It’s been four days since I returned home to Prosper, Texas, USA. People keep asking me if it feels weird to be home. I think people expect me to say something along the lines of “Yes, of course! Everything is so different! What a strange feeling!” And it’s true that lots of things are different. I’m readjusting to driving on the right side of the road. My family and I stopped at Buc-ees on the way from the Houston airport to my hometown near Dallas on the day I got back to the states. For those non-Texans who are unfamiliar with Buc-ees, it’s basically this massive gas station general store. It has every gas station snack you could ever imagine, times ten. I was sleep deprived from over 45 hours of travelling at that point, and I almost had a meltdown when my sister walked my half-asleep self into the Buc-ees. It was something to behold. I had forgotten how absolutely massive stores in the US are. The sheer number of options was unsettling. Another area where the differences particularly struck me was this morning when I went to the GP for my yearly doctor’s check-up. After spending weeks growing used to the state of hospitals in Malawi, the cleanliness and abundance of technology and resources in my GP’s office really struck a chord. As the nurse took my blood pressure, I stared at the mobile BP machine and all I could see in my mind’s eye were the dozens of mobile patient monitors sitting broken in PAM facilities that I visited over the last two months. She took my temperature and all I could think about was the lack of temperature monitors in the labor wards at the hospitals we visited and how nurses often resort to using the back of their hand to guess if a patient has a fever. There are so many differences, and it’s important to recognize them and talk about them.

It is important to talk about the differences between our two countries. It is true that I will move forward being eternally more grateful for all that I have in this amazing country I was lucky enough to be beorn in. I will never again use random and obscure electrical components from the OEDK without thinking about how the Poly Design Studio didn’t have access to a pulse sensor for Nimisha’s team to complete part of their prototype. I will never walk into a hospital or doctor’s office without remembering the babies wrapped in chitenge in the neonatal ward of Queens Hospital. But what I think is a more important thing to say after this experience is not so much how different Malawi and the US are, but actually how we are both the same. While some differences are critical to speak about and deserve attention, most differences are illusions. During our last week, we had a really fancy dinner with our boss, all the interns, a handful of professors at Poly, and people who work in the design studio. Our boss asked one intern from each of the four universities to speak to the whole group on behalf of our cohorts: What had our experience been like? What did we expect coming in to the internship, and what did we take away at the end? It ended up being an emotionally charged moment. All four people who spoke talked about how in the beginning they were afraid that it would be difficult to relate to people from other countries, but how working with and becoming friends with all the interns was actually so easy. Everyone spoke of learning from each other and growing close to people they feared they’d never relate to. I am so, so sad to leave these friends behind. In Tebogo’s speech, he looked right at the US interns and told us “The studio is going to feel empty without you.” I almost cried.

Dr. Ng’Anjo spoke towards the end, and he told us that we shouldn’t let this internship just become an experience in our past. We should keep talking to each other, and we should make sure this week is not the end of something small but the beginning of something great: careers that transcend borders and save lives with technology. He told us to keep talking to each other, because we understand each other and the unique challenges that engineering students in the global health field face. Twenty years from now, we should be reaching out to our friends in Malawi and Tanzania to work together to start startups, help each other network and get jobs, to work at as team on the next generation of medical innovation. More than that, though, I know I will hold these friends in my heart forever, a shining testament to the fact that yes, there are differences between the US and Malawi, but at the heart of things, people are all people. For the many, many people in this world who grow up in homogeneous, small communities, it can be hard to internalize the sameness of people from very different places. But, for people making careers out of global health, or heck, even people just watching the news and voting in elections these days, it is so critical to remind ourselves that the same friends and family in our own backyards who we’d all fight for are the same as people all around the earth, and it’s important to fight for them, too.

Zikomo kwambiri, Malawi, and I will see you again.

 

 

Zikomo (Thank You), Everyone

I’d like to thank the generous donors of Rice 360 for making this internship possible. If it weren’t for you, I wouldn’t have planted a small part of my heart on the other side of the world, and I will always be grateful for that.

 

I’d also like to thank all the staff members and professors involved in Rice 360 and the Polytechnic for your support and guidance throughout these weeks and beyond. It is because of your investment in education that us interns are empowered to shape our lives into careers that might change the world. Thank you for believing in us.

 

To the Malawian interns: Racheal, Maureen, Foster, Boniface, Christina, Chisomo, Tebogo, and Rodrick: Thank you for showing me your country. Thank you for becoming my friends. I know many of you are graduating soon, and I wish you the best of luck with your future careers. I know you’ll all do great. 😊

 

To the Tanzanian interns: Nanah, Betty, Cholo, and Joel: Thank you for being so much fun to live with for seven weeks. It was wonderful getting to know you all and exploring the country of Malawi together. I know our many inside jokes and memories will last a lifetime. Keep in touch. <3

 

Finally, to my fellow Rice interns: Nimisha, Alex, Shadé, Sally, Kyla, Liseth: It was such an honor to get to know you all better than I did before. My life is much brighter now that you’re all in it. I can’t wait to keep learning alongside you. See you in two weeks!

