Week 6: Independence and Interdependence

Posted on July 20, 2019April 19, 2024 by Sally Yan

Part 1: Independence and Interdependence

Paintings at Kwa Haraba Art Gallery and Cafe

“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.)

Tea leaves from the tea estate we visited on Saturday (pc: Alex Lammers)

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.).

Our guide who works at the tea plantation (pc: Alex Lammers)

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.

The Ballard Score poster I put together hanging in the NICU!

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/

Week 4 and 5: Looking to the Future

Posted on July 7, 2019April 19, 2024 by Sally Yan

Welcome back to my blog! It’s been a very eventful weeks in which I visited two hospitals, traveled to Lilongwe and back for a pitch competition (and got a broken tire on the journey), and hiked a small mountain (or rather, a plateau) on our weekend adventure (while unknowingly having a fever). In an effort to keep my experiences on this blog in real time, this will be a three part blog (four if counting the customary fun photos section) featuring the highlights of what I’ve learned over the last two weeks.

Flat tire on the bus on the trip back to Blantyre

Part 1: A Small Glimpse at What it Means to be a Doctor

Kyla, Liseth, and I have had the opportunity to attend to the daily handover meetings of the pediatric department at QECH, in which the doctors on call for the night shift inform the other doctors on new admissions and deaths that occurred in the various wards during the night. The first meeting I attended occurred on a Friday, on which the mortality report for the week is presented. Each case was displayed as a row on the spreadsheet with a patient number, a date of admission, a summary of symptoms, and laboratory test results. Initially, this information seemed so abstract—just tiny black text on a white screen in a dimly lit room. Then, it hit me.

Our path to and from the CPAP office passes a busy intersection that contains, among other things, the path between the pediatric wards and the morgue. The week prior, we saw a stretcher with white sheets covering the faint outline of a small body being wheeled along this path followed by a line of bereaving family members. In that moment, I realized that that small body could have very easily been any of the data points displayed on the projector, and it deeply perturbed me that patient—that child—could be simply turned into a collection of clinical criteria. The doctors’ discussion of these cases augmented this effect, picking apart the symptoms they witnessed and treatment details.

At one point, there was some confusion over which case was being discussed due to the symptoms being fairly common. Then, one doctor exclaimed, “I know who you’re talking about,” another doctor echoed, “the one with…,” several others nodded in confirmation, as if there was something more memorable than symptoms about this patient that was etched into their minds. Then, I understood: Being doctors, they had to simultaneously recognize the humanity of each of their patients in and think of them as cases whose symptoms had to be solved and, in the worst case scenarios, whose deaths had to be learned from to prevent similar ones in the future. Sometimes, it seemed, these two aspects were in direct conflict with each other, and like the doctors in that room, in my future, I will have to handle the precarious yet crucial balance between them.

Part 2: More Thoughts on Implementation

One of the things my team in the GLHT 360 course initially struggled with when designing the Ballard Score training model during the semester was envisioning a role for it. During our research process, we repeatedly learned that the Ballard Score was seldom, in practice, used to determine gestational age, and we struggled to see how a training model could change these established norms. The missing piece of this puzzle that we weren’t thinking about was implementation: obviously a training model by itself couldn’t compel healthcare providers to use the Ballard Score, but with proper implementation, it could be a key part of the process to encourage increased use.

Showing student nurses at QECH the Ballard Score training model

The visit to QECH two weeks ago (along with the visits to Zomba Central Hospital and Mulanje District Hospital the first week) truly allowed me to envision how, at least hypothetically, implementation of the training model could work. At QECH, we met with student nurses in their final year of nursing school, and they, along with Prince (a nurse in the NICU who works with Rice 360), explained how training for the Ballard Score currently works. In short, during their unit on prematurity, for a few hours on one day, they are given a presentation on the Ballard Score, and, at best, the instructor demonstrates the neuromuscular signs on a normal baby doll at front of the room. However, there are other procedures that they practice on baby models during skills labs in nursing school, and I think it would be possible to incorporate the Ballard Score into a skills lab if an adequate training model were developed.

