Hello from Blantyre! We went up and down the countryside collecting data with the bCPAP team this week, which means that we got to see quite a few new hospitals and even more road. On the way, I thought about what I posted last week about poor malaria net and ARV usage. Why does ORS seem to have such better adherence than malaria nets? What is different about the technologies? What was the difference in the implementation strategy?

The Malawian highways are dotted with billboards. People lean against them in the trading centers and little kids climb on them in the mountains. It seems that the vast majority are pretty evenly split between telephone/internet companies (Airtel and TNM), beer, and internationally-funded health-related advertisements.

In particular in the healthcare sector, we see Thanzi-brand ORS advertisements all over. In the south part of the country, too, we started to see billboards and painted buildings for Chishango brand condoms (though their scarcity in the North might be an artifact of our being so close to St. Gabriel’s—the immediate surroundings are markedly Catholic.)

A major difference for implementation is that unlike malaria, for which many people feel they need to see a health care provider, HIV/AIDS transmission and dehydration prevention are thought of as issues for which people should take personal responsibility.

Because it was heavily subsidized by USAID until 2012, Thanzi was very cheap and widely available. Now a cheaper, Kenyan-produced brand has taken much of the market, but since the technology is still effective even when produced more cheaply (as far as I can tell, the biggest difference for the end-user is that Thanzi includes small pictorial instruction cards). The initiative behind Thanzi’s marketing, PSI, made ORS a standard part of patient care and worked with the Malawian government to work it in to the massive HSA program. Because the market was so well-primed by PSI from 1990-2012, there doesn’t seem to be a dip in ORS use with the change in companies. Thanzi ads are still up everywhere and I see ORS very widely available at grocery stores and for free at the hospitals.

Interestingly, PSI is also behind Chishango condoms. Though stigma clearly makes it slightly more complicated to paste “Chishango” across every building, the condoms are very widely available. In the cities, Aqua Pure water bottles carry a red ribbon and the statement “Aqua Pure Cares. Love Life. Avoid HIV/Aids.” Though I don’t necessarily agree that we can place the entire onus for prevention on individuals’ safe sex habits (other transmission risks like occupational hazards are often overlooked), conversations with people here have shown us that sexual safety tends to be considered a personal matter.  [2]

PSI has had less success, from what I can see, with its malaria nets and water purification systems. I think there’s less of an interested market because Malawians don’t think they’re as necessary. With HIV transmission prevention and dehydration prevention, PSI has been effective because they have either found ways to build a cultural concept of personal responsibility and importance or built on what was already there. [3]

[1] Gates Foundation Case Study on ORS in Malawi.

[2] This climate is sadly often observed in the breach—in discussion of times when personal agency is negated. I have heard it said, though I can’t find it specifically online, that roughly one in four Malawian women’s first sexual experience is forced.

[3] USAID evaluation, Sept. 2004.

Hello everyone!   Sorry about the sparse posts recently but we were traveling this week.  On Monday we met up with Sam and M.K. in Lilongwe to help out with the ongoing CPAP project.  Over the last few days we’ve been to Kasungu, Machinga, Mwanza, and Blantyre!  It’s been really hectic but I really enjoyed getting to see other hospitals and other parts of the country.  After spending so much time in Namitete, where it is very rural, it’s been fun being in larger cities where they have things like restaurants!  We had forgotten what it was like to go out to eat and have 3G Internet.  It’s been a refreshing trip these last few days.

Getting to see other hospitals in the country was a really awesome experience.  It made me realize how small St. Gabriel’s is!  The hospitals we went to all seemed way bigger than St. Gab’s and even more shocking was the number of patients at the hospitals.  The district hospitals have so many more patients to take care of because they cover such a larger and more densely packed area.

Driving around the country we got to see what it was like in the southern region.  It’s so much colder!  It’s much more mountainous and rugged with some pretty serious terrain compared to the central region.  It’s also really green and looks very jungle-y.  The interesting thing about Malawi is that there are people everywhere.  In the many hours driving around the country I don’t think we saw a single stretch of land that didn’t have people living there.

Doesn’t it look like a jungle?!

We are staying in Blantyre for the weekend and will exploring the big city as much as we can while were here.  We will also be taking advantage of the resources in Blantyre and work on some projects that we still have in Namitete.  As fun as it has been getting to do some traveling, I will be excited to get back to home sweet Namitete this week and see our friends at St. Gab’s again!

