These are the 5 ways my internship has been like a Pumani CPAP machine:

1. It’s fairly simple: I didn’t bring a lot of technological knowledge or engineering education with me to Malawi. A lot of the work that has proven most helpful to the BTB team or to Queens has been very simple, such as designing a poster or typing up nursery register data. It isn’t revolutionary and it doesn’t take a genius to get the job done, but it is far more important for me to address the needs here than to try to suit this internship to my own personal growth. The brilliance of the Pumani machine is that it is very simple; it didn’t require a lot of complicated machinery or electronics that would make it too expensive for a place like Malawi. The CPAP meets a need, and that has always been my goal in this experience.
2. It has sometimes taken adjustments: In the BTB office there are many CPAP machines that have been brought in from the wards to be inspected and fixed. The problems they contain are varied; sometimes straightforward but other times slightly more subtle. There were many things I was unprepared for at my arrival to Blantyre, and there have been many other changes I have had to make in my perceptions or my work. I have modified projects based on their usefulness in the office or the wards, and as time has gone on my interactions with those around me have changed- even just the simple expansion of my chichewa vocabulary has made a large difference. The breaks in the CPAP machines are not reflective of an inability to deliver, and neither are the faults I find in my own actions. Changing a pump in a CPAP or changing a question in one of my tech surveys has sometimes been all it took to return everything to a fully functioning state.
3. It’s multifaceted: In my conversations with some of the CPAP nurses in the wards, I learned that often the nurseries will have more babies that need CPAP than they have machines available; they have to make a decision based on the chances of each child’s survival as to who gets hooked up. I have talked in previous posts about how without proper education and reminders, the CPAP can actually prove dangerous to life instead of protecting it. It’s easy to glance at the CPAP project and see a simple program with a straightforward goal. The purpose of the program is the same as that of my internship; to develop and deliver a life-saving device. The application of such a large and noble goal is inevitably more complicated than it’s definition. In my work, I have seen good ideas or promising technology that haven’t turned out as expected. Very few things are as uncomplicated as I initially think or plan for. It has been essential for me to remember in reference to my work’s multifaceted nature that regardless of any complications, the goal of the work and the integrity of that goal are unchanging.
4. It bears witness to a lot of hard work and perseverance: There are a lot of strong, intelligent, and diligent people working at Queens’ hospital. My interactions with the rest of the CPAP team, the nurses in the wards, and doctors and clinicians has been inspiring because of the dedication so many people have demonstrated to their work. While it has on occasion been hard for me to digest the conditions that are present even in Blantyre, the people I have met that care so strongly about what they do have made it easier to swallow. I know as well that the people behind the CPAP project are equally dedicated and motivated; it is evident in the way the program is run that it was built on giant’s shoulders. The people around me have been great inspiration and motivation to try to act with the same levels of care and diligence that they do.
5. It has pressure: This one may be kind of a reach, but it’s still true. The CPAP machine delivers positive pressure into a neonate’s lungs so that they are able to inflate them and get oxygen. My experience here has also delivered to me a similar positive pressure. You cannot just be a witness to such need and such hard work to fill that need. It would be a disservice to everyone that has sent me here to come home and let the things I have learned from this summer collect dust. Spending this time in Malawi has illuminated medical and technical opportunities that my next three years at Rice will give me the chance to fill. Now that I have seen the resources that exist and are still necessary to Queens, I am better prepared to try and contribute. This internship has been a privilege, but it comes with a responsibility to make a sustainable difference while I’m here, and make sustainable contributions to BTB and the CPAP program even after my departure.

Sorry for the long delay in posts! My small computer has been otherwise occupied over the past couple days trying to run a couple of programs for DataPall (a topic that we’ll save for later, as I think deserves its own post).

Last week, I did something a bit uncommon for a non-premed engineer—shadowing doctors. Even though it was a tiny bit outside of my comfort zone, its been quite the experience to directly interact with patients and to see how the everyday process of diagnosis and prescription works.

Paediatric Ward

Many of the technologies that we’ve brought are geared towards neonatal and paediatric patients, including the neonatal thermometers, temperature probe, phototherapy dosing meter, and BabyMetrix (which Jesal did an awesome post about). So I was really excited about the chance to shadow the paediatrician during his rotations. It was interesting seeing how meticulous and careful the doctor was in checking up on his patients, and how he seemed to emit genuine empathy towards the patients, at a level not oftentimes seen in Western hospitals.