Receiving feedback from Prince on the Ballard Score training model

In addition, for nurses who have already graduated, this training model could be incorporated into periodic training workshops on the Ballard Score. From some of the checklists I read in the CPAP office filled in by national supervisors, I learned that trainings on other topics such as CPAP, COIN, and Helping Babies Breathe are currently held in hospitals throughout Malawi. Multiple nurses at all three hospitals also told us that they recognized the importance of the Ballard Score and, at least hypothetically, would attend Ballard Score trainings to be able to do the procedure more efficiently and use it more often. (This is in addition to the amazing app the team at the Poly is developing to make it easier to record ratings for the Ballard Score and thus reduce the time needed to perform it).

Broken syringe pump on shelf in NICU of QECH

However, I fully recognize how far away this hypothetical implementation of the training model would be even in the best case scenario (though the Poly team is making amazing progress- they are determined to prototype five neuromuscular signs this summer and have started at least two already!). I was made even more aware of this during the QECH visit. Prince showed us a broken syringe pump in the shelf of old devices in the NICU and explained to us how important syringe pumps were in delivering fluid medications and how the fact it only worked with one size of syringe was troublesome. The fact that even Prince, who works for Rice 360, did not know about the syringe pump being developed by Rice 360 addressing these exact issues, even though it has already been in the prototyping process for a few years (I think?) emphasized just how long the process from needs finding to prototyping to clinical trials to manufacturing and implementation was. This made me appreciate the fact that the patients and maybe even the nurses and doctors that we meet on hospital visits aren’t going to be the ones who benefit from the technologies we develop based on their feedback; technology development and research in general doesn’t really solve the problems of today but those of tomorrow.

Part 3: An Overarching Theme in Needs Finding

Suction machines in need of repair at PAM at Kamuzu Central Hospital

Our visits to the nursery ward a QECH and to the Physical Assets Management (PAM) department at Kamuzu Central Hospital in Lilongwewere amazing opportunities for needs finding. Hearing two contrasting perspectives—the nurses that serve as the users of the devices and the biomedical engineers that are responsible for maintain them—successively was both intriguing and informative. There were definitely some differences in their views of the challenges that they face with medical equipment (viewing pre-set settings of suction machines as a benefit vs an obstacle, seeing the failure with temperature as user error vs a flaw in device design). Nevertheless, a lot of overarching themes emerged.

The theme that stood out most to me, that I had somewhat picked up on at Mulanje DHO and Zomba Central Hospital, was the constant scarcity of consumables. By consumables, I really do mean all types of consumables: plastic tubing of all kinds, stationary (both normal printer paper and special types of paper), test strips, etc. You name it, if it is meant to be used only once, there is definitely an issue of lack of availability with it. The consequences of this became apparent:

Disposable plastic tubing being disinfected for re-use in chlorine solution in NICU at QECH

To make up for the lack on consumables, many disposable devices are re-used after sterilization with chlorine. While this is a clever and necessary work-around in these lower resource hospitals, it does not come without unintended effects (in addition to the clear possibility of insufficient disinfection). For instance, after sterilization, plastic suction tubes change texture and are more likely to cause trauma when inserted in an infant’s trachea, and the labeling on syringes used in feeding sets fade and then disappear, leading to less accurate measurements. When certain types of disposables aren’t available at all, sometimes other similar disposables are used in their place (suction tubes in place of oxygen tubes, components of IV sets for feeding sets). However, some consumables can’t be re-used or replaced—such as glucose test strips and hemoglobin test strips, and when these aren’t available, the critical functions they provide simply aren’t fulfilled.

While the scarcity of consumables may be, in large part, a distribution problem, I think there could be engineering design-based solutions to help address the issue—namely, creating versions of products that are meant to be reused. While, at least in my experience, the motivation behind designing reusable products is to reduce overall cost, it also ameliorates the difficulty of needing to continuously re-stock supplies. Looking beyond this, as suggested by Dr. Bond—the GLHT 360 professor that reviews all of our project ideas, designing better systems of sterilization that ensure more thorough disinfection or are less harmful to the material could fulfill part of this need, allowing some existing “disposable” devices to be become truly reusable and thus more compatible with the setting.

Overall, the last two weeks have allowed me to glimpse into the future—my personal future as a doctor, the future of the Ballard Score model, and potential for developing future technologies—with both hope and excitement but also an heightened awareness of the challenges that lie ahead.