The past two weeks can be summarized by two words: rapid prototyping. Everyday, we walk into the studio with ambitious goals of finishing multiple attachments to our model, but somewhere along the line we’ll hit an obstacle. One 3D print’s dimensions are incorrect. A ball and socket fails to replicate the range of motion of a human shoulder.  Our elastic strings don’t properly simulate muscle tension. But once a prototype falls short, its life is not over. We immediately begin shaving away extra material, cutting new holes, and taping on components to test potential directions that our next iteration could take. After a new low-fidelity prototype has been created from the remains of our previous failures, the cycle begins once more. We arrive at obstacles, meet to discuss the shortcomings of a design, and a new design is born. It’s kind of like the Circle of Life (sorry but I’m listening to the soundtrack of the new Lion King movie as I write this).

By the end of Friday, we had completed all neuromuscular attachments to our training model, and with only one week remaining, our focus shifted to developing the assessment app. In the last half hour of work before the weekend, my team grabbed a huge white sheet of paper from the back of the studio. We then began to create a flowchart, outlining the basic progression of screens within our app. Once we decided on the placement, text, and purpose for a component, I would draw it onto our plan with a vibrant red marker (I found this part super satisfying). Not only did this process help us produce complete idea of what our app would be, but every member of our team left the studio visualizing our app in the same way. In engineering design courses back at Rice, it was always stressed that a crucial step in any project is making sure all of your team is on the same page. This helps avoid any major misunderstandings later on while prototyping.

On Saturday, we drove to the Satemwa Tea plantation, the first fair trade registered tea plantation in Malawi. We began the morning with a tasting at the factory, where we each tried a spoonfuls of 18 varieties. I never knew this, but apparently even without flavoring, the different methods of rolling tea leaves have a large impact on the taste. My favorite teas were the white hibiscus, red hibiscus, green verbena, and the green mint. We then went on a walking tour through bright green rolling hills of tea plants, some of which were close to 90 years old. In the evening, we had dinner with some previous 360 interns from Malawi who had worked in Houston last fall. It was neat to compare experiences between the two different internship locations and hear about their time at Rice.

Sunday morning, Shadé and I woke up early to put finishing touches on the Clean Machine. With the craziness of prototyping our own projects, recreating this technology was a responsibility that we had pushed to the side. Taking it home to Kabula and working on it over the weekend was a good call, but looking back, we definitely had to get a little crafty with some components. For example, we completely forgot to bring the pulley’s counterweight from the US, and not being at the Poly, there was no clear replacement or way to attach the counterweight to the belt. Still wanting to test our work, we borrowed rocks from the garden and used some clothespins…

After working on Clean Machine and making a little progress on this blog, we began to prepare food for a cookout we were having with all of the interns. We underestimated the amount of time it would take to chop all of the veggies, cook the hot dogs, and fry all of the chips, samosas, and spring rolls. As a result, dinner was delayed a little, but boy was it worth the wait! I think all of us were surprised at our ability to create such a spread of food.

Returning to work on Monday, our team began to develop our simplified assessment app for the Ballard Score. Looking at our plan, we started with the simple stuff: creating different screens and adding in buttons. Once that was done, we had to think a little more on how we wanted to program more complicated things like our sliding scale. Being that I was the only one who had done something like this before, I initially felt as though I had to serve as a resource for the rest of my team, but this didn’t last long. I remember the moment we tested our work on a phone emulator for the first time. At that point, we had only made the buttons that switch between screens. Still, the feeling of seeing your work come to life is thrilling. Everyone soon began to practice with the program on their own time, and our team began to fly through developing the rest of the app.

Since last Thursday, we have been testing and tweaking our work. You can find our most recent version attached below. If you are viewing this blog on an android smartphone, simply download, open, and install the file to try it out!

Download SimpleBallard App

Early Friday morning, I hopped in a taxi to Queens for a meeting with Prince, a nurse who frequently collaborates with Rice360. He was able to give plenty of useful feedback for the Clean Machine prototype and even had the time to look at our new Ballard Score training model. After talking with him, I arranged to observe in the NICU for a few hours until work started at the Poly. Heading into the ward, I was very concerned about my presence becoming an obstacle for nurses to work around. This was the last thing I wanted, so I began by sitting in the corner towards the back of the room. After a short while, Sarah, a fellow at Rice 360, tapped my shoulder and told me that something was happening on the other side of the room that I might be interested in seeing. A new baby had been admitted into the high-risk section of the ward. From a distance, I saw nurses quickly retrieving equipment from all around the room. The level to which every nurse is able to work with one another is incredible. Their communication is clear, quick, and their collaboration is efficient. Observing led me to better understand the role in which an engineer could contribute in this setting.

 

When the new baby was admitted, I saw Prince run to the other side of the room and grab a linen blanket. He then held the blanket up to a radiant warmer used to heat the room for at least 30 seconds. As I was reminded by Sarah, the best treatment for a cold baby is a warm blanket, warm socks, and warm hat. After the situation had calmed down, Prince came over to tell me that a useful project would be a warm storage container for linen blankets. This idea would save time in situations where every second counts. Prince’s suggestion got me thinking about ways to simplify processes, and I soon began to observe other opportunities for engineering to have an impact.

