It’s not uncommon to run into foreign doctors in every ward at Queens. Since it is a teaching hospital associated with the College of Medicine there are numerous foreign doctors, visiting professors, and researchers roaming the halls. It’s great to have so many varied, international perspectives, but it also makes doctor-patient communication very hard. A lot of the patients at QECH know little to no English, and doctors’ inquiries into their complex medical histories are usually met with blank stares or detailed explanations in rapid Chichewa. So when their limited grasp of the local language fails them, the doctors flip through the patient charts and find the small, meticulously-kept, well-worn yellow booklets that act as windows into the lives and medical issues of each patient. These Health Passports are a health management information system that chronicles the check-ups, hospital visits, laboratory test results, and health conditions of each Malawian.

Health Passport from the Ministry of Health

Record of medical visit and the doctor’s notes

Given free to newborns or purchased for 200 kwacha (about $0.50) by everyone else, the passports are a great way to manage patient care collaboratively across institutions in the Malawian healthcare system. Since there are no standardized electronic systems that would allow hospitals to share electronic medical records (EMRs) with each other, the patient acts as the messenger, in charge of caring for and presenting the Health Passports at each medical visit.

It’s not always a perfect system. Often health centers forget to conduct routine tests or record the results of those tests in the health passports, which means doctors have to diagnose and treat patients using incomplete information. Yet, even with some holes in information, the health passports are invaluable in bridging language barriers and in providing a comprehensive report of patient history.

Once health passports are brought to hospitals, they’re incorporated into the medical charts for the patient. These charts include referral forms from other hospitals, basic information about the patient, surgical updates, doctors’ notes, and more. Since staples are at a premium here, gauze is used to hold the records together and the charts are usually placed wherever there is space (walls, sinks, hanging nails). Sometimes this leads to misplaced files in the hospitals. Karen and I talked to a few doctors and nurses about this problem and came up with the idea of putting laminated folders on the walls next to each patient bay as a chart holder. It’s an exceedingly simple solution, but we hope it will make the jobs of the doctors and nurses just a little bit easier. So far we’ve made one chart holder as part of a trial run and have seen a lot of excitement from the nurses in the ward, which hopefully means that we can start expanding this to more patient bays.

Records held together with gauze

Patient chart resting on the side of a hot cot

Chart holders may be a stopgap solution, but the bigger problem at QECH and other hospitals is the lack of storage space and organizational materials to help keep track of patient records. Already, nonprofits like Baobab Health Trust are encouraging longer term solutions–in Baobab’s case they do this by creating EMR systems out of recycled computers. At Queens we saw another newly implemented electronic system that creates international birth certificates for babies born in the hospital. The Malawian healthcare system has been fairly slow in the uptake of some of these electronic systems, but as momentum begins to build, telecommunication infrastructure improves, and computer literacy grows, it is increasingly likely that battered charts held together by tenuous ropes of gauze will become a thing of the past.

Malawi is officially ranked as one of the world’s poorest countries in terms of GDP per capita, but it’s often hard to see what that means when you’re living in the commercial capital of the country. No doubt, there’s a different standard of living, but the people here are thriving and Blantyre’s hilly streets run with the ebb and flow of a healthy city. Yet, when you look at the statistics, 40% of Malawi’s budget comes from donors and foreign aid. Or, rather, it used to. In 2013, the EU, World Bank, and the UK all withdrew aid to Malawi over “cashgate” (1)–a corruption scandal that involved high-ranking members of Joyce Banda’s administration, $10 million of misappropriated aid money, and a botched murder attempt (2). In the past when foreign donors withdrew aid under President Bingu wa Mutharika, Malawi operated on a “zero-deficit budget”, mandating cuts across the board that sent the country reeling with fuel shortages and commodity scarcities. This time, however, President Peter Mutharika (not to be confused with his brother) adopted a “zero-aid budget” that left a 107 billion kwacha ($150 million) deficit (3).