That being said, you still cannot compare the standard of care to that of a Western hospital. While the doctors and nurses work extremely hard to ensure that their patients have the best chances of a successful recovery, if all the ports on the oxygen concentrator are being used and a child with TB comes in, not much can be done. This dichotomy reminded me of a passage in A Heart for the Work (which I enthusiastically recommend to everyone!), where the author argues that the ‘ideal doctor’ presented to Malawian doctor was not one of supreme technical expertise sometimes at the sacrifice of empathy (which is oftentimes the case in the West). No, an ideal doctor in Malawi was one who had a heart for the work, combining technical expertise with humanity, as in grave circumstances, the patient can at least felt looked after and cared for.

Surgery

Truce and I also had the opportunity to observe two surgeries earlier this week (at a safe distance of course)! A professor at Rice is developing a sterile processing unit for low resource settings, so we kept a close eye on the sterile workflow of surgeons and nurses throughout the procedure (e.g. how an instrument moves from the ‘sterile space’ to the operating space, how biohazards are contained, etc). I got a bit queasy when the surgeons started cutting through layers of muscle and fat, and then seeing various types of multi-colored fluids gush of the the openings; but at the very least, the experience reaffirmed that medicine wouldn’t really be for me (sorry Mom and Dad!).

As I’ve mentioned before, I feel that as an engineering student who eventually wants to work on problems relevant to global health, oftentimes it is simply not enough to come up with a good technical solution; it also needs to be able to be easily integrated into a healthcare professional’s workflow and be easy to use. Therefore, I think it is incredibly useful to be able to see how the doctors and nurses work and utilize different technologies on a daily basis.

Blantyre

We also visited Blantyre last weekend! We needed to take a huge suitcase full of Bililights, bCPAP materials, and various other technologies. It was a ton of fun exploring Blantyre and hanging out with the interns there! But, I think my favorite part was visiting the Blantyre market—we’ve gotten used to the somewhat limited selection in Namitondo/Namitete, so seeing rows of spices and all kinds of fruits and vegetables was more than enough to make my mouth water.

Quote of the Day

“It’s nsima time!” – Everybody

This week has been very exciting. Jacinta and I have spent a lot of time in different wards, getting to know the nurses and gathering feedback on some of the technology we brought with us. The surveys have allowed me to see a lot more of the hospital, and investigate its most profound technological needs. Even with extensive research and good communication, there is often a gap between what we back in the states think is appropriate or useful and what is actually practical in the recipient site. After being a witness to events like that with the Fahrenheit thermometers I talked about in a previous post, I can really appreciate the importance of doing surveys early on in the design process so that the projects students at Rice work on remain true to what is needed in Malawi.

Today and yesterday we brought four new technologies to the wards besides the liquid crystal thermometers I’d been working with previously. The four include Chemoseal, which protects healthcare workers while delivering chemotherapy; Biliquant, which measures biliruben in the blood to diagnose jaundice in infants, EasyFlow, which allows multiple patients to be connected to the same oxygen concentrator; and a temperature sensor for neonates in incubators.  While a lot of enthusiasm was shown for all of our technology, not all of it was deemed completely applicable to our location. For example, Paeds nursery doesn’t have any incubators. A temperature sensor would be of penultimate importance to having an incubator itself. Also, both Paeds and Chatinkha nurseries have access to very high-quality flow splitters, which are sufficient for the needs of both nurseries and their access to working oxygen concentrators. When a nursery only has two working oxygen concentrators, it doesn’t need three oxygen flow splitters. Despite some of these realizations, the nurses we interviewed were happy to continue giving us feedback about the technology even when they didn’t think it applicable to them. I think we will return to Houston ready to give the design teams who made this equipment a lot of information on the pros and cons of their designs.

For me personally, the technology surveys have been some of my favorite projects in Queens. As someone with a strong interest in global development and healthcare, it has been a privilege for me to get to explore more of the wards and spend time talking to nurses and clinicians. Working here has taught me so much, and my technical, medical, and cultural knowledge base has grown incredibly. I have matured a lot as a person because of my experience so far, and I have a much stronger faith in my self-awareness and my awareness of the rest of the world. With any luck, the next three weeks will give me the chance to ensure that I have been giving back to the same degree as I have been receiving from this trip.

Through observation of U-5 hospital clinics, outreach efforts and the pediatric ward as well as discourse with clinical officers/community health workers/nurses, I’ve attempted to understand how pediatric measurements – a central aspect of care for children – occur at St. Gabriel’s. I also hope to provide some background on the importance of anthropometrics, measurements of the body, and how Babymetrix could fit in the current framework of the hospital.