[We’re in Lilongwe with MK & Sam! In honor of the internet connection being relatively amazing here, I’m going to cover a topic to which I’ve been looking forward for a while: toys and games. Legos, K’nex, and trains were the toys that made me want to be an engineer as a kid, but they’re not really available here. Instead, the kids have figured out their own ways to play.]

Liz and I have also been occasionally playing in the nurses’ evening pickup netball games, but we neither of us has wanted to take time away from the action to take pictures. Netball here is played on a weedy dirt court and what are essentially two small basketball hoops with no backboards, with a carefully-kept children’s soccer ball that Comfort stores at home. The movement of the ball follows rules much like ultimate frisbee, but only two people can shoot and there are 7 players for each team on the pitch at a time. We’re not very good, but it’s fun!

The time is flying by so fast here! This week was a bit lonely since Ariel was not feeling well and stayed home to recover. Luckily I now have lots of friends and familiar faces to keep me company over at Queens now. My average day includes a chat with the nurses at the High Dependency Unit at Pediatrics, the nurses at the neonatal center in Chatinka, a brief Chichewa lesson and life chat at Medical Records, as well as (a laughed at) attempt to talk in Chichewa with the mothers at the Pediatrics nursery. I get to work on technologies and my social skills at the same time! It really is easier to get things done once you’ve established a relationship with the hospital staff, and it also makes the job more enjoyable.

Data collection was very successful this week. Even with just one person working on it, I think we have been able to reduce the amount of time it takes to get data from the 3 main areas of CPAP patients: Chatinka nursery, Peds nursery, and Peds High Dependency Unit (HDU). In fact, the nurses over at Chatinka are definitely able to do the data collection there without our help at all, but we still have to stay on top of everything going on there for when the crucial CPAP nurses are gone for the training sessions coming up in July. Many of the doctors here are volunteers, so the staff is somewhat fluid, but the permanent doctors have been very friendly and helpful.

This last week I had a successful technology meeting/presentation with Dr. Queen Dube which was encouraging. I was particularly happy that she liked our bCPAP sleeve prototype! Although the price for the one we brought (a little under  50 USD) is a little on the higher side, she thinks it would be a worthwhile investment for the hospital. The key component that increases the cost for the newest prototype we brought is the heating pad. The inside wiring from the heating pad is cut out and re-sewed into our sleeve, but we had a hard time finding a cheap heating pad that used  220V. We have students in Houston working on the sleeve this summer, so hopefully we can do a lot of testing on the designs from last semester and reduce the cost. When we were originally assigned the project, we worked under the assumption that the heating device would be necessary to prevent hypothermia in regions with colder climates (like Pakistan) where the ambient air is too cold to be delivered directly to the baby. However, Dr. Dube was confident that it would make a significant difference even here in Malawi where it is usually warm. They don’t have functioning incubators and the windows are usually open for ventilation, so the neonates are much more exposed than they would be in a developed hospital setting. And it also gets quite cold during Malawi’s winter! Even now when it is still pretty warm it is so difficult for such tiny babies to maintain a normal body temperature. On a related note, Jocelyn brought to Malawi with her the button batteries we ordered, so Chatinka nursery now has functioning thermometers!  We took all of their broken thermometers and told them we would try to fix them/put batteries in them. After a couple of days of us failing to find the proper batteries in Blantyre, they asked for them back. We were slightly worried that they were going to lose faith in us. No worries though, the batteries solved the problem, so we are in the clear.

Mt. Mulanje 

Our hike at Mt. Mulanje was absolutely incredible. Never a dull weekend in Malawi! We attempted to climb the most difficult peak at Mt. Mulanje (we were ill informed) and made it to a halfway point. I can’t wait to go back again already.

The Flames 

In other news, the Malawi Flames (the national football /soccer team) beat Namibia 1-0 in a very important World Cup qualifying match! As I was walking home from Queens the other day, I noticed a lot of people crowded around radios listening to something. Even the guy I bought produce from at the market had his radio pressed to his ear the entire time, which was very unusual. By the time I got to Cure, I realized it must be a football match and the guards at the gate filled me in on it. I also knew immediately when they won because we could hear people chanting celebrations all around the neighborhood!

Hello! After nearly a week at home and sleeping, I have finally recovered from strep throat! In this past week I have gotten quite good at taking photos of my throat. They are available upon request, but I will spare the rest of you who are probably not interested.