Recently, I’ve been thinking more and more about the scope of this program. As an intern, one of my primary responsibilities is needs-finding for projects at Rice. These projects are then worked on, and taken back for feedback. Looking forward into my next few years of education, I may even end up working on a need we identified through this internship. It truly is a cycle, involving every stakeholder at every stage. From nurses in hospitals across Malawi, to the students from four separate universities, to the professors and organizers that make it all possible, everyone is fully invested in a common goal. Step by step, prototype by prototype, progress is made, never losing sight of the bigger picture.

It is surreal that we only have a less than a week left in Malawi. Somehow the time has gone by and I didn’t notice it, but on the other hand we started prototyping! Our focus for the past couple of weeks (sorry it’s been a while since my last post) after the pitch competition has been on finalizing our solution design, get materials, and physically build our prototype. We started by making a few alterations to our final design transitioning from a water heat source to a light bulb heat source and deciding on the exact dimensions for each compartment. Once we had a plan in place, we transitioned towards dividing the work into three components the electronics, heating compartment, and the neonate’s compartment. For our first task, we collectively decided on how the heating system should operate:

1. Contain a manual on/off switch
2. Measure the temperature of the neonate’s heated environment
3. Turn the light bulbs off when the temperature exceeds the desired temperature
4. Turn the light bulbs on if the temperature falls below the desired temperature
5. Alert nurses of the temperature

With these criteria in mind, we used various electronics, such as a thermistor, relay, Arduino, LEDs, resistors, and light bulbs, we spent multiple days trying to fit them all together. Each day we were able to build the circuit using the component and then program the Arduino to control the function of that component until we had a completed circuit. Of course, there were challenges along the way with not knowing the proper way to integrate the components together or the code not working, but eventually with enough trouble shooting we were able to acquire accurate temperature readings, automatically turn on/off the light bulbs, and indicate extreme temperatures. Not only were we able to work together and accomplish this task, but we took the time to teach each other the skills and reasoning behind each component so we understood their purpose (relays are really cool by the way).

       

Once we completed designing the electronics portion of our design, our next goal was to complete the heating compartment which contains the light bulbs, wiring, metal sheet, and insulating material. One challenge we faced in this portion of the   design was obtaining the physical materials themselves. It seemed that the best way to know where to get the proper materials was by word of mouth. Luckily the design studio already had plenty of wood available to use, however, the more specific materials were difficult to find. Working with the materials we had in the design studio, we built a simple rectangular box out of sheets of wood. On the bottom face of the box, we decided to add a plank of wood across to attach the light bulbs parallel to bottom and ensure they fit within the specified dimensions of our design. We also added a metal sheet above the incandescent light bulbs to retain heat and lined the inside of the box with aluminum to retain heat for a longer duration of time through insulation and radiation. As we continued to work, there were many decisions and adjustments that needed to be made such as adding a closed off housing area to separate the electrical components from the heat and laser cutting outlets in the box before assembling so the LEDs are visible and power switch inlet could be added. Despite planning our design for a significant amount of time, I realized that there are always going to be on the spot changes when completing a design. Because of this, my team and I had to discuss each possibility and would only move forward when we all agreed on the best option.

After completing the heating compartments, we then started on the base of the design to make the device mobile. Because we had already assembled the heating compartment with limited available space, figuring out a way build a secure and stable attachment point between the legs of the cart to the heating compartment was a challenge. At first, we attempted to attach for legs as a base and then add the wheels however, when we test it, legs were uneven causing it to be slanted (sawing perfectly level and straight lines with a hand saw is difficult). Unfortunately, this meant we had to either redo the base with the hopes of it being level or try an alternate method of attaching the wheels. Knowing that we were still unable to cut straight, we came up with another design that relied less on how the pieces of wood were cut but still stable enough to handle any obstacles when being pushed and this time we were happy with the physical results.

Despite having completed majority of our design, there are only a couple of days left before final presentations and we still have a lot to do, but I am hopeful that we can get it done in time. As for our time outside of the design studio, we had the opportunity to have dinner with the past Malawian interns who did their internship in the United States last year. It was really nice to compare our experiences having both traveled to different countries to work on global health projects. Something I found interesting was that they actually did their internship while Rice was still in school, so they worked mainly with Rice 360 fellows rather than other undergraduate students. I personally was curious to hear some of the cultural differences they found shocking in the US. Apparently one observation they had is how people treat pets as members of their family especially dogs. I can understand their surprise considering all the dogs I have yet to see in Malawi are either guard dogs or strays. It turned out to be a very nice dinner and I wish we could have spent more time with them or even met while we were at Rice.

On another note, here are some pictures from the adventures we have had over the past couple of weeks that I hope you enjoy as much as I did.

 

Until next time!

-S

 

 

 

 

 

Part 1: Independence and Interdependence

“Thirty-five years of independence, but are we really independent?” This question rang out at the Kwa Haraba Art Gallery and Café last Wednesday, the week of Malawi’s independence day, as the first poet of the night finished his poem. The answer was not spoken but was palpable in the night air. As the evening went on, more poets performed, many of them also contemplating the fragile state of Malawi’s independence. (The only guy who claimed otherwise was a Caucasian man who sang a song whose only lyric was “One Malawi, One People”…).