Brief Background on Babymetrix

Before proceeding to my observations and thoughts, I figured I’d provide some information on the technology. Babymetrix is a device that measures the height, weight and head circumference for babies from 0 to 2 years of age. While these measurements seem awfully simple to attain, this is not always the case in many developing countries. Often measuring practices are unsafe, unreliable and costly. For example, the current gold standard for height measurement in this target group is a length board, but the commercial cost of such a device is ~$300 to $500 (Babymetrix is under $40). Moreover, many have asked why such a device is needed when a simple tape measure could do the trick; however, studies have shown how unreliable and imprecise such a technique truly is. These values are vital in ensuring the health of babies and errors can lead to improper diagnosis/treatment. Finally, Babymetrix affords multiple additional advantages: integration, portability and simple manufacturing. Currently, there is no technology that provides all three forms of measurement in such a low-cost manner. In addition, the lightweight and foldable structure of the device can adapt to the traveling health worker. Lastly, the device’s material of wood and tarp can make it suitable for production in local areas.

Role of Anthropometrics

So the question naturally arises, why is important to have Babymetrix? Why are measurements necessary? First, malnutrition and the host of developmental/growth faltering (stunting, wasting, underweight, kwashiorkor, marasmus, failure-to-thrive, chronic vitamin/mineral deficiencies, etc.) impact an extremely large portion of children worldwide. In fact, thirty percent of the world’s children are considered stunted/underweight, with seventy percent found in developing countries. This statistic holds true in Malawi, where approximately 46 percent of children under five are stunted and 21 percent are underweight. Malnutrition has severe long-term consequences, such as irreversible, crippling damage to cognitive development and increased susceptibility to chronic diseases, which only intensify the vicious cycle of poverty. More proximately, malnutrition can predispose the child to pneumonia, diarrhea, malaria, etc. that can be deadly for such a young, unhealthy population. UNICEF cites that 50% of child death can be attributed to malnutrition. Measurements also play a dominant part in drug dosing for children, which requires accurate knowledge of the body’s surface area to prevent toxicity or insufficient amounts. Furthermore, measurements and growth faltering often signal underlying diseases, such as infections of parasitic worms, that could go otherwise unnoticed and lead to lasting damage. For the cases mentioned above, it has been deemed that interventions in the first 18 months of life provide the greatest benefit and later fixtures do not completely correct the harm. To this end, instilling a culture of measurement and providing a user-friendly, affordable tool can go a long way.

Measurement Practices at St. Gabriel’s and implications for Babymetrix

Having provided a small overview of the importance of anthropometrics and Babymetrix, I was extremely interested to observe the practices/methods firsthand at St. Gabriel’s. I came in expecting what my research told me, limited measurement instruments and an absence of focus on anthropometrics. However, I was surprised to see that this was simply not the case. They had a well-established organization and detailed record keeping/monitoring. Moreover, they had all the World Health Organization (WHO) charts useful for assessing nutrition/growth status.

• U-5 Outreach Clinics: Each Thursday, a group of community health workers/volunteers would travel to villages surrounding the hospital in a vehicle and set up prenatal and pediatric care. This included updating on vaccines, checking the health of the fetus as well as measuring the weight of the child. All of this information was written in booklets called Health Passports, which mothers carried around carefully, to ensure proper long-term care. I am truly impressed by how integrated health passports are in providing care.
• U-5 Hospital Clinics: Occurring each Friday, this clinic brings those pediatric patients deemed malnourished and continuously monitors their growth, in terms of height/weight and mid-upper arm circumference (MUC). The health workers particularly liked using this band, which was colored coded and easy to understand. Height was measured by a donated lengthboard and weight occurred through a food hanging scale mechanism. Weight measurement was particularly interesting, mothers used chichenyes, cloths formed into a “baby backpack”, to attach the infant to the hanging scale. This “backpack” is ALWAYS with them and is a culturally assimilated technique that was amazing to watch. Upon completion of measurements/record, mothers were provided nutritional supplements.

• Pediatric Ward: The emphasis here is on weight. There are various types of scales for this purpose and drug dosing occurs using this measurement.

I quickly realized that Babymetrix wouldn’t provide a revolutionary change to pediatric measurement practices at St. Gabriel’s Hospital. This finding posed the difficulty of working on a global health challenge from abroad and stressed how important it is to field-test/conduct site visitations to properly design. With that being said, there were some aspects in which Babymetrix can definitely be useful.