Here is a quick few points of what has happened since I last wrote:

• Sam and I presented technologies to Dr. Queen Dube and received some good feedback
• Presented the Sphygmo to people in the maternity ward
• Scheduled a day to present all the technologies to the pediatrics department!
• Jocelyn brought batteries from the US and now all the thermometers in Chatinkha work again!
• Dr. Richards-Kortum and Dr. Oden came to Malawi and treated Sam and I to Bombay Palace, the best restaurant in the country.

This medical equipment broke…

For a long time, Sam and I heard rumors of this mysterious place where broken medical equipment goes and never returns. Essentially, Physical Assets Management (PAM), aka the engineering department, is known to be a one-way street. Curious, we spent a morning searching for this place and exploring it. We were surprised to find a relatively organized warehouse with few nice Malawians who showed us around. After an hour or so, we learned about various reasons why machines are so difficult, nearly impossible to repair.

First off, donated machines sometimes simply come broken. And then there’s the problem that US operates differently from the majority of the world and uses 120V instead of 220V. This causes damage in the machine if there is no transformer. In addition, there is no standardization of brands. So if there are 10 broken autoclaves, you might need to order parts from 10 different companies to fix it. And a huge barrier to repairing these machines is that there is often times a single part that is needed. However, this part must be ordered by someone higher up. They said that they will submit requests for ordering parts, and never hear back again. And that is how dozens and dozens of oxygen concentrators end up being collected over at PAM.

Also, the hallway connecting Chatinkha and the rest of the hospital has been under construction since before I got here, which is over a month ago. And last week, two babies from the NICU here needed an X-ray. So what did the nurse do without this hallway? She packed these two babies up in a semi-stable rolling cart, and rolled them through gravel paths to the hospital. When I volunteered to help her, I was shocked to realize taking them to get an X-ray involved helping her navigate the cart through rocks and various other barriers.

Other than that, Queens has been the usual and we have collected data for over 100 babies now!

Emails from my dad
For those of you who don’t know, my dad always sends me caring, succinct, and funny emails. Here are a few that I have received since being in Africa.

After a week of being sick:
Ariel,

I have ordered some ebooks of meditation for you.

Try to find one that suites you and practice. It will heal you.

After I posted a photo from the safari:
Special comment on the Safari post. Is your iphone inside the purse on your lap? Please don’t leave it inside Safari.

After I mentioned my mom as a loyal reader in my blog:
Ariel,

Daddy checks you blog every day as well.

Malawi’s Island in the Sky
Last weekend, Sam, Amber (a doctor who has been taking a tropical medicine course), and I spent a beautiful weekend hiking. Here is a photo of our group with our guide and porters.

Also Pelham (the grad student) has arrived and seems to be enjoying Malawi. 🙂

You know how when you’re in a pool in the middle of the summertime and it’s just about to start pouring, you can tell because you can see the drops making circles in the water? I used to love those minutes in between when the rain would start and the lifeguards would blow their whistles for us to leave the pool because if you swam to the bottom and looked up, the sky looked like a dalmatian.

Every day at about 5:00, we see those spots on the water by our cottage. After the first few days, though, we realized that it wasn’t drizzling– the spots were bugs hitting the water. Today in the late afternoon, we went out in canoes on the dam and I realized just how thick the air really is with bugs at that time of day. No one here seems to think twice about it, though, even in the dry season.*

Malaria, HIV/AIDS, and Yellow Fever are so common here that most people laugh to see how afraid we are of them. Every bed at the hospital has a malaria net, but they’re commonly misused because malaria is seen as such a minor issue. In the village, malaria nets are more useful as a makeshift garden fence to keep the animals out, because a full course of malaria medication is only 150 kwacha ($0.44) at Jey Jey, right behind the register next to the razors and super glue.

Millions of dollars a year go to distributing those malaria nets; technically, it’s punishable by Malawian law to misuse them. Yet people who have them often don’t use them because they know that malaria causes minimal damage if it’s treated early, and that they can easily obtain the treatment. That attitude unfortunately leaves children at risk, because for them it’s more dangerous and less easy to diagnose early. Reportedly, during the wet season the pediatric wards are full to the hallways of malaria patients. Overall, though, the attitude we see is that people who live here can recognize and self-treat malaria more efficiently than nets or prophylaxis can stop it.