Considering what we’ve seen in Malawi, it’s easy to understand why they might feel that way. Driving through the city of Blantyre, you can see UNICEF, UKAID, and the names of various religious institutions plastered on signs outside buildings. The shiniest, tallest office building around the Polytechnic/QECH belongs to a Chinese company, and stickers with Chinese characters are plastered on the windows and doors of trucks. A good portion of the businesses are staffed by Malawians but owned by South Asians. And many of the doctors who work in the QECH pediatrics department are from other (mostly European countries). (In fact, approximately 60% of Malawi’s healthcare expenditure comes from foreign donations.)

This thought lingered with me when we visited a tea plantation right outside of Blantyre on Saturday. When we got to the entrance of the tea estate, I was surprised to find that the manager of the estate was a Caucasian woman with a crisp British accent and later learn that the estate was founded by and has continued to be owned by a Scottish family for three generations. In the video we watched before tea tasting, the tea estate was billed as a sustainable business and community with a portion of the plantation left for the natural forest, a self-sufficient bluegum tree logging and replanting operation, two clinics for the workers, and a primary school for the workers’ children. Later online investigation showed that this was the only Fairtrade certified tea plantation in the country and numerous other projects had been undertaken under the Fairtrade agenda (investment into the nearby Thyolo District Hospital, subsidized solar panels for workers, construction of roads, etc.).

Nonetheless, it’s hard to forget that the tea plantation was founded during and built off a legacy of neo-imperialism that lined the pockets of western nations and exploited the workers. And it could hardly be claimed that the plantation is an utopia now—only half the workers’ children are able to finish primary school, and food insecurity is an issue during the dry season. This exemplifies the issue that the poets at Kwa Haraba lamented and that I noticed while here: it is difficult and almost impossible to differentiate between the lingering effects of colonialism that put Malawi in this position and the efforts of foreign aid that attempt to improve the situation.

As a result, some people, especially many young Americans, would argue that it is better to avoid foreign intervention (and, to some extent, foreign aid) all together, at least at the national level. Although I truly do not have enough information to make judgments about the tea plantation or any of the other instances of foreign investment I described (clearly they’re not all equal), despite, or perhaps due to what I’ve seen here, I strongly believe past mistakes do not excuse in current inaction. While the ultimate goal is a Malawi that is truly independent from foreign influence, in the meantime, we, as an interdependent global community, have a responsibility to help Malawi and other countries like Malawi get to that point.

Part 2: Scales of Change

I fully admit that the last part of my blog was a statement of lofty thoughts and aspirations that I personally can do very little about. However, the importance of differentiating between ultimate goals and current realities has also been impressed upon me on a smaller, more personal scale recently.

As I was walking through the hospital grounds to lunch from the Rice 360 CPAP office one day last week, a man stopped me and telling me that his brother was being discharged and that he needed 2000 kwacha to pay for the minibus trip from QECH to their home in a village. I didn’t know what to do. The other interns and I had encountered people asking us for money before, and we had discussed it extensively. We talked about how giving people on the street money ultimately perpetuates an unsustainable system since it incentivizes them to keep coming back to the random people on the street instead of seeking more long-term aid from nonprofit organizations or government agencies and, consequently, prevents the social issues from garnering the attention they need. For the most part, I believed this, but, in that moment, I realized the flaws in this perspective.

I knew that transportation was a major barrier to access to healthcare services, even in the United States. For instance, during my Alternative Spring Break on maternal mortality in Texas, I learned that a major reason that pregnant women missed prenatal appointments (putting them at increased risk for maternal mortality) was that they could not bring their other children to these appointments using Medicaid covered transportation. (Though this has changed during the last state legislative session.) How could I blame that man for his country not having adequate public transportation to health facilities when this was so recently still a problem in Texas, which has exponentially more resources than Malawi?

I ended up giving him the money. (I’m aware that he may not have been truthful, but I choose to believe otherwise.) In the end, 2000 kwacha was not a lot of money to me, and while I may not have contributed to improving rural healthcare access or the public transportation system, the money allowed that man and his brother to return home after receiving the healthcare they needed.

This realization about the difference between long-term sustainable change and short-term measures led me to decide to pursue a side project I had been thinking about. Seeing the Ballard Score poster, which was really a sheet of letter sized paper with the diagrams in black and white, in the NICU at QECH made me want to make a larger, laminated, and colored poster to at least match the other poster in the ward. However, I kept going back and forth about whether I should do this initially. A larger poster really doesn’t change the fact that the Ballard Score to difficult to use and that nurses don’t like performing it. Nonetheless, in my last blog, I talked about how, even in the best case scenario, a Ballard Score training program and assessment app would take years to implement. In the absence of a better training system or a better method of gestational age determination, at least a better poster would make it easier for nurses and doctors in the cases where the Ballard Score is used.