The effects of the aid cuts aren’t readily apparent to the untrained eye. Even after being underfunded and underprepared for the flooding earlier this year, the country seems to have returned fairly quickly to business as usual. However, when talking to people at Queens, it seems that almost every dilemma leads back to the lack of aid. Dr. Edward Kommwa first mentioned this to us when we were studying MgSO4 procedures in the Maternity Ward. He explained that for the past two years, Queens has had to deal with intermittent drug shortages due to the lack of donor aid. Since Malawi still relies on its remaining aid flows from countries such as China, India, and Russia, it gets a lot of its pharmaceutical products from these nations in the form of donations or cheap contracts. The $150 billion deficit has made it hard to acquire a steady supply of drugs even with outside help. Just last year there was an entire month during which the Maternity Ward had no access to MgSO4 for its pre-eclamptic mothers.  “One of the most frustrating experiences was knowing exactly what was wrong with my patient and how to fix it, but being unable to do anything about it,” Edward noted grimly. Clearly, fluctuating and conditional foreign aid has far reaching consequences, creating instability and uncertainty in government-run establishments like QECH.

An unopened donation from “People of India to the People of Malawi”

The other aspect of medical procurement involves hospital machines and equipment. As I mentioned in my previous post, PAM is in charge of maintaining, inspecting, and repairing medical equipment, but budget cuts have relegated PAM’s efforts to the back burner. If PAM is a graveyard for broken machines, then the headstones are the paper labels inscribed with the names of a dozen donor nations. Though Malawi still receives aid in the form of capital, the problem is that the donated equipment is often unnecessary or hard to maintain. Joseph, a PAM engineer who graciously answered our barrage of questions, pointed to a wall of boxes twice my height explaining that they were soft collars that were donated to QECH instead of the hard neck braces that the hospital needed. So the collars were going to be sold for a few hundred kwacha each, which in American currency amounts to pennies on the dollar. Moreover, even the useful donations (oxygen concentrators, suction pumps, autoclaves) usually end up breaking. In a lot of cases, it’s nearly impossible for PAM to get the correct parts to fix the machines because the budget is out of their hands and hospitals usually choose to spend what little money they have on life-saving drugs rather than machine repairs.

Various models and brands of donated suction pumps on the shelves at PAM

The conversations I’ve had with Edward and Joseph have taught me how essential it is to develop sustainable interventions. Currently the Malawian government is trying to win back favor with its donors by rooting out corruption with the help of institutions like the Anti-Corruption Bureau (4). In the meantime, health interventions and technologies need to focus on local sourcing and manufacturing as well as supply chain solutions that don’t rely exclusively on foreign aid. This level of sustainability obviously can’t be achieved overnight, but moving in this direction is beneficial because it encourages the convergence of advances in healthcare and economics, creating a positive feedback loop for innovation and economic growth.

I think it’s about time that I mention a book that really shaped my perspectives about development and innovation in Malawi coming into this internship. It’s called The Bright Continent by Dayo Olopade, and it focuses on development efforts in Africa as led by African entrepreneurs, innovators, and visionaries. Central to the book is the idea of kanju, a Yoruba word that meaning “hustle” or “make do”. Olopade uses it to refer to the “specific creativity born from African difficulty” that can be characterized by “recycling, resilience, and… irreverence”. Kanju describes everything from Nigerian email scams to a South African cervical cancer clinic running out of shipping containers. Emily (who is also obsessed with the book) and I often geek out about the concept of kanju (to the point of annoyance for all the other interns, I’m sure) and how we see it playing out in our respective experiences at the Polytechnic Institute and QECH. So I thought I would take this opportunity to talk more about the instances of kanju I’ve noticed and how useful it can be to engineering and innovation.

Kanju Skills
The first evidence of kanju I noticed came from my interactions with our Malawian interns at the Polytechnic Institute. Francis, Charles, Christina, and Andrew are all incredibly talented engineers who have both book smarts and a natural aptitude for building, improving, and redesigning technologies. The day I first met them, we were coming to them to ask for help on the circuitry of the IncuBaby device because we knew that three of them were electrical engineers. The moment they set eyes on the circuitry, they immediately jumped into action and had rewired the device into working condition within 30 minutes, something that Karen and I struggled with for weeks even though we had the help of some experienced engineers.Even when one of the main electronic parts in the device broke down, the Poly students were able to find a way to continue testing the circuit by using a simple LED as an indicator for whether the device was functioning correctly. It’s these kinds of skills that go beyond theoretical classroom knowledge. Their talent is something born of interacting with machines hands-on–putting them together and breaking them down to understand how they work. It’s also this kind of talent that can lead to out-of-the box innovations that have kanju written all over them.

