Wow, it’s hard to believe that in two weeks Caleb, Jacinta and I will be on a plane back home! It’s been an amazing summer and I can’t wait to see what the next two weeks have in store. 🙂

The rest of this past week was definitely busy. Not only was the week full of national holidays (Canada Day, the Fourth of July, and Malawian Independence, all in one week), but several of our housemates returned to England, and Emily, Jacinta and I have been running around trying to complete souvenir shopping! And on top of all of that, our work to do in the office has really picked up as well!

With MK and Shannon returning from traveling the past two weeks, Caleb, Jacinta and I have suddenly found ourselves with a plethora of new CPAPs to fix (though we are still waiting on zip ties to come from the states so that the repaired CPAPs can be bound and sent back to their homes in the hospitals). Additionally, now that our technologies are finally in Blantyre, tech surveys have been taking up a large amount of time. Finally, Caleb and I have made friends with Doctor Pam, an oncologist who is from the UK and working at Queens for 2 years; she has found lots of medical supplies for us to sort through and fix! For the rest of this post, I will talk a little more about tech surveys and supply repair.
Tech Surveys:
On Thursday and Friday, I had the opportunity to do some tech surveys with Emily. Since Emily spends most of her internship in Queens, she has provided all of us with valuable connections to nurses! We spent basically the entire morning Thursday and Friday walking around the various pediatric wards with our basket of technologies. It was definitely a valuable whirlwind experience! The feedback by the nurses was very helpful, and I think it will definitely help guide my work in my senior design project next year. Additionally, I appreciated the eagerness of the nurses to help us with our projects, as they were willing to take time away from breaks in their shifts to look at our devices. Next week, Emily, Caleb and I are going to get some feedback from attending physicians on the wards, and I cant wait to see what they have to say.

Doctor Pam:

Since our arrival at Queens, we have been able to make friends with several of the physicians here. One of our favorite doctors to work with is Pam, a pediatric oncologist that is always willing to give us tips about Queens, Malawi, and travel! Additionally, halfway through the summer Becky found out that Pam was sorting through a huge storage closet of medical supplies, but as a physician she was frequently too busy to see what devices were working or to make steps to repair them. That’s where we come in! For the past two weeks, Caleb and I have been systematically going through medical devices from the storage closet, figuring out what they are, making sure they work, and creating plug adapters to allow them to be used in Malawian outlets. I’m proud to say that, although there are plenty of devices left to go through, after two weeks we can definitely see a difference in the supply closet – I think we are on the home stretch! It has also been fun to work through all the different medical devices and learn about what they do and how they work, something that I definitely hope to be able to use later on as an engineer and physician.

Tea:

In other news, this weekend our team took a Sunday afternoon trip to Satemwa tea plantations in Thyolo, Malawi. It was a beautiful drive and a good way to relax after a long week! Once at Satemwa, we drove to Huntingdon House, where the owner of Satemwa tea plantation used to live. The house has since been converted into a beautiful hotel and restaurant. Our team got a chance to bond over afternoon English tea and a game of croquet (which I’m sure would have been more productive if we had used any rules). Overall, it was a lovely day and a part of Malawi I am glad I got to see before we left!

It’s a beautiful morning in Malawi today, and I’m happy to report that our week has been quite successful! The beginning of this week started off on a good foot with our presentation to the electrical engineering staff at Poly. Our entire talk took about two hours, and we covered the basic set up of electrical engineering labs at Rice, the class objectives and goals, the equipment we used in the labs, and the final projects for the labs we completed. We were also able to demo some final project solutions that students have come up with over the years, hopefully beginning to showcase the ability of ELVIS protoboard and LabVIEW software that we brought with us.

After our presentation, Caleb also gave an impromptu introduction on how to use LabVIEW. As the professors pointed out, if they want to introduce anew software to students, they first need to be experts in the program; students will expect them to know all the answers about it! Luckily, there are several years until the first bioengineering class will reach the LabVIEW portion of their education, so the faculty has time to learn about the software.

Following our presentation, we have been working at Queens in the BTB office quite a bit. This past weekend, the Namitete team brought some of the missing parts for the technologies that we planned to get feedback on while we were here. Now we can actually begin to get answers to our surveys. Thus far, Jacinta and Emily have gathered data on the BiliQuant, ChemoSeals, and Incubator temperature sensor. In the next few days, Caleb and I hope to gain feedback on the dosing meter, and Aakash is going to introduce the concept of tablet vitals to the nurses. We have already received a lot of good feedback on the devices; hopefully what we are learning now will be able to be used constructively in design projects to come.