After corresponding with Prince (the nurse at QECH who works with Rice 360) and getting approval from the ward in charge to post the poster, I ultimately made four copies of 11 x 17 inch poster with a colored coded version of the Ballard Score diagram to hang in the NICU, the low risk area, and the Kangaroo Mother Care ward. While this poster clearly doesn’t make any meaningful, large scale change, I’m happy to have helped the nurses of one ward in one hospital in a small way. This week has been a valuable lesson in distinguishing between overarching aspirations and immediate measures and understanding the importance of contributing to both.

Sources:

https://mwnation.com/health-budget-at-donors-mercy/

https://www.fairtrade.org.uk/Farmers-and-Workers/Tea/Satemwa-Tea-Estates-LTD

https://doctorsforchange.org/dfc-2019-policy-priorities/

Hello everyone!

It has been such a whirlwind of a week (2 weeks?) since I wrote my last blog entry. I have many new updates to share so I’m just going to dive right in.

This past week and a half, Liseth and I have been busy continuing our usability observation project. We wrapped up our note taking from Queen Elizabeth Hospital with a visit to the pediatric oncology ward, pediatric special care ward, and an overnight stay in the neonatal intensive care unit (NICU). From speaking with nurses in oncology, we learned that the lack of syringe infusion pumps meant that nurses had to calculate the average amount of fluids and chemotherapy drugs administered per hour. They discussed with us the challenges of manually regulating these dosages for every chemotherapy patient.

While spending the morning in the special care ward, we observed that the bulk of the medical equipment and technologies (oxygen concentrations, bCPAP machines, patient monitors) were concentrated to the high dependency unit (HDU) for special care patients requiring respiratory support. At first, we were surprised to see that all of the patients were in the HDU and the main bay area beds were completely empty. But around 9am, floods of kids and families entered the ward from outside and filled up almost every bed in the main bay area. In the special care ward, patients and their families must gather their belongings and leave their beds to wait outside twice a day while the ward gets cleaned in the morning and afternoon. We learned that many of these main bay patients were typically kids suffering from anemia, malaria, HIV, and tuberculosis. These serious conditions would generally warrant the use medical equipment and monitoring devices, however the limited resources available simply must be used towards the HDU patients.

Our overnight stay in the NICU at Queen Elizabeth was my first experience spending the night in a hospital setting. I did not really know what to expect, as my hospital expertise stems from episodes of Grey’s Anatomy. At Queens, we noticed that the night shift was when many of the babies get put on and taken off of different medical devices. We saw the setup of oxygen concentrator machines, the preparation for phototherapy treatment, and the administration of various drugs. The night provided excellent insight into how nurses and doctors interact with the technologies and Liseth and I got pages of informational notes from our time here.

Our next overnight visits provided additional insight into the night routine and ward procedures for Zomba Central Hospital and Mulanje District Hospital. The Zomba Central Hospital nursery was quite large; it had 4 separate rooms for high risk patients, low risk patients, patients who were brought in from home, and for kangaroo mother care. 1 continuous monitor was available for all patients to check vital signs so again, Liseth and I watched as a lack of resources continued to influence healthcare and outcomes. Seeing the nurses face difficulties to keep neonates alive was extremely difficult and probably the hardest part of my internship experience so far. Our overnight visit at Mulanje shared many similarities. Here, human resources were scarce as 1 nurse was on the night shift for the entire NICU. No continuous monitor was available for the ward, so vital signs and recording were limited to temperature checks using 1 thermometer for all the neonates.

The health inequalities were extremely evident as my mind couldn’t help but draw comparisons to the equipment availability in the United States. After looking more into a holistic economic picture of the country, I learned that Malawi suffers from a climate vulnerability that has widespread influence upon agriculture, energy, forestry, water, gender issues, and human health. In 2015 and 2016, Malawi suffered from a pattern of floods and droughts that impacted over 5 million Malawians with food insecurity. Any extreme floods and droughts of a growing season can be detrimental to the climate-sensitive agriculture sector which contributes to up to 40% of the gross domestic product, employs 85% of the workforce, and supplies 70% of raw materials for manufacturing. With an under-financed health sector, 60% of the country’s total health expenditure needs to be obtained from external sources such as donations.  Reports suggest that in order to break out of a cycle of systematic poverty and dependency, Malawi needs to target the rural poor who depend on mainly agriculture alone for subsistence. Expanding the access and quality of health services available these rural communities in Malawi would help address some of the social, economic, and environmental determinants of health as a means of reducing overall health inequities. (Based on WHO Country Cooperation Strategy: Malawi https://apps.who.int/iris/bitstream/handle/10665/136059/ccs_mwi.pdf;jsessionid=55B8169FD0E2EFBE8B253B154BF5AF96?sequence=3).

When examining global health, I feel that it is incredibly crucial to consider all influences and factors that contribute to current health situations. Policy reforms targeting healthcare delivery and accessibility systems, human and monetary resource allocation, and overall health development are so vital to helping alleviate morality and disease burdens for a country. Although it can be an uphill battle, tackling global health with a comprehensive economic and policy approach lays the groundwork for sustainable widespread change.