Kanju in Practice

Where the Poly Interns demonstrate a more refined engineering-based form of kanju, the quick fixes and adaptations found in the wards around Queens showcase an unpolished version of kanju that is a response to scarcity and necessity. In practice, it seems that the kanju in QECH revolves around gauze. Gauze, perhaps because it is so readily available, is used for everything from holding patient records together to hanging Rice 360 bilirubin lights over a crib with the help of a wooden stick (as shown in the picture above). In the spirit of using what’s available, it’s also interesting to note how different each ward is in terms of how they organize their supplies and dispose of things like syringes and gloves. In the Paeds Nursery, empty beds don’t just take up space. Instead, they are used to store tubing and other necessary materials. Meanwhile, nonsterile trash is placed in plastic buckets (labeled “Dirty Prongs and Other Tubes”) which are easy to access and more convenient to clean.Another good example is a wheelchair that was constructed out of a white plastic chair mounted on wheels. There are countless other instances like these all around QECH. Not all of these practices are ideal, but they are all prime examples of making do with what’s available. They also give important clues about what will and won’t be useful at Queens. Designing technologies that don’t account for the scarcity of resources or don’t fit into the realities of daily practice in the wards will be a waste of time and effort.

Kanju Innovation

The interns this year are hoping to channel the kanju spirit in order to establish new means for innovation and education for engineers at the Polytechnic. Physical Assets Management (PAM) is a department housed at Queens that maintains the medical equipment at hospitals across Malawi. They are currently a graveyard for broken equipment that can’t be fixed for lack of appropriate parts and adequate budget. The picture to the left shows one of PAM’s many shelves of machines awaiting repair. We hope to create a collaboration between the new Biomedical Engineering program at the Polytechnic Institute and PAM so that engineering students have a chance to do hands-on engineering work with the broken machines at PAM and PAM has a chance to benefit from the innovative ideas of these students. Though the idea is still in development, we hope it can be a mutually beneficial arrangement that utilizes kanju to create a sustainable cycle of problem-finding and solution-engineering between PAM and the Poly.

 

[P.S. As a more fun example of kanju, here’s a picture of our wonderful CPAP Data Officer, Vanessa, opening a Coke bottle for me on a doorframe!]

 

Queen Elizabeth Central Hospital challenges every notion of a traditional hospital. Its mudbrick buildings and outdoor hallways create a haphazard facade that hides the bustle of doctors and nurses caring for their patients. Most striking is the crowd of people sitting, standing, cooking, cleaning, and eating on every grassy surface outside the hospital. A deconstructed waiting room, the wide, open courtyards at Queens are filled with families who are waiting to feed, clothe, and comfort their sick loved ones. Given the limited resources they’re working with, QECH can’t afford to provide nutritious and filling food to all of its patients, which is why families wait outside with ample supplies. These people come from all across Malawi, traveling days to get their sick relatives the best possible care at the premier government hospital in the country. Which is why they can’t afford to commute every day. Instead, they set up camp and lay out on a lawn of colorful chitenges (all-purpose cloth wraps) that sport designs as strange as eggplant-purple pineapples and political propaganda in favor of one-term ex-president Joyce Banda.

Sheets, chitenges, and aprons hung out to dry near the Maternity Ward

This community of waiting women (women still being the primary caregivers for sick family members) is a great captive audience for people who want to educate and spread news. Often, preachers come to sing songs and lift spirits in the crowd. Karen and I discussed an interesting twist on this idea: NGOs, nonprofits, and even doctors or nurses could use this opportunity to talk to women about health and sanitation practices or even teach them marketable skills.

Preachers and public health aside, the families there are waiting for a reason. The hospital has very strict times when families can visit: an hour and a half during breakfast, lunch, and dinner. At mealtimes, there’s always a long line of men and women waiting outside the entrances to the wards being told to wait just a little longer by a worn down security guard. In a lot of ways it seems unfair and wrong to make these families wait in line to provide their relatives with care and attention. The strict mealtime visiting hours definitely do not fall in line with a patient-driven approach to providing healthcare, but in a hospital with as limited space as Queens there’s no other practical way to deal with the crowds. Already, skinny walkways and cramped spaces make it a struggle to move freely in the hospital. Crowd control is a necessity. And so families settle for a system of patient waiting and limited contact.