On the other hand, we see Oral Rehydration Therapy (ORT) integrated into the local culture as something mothers standardly buy for their children when they’re sick, even though we tried some and it tastes absolutely awful. Advertisements on buildings show the packets and they’re available cheaply at the local market.

Giving people things doesn’t seem to work nearly as seamlessly as making it an option for them. Without end-user adoption, we can throw all the money in the world at getting people to use malaria nets and young people with HIV to use condoms and still not do much good. If the people here don’t think it’s an issue, aid-givers in the proverbial there can’t do much to solve things. Either we all, local institutions and global ones, have to intelligently enough educate the people on the benefits of a technology to change their attitudes, or we have to adapt the technology together to better fit the environment.

The mosquitos are swarming, but at the end of the day Malawians don’t need more malaria nets. They need people to listen to them.

*Disclaimer: while we were on the water we were wearing a heavy perfume of bug spray and we’re faithfully taking our prophylaxis every day before we go to sleep under our appropriately-used untorn mosquito nets.

This week some of the health problems we learn about in our classes back at Rice hit a little too close to home for me.  I got to experience some of the healthcare here firsthand when I got a little stomach bug.  I saw one of the doctors at St. Gabriel’s who helped me get the medicines I needed.  Healthcare in Malawi is free, and since I was the patient for the day that meant all the medication was free for me as well.  The most exciting part is that now I have my very own Malawian Health Passport!

I was feeling better today, just in time because we got to go out into the villages with Alex from the hospital to see the HSA Backpacks.  We went to four different villages and saw how the backpacks were being used, and asked the volunteers lots of questions about how we could improve them and how they liked them.  Interestingly enough, one of the things the volunteers like the most about the backpacks is that they give them an identity.  The volunteers like that when they are carrying the backpacks they feel empowered.  Going off of the same idea, they asked if we could make them badges or nametags that said they were Community Health Volunteers from St. Gabriel’s Hospital.  That way people would know who the volunteers were and what they were doing.  I think we are going to try to make up a few of these badges while we are here so that we can leave the volunteers with at least some immediate action so they know their concerns are being heard.

With the Community volunteers

We don’t have anything in store for the weekend yet but I’m sure we will venture into Namitete, likely via bike taxi (wish me luck).  Then next week we begin our travels around Malawi with the CPAP team.

We asked Comfort. She said that a fatal road accident had come in; the singers were the members of the deceased patient’s church, singing hymns with the family until the funeral. They weren’t Catholic, she thought, probably Presbyterian. Religion is very important here. Most of the population is Catholic, Presbyterian (CCAP), or Muslim. Parochial schools dot the road between Namitete and Lilongwe. We see Hallal butcheries, bakeries, and restaurants in trading centers. Mostly, though, as you might have imagined given that we’re at a hospital called St. Gabriel’s, we interact with Catholic institutions.

The hospital was founded by a Carmelite sisterhood of nuns from Luxembourg, and it’s currently run by a group of those sisters who work with Malawian sisters living on the hospital grounds. Both groups of sisters feel a sense of ownership of and responsibility for the hospital. They set the tone of hospital pride that we’ve seen in the clinicians, nurses, and staff here.

Our first Sunday here, we went to the Malawian sisters’ mass in Namitondo. The service was from 7:30-10:00 (scheduled until 9:30, but naturally ran long) and it was conducted in Chichewa. The choir at the front all wore white shirts and sang with a rotation of upbeat backing tracks. Because the service was in Chichewa (includings the bible readings), I didn’t understand most of it. Even Liz was surprised, though, near the end when a long line of women and couples came in carrying 50kg sacks of maize to be blessed. Men sat on the left and women on the right. By the time the service let out, the church was full of worshippers in their Sunday finest.

Sister Justa is our friend, mentor, confidante, and guide. She and the Malawian nuns sold us fruits, vegetables, and a chicken, then took us to Namitete to get everything else we needed. (The bottom picture is mostly for the benefit of everyone who’s asked me if I’m eating enough here. Hi, mom!)

This past Sunday, I trekked to the Luxembourg sisters’ mass at 6:30. It was in English, but I honestly still didn’t understand most of it. It was just me, Sister Justina, two other sisters, and Father Williams, and they were very gracious hosts. The things I did understand this time, though, were the sermon and readings: fish and loaves and a selection on Abraham’s generosity.