 

 

Thanks for reading! I’ll check in again soon for my last week in Malawi! See you next week!

Thinking about how fast these first few weeks have flown by, it’s really hard to accept that we are halfway through this internship. Recently, I have been taking more and more pictures of regular day-to-day tasks, not wanting to forget the small things: the sunrise, the walk from Queen Elizabeth to the Polytechnic, and our home-cooked family dinners at Kabula Lodge. The following blog will take you through one day of our lives here in Malawi. I’ll walk you through decisions my team makes while prototyping, things I notice on the streets of Blantyre, and my thoughts from when I untuck my mosquito net in the morning until I tuck it back in at night. Hopefully this blog gives you a sense of what it is like to be an intern in this amazing program. 

– July 5th, 2019 –

7:26 AM

It’s become kind of a tradition that every morning as we are eating breakfast, I will set down my tea and declare the time to be 7:26. The bus from Kabula leaves every morning at 7:30, and through trial and error, we’ve discovered that in order for every intern to take their seat on time, this is when we all must begin to scarf down our remaining tea and toast. 

This morning the normal bus was out of service. Instead, we rode to work in a smaller replacement bus with fewer seats and unfortunately, less leg room. Once at Queen’s we began our usual walk along the busy streets of Blantyre: through the small market outside of the hospital, under the bright blue walking bridge, and between two tall palm trees marking the side entrance to the gated Polytechnic campus. From there, we usually have around 30 minutes until work starts, so we spend our time either reading or journaling in the sunny seating of an outdoor amphitheater.

8:30 AM

Wongani, a technician at the design studio, waves to us from the covered red walkway on his way to unlock the doors to the studio. Inside, light pours in through the 360º windows onto the clean and shiny tables, signaling a fresh start to a new day. While we wait for the rest of our project teams to arrive, Shadé and I make progress on the Clean Machine prototype. 

9:00 AM 

My Ballard Score team sits down and begins a brainstorming session for one of the training model’s attachments. For 10 minute intervals, we sit in silence, each writing down whatever comes to mind in our journals. At the end of the time, we each have several pages filled with a mix of potential solutions and mechanical components. Each one of these ideas is then shared with the group, free of any immediate criticism. As someone reveals a drawing, others build off of it, presenting their own related thoughts and combining concepts. 

Betty and I spend the rest of the morning developing low-fidelity prototypes for two of the brainstormed ideas. While we bend pipe cleaners and straws to create proof-of-concept models, Rodrick and Racheal continue work on two other neuromuscular attachments: heel to ear and the popliteal angle. With a goal of finishing prototypes for both of these attachments by the end of the day, they make final adjustments to dimensions in various CAD files. 

12:07 PM

Not wanting to waste valuable time, my team hangs back a few minutes into lunch to get our 3D prints started. With stomachs growling, we all make our way across the street to Miko’s Dessert Shop. Rather than getting their extravagant ice cream waffle cones (like we do every Friday), we instead order freshly baked cinnamon rolls. Unable to resist the smell, I finish mine on the walk to get an actual lunch from LJ’s – a small red shack across from Queen’s.  

At LJ’s you get a choice of nsima or rice, a meat, and a variety of vegetables. I prefer to have nsima over rice, mainly because I think it is way more fun to eat. From what I have been taught, here’s how to best enjoy these bouncy scoops of corn flour: first roll a ball in the palm of your hand (quickly because it’s hot), use your thumb to press a hole in the center, then use the nsima as a spoon for the rest of your food. 

1:30 PM

The work ethic of the Polytechnic and MUST interns is incredible. In addition to the internship, they are still attending classes, completing homework, and working on their own side projects. I honestly have no idea how they manage to do it all. Today, Rodrick had to leave for a few hours to give a presentation. In his absence, Racheal, Betty, and I have found little ways to be productive. Racheal has begun working with the software we will be using next week to design our app. Betty continues to work on her low-fidelity prototype, and I start designing components of the training model’s arms in SolidWorks.

3:30 PM

Just as bright light pours in through the windows every morning, the warm beginnings of a sunset flood the design studio starting at around 3:30 p.m. Over the past few days, I’ve begun to notice the effect of this lighting on our productivity. This final hour truly becomes a test of our willpower to accomplish the goals we established in the morning. Today, we had hoped to finish prototypes for both of the neuromuscular attachments on the hip, but as the orange tint of the sun overtakes the fluorescent blue of the LEDs, we haven’t assembled either. 

When Rodrick returns from his presentation, I am staring with frustration at my computer screen, unable to get one dimension of an arm to change without having to start over again from scratch. Unlike the rest of us, he is somehow still full of energy. It spreads to the rest of us, and the next hour becomes a mad rush to finish at least one of the attachments.  

4:26 PM

With 4 minutes to go before the end of the day, we have completed the prototype for the heel to ear attachment. My fingertips are encrusted in a layer of solidified super glue and our table is a mess of PLA shavings, bits of elastic, and random hand tools. During the walk back to the bus, I reflect on what we were able to accomplish.