Part 4: Fun Photos from This Week’s Adventures

Looking at Mandala Falls during adventure to Zomba Plateau

Jumping with excitement after a day of hiking at Zomba Plateau

-Sally

Week 3: Healthcare Disparities Here, There, and Everywhere

Posted on June 29, 2019April 19, 2024 by Sally Yan

Part 1: Healthcare Disparities Here, There, and Everywhere

I’ve spent most of last week analyzing monitoring data for the PUMANI bubble CPAP in hospitals throughout Malawi. I was tasked to use the data to create graphs looking at the impact of power outages, time of death, temperature, and weight on mortality rates of CPAP. In addition, I was told to make separate graphs for this data for the hospitals in the Ministry of Health (MOH) system and the Christian Health Association of Malawi (CHAM system) since they are given separate reports. (MOH hospitals are public, government run hospitals that offer all services free of charge, serving 63% of the population while CHAM hospitals are private not for profit hospitals that serve 37% of the population.)

While this technically wasn’t something I was analyzing, what surprised me most was that the overall mortality of CPAP patients in CHAM hospitals was consistently lower at 20-30% than that of patients in MOH hospitals at 40-50% over the last two years. In addition, the mortality rates were consistently decreasing, and the number of patients put on CPAP was consistently increasing across quarters in the CHAM system while this fluctuated a lot for MOH hospitals. (This part may, however, be partly attributed to the fact that CPAP was introduced quite recently in CHAM hospitals and longer ago in MOH hospitals.) This suggests that private hospitals in Malawi provide better quality healthcare than public hospitals. (Granted, this is a relatively limited set of data covering only CPAP patients and looking only at the past 2 years). While technically CHAM hospitals only charge “nominal” user fees to cover the cost of operations, when explaining the healthcare system to me last week, Rodrick (the Poly intern who used to be a data clerk at a rural health center) seemed to imply that the fees were still exorbitant for most people, which I also read online. This public-private divide in healthcare reminded me of that in the United States.

Graph of overall neonatal mortality for CPAP patients in CHAM system

Graph of overall neonatal mortality for CPAP patients in MOH hospitals

Ben Taub Hospital in the Texas Medical Center

While the most apparent or, at least, the most discussed issue on the political stage regarding healthcare in the U.S. is the lack of affordability, another important factor that should garner more attention is the quality of the publicly subsidized healthcare that exists. For example, the quality of healthcare available at Ben Taub Hospital—a hospital that is part of the Harris County Health System and offers local and state level programs to help subsidize the costs of services for low income patients—is, to some extent, different from other hospitals in the Texas Medical Center. For instance, I remember our mentor for the Ballard Score training model project last semester—a neonatologist at the Texas Children’s Hospital—telling use that while the Ballard Score never needs to be used at TCH due to the abundance of prenatal care (including early ultrasounds that allow gestational age to be tracked) that expectant mothers receive there, it was actually, to her knowledge, used occasionally at Ben Taub since patients there have less access to prenatal care. Additionally, I remember one of my friends who volunteers there said that patients could occasionally be in the waiting room for twenty something hours before being able to see a doctor due to relatively low doctor to patient ratio. (This congestion is also a problem that occurs in Malawi by the way—the courtyards at QECH are filled up with families waiting for long periods before they receive treatment.) (Also, this is not to say Ben Taub is not an outstanding hospital by any means. When I was reading about the hospital online, I found out it was one of only three level 1 trauma centers in the TMC and had earned numerous awards.)

Anyways, this led me to think about other disparities in healthcare that Malawi and the U.S. have in common: namely, the difference in care available in rural and urban areas. In Malawi, the healthcare system has multiple tiers providing different intensities of care. At the top are the five central hospitals located in major cities (QECH being one of them) that serve as tertiary center with many specialties available including functional operating theaters. Under that are the district hospitals for the 27 districts, which serve as secondary centers. Because the healthcare system is structured such that the available (and relatively limited) resources (both equipment and human resources) first fulfill the needs of central hospitals before the other tiers, there are substantially less resources in district hospitals. As one nurse put it when we visited the Mulanje District Hospital, they only treat the conditions that they are able to treat there—an understandable statement considering they have no incubators, one radiant warmer that was not working during the visit, and even an occasional scarcity of thermometers. The trickle down model of resource distribution even more so affects rural health centers that have very, very few resources. As Rodrick said and I later read online, these have only a few nurses—sometimes even just one as Rodrick stated—and often no clinicians. While the CHAM hospitals aim to fill this gap of healthcare availability in rural areas, as previously stated, the costs are often prohibitive.