It made me realize how strongly many of the people here draw their sense of purpose from religious teaching. Many of the expats here give a lot of thought to the nature and effectiveness of charity, and the sisters in particular have given their lives to serving this population.

In morning report, the nurses often read bible passages focusing on Jesus’ administrations to the poor, though they tend to be less explicitly about charity. Tertiary education, especially here in the rural areas, is exceedingly rare; healthcare workers in Malawi take on a very difficult career path for less compensation than they could get with comparable degrees despite the great cultural honor given them. The majority of medical students in Malawi come from the city and doesn’t truly encounter village poverty until the immersive public health unit in medical school. I wonder how they see the parallels between their work and biblical narratives.

In our interactions with patients, I’ve seen that the religiousity here gives them a deep sense of identity. “Traditional” village medicine, muti, is often posed at odds with biomedicine at home. Here, though, many patients’ care regimen includes both. “Traditional” religion, for many patients, isn’t something apart from global religious structures and biomedical ideas. Rather, they simply coexist naturally in the patients’ minds.

During the next two weeks we’ll be travelling the north part of the country helping with bCPAP data collection. We’re excited to get to see more hospitals and spend time in Blantyre!

Almost five years ago, a bunch of Rice students did something pretty incredible. They’d designed a simple, easy-to-use and rugged clip that caregivers could use to dose liquid ARV’s for children. Misdosing can be dangerous for any patients and any drug, but inaccurate dosing of ARV’s can lead to fatal drug resistance.

The part that awes me, though, two weeks into our eight here in Malawi, isn’t the elegance of the design. It’s what happened next. After demonstrating the technology for the Swaziland Ministry of Health in summer 2010, by 2011 BTB had turned around and engineered a coalition of the Clinton Health Access Initiative (CHAI), the Swaziland Ministry of Health, and manufacturer 3rd Stone Design to get the clips made and included in a nationwide Prevention of Mother to Child Transmission (PMTCT) of HIV/AIDS program. Now, over 213,000 of the clips the Rice team designed are being used by almost 12,000 people in Swaziland.

It’s an almost fairytale success story– elegant design, appropriate national scale up, the right architecture and smart enough donors to allow the technology to make a difference. Unfortunately, though, outside the scale of a major national scale up device-specific technologies can be tricky to make universally useful.

Last year, BTB sent St. Gabriel’s prototypes of similar clips and matching bottles rescaled for morphine dosing. They’re designed so that you fill the bottle with liquid morphine, screw on the syringe, insert the clip, invert the bottle, and draw the correct amount of morphine.

Yet last week I posted a picture of a patient taking home morphine in a water bottle, and this week we were a bit chagrined to note that when we asked to see the Doseright™ clips, they had to dig them out of a box at the bottom of an old supply closet.

A big barrier to developing detailed dosing technologies in the developing world is supply inconsistency. When Tara, Teresa, and Kamal brought the clips last year the hospital was using syringes that worked with the bottle caps and access to patient bottles wasn’t a major issue. Because funding sources have shifted slightly, though, now the hospital uses a different kind of syringe and many patients bring home their medication in plastic water bottles with imprecise dosing caps that came with bottles of an antibiotic that the hospital recently got in stock.

To effectively implement this kind of dosing technology, we need a design plan more than a single device: something that is adaptable and integrable enough to be truly sustainable, rather than a clip that is suitable for only one size or brand of syringe. The hospital seems to have a consistent supply of 25mL syringes with the slip-tip tops in this picture, and Comfort assured us that if we had a sustainable, functional prototype that they could distribute to all their patients, it would be a better option than the current cups.

Dr.Richards-Kortum, Dr.Oden, and MK visited us at St.Gabriel’s this week, and we brainstormed some ideas for water bottle cap/syringe innovations that could just slightly modify what the hospital has to make the dosing clip concept work here. The store-bought water bottles work well because the hospital can reliably get them and they’re easy for the patients to transport on bicycle, so anything BTB would bring to the table needs to be similarly integrated. We’re planning to play around with some ideas for on-site punching slip-tip sized holes in the water bottle caps so they can be inverted, maybe with secondary caps attached by the bottle neck for easy transport. We’ll also be bringing home a syringe for future GLHT classes to try their hand.

DoseRight™ has, by all accounts, been a pretty incredible success thus far as a device. The next step is to adapt the concept to make it even more integrable and sustainable as a design.