In addition to the technology surveys, Caleb, Jacinta and I have been working on an oxygen concentrator repair manual that is similar to the CPAP repair manual we created last week. Oxygen concentrators are much more of a black box than the CPAP, and as a result there is much less we can do to repair them. Therefore, our manual is currently quite short! However, in the final version of the manual we hope to also include some basic design background about how oxygen concentrators work, as they are not very intuitive to understand.

Otherwise, our week has been relatively uneventful. Now that we are back in the office at Queens, Caleb and I have had the opportunity to go to morning meetings again. Interesting cases are always discussed, and it’s a great way to learn! Additionally, Shilpa, a neonatologist from Texas Children’s Hospital, has just arrived in Malawi to help with the CPAP project. During the morning meetings, she has been giving Caleb and I insight into some of the finer points of the discussion that we don’t understand, while also explaining the different ways these cases are handled in the US. We have already learned a lot from Shilpa and I am certain she will be a great addition to the CPAP team!

In other news, Saturday was Becky’s last day in Malawi. Though we were all sad to see her go, we made the best of it – eating real-from-a-box-almost-american-brownies and singing “Happy Last Day in Malawi to You!”

Many people in the United States are familiar with diabetes, the devastating effects of kidney failure, and the impact dialysis has on everyday life. As a bioengineering student at Rice, my fundamentals of bioengineering class focused on the renal system for an entire semester, so I feel particularly well versed in this area. Before coming to Malawi I knew that:

1. Diabetes Mellitus (aka diabetes) is a metabolic disease characterized by unusually high sugar in the blood stream
2. Insulin is a protein provided within the body to remove excess sugar from the bloodstream
3. Type 1 diabetes, which has an unknown cause, is due to the body’s failure to produce insulin.
4. Type 2 diabetes, frequently caused by excess body weight and an unhealthy lifestyle, occurs when the body begins to fail to respond appropriately to insulin
5. Long term effects of high blood sugar and diabetes can include end stage renal disease, the fifth stage of chronic kidney disease, a condition in which the body’s kidneys cease to function
6. Other main causes of end stage renal disease are hypertension and inflammation of the kidneys

From these facts, I profiled the types of patients who would eventually need dialysis – a treatment in which a machine acts as a patient’s kidneys, filtering their blood and removing metabolic wastes from their system. To me, this patient would eat too much junk food, not exercise regularly, and frequently be overweight or obese. With this assumption in mind, I was surprised to walk into PAM this past Monday to be told that the technicians would be busy this week – occupied with the installation of five new dialysis machines at Queens!

Many of the Malawians I have seen eat significantly healthier than Americans, walk or bike everywhere, and are seldom overweight; I had never thought about the need for dialysis or the presence of diabetes as a pressing concern in the country. Though I did not assume that kidney failure was unheard of, I never stopped to think that it would be a significant enough problem that the Ministry of Health would invest resources in a dialysis center. Additionally, while Queens is certainly a high functioning hospital, many of the patients who come to Queens are referred from hospitals across the country. Dialysis is frequently a lifetime treatment, where patients need to come into the hospital at least once a week. For many Malawians, visiting the hospital this frequently, taking time off work and traveling long distances, would be incredibly difficult.

Eager to learn more about the dialysis center, Jacinta, Caleb and I headed off to ward 2B, planning to talk to the PAM technicians about the installation process. We were also interested in the reasoning behind the new installation and how the process of attending to patients on the machines would actually occur.

Fortunately, learning about the new dialysis machines was relatively straightforward. When we arrived at the installation site, Joshua, an engineer from Botswana, greeted us at the door. Discovering that we were engineering students, he was more than happy to give us a tour of the dialysis system. The ward itself was incredibly clean due to renovations for the new equipment. The walls were freshly painted, a new nursing station had been installed, and all of the equipment and chairs were brand new!

According to Joshua, the new dialysis center at Queens will have five stations, costing 3.6 million Kwacha per station – or about 900,000 USD. Four will be in a common dialysis center, and one will be an isolated dialysis station for patients infected with Hepatitis B. When the dialysate solution (a solution used to osmotically extract waste products from the blood) flows through the system, it passes through the Hep. B station last, ensuring that no contaminated solution is transferred to non-infected patients. When Caleb, Jacinta and I visited, the engineers (with the help of our PAM technician friends) were installing the water filtration system for the ward. To create ultra pure water, the water goes through five separate procedures, the number of particulates in the water decreasing after every step. Depending on the quality of the water being filtered, the filtration canisters will need to be serviced every five to ten years. Additionally, there are several safety mechanisms in place to ensure that no impure water is used in the dialysate solution. After he walked us through the installation process, Joshua invited us back on Friday to see the calibration for the machines; hopefully, we will be able to stop by tomorrow and see the final setup!