• Reliance on only weight measurement for outreach clinics is not optimal, as the belief that weight correlates with growth is often inaccurate. Weight is largely dependent on hydration status and fat mass and is thus, error prone. Babymetrix, with its integrative functions, can expand these criteria. Unfortunately, the real challenge would come in updating Health Passports, as presently there is only a graph for weight over time versus height over time.
• Weight measurement method used currently is not the safest. The baby is lifted multiple feet in the air and linked to a scale in a human-tied knot. I observed 5 or so almost falls in the ~50 patients weighed. Though two people, mother and health worker, are attentive, this process puts undue risk and discomfort on the baby. Babymetrix, which only requires a lifting of one/two inches, can address these issues.
• Would a Babymetrix one-stop station be quicker? This is something I want to explore as the process of measuring and recording utilized seemed pretty efficient. However, two Babymetrix devices could expedite this process.

The above observations were in contrast to what one of my teammates observed in a low-resource small hospital in India, which didn’t have established measurement processes, and could very likely clash with other rural hospitals/clinics/centers in Malawi. In both cases, the feedback came from a single hospital in the country and by itself cannot be universalized. For example, while the portability of Babymetrix was not as significant for St. Gabriel’s which provides vehicular transport for its health workers, it could mean the difference between use and disuse in settings where walking/biking is the primary method for outreach. This emphasizes the potential challenges in technology implementation; there is a need to find the proper niche for the technology, to create a culture/incentive where the technology is desired, provide a method to make it useful (record keeping, provision of nutritional supplements, etc.), etc. A device designed for a broad problem far away in another country cannot alone lead to implementation. The progression requires iterative communication and tailoring. With that being said, the on-the-ground experience has been essential in broadening my perspective and gaining valuable device feedback. So from this hospital begins the quest to continue improvements and more aggressively understand how Babymetrix can be effectively deployed in the field.

A Day in Blantyre

This past weekend, we took a coach bus from Lilongwe to Blantyre, to drop off various technologies and medical supplies to the other interns. Of course, it was great to see how they were living and experience the largest city in Malawi. Unlike Lilongwe, which has vast patches of green space, Blantyre felt like a much more cohesive city with building following building. We got a chance to go about a gigantic, maze-like market, which included an enormous vegetable/fruit section and countless clothing/technology/other random vendors. It was ridiculous. We concluded the day with some excellent Brinner (Breakfast-for-Dinner) that our fellow interns so graciously made. It was an overall great trip. Enjoy the pictures!

I’ve seen a recurring theme going through my fellow BTB interns’ minds: time in Malawi has seriously flown by. I agree 100% with this.

On my first day working at St. Gabriel’s I was amazed at the organized structure and tidiness of the hospital. A thorough tour of the facilities reinforced my initial thoughts. The hospital is small, but widespread with a long hallway that has wards on both sides . Additional buildings are found and attached to the main building through covered walkways. All the hallways are open to the outside with a number of gardens in between each ward. The hospital takes great pride in its gardens as they are very well kept.

In the back of the hospital is a long building that is available to any patient and his/her family members. This building contains spaces to sleep and is free of charge. Next to this housing is another building which is full of furnaces and stoves. Here, the residents cook for themselves. The hospital staff does nothing except for supply the firewood. The residents are responsible for making sure their space is tidy. Almost all residents are pregnant woman because many of them are not from neighboring villages. In the late stages of their pregnancy, they come to stay here so that once they are ready to give birth they will not have to travel the long distance. Like Dr. Mbeya, the hospital director, said, “It’s a home away from home”.

This free housing was provided to encourage pregnant women to come to the hospital, rather than try to go into labor without any medical attention. To come to St. Gabriel’s from distant villages can be difficult and costly, and this solution keeps St. Gabriel’s labor ward busy.

However, after speaking to a few pediatric doctors, it is obvious that solutions like these are needed in other wards as well. The absence of babies in the neonatal ward is due to the difficult and costly visits to hospitals. Today, St. Gabriel’s received another incubator from the Netherlands. When a pediatric doctor brought us to see the incubator in the kangaroo care ward, I couldn’t help but notice the entirely empty beds. There was not a single child or mother in there. The two incubators, two bililights, and one phototherapy bed were unplugged and sat pushed to the wall. Mirroring my thoughts, the pediatric doctor explained to us that because of low patient health literacy, parents of premature children do not see that it is necessary to come to St. Gabe’s for treatments. St. Gabe’s hopes that in the future this problem will be lessened by their outreach clinics and patient education teachings.

On another note: This past weekend we went to visit Blantyre. We had donations and also technology supplies to bring to the other BTB interns. Blantyre was very modern and had great craft and food markets. It was a great weekend trip!