It’s difficult setting goals and then not being able to accomplishing them fully. Back at Rice, the OEDK is just a short walk away from my dorm room, allowing me to work on a project until I am satisfied, sometimes into the early hours of the morning. Here, a 15 minute bus ride separates me and the design studio. At the end of every day, we must set down our tools regardless of whether or not we have reached a natural stopping point. As frustrating as this is can sometimes be, I feel that it has helped me to become a better teammate. 

In the past, I have struggled to let others take the reins in group projects. If a calculation was being made, I wanted to double check it. If a prototyping method was modified, I wanted to be there to understand the decision. But for the first time in my life, the engineering design process has been shoved into the time constraints of a workday. With so much to do, there is no longer time for me to obsess over every detail. My group at the Polytechnic has learned to strike a balance of task-division and making sure the whole group remains on the same page.  

5:30 PM

Once back at Kabula, we all walk under the beautiful orange flowers that drape over the reception area. Having done laundry the night before, I take down my clothes from the line and begin to pack for our weekend hike of Mount Mulanje. Hannah, Liseth, and Cholo start preparing dinner in the kitchen. At the very beginning of the internship, we randomly selected four teams to trade off cooking duties. The system works well and has been a fun opportunity to learn how to make some new dishes from the Tanzania interns. For our last meal, Joel taught Kyla and I how to make nsima, or as it is called in Swahili: ugali. The process turned out to be more difficult than expected and requires a lot of arm strength (more than I have), especially when you’re cooking for 11 people.  

8:00 PM

Eggplant parmesan is ready. People slowly begin to crawl out of bed, up the stairs to the terrace, and take their seat around the dinner table. While eating, we joke about how we’ll probably die climbing the mountain this weekend. Liseth retells stories of Cholo’s misadventures in the kitchen. We laugh, talk, and eventually move into the lounge area. Some 0f us do research for our projects. Others snuggle up in a blanket to read a book. I begin writing.

10:00 PM

I finish this blog! 🙂

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After three weeks of needs finding, research, and brainstorming, we’ve finally begun to delve into the prototyping phase of the engineering design process. This week, we began to CAD parts, 3D print them, and prepare for the assembly of our prototype.

I should probably take some time to explain my team’s project, since I don’t think I’ve done that yet. We are Team Suction, and we’re working on a neonatal airway deep suctioning training model. I’ll explain what that means in a moment. My teammates are:

Napendael (Nanah) Msangi from Dar Es Salam Institute of Technology in Tanzania
Foster Sentala from Malawi University of Science and Technology (MUST)
Chisomo Mbale from Malawi Polytechnic (Poly) 

Different people with different levels of technical and medical backgrounds will read this blog, so I’ll take some time to explain neonatal airway deep suctioning and the approach we’re taking to developing a training model.
Sometimes, babies are born with their lungs and airways full of amniotic fluid, and this prevents them from taking their first breath. In order to remove the fluid, nurses must use a catheter and a suctioning machine. The catheter is a long, thin tube that must be inserted into the trachea of the newborn. One end of the catheter attaches to what they call a suctioning machine, which creates negative pressure in order to suck the amniotic fluid out of the airways of the newborn, enabling them to breathe. There are a few difficulties associated with this procedure. First, it is common for nurses to overestimate the amount of tubing appropriate to insert into the infant’s airways. If the tubing is not inserted far enough, not all the fluid will be suctioned out. If the tubing is inserted too far, past the trachea and into the lungs, the baby will go into respiratory arrest. The second issue is that it’s easy to traumatize the newborn’s airways with the catheter if one isn’t gentle enough. This is particularly difficult to avoid if the newborn is premature or is moving around a lot during the procedure. Trauma to the airways can cause a variety of issues, including scar tissue build-up within the airways, which could restrict breathing. For these reasons, it is critically important that nurses are empowered with the knowledge and confidence to complete this procedure carefully and effectively. My team and I have decided to develop a mannequin-style training model in order to give nurses the opportunity to get hands-on practice of this skill during their schooling years in order to gain confidence and experience before entering day one of their jobs in hospitals.

On Monday, we were able to visit the labor ward at QECH, where the deep suctioning occurs right after babies are born. We actually entered the ward right after a suctioning procedure had taken place – we just barely missed it! When we arrived, a nurse was wrapping a newly-suctioned newborn in chitenge and connecting them to oxygen.
The most valuable part of our visit was that the head nurse in the labor ward was able to show us an existing training mannequin. It’s used to teach manual airway ventilation, which is a totally different procedure from deep suctioning, but we were inspired by the model itself. It was a blow-up doll with a shell for the face and for the torso, underneath which the tubes reside. Similarly, we decided to use a baby doll. We made a plan to cut off the face and reattach it using hinges, making it able to open and close. The tubing will reside on top of the doll’s chest and underneath its clothing.
We have begun the process of creating CAD models of the tubing and airways. Foster pioneered the CADing process, since he had the most experience with Solidworks. So far, we have CAD models of the trachea, larynx, and airways to connect to the nose and mouth. We have also begun 3D printing these files. We finally managed to procure a baby doll that would work for us (shoutout to Sally for having an extra one from the Ballard Score project).