Unfortunately, figuring out how the new dialysis system will be implemented has proven to be relatively difficult. In talking to some of the physicians here, I have learned that, especially in African countries, end stage renal disease is an important co-morbidity of HIV, occasionally because of the direct impact HIV has on the kidney, or due to opportunistic kidney infections from HIV. (Struk et. al, 2011) – Due to the high prevalence of HIV in Malawi, I now have a better understanding as to why the Ministry of Health would invest money in these machines. However, I have not yet been able to figure out how patients will be treated. The center can treat around 40 patients in one working day, or about 300 patients a week. I am certain that there are more than 300 patients in Blantyre who could benefit from dialysis, not to mention patients throughout Malawi. Will these patients be treated on a first-come-first-serve basis? Will patients with chronic kidney failure be able to return to the clinic week after week, or will the clinic be open to acute patients who only need dialysis for the duration of their hospital stay? And how would being on dialysis impact the daily life of a Malawian? I have not been able to find the answers to any of these questions, but hopefully next week will provide me with the opportunity to talk to physicians involved in the project, getting more answers and understanding more about the Queens health care system.

Apologies for the delay in posting a blog! As I mentioned last week, our entire Rice-Malawi team spent the weekend on the shores of Lake Malawi, taking a much -needed weekend to relax and recharge for the rest of our internship. Words cannot describe what an amazing time we had!

The weekend began on Friday with a late afternoon drive up to Cape Maclear, a town just outside Mangochi, where Aakash and I had been just two weeks before collecting CPAP data. After passing through Mangochi, we turned off on a dirt road, and one bumpy hour later we were at the lake! The lodge we stayed at for the weekend, Mgoza lodge, had delicious food (I highly recommend the goat burger to anyone who happens to be in the area). I was most excited that cheese was available – cheese in Malawi is rather expensive, so we never buy it for the guesthouse! Additionally, the lodges at the lake are all situated just meters away from the beach, leaving us with a gorgeous view of the water from our tree house style dormitory.

Friday evening we met up with the interns from Namitete and spent time getting to know our way around Cape Maclear. We took a leisurely walk up the beach, and being conspicuously the only non Malawians in the area, were instantly met by about a dozen shopkeepers, all trying to sell us trinkets and fabrics as souvenirs. Tourism makes up approximately 10 percent of Malawi’s GDP, as the tourism sector has been rapidly growing over the past decade. Tourist attractions are common in Malawi, from small wood carving shops on street corners in Blantyre to the more expensive safari lodges, but Cape Maclear seemed to have an economy that was based almost 90 percent on tourism (and 10 percent on fishing)!

Following our beach walk, we headed back to our lodge, taking a detour through town. As a large group of foreigners we were instantly noticed by the children from the village – they ran up to us giving us high fives and holding our hands as we walked down the street. Emily in particular was a big hit with the kids, and for the rest of the weekend whenever we were on the beach they would run up to us, asking for piggyback rides and giving us impromptu Chechewa lessons. We even got a chance to meet their mothers – Emily was introduced to them while we walked by the lake. Personally, I felt a lot better playing with the kids by our lodge knowing that their family was close by and approving!

Exhausted from our travel and exploration, we arrived back at Mgoza and found out that we had an additional roommate in our dorm. After about five minutes of conversation we found out that the new guest, Michael, was a Rice Alum and a fourth year student at Baylor College of Medicine! It certainly is a small world after all! While Rice and Baylor are some of the more prominent American institutions invested in Malawi, it was totally unexpected that we would meet a Rice Alum, not at a hospital, but at Lake Malawi! The chances are even smaller that he would be staying at the same lodge, on the same weekend, and in the same room as us! Michael was completing a global health rotation with a focus in ophthalmology at KCH in Lilongwe, and our conversations with him gave us all more insight to the differences between private and public clinics in Malawi.

Saturday, our only full day in Cape Maclear, we went on a boat ride and spent the entire day on the lake! We hung out in the sun, went cliff jumping and snorkeling, and ate delicious fish, freshly caught and cooked on the beach! Many of us bought souvenirs for friends and family, and we spent the evening watching the Ghana-Germany world cup at gecko lodge, the lodge where the Namitete team was staying. Sunday morning we enjoyed some final cheese omelets, said goodbye to the children who had become our friends for the weekend, and headed back to Blantyre. Everyone slept very soundly Sunday night, exhausted but refreshed and ready for work on Monday!