The line of families waiting to come in during dinnertime

The dilemma of patient preferences versus practicality manifests itself in a lot of situations around QECH. This week, Karen and I got an inside look at the Maternity Ward and the Delivery Suite under the guidance of Dr. Edward Kommwa. We were there to do some research on current practices for delivering Magnesium Sulfate (MgSO4) to pre-eclamptic patients in order to prevent seizures. The procedure is fairly simple and there are two ways to do it. In the infusion method, the patient gets a 4g loading dose over 5-10 minutes and then receives 1g of MgSO4 per hour for up to 36 hours after delivery. The intramuscular (IM) method requires a 14g loading dose with 4g delivered as IV and 5g delivered via injection to each buttock. Subsequently, the patient has 5g maintenance doses injected intramuscularly every 4 hours for up to 36 hours. The latter method is extremely painful for the patient and has to be delivered with local anaesthetics. According to Edward, Queens is transitioning towards the more patient-friendly infusion method. But here’s where we run into the problem of practicality. When we watched nurses perform the MgSO4 procedures, they all used the more painful IM method. Why? Because it wasn’t feasible for these busy nurses to continuously monitor an IV drip and make sure the  patient was getting exactly 1g of MgSO4 per hour. Normally, this job can be automated by an infusion pump–a device that slowly pushes out the right dosage of a medicine into an IV line–however at Queens only the High Dependency Unit (HDU) has working infusion pumps and even the nurses in that ward rarely, if ever, use it for MgSO4 delivery.

Naomi, an HDU nurse we talked to, cited lack of adequate equipment (for example 60mL syringes) and lack of knowledge about the infusion pumps as the two main reasons why they’re never used. The first problem–lack of equipment–is something Rice 360 is trying to address with AutoSyp, a low-cost infusion pump that will hopefully allow nurses to deliver MgSO4 using the more patient-friendly approach. In order for AutoSyp to be successful, though, there has to be an educational effort to give nurses the knowledge and skills they need to successfully operate the infusion pumps in a practical and efficient way.

Karen asking Naomi about infusion pumps in the HDU

At first glance it’s easy to criticize QECH for disregarding patient preferences. After all, quality of life is an important consideration for those who are hospitalized for long periods of time. But when you look beyond the surface, the very practices that seem unfair are those that were born out of a need to run an efficient and effective hospital that can adequately address the needs of its countless patrons.

For all the technologies that Rice 360 has built over the years, one of the most dramatic and impactful projects has been the bCPAP machine. In just one week at Queens, I’ve been able to see how important the bCPAP is for patient care in the Pediatrics Ward and the Chatinkha Nursery. Additionally, one of our main jobs last week was to enter data from the bCPAP clinical trial from hospitals in Malawian districts as far away as Mzuzu and Rumphi, a task that showcased the reach and impact this simple technology is having not only at QECH, but also across the country.

Though previous interns have written extensively about various aspects of the machine, I thought I would take this opportunity to lay out an overview of how the device was developed, how it evolved, and how it continues to spread to new areas and new patients.

What is the bCPAP?

The Bubble Continuous Positive Air Pressure machine is a device that helps neonates with respiratory distress breathe properly through the use of bubbling water. The device is an innovative redesign of an existing medical technology that costs $6000 in US hospitals. Made with aquarium pumps, a water bottle, and sheet metal casing, the bCPAP only costs $800. (1) It is astounding to see the impact this technology has had in Queen Elizabeth Central Hospital as nurses and doctors have embraced the bCPAP and are starting to use it as a new standard of care for their sickest patients.

What was the timeline?

Working in the bCPAP store room  last week gave me the opportunity to look at the various design iterations of the machine and at the cyclical nature of the design process itself. Though it now has prettier packaging and a cooler name (Pumani means “breath” in Chichewa), the essentials of the bCPAP haven’t changed much over the years. 3rd Stone Design, with feedback from Rice 360 staff at QECH, continues to make important changes and improvements to allow for wider acceptance and use of the device. With the help of several grants, the device spread from QECH to district hospitals across Malawi and is now making the transition to Zambia, Tanzania, and South Africa.

Implementation and Acceptance

The bCPAP is now used in hospitals around the country, but it was by no means accepted immediately. The machine was designed with affordability in mind and 3rd Stone Design made sure it would be available in adequate quantities. However, there were still several barriers to adoption, as with all new healthcare interventions brought to a community. At first, some bCPAPs weren’t used because nurses felt they lacked adequate training and were not comfortable with it. However, with better training procedures, nurses are beginning to accept and use the devices. At QECH, I was introduced to Nurse Florence (Chatinkha Nursery) and Nurse Chrissie (Paediatric Ward), two CPAP nurses who are prime examples of well-trained, proactive healthcare workers. These two are the bCPAP’s most ardent supporters at Queens, regularly encouraging health workers to use bCPAPs on patients and traveling to district hospitals to provide CPAP mentorship.