 

On Friday, we began to dissect our baby doll. We cut off the face of the doll, and spent far too long attempting to reattach it partially using tiny hinges. Who knew that pieces so tiny could prove infinitely more difficult to work with than their normal-sized counterparts?

Over the next two weeks, our biggest challenge will be figuring out how to mimic the trauma that can be caused by suctioning. We want nurses to practice on the model and know when they have not been gentle enough. Therefore, we want to include some sort of membrane which ruptures when too much force is used. The membrane would then be removed and observed in order to inform nurses whether they made a mistake. We are considering different approaches to manufacturing this rupturable membrane. Hillary recommended the use of a thin plastic such as tephlon, which could be cut into small strips and secured together at the ends to create a cylinder. I am also exploring the option of molding and casting using a delicate type of silicone. Unfortunately, we don’t have the ability to special order unique types of silicone molding and casting materials, so we’ll have to improvise if we go this direction.

Overall, I’m thrilled to have finally entered the prototyping stage. As critical as I believe the first steps in the design process are, they can feel arduous. There’s a certain exhilaration that comes during prototyping. It feels powerful to be able to turn the ideas we’ve been discussing for weeks into physical realities. This must be what it feels like to be an engineer.

 

BONUS CONTENT

Going into our 4^th week of work, all 4 teams have finally begun prototyping. After 3 weeks of extensive needs-finding and research at various hospitals, we are ready to get our hands dirty. And I mean that literally. I leave the studio every day with my hands covered in a layer of solidified hot glue.

Before I get into the details about my project and the progress we made this week, I want to formally introduce my three teammates:

Joel Ngushwai: Dar es Salaam Institute of Technology

Christina Kalulu: The Malawi University – Polytechnic

Boniface Kaseka: Malawi University of Science and Technology

As I mentioned briefly in previous blogs, my team was initially tasked with developing a low-cost continuous temperature monitor for mothers during labor. The project was actually started by a team at Rice University, and now we are taking over from where they left off. The current version of the device uses a thermistor to measure temperature from the axillary artery on the upper arm. It has 3 LED’s (blue for when temperature is too low, green for when the temperature is within a safe range, and red for when the temperature is too high) and a buzzer to alert a nurse when the mother’s temperature is unsafe.

Before I delve into the details of our prototype plan, I want to talk a little about the need for continuous monitoring devices in countries like Malawi. Over eight million neonates die due to complications during pregnancy and labor per year, and 95% of these deaths take place in low resource and developing areas. Many complications that contribute to these deaths are due to changes in maternal temperature and pulse rate during labor. Intrapartum fever (≥ 38°C) and high pulse rates (≥ 100 bpm) can lead to an increased risk of complications including infections and fetal distress.

After talking to many nurses at Zomba Central Hospital, Queen Elizabeth Central Hospital, and Mulanje District Hospital, my team learned that currently, most hospitals in Malawi use non-invasive thermometers which are often lost or easily broken, and many nurses end up relying on using their hand to check whether a mother has a fever. Additionally, many wards don’t have access to pulse rate monitors, and oftentimes, nurses have to manually count the patient’s pulse rate – which means it is too time consuming to be done regularly. As a result, nurses are typically too busy or overwhelmed and don’t always end up using a partograph to record maternal vitals. In fact, a 2017 study in Malawi found that on average, 65.3% of partographs lacked temperature recordings.

These findings confirmed the need for a continuous and accurate vital signs monitoring device that can assist nurses in monitoring and recording the incidence of maternal fever and high pulse rate during labor.

With guidance from Francis Masi (who mentored the team working on this project last summer), my team has decided to make the following changes to the existing prototype:

1. Include a circuit for pulse rate detection
2. Transition from 4-Digit 7-Segment display to an I2C LCD or TFT LCD display
3. Include a bluetooth or WiFi module to allow patient information to be stored on the device (so that nurses can access past data and view trends of temperature changes)
4. Transition from a cloth armband to one that is more easily cleaned, adjustable, and comfortable
5. Include battery life indicators

My team is slowly starting to formulate our project idea into a reality. This week we began recreating and troubleshooting the device’s temperature circuit using a thermistor, a basic I2C LCD Display, and 3 LEDs as a visual alert system. We also began designing the control unit (which will ultimately be 3-D printed) on SolidWorks.

It is absolutely crazy to think that we are over halfway done with our time in Malawi. In 4 and a half short weeks, I have grown to love this country and its people. I love waking up to the beautiful sunrise over the mountains that Kabula Lodge overlooks. I love cramming over 20 excited and passionate young engineering and medical students (onto a bus meant for 14 people) every morning to Queens. I love working with my team at the Poly Design Studio, eating lunch at LJ’s (a small red shack by Queens, which we have, rather appropriately, nicknamed “red shack”). I love family dinners back at Kabula with all the Rice and DIT interns. I love everything here and I’m determined to make the most of every day we have left.

***bonus content***

This weekend we finally attempted the long-overdue 3-day hike up Mount Mulanje! It was so hard that many of us found ourselves joking about how we might die before we make it to the top. Here are some pictures as proof that we made it out alive!!

— Nimisha 🙂