While we had lots of fun times at the lake, I also learned a lot – especially from getting to talk to Michael and the Namitete interns. All of us have been to different places in Malawi, and we all have a different perspective about the challenges to healthcare here. One of the great things about this program, and about the opportunities that Rice provides, is that it allows us to connect with people from all over Malawi, and all over the world. The different perspectives that this provides us with allows us to take a holistic approach to any technology we may develop, providing technical solutions, like the CPAP, that are able to be used in a wide variety of settings. The people that are currently involved with Rice projects are American and Malawian. We are bioengineers, doctors, and humanities students, and we are undergraduates, grad students, post docs, and professionals. From the program directors back home, to Dr. Gamula and the employees at PAM, to medical students like Michael and Becky, the diverse nature of the people I have met on this trip are truly amazing, and I have made friendships and connections that I hope to maintain throughout my life.

After several of weeks of doing data collection and being constantly on the road, it’s been nice to stay in Blantyre for a while! This week I made the switch from CPAP work to working with Caleb and Jacinta at QECH at the Poly, and it’s nice to use some more of my engineering and design skills!

ParagraphOn Monday Caleb, Jacinta and I were supposed to have a meeting at the Poly to discuss how we will implement our plans for demoing a systems and physiology lab – but unfortunately the meeting got postponed until Thursday. Luckily, we had more than enough work to do, and headed over to Queens to work on the CPAP repair manual. First we made a list of all the common breaks we have seen in the many CPAPs we fixed over the past weeks. Currently, there is only a repair guide for the most common type of CPAP break, a broken pump diaphragm. The new manual we are working on includes diaphragm replacement, but we also provide troubleshooting options for loose screws, leaks, and faulty valves. Hopefully we will be able to send out our repair manual to some of the PAM staff across the country who Aakash and I have met in the past two weeks; this is a great project and relatively simple to complete during our time here! We hope to finish adding our step by step pictures today, so we can show our work to Shannon tomorrow when she comes back from a hospital visit in Zomba.

On Tuesday, Caleb went on some CPAP travels to the central hospital in Zomba, so Jacinta and I headed over to the Poly to meet with Rodwell about another potential design project. He wanted us to look at a senior design project some elec students had completed this past year. Essentially the project is an IV drip regulator that uses an electrical circuit to control the amount of fluid dispensed by the IV bag. Currently Rice has a very promising IV drip device, so we were surprised at this assignment. However, Rodwell was interested in examining an electrical engineering solution to the problem, which had been solved using a mechanical engineering solution in the past. So after getting our new assignment, Jacinta and I headed back to our house at Cure to read up on electrical engineering. We ended up borrowing a thick textbook from Rodwell and learning about 555 timers. Though it was initially overwhelming, I feel like we have learned a lot in the 24 hours which we have been assigned this project. After with Rodwell today to go over a few constraints for our system, I am confident that we can come up with a feasible schematic in the next few days!

Today has been another relaxing and productive day around Blantyre. After meeting with Rodwell in the morning, Jacinta and I got our weekly Magnum ice cream bars from Superior market – a (new) Wednesday tradition and a nice taste of home! We are spending the rest of the afternoon blogging, finishing the CPAP manual, and putting the final touches on our systems and physiology lab lesson plans.

Unrelated to work, everyone in the house is looking forward to this weekend, when we plan on taking a trip to Lake Malawi. Lake Malawi covers a very large portion of the country, and is known for it’s delicious grilled Chambo (a type of fish) and beautiful lakes. We are heading up to the lake with some of our British friends, and plan to meet up with the St. Gabriel Malawi team as well! I cant wait to hear about their experience in Namitete, I am sure we will both have a lot to learn from each other!

Some pictures from the past week! Having fun and getting work done at the same time!

Over the past week, I have had the opportunity to think a lot about obstacles to implementing sustainable projects, especially in regards to the bCPAP project. When traveling and collecting data, it is easy to focus on what is working now, and to find temporary solutions to projects. However, the CPAP, like any other new device, will be in hospitals long after our study is over. Therefore, when working with different hospitals, it is important that we focus on more than just getting good data; rather, while we are still equipped by the generous funding resources that our study has been given, we must focus on preparing hospitals to use CPAP many years from now, when Rice is no longer making follow up visits and checking in on hospitals every week.