Another major problem in the implementation of the device was accounting for hypothermia in neonates. Especially in the winter months, data collected from the bCPAP clinical trial showed lower survival rates since babies were hypothermic and unable to get the warmth and care they needed. This led to another innovation by a team at Rice: the CPAP heating sleeve. Designed by Sarah, Renata, and their teammates, the heating sleeve is a cloth cover for bCPAP tubing that uses resistance wires to keep air warm as it flows to the infant. We’re hoping to get useful feedback on this addition to the bCPAP system by talking to people like Nurse Florence and Nurse Chrissie, who are highly familiar with and highly invested in the CPAP project.

What’s the impact?

The main criteria for success in the bCPAP trial are the survival rates and the cost-effectiveness of the device. In its initial pilot trial at Queens, the bCPAP showed stunning results. Infants put on CPAP had a 71% survival rate as compared to a 44% survival rate for infants given the standard-of-care oxygen treatment. Specifically, the bCPAP was good for treating Respiratory Distress Syndrome (RDS) and Sepsis. (2) In a follow-up cost-effectiveness study on the same data, the bCPAP was found to have an incremental cost-effectiveness ratio of $4.20 per life year saved, making it an extremely effective investment in neonatal care. (3)

Numbers aside, a more visible indicator of success is the integration of the bCPAP into the clinical practices of nurses and doctors at Queens. A quick walk through Chatinkha Nursery brings you in contact with numerous infants breathing steadily with the help of Pumani bCPAPs under the watchful eye of a trained CPAP nurse. Additionally, Karen and I often go to the morning handover meetings in the Paeds Ward where doctors debrief on the status of their patients during the previous night. The most striking moment for me was when an attending physician interrupted a debrief on an infant with RDS to ask, “Why wasn’t this baby put on CPAP sooner?” The fact that this technology is now such a crucial part of clinical decisions at QECH is both telling and encouraging. Hospitals like Queens need access to low-cost technologies like the CPAP, but more importantly, the technologies have to be accepted on all levels–by healthcare workers, doctors, and families–in order to make a meaningful difference.

I don’t think the reality of my upcoming stay in Malawi has quite hit me, but as I sit in the Frankfurt airport waiting for a 10 hour flight to Johannesburg, I can’t help but feel some pre-trip jitters of excitement. Since school ended, our internship team has been working at the OEDK to prepare technologies to take to Brazil, Namitete, and Blantyre. From circuit building to laser cutting, the past few weeks have been quite the crash course in engineering. As an Economics major I was a little out of my element at first, but I’m proud to say that I’m now pretty savvy with a soldering iron (see Figure 1). Since there were quite a few technologies to prepare for the trip, we split up the responsibilities. Karen and I were in charge of:

1. IncuBaby – a low cost incubator that aims to prevent neonatal hypothermia

2. AxillaProbe – a low cost binary thermometer for home use in rural areas of Malawi

3. FirstHug – a warming system for neonates that is a shift from the maternal-focused standard of care

4. Respiratory Rate Timers – simple devices to help nurses keep track of a baby’s breaths per minute.

IncuBaby was without a doubt our most challenging prototype to prepare. Despite the extensive instructions that the team left behind, there was a lot of guess and check involved. Using the original version of the device as a blueprint, we soldered, stripped, and wrestled wires into place and ended with an impressive replica. We still have a little troubleshooting to do, but we’re optimistic about our progress. Based on our meeting with the IncuBaby team, we want to get feedback from clinicians and engineers in Malawi about the physical design of the device as well as their suggestions for on how to improve and develop the incubator. A more unexpected issue that we probably should have planned for was the problem of packing an entire incubator for international travel. Since the incubator is made up of interlocking lasercut wood pieces, we planned to take the boards of wood in our baggage and assemble the device in Malawi. However, the biggest pieces were a little too large to fit in normal luggage, which led us to some unconventional packing solutions in the form of boards of wood sandwiched between pieces of cardboard (see Figure 2).

After a month of preparation and packing, we’re definitely ready to see how the innovative technologies we have worked on will perform on the ground. We’re starting to switch gears from building to implementing and I could not be more excited to learn more about the realities and interactions of healthcare, technology, economics, and culture in Malawi!

Figure 1 – A section of the IncuBaby circuit

 

Figure 2 – Redefining Checked Baggage