any fluids from patients. On this project, we are eliminating the common problem which most suction pump encounter in the hospitals here in Malawi.The problem is that when the collection bottle is full the fluids start going to the machine (pump) which result in damaging the motor.

So we found solutions to this problem by coming up with control systems to monitor the level of the fluid in the collecting bottle. The first solution is to come up with an alarm to alert the nurses when the collecting bottle is three quarter full. The second solution is an optical sensor which will sense the fluid in the collecting bottle when full to switch off the  suction pump. As of now we are through with project research,hopefully this week we are going to build circuits for control systems.

CALIBRATION OF PHOTOTHEREPY DOSING METER

We did also the calibration of our phototherapy dosing meter using the commercial standard Olympus billimeter meter with the aid of matrix laboratory software.

JACARANDA ORPHANAGE SCHOOL

We went  also to jacaranda orphanage school where we did showcase the phototherapy dosing meter to the students as the part of encouraging the students to work hard in science subjects. I was very excited to see the way students were interested with our visit.

Lastly, i would like to encourage you all to look forward for this project.

We are still doing the research about the suction pump machine. A suction pump pumps fluids from patients to a bottle that needs to be emptied once it is full. The problem that we found was that when the bottle is full, the nurse sometimes forgets to empty the bottle so the fluid tends to flow into the machine and damage the motor. We are trying to design a circuit that will help to alert the nurses or guardians that the bottle is about to be full so that they can empty it.

We thought of designing an alarm system that will be attached to the machine. The system will have a water level sensor that will sense the level of fluid and then activate the buzzer which will then produce a sound.

I’ve posted a lot of photos and descriptions of my work so far, but I don’t think I’ve painted a true-to-form picture of the place I live. Blantyre is a city with a lot of sights to take in, but even more so it’s a place that’s filled with sounds. The noises are many and varied: minibus drivers peddling their hundred-kwacha fares, honking traffic screeching to a stop in front of unconcerned pedestrians crossing the street, the low hum of chatter in the courtyards at Queens occasionally punctuated by bursts of unconstrained laughter. More than just sounds, it’s the music that has captured my attention on numerous occasions. I’ve chosen to highlight a few of those occasions here.

We went to church (actually a megachurch) last weekend and it was quite the experience–4 hours filled with song and dance. The congregation was on its feet for nearly the entire service and the melodies they sang were infectious. The one song that remained stuck in my head, though, was a Chichewa song of praise. I left the service with an echo of the tune ringing in my ears, disappointed that I hadn’t recorded it when I had the chance. Two days later in the CPAP Office, my ears pricked up as I heard the familiar chorus. It was the women in the sunken amphitheatre outside, the ones who were waiting to attend to their sick children in the Paeds ward, raising their voices under the direction of a pastor. The clip I recorded of their spontaneous song is a glimpse into daily life at Queens and the people who populate its walls.

Lyrics
Kumadze ake odikha,
Anditsogolera,
Ndimoyo wanga wofoka
Awulimbikitsa

(A rough translation of Psalm 23 from the Bible: “he leads me beside quiet waters, he refreshes my soul”)

This past Thursday, we visited the Jacaranda School, an institution 20 minutes outside of the city that provides education for children who are orphaned by HIV/AIDS. We were welcomed with open arms by a group of bold, outspoken, and whip-smart kids. Bright murals adorned nearly every wall of the school and neatly planted vegetable gardens were tucked away in every available nook. We were invited to come speak about our technologies, about women in STEM, and about pursuing higher education. It was an incredible experience to engage the Jacaranda students and answer their questions about our devices, the program, and our fields of study. Christina, speaking about her own experience as a Malawian woman studying Electrical Engineering at the Poly, gave one of the most empowering speeches I’ve ever heard. After her talk she was immediately surrounded by a huddle of wide-eyed girls who were interested in being doctors and scientists. Though Christina’s speech was definitely the highlight of the trip, my personal favorite moment was when the girls acapella group (Jacapella) sang us a song called Malaika to showcase their talents and welcome us to the school:

Yesterday, we dropped by a wedding we were invited to by Henry the Honey Man. He’s a professor at the Polytechnic who sells us amazing honey that he makes in his village. His nephew was getting married and he knew we were interested in learning more about Malawian traditions, so he invited us to the reception. There were a lot of similarities to American weddings: a bride in white, stunningly color-coordinated bridesmaids and groomsmen, middle-aged relatives videotaping the ceremony on iPads. Yet there was definitely a lot of Malawian flare, especially when the bride and groom walked into the room strutting down a rose-petal strewn red carpet to dance with their wedding party while relatives ululated and threw money in the air. The “money dance,” as we started calling it, is a way for relatives, friends, and visitors (we were singled out, of course) to come dance with the bride and groom. You’re supposed to exchange your money into small bills (20 or 50 kwacha) and then throw money at the beaming couple for the duration of the song. This entire process was repeated for about 5 hours. There were a range of songs including autotuned, reggae dance hits and a Malawian rendition of “Little Drummer Boy” that were blasted from stacks of speakers 15 feet high. The best, though, was a drum song played live by the band. It was a song that everyone seemed to know and that they all sang along to:

Out of all the faults we encountered from different devices, we as a team decided to work on the suction pump. This was so because they have a few of them and they happen to be some of the most important machine being used in the hospital which are prone to damage.

Problem: The fluids being pumped can sometimes overflow into the pump when the bottles are full hence damaging the motors windings. This can happen if the Nurse giving treatment is not monitoring the process of sucking.

Solution: We spent most of the times in the library this week researching on possible ways to come up with a low cost overflow control mechanism. The research took some days because we specifically choose a control mechanism that lies outside of the suction bottle. The suction machine can be used to suck different fluids from human body of which it would not be hygiene to be placing a sensor inside the filling bottle.

So the best solution we came up with is to use infrared sensor. We plan to start designing it the upcoming week and do some testing.