Although the U.S. does not have a centrally mandated healthcare system that purposefully imposes this type of disparity and admittedly has a lot more resources overall, this disparity between healthcare in rural and urban areas still exists. I honestly was not aware of this (and I suspect a good portion of the general public also isn’t) until Dr. Sonia Parra’s lecture on LUCIA—a training modeled designed by Rice 360 to improve cervical cancer screening and treatment—in the Introduction to Global Health course. It surprised me so much to learn that, like many lower resource countries, the Rio Grande Valley—located in the same state as the world’s biggest medical center—has a high incidence of cervical cancer due to the lack of availability of screenings for HPV. To further emphasize this rural-urban divide in healthcare, statistically speaking, the doctor to population ratio is almost 2.5 times higher in urban areas (at 31.2 physicians per 100,000) compared to rural areas in the U.S. (at 13.1 physicians per 100,000). The commonality in the health disparities between Malawi—with a government run healthcare system—and the U.S.—with an almost entirely privately controlled healthcare system—show that the question we should be asking about healthcare policy is not merely how do we make healthcare affordable and available for all in the U.S. but how do we make high quality healthcare affordable and available truly for all on a global scale.

Sources:

http://www.aho.afro.who.int/profiles_information/index.php/Malawi:Service_delivery_-_The_Health_System

http://www.health.gov.mw/index.php/2016-01-06-19-58-23/national-aids

https://www.malawiproject.org/zzz/hospitals-healthcare/

https://www.harrishealth.org/locations-hh/Pages/ben-taub.aspx

https://www.ruralhealthweb.org/about-nrha/about-rural-health-care

Part 2: Fun Pictures from this Week

I realize this was more of an op-ed than a blog, so here’s some fun pictures (and captions) highlighting last week’s adventures.

Up-close snapshot of elephant from safari at Majete wildlife reserve (pc: Alex Lammers)

Sunset yoga pose during stop on road back from Majete wildlife reserve

Group photo in front of beautiful sunset landscape on road back from Majete wildlife reserve

Week 2: From Textbook To Reality

Posted on June 17, 2019June 17, 2019 by Sally Yan

June 10^th (Monday): The Bumpy Road to Implementation

This was my first day working in the Rice 360 CPAP Office! The Appropriate Design for Global Health (GLHT 360) course drilled in my head that the engineering design process is long and arduous, especially the implementation phase and even more so in the field of global health. However, I don’t think I truly conceptualized exactly how long and arduous this process is until today when reading previous monitoring reports for the implementation of the PUMANI bCPAP device, considered one of the most established Rice 360 technologies.

So I was surprised when I read that some hospitals were still (or as recently as 2017—the most recent report I saw) hesitant to begin using the devices after being given them and that every once in a while, for a couple of hospitals, the CPAP mortality rate increased instead of decreased between quarters or between the same quarter in multiple years. That’s not to say there haven’t been major improvements in CPAP adoption (there have—more nurses allocated to the nursery wing, more reliable backup generators, etc), and obviously I don’t have the full scope of information about CPAP implementation. Nevertheless, I was so surprised by how challenging the implementation process still is despite the long journey its already taken, and I think I finally began to grasp what it what actually take to turn any of the projects we worked on to a device that could reach its full potential for social impact.

June 11^th (Tuesday): What About the Glucometers?

At the CPAP office today, I worked on entering information from a set of forms regarding the conditions of nursery wards in various hospitals throughout the country into an excel spreadsheet. To further explain, national supervisors (selected clinicians from other parts of the country) visit other hospitals and report on various aspects of the nursery ward to help them make improvements. One of the sections in Essential Equipment and Supplies (EES), and the list of supplies included lots of things I was somewhat familiar with—phototherapy lights, CPAP machines, radiant warmers, etc—but also a device I did not expect at all: glucometers. I was puzzled—I had always associated glucometers with the monitoring and treatment of diabetes not neonatal care. So what were they doing on the list of EES? Furthermore, I remembered reading some monitoring reports listing the lack of glucometers as a primary challenge in the neonatal ward of many hospitals.

Later this evening, out of curiosity, I did a little research online on the use of glucometers in neonatal contexts and found some interesting information: Hypoglycemia (low blood sugar) is a major issue for neonates, especially for those with low birthweight (affecting 45% of neonates in the NICU according to one review). And glucometers are more adapted to use in adults with diabetes than neonates with hypoglycemia but are commonly used to make clinical decisions since other methods of glucose detection either take too long (laboratory methods) or are too invasive for infants (continuous monitoring). I think a low cost method for glucose level detection in infants could be a possible project idea to bring back to Rice 360 (though I suspect it may have already been proposed in the past) and will definitely look into it further this summer as we get more opportunities to talk to doctors and nurses here!