In my opinion, the first step to achieving this goal is integrating CPAP as a hospital norm. When the device was first introduced, it was novel and new. Many nurses had never been trained on CPAP, and Rice developers had to work with clinicians to develop regulations, indications, and best practices for CPAP use. This meant, as I mentioned in my previous post, that many nurses were hesitant about using the device, unsure if it would make a difference. Frequently, the CPAP coordinator was the only individual putting the baby on CPAP.

However, now we need to work on moving the device away from being novel – it needs to become routine. When new nurses come into the nursery, CPAP should be a routine part of training. When a baby with respiratory distress is admitted, CPAP needs to be considered immediately as a possible treatment, not only by the coordinator, but by any staff that happens to be on call. Putting an infant on CPAP when necessary should become the norm, not the exception.

This week, the hospitals that Aakash and I have visited have had varying success in integrating CPAP as a nursery norm. On one end of the spectrum, Queens has done an exceptional job. On my rotations there, I watched as our four CPAP nurses personally oriented nursing students to use the device. The next day, when I came on the ward, these same students were putting neonates on the device, on their own initiative and almost unassisted. And even when the delegated CPAP nurses were not around, clinicians and nurses alike were putting babies on CPAP and weaning them appropriately. At Queens, it is clear to see that CPAP will be in use long after Rice is gone.

However, on the other end of the spectrum, some of the hospitals we have seen are struggling to use CPAP effectively. A small few of the hospitals only had a handful of patients on CPAP in the past month, despite the large volume of patients they have in and out of the nursery. At first I was surprised at the stark contrast between these hospitals and Queens, before I realized that there are several key differences between our “home base” hospital and these other institutions.

1. Time – CPAP has been at Queens longer than any other hospital. This means that clinicians, nurses, and patients alike have been given more time to adjust to the device. They have been able to observe, over a long period of time, that CPAP is effective, and there has been time to integrate CPAP usage into nursery culture. I believe that time, and familiarity with the device, is one of the most essential things necessary to create sustainability. When practitioners at other hospitals begin to habitually use CPAP, it will be passed on to future generations of clinicians as a norm.
2. Support – With essentially all of our program associates posted in Blantyre, it is easy to check up on the progress of CPAP at Queens. In the early stages of the clinical trials, if clinicians had doubts or questions about the device, we could stop by the nursery almost daily to encourage them. Additionally, many of the doctors who head up the CPAP study are well known, well liked, and well respected doctors at Queens. Nurses who may feel uncomfortable trusting us have trusted these familiar faces, who act as an additional in hospital resource. Program associates here do an excellent job of providing support to the other district and regional hospitals, making monthly visits and weekly phone calls, but it is impossible to provide daily support as was initially done at Queens. This is why our hospital coordinators are so helpful, they provide daily support for CPAP in the nursery. However, this is a big job for one person to have. Hopefully, moving forward, we can get more clinicians at each hospital involved in our network of support for CPAP, with the bonus of having a sustained and unofficial CPAP support team at each hospital by the end of our study.
3. Feedback – At Queens hospital, clinicians have been able to see how CPAP drastically improves the mortality rates of babies with respiratory distress. This has been seen by personal experience, over time, and it has also been seen through the data that we have gathered. Hospitals who have only received CPAP several months ago, and therefore who have limited time and exposure with this device, have yet to see these positive results. One of the projects that Aakash is working on while we are here is a computer program that automatically generates a feedback report from the data we gather. Upon successful programming of his program, hopefully we will be able to take a monthly data summary to each hospital on our follow up visits, providing them with better, more hospital specific feedback than we currently have been able to give. This, along with more time with the device, will allow them to see the benefits to using CPAP on their patients.

One of the great things about the CPAP study is that everyone involved cares about integration of CPAP. In some clinical studies, the three things I mentioned above would definitely be ignored, shoved under a rug while field workers strove to get publishable data. Then, when the study was over and the papers were written, researchers would move onto a new project. However, all of the individuals involved in our project, from BTB to GSK, truly care about the success of the device beyond the study. On our way home from Mzuzu last week, Aakash, Shannon, Carol and I had a long brainstorming session in the car, discussing ways to personalize support for hospitals, and figuring out new ways for hospitals to take ownership of their own CPAP success. It truly is encouraging to see how much everyone is investing into the sustainability of this project.

In other news, I am still working on reading A Heart for the Work – I highly recommend it to anybody even remotely interested in public health. For me, I am so glad I waited to begin reading it until I arrived in Malawi. It is exciting to read about towns, hospitals, and streets, realizing that I have been where the author has. The history and insights the book provides have definitely enriched my understanding of Malawian culture, and hopefully will impact my work here as an intern, and my work as a doctor in the future.