(Source: Woo, Hyung & Tolosa, Leah & El-Metwally, Dina & Viscardi, Rose. (2013). Glucose monitoring in neonates: Need for accurate and non-invasive methods. Archives of disease in childhood. Fetal and neonatal edition. 99. 10.1136/archdischild-2013-304682.)

June 12^th (Wednesday): New Perspectives, Old Project

I went with the Polytechnic interns to do a site visit at the Zomba Central Hospital today. As I mentioned in a previous blog, one of the projects that the interns at Poly are working on this summer is the continuation and extension of the Ballard Score training model, and I unofficially became part of the team that is continuing that project! We spoke to nurses in the neonatal and maternity ward of the hospital, and we learned lots of unexpected information. It was super interesting to basically repeat the interview portion of the research process my team did at the beginning of the GLHT 360 course but from an entirely different perspective. During the semester, almost all of the information we received was from a clinician’s perspective and mostly from a clinician in a very high resource setting at that.

We found out that while we had previously had been given the impression that only clinicians were trained in the Ballard Score and, in the U.S., actual familiarity with it was generally limited to clinicians in relevant specializations (neonatology, pediatrics, etc), all of the nurses we spoke to at Zomba told us they learned about in nursing school. (Though it seems that only the nursery ward doctors actually used it—well, only parts of it due to its time intensiveness.)

June 13^th (Thursday): More Perspectives and More Info

This was the second day of site visits (this time to Mulanje District Hospital) to ask questions about our projects, and it was every bit as informative as the first! I had a brief meeting with the new Ballard Score team, and we came up with a second set of questions based on the answers we received yesterday. One of the interesting discrepancies that came up was that while the nurses we spoke to in the neonatal ward at Zomba yesterday were familiar with the Ballard Score, the other half of the team that went to Mulanje yesterday were told by nurses that they had only vaguely heard of it.

I had originally cast it off as a matter of individual differences, but Rodrick—a member of our team who was a lot more familiar with the Malawi health system (he was previously a data clerk at a health center and has several friends in nursing school) brought it up that it might be a difference in the level of education that the nurses at the two hospitals receive. Since none of his friends, who were in diploma level programs for nursing, had never heard of the Ballard Score, he suspected that degree level nurses may be trained in it while diploma level students may not. Also, because there is only one nursing school in Malawi that offers a degree level program, he said it is very possible that all of those nurses were assigned to central hospitals such as Zomba.

When following up on this question with the nurses at Mulanje today, our suspicions were likely confirmed since the nurse we spoke to said none of the nurses there had been trained in the Ballard Score and had only heard it mentioned in passing by the clinicians. This is when I realized the importance of having individuals of different backgrounds on an engineering team and, in this case, having members who were familiar with the local context. If it weren’t for Rodrick, I don’t think we would have discovered this key fact that will no doubt influence since of our decisions.

Me with a group of interns from the Polytechnic in front of Mulanje District Hospital

One of many signs promoting breastfeeding at Mulanje District Hospital

June 14^th (Friday): Back to CPAP Office!

I finally was able to meet Sara, who will be my boss at the CPAP office, today and got a better perspective of what I will be doing for the next several weeks: helping with data entry and analysis for CPAP monitoring data, reading and helping with the qualitative reports, and maybe having the opportunity to observe in the Malaria Alert Center and/or Wellcome Trust Center (I’m really passionate about infectious diseases!) if everything works out.

I spent most of the day making charts to analyze the final diagnosis of neonates put on CPAP for the last quarter and the time of death for CPAP patients. It was super cool to put a little bit of the information I learned from my Statistics for Biosciences course last semester to use on actual data (though the statistical program the CPAP office uses and the one I learned are different—definitely plan on learning a little bit of Stata.)

Overall, this week has been filled with amazing opportunities to see and apply to the lessons—practical and technical—I’ve learned to the real world. It’s one thing to learn about the importance of implementation, different perspectives, and diverse collaborations through textbooks and readings and another to see this unfold before my eyes.

More Fun Photos from this Week: