Two weeks ago, I wrote about how important it is to get a good understanding of the context a design will be implemented in, and the user of a device. This past week on my blog, I was more focused on what qualities of a device this understanding changes. Now, I’m going to focus down even more and use a device I’ve been working on for the past few months to explain with more concrete details the nuances of global health technology design.

I took a Global Health Technology course this past semester at Rice about appropriate design, during which I was part of a four person team tasked with developing a heating sleeve to be used in tandem with Rice’s bCPAP technology. The bCPAP helps babies with underdeveloped lungs to breathe, and right now it supplies the patient with room temperature air; warming the air–which is what our device does–will potentially increase the survival rates of babies treated with bCPAP. Our basic design is a 9 foot long sleeve that snaps around the tubing delivering air from the bCPAP to the baby. The sleeve has heating wire sewed into it, and connects via a plug to a control box that regulates the temperature of the air delivered to the baby to 37C. Essentially the device is a long and skinny custom heating pad, made to heat bCPAP air to body temperature.

We spent about four months working on the device, and this summer two members of the team (Renata and myself) are interns in Malawi. We’ve been able to gain a much more thorough understanding of the context our device will be implemented in, and get feedback from intended users about how best to improve our device over the next year.

Through this experience, it’s become obvious what considerations we didn’t know we had to take so seriously. The thorough research we’ve been able to do has revealed flaws in our design that would bar maximally successful implementation, and has been an interesting reflective process to go through. Here is some of the feedback we’ve received, which I think shows what sorts of concerns are difficult to imagine without having visited the hospitals our device is targeted towards:

• Ability to be cleaned. Our device has current-carrying wires running through the sleeve that heat it up. This makes the device especially difficult to be cleaned, as we don’t want any liquid to make contact with the charged wires while in use. Waterproofing our device, though, is also challenging, as most of the waterproofing materials are not very thermally conductive, which makes temperature control difficult. We decided to sew a layer of nylon as the outermost layer of our sleeve, as this made the sleeve moderately waterproof but still adequately thermally conductive. Since the sleeve doesn’t come into contact with the patient, we thought this moderate waterproofing would be sufficient to allow for spot cleaning as needed. Since being here, I’ve learned that was a pretty unreasonable assumption. The bCPAP babies frequently lay on the same cot as two other babies, without any divider separating them. This means the tubing easily touches the other babies, as well as anything lying in the cot. Many of the program associates for the bCPAP clinical trials have indicated that the tubing often comes into contact with blood, feces, and other bodily fluids while in use at the district hospitals. Additionally, the tubing often is coiled up on the ground between the bCPAP machine and the patient. This not only would cover the sleeve with dirt, dust, and any other mystery liquids that lie on the ground, but also makes it susceptible to being doused with the ample amounts of mop water that is used to clean the wards, or any spilled liquids. However, we don’t want to make cleaning the sleeve a difficult process, as that would be an additional barrier to use; if there are many steps involved in attaching/removing the sleeve from the tubing and cleaning the sleeve, nurses may opt not to use the heating sleeve at all in order to save time. Alternatively, because many of the nurses didn’t grow up with electrical devices, they don’t have the same instincts concerning wires, power, and water; some nurses may submerge the heating sleeve with the electrical wires into the same bleach/water solution used to clean the bCPAP tubing because they don’t understand why not to. Finding a balance between ease of use, sterility, and functionality will be something we have to spend a lot of time with next year.
• Patient/guardian perceptions. One of the difficulties currently facing the bCPAP clinical trials is how the mothers, especially in rural areas, perceive the machine. It can look scary to mothers due to the apparently invasive nasal prongs, and there’s been a lot of talk about how to best get mothers “on board’ with the device. Some have expressed concern that the sleeve covering the bCPAP tubing would make the mothers more wary of the bCPAP, as they cannot see into the tubing delivering air to their child—she wouldn’t know what was in the tubing. The color of the device was also frequently discussed with nurses and the program associates, trying to determine which color is the most comforting to mothers.
• Weight. We were aware of the fragility of the babies treated with bCPAP, and knew this meant our device had to be lightweight. However, we figured that the tubing would be resting on the bed or on a table nearby, so the weight of the entire 9ft tubing + sleeve wouldn’t be tugging at the baby’s face. As a result, we were initially satisfied with our heating sleeve weighing 195g, which is about as much as the tubing weighs. However, being in the wards and watching the device in use has changed that assumption. The babies treated with bCPAP are often resting on beds a meter up from the ground, and the bCPAP tubing I saw often draped directly off the bed towards the ground. This means the weight of 1 meter of the tubing (and possibly in the future, the sleeve) is tugging at the patient. Since the neonates are already so tiny, and their skin so delicate, the added 195 grams of our sleeve would make a significant difference. Over the next year, we will have to work to bring down the weight of this device significantly.
• Other unforeseen difficulties. One medical student had noticed that in the special care ward, there were many bugs that flocked to the oxygen concentrators, as they heat up during use. While bugs aren’t too common in QECH, they are in the district hospitals. Since our entire sleeve gets warm and is often laying on the ground, we realized this may be a big problem. We’ll have to figure out how to heat the air without making the outside of the sleeve warm, so as not to attract any unwanted visitors.

In addition to these notes, I’ve gotten feedback from various doctors about what testing they think is necessary to run before the heating sleeve moves forwards. While these changes and tests will be difficult to navigate, understanding the potential barriers to implementation of our current device while we are still early in the design process has been lucky, and hopefully will significantly improve the chances our device has for long term success.

In my last post, I talked about how the scarcity of resources is arguably the biggest challenge that hospitals in low-resource settings face. There are many different needs pulling hospital funds in various directions, which further increases the need for affordable healthcare technologies; the devices don’t simply need to be low enough cost to fit into the hospital’s budget, but they need to be worth the dollars that as a result won’t be spent on medication, supplies, or human resources. This is part of why the research phase of design (which I talked two about two blogs down) is so crucial: a thorough understanding of what technology attributes will best set a design up for success—and what traits add cost but not practical value—enables the creation of devices that are worth the allocation of hospital funds.

Through my time in the Rice 360 program, conversing with nurses and doctors at QECH and observing a bit of ward practices, and working this summer at the Polytechnic designing new health technologies, I’ve noticed a few common attributes that string together many of the successful devices. Here are a few of those traits:

• General Qualities
  • Low cost. This is perhaps the most obvious quality on this list, but also one of the most important. To give a few examples, the commercial CPAPs in the States can cost $6000, while the Rice bCPAP costs under $400; the States’ gold standard phototherapy dosing meter costs $2000, the one we’ve built costs under $50; commercial phototherapy lights in the US cost over $1500, the Polytechnic BabyLights costs around $100; American commercial ophthalmoscope costs $300, while the one we saw in use at QECH is $4—the list goes on and on. In the meetings I’ve been at with physicians, when we show them technologies in development at Rice to gather feedback, one of the first questions asked is often “how much does it cost?”
  • Durable. In the busy and crowded wards at QECH, devices need to be able to withstand a good bit of wear and tear. Machines tend to be stacked onto one another; tubing is coiled, pinned, and draped into the proper position; power cords and adapters lie in corners and can be splashed with mop water. Without proper storage space, devices and components often must be fit into small spaces on top of cabinets or into cramped packing boxes.
  • No consumables. The continuous cost of consumables is a drain on hospital funds that is difficult to sustain. If a machine requires consumables to run properly, whenever there is a lapse in supply or an inability to purchase new materials, the machine becomes effectively useless.
  • Easy to replace parts. It’s very difficult to get machines fixed once broken (as discussed in a previous PAM blog). Since devices sent off to be repaired often never make it back to the wards, there’s a pretty common of practice of simply setting aside broken equipment, where it sits unattended and unused. In order to mitigate this practice, machines with locally available replacement parts are great; providing a machine with the components that are frequently needed to be replaced is also convenient. For example, if a circuit component blows, supplying an extra circuit that can pop into the broken circuit’s slot requires only a simple few steps that a nurse could execute. As another example, the bCPAP provides a small bag with replacement parts within every device, to ensure broken devices are not so easily discarded.
  • Transportable. High risk patients often must travel a lot within the hospital—from labor to the neonatal ward to the X-Ray machine to the high risk unit and back to the neonatal ward, for example. Making devices, such as incubators, that are small and light enough, or have wheels, to transport with the patient between wards marks them both more attractive to the hospital and more useful.
  • Backup power source. Power can be a bit unreliable in low resource settings. In clinical settings, this can be life-threatening. Making a device capable of running on its own for short periods of time between power outages—or at least provide enough backup power to give nurses time to offer alternative, electricity-free care—can save lives.
  • Easy to clean. Not only does sterilization need to be quick and easy, as the wards are so busy, but thorough as well. Devices can come into contact with a lot of blood, feces, and infectious disease while in use, and with the large number of patients requiring treatment in combination with the often short periods of time between the treatment of different patients, devices must be quickly but methodically sterilized.
  • The simpler, the better. This mentality has been repeated to me many times from professors, doctors, nurses, and other interns. The simpler a device is, the more likely it is to be successful—often because simplicity requires it to have the above attributes. Sometimes as engineers, we get sidetracked by the possibility of designing a really “cool” device with complicated circuitry and fancy features. However, that often decreases the likelihood of long term success for global health technologies. Complicated devices usually require more time to understand and use—time that nurses don’t have free to devote. They also tend to have many parts, which are just more things that can break and cause the device to be discarded. Simple devices with few parts, however, have a greater likelihood to be “figured out” and repaired when necessary. They also tend to not be as “scary” looking, which is a common problem when mothers don’t understand what a device does and is thus afraid of it being used on her baby.
• More Specific Features
  • Solar power. I’ve noticed that solar panels are really well received here, as they require no costly resources and are reliable. There’s a lot more faith in solar panels than in an AC power cord or a battery pack, and healthcare workers I’ve talked to are quickly excited by and convinced to support a technology when it’s powered by solar energy. This is another big benefit to using solar—if the users are already behind it, implementation and sustained use are inherently smaller barriers.
  • Size: wristbands, necklaces, clips, and pockets. This is another attribute I’ve noticed that quickly garners healthcare worker support and generates excitement. The doctors and nurses here are busy; they have many patients to attend to, and their work is very difficult. There are already dozens of machines they must learn how and when to use, so sometimes a new machine can seem like more of a burden than a help (especially in a place where confidence in machines can be pretty low, considering how often they malfunction). Devices need to not only cater to the doctor’s needs, but in some cases also to their convenience. Techs that can easily fit into a pocket, or be slipped around a head in the form of a necklace, help to lessen the load on the healthcare workers. That way, the device is readily available, and has less of a chance to being lost. Of course, this isn’t applicable to all technologies, but for machines commonly used on rounds—respiratory rate calculator, ophthalmoscope, heart rate timers—this can be enormously useful.
  • “On” indicators. While this may not seem like a vital component for a device, it can be very useful for busy doctors. Machines that don’t have an easily visible, bright LED to indicate when the device is and isn’t on (sometimes the switch is on the back, sometimes there is no LED, etc.) make it difficult to know whether a device is still treating a patient when it is supposed to be. If an outlet is accidently switched off or if a battery runs out, the nurse needs to be easily aware of this change in status.
  • Internal transformer. Unfortunately, many commercial machines require specific plugs to adapt the wall voltage to the voltage the device runs off of. The problem with this is that in the case the particular plug is damaged or lost, it’s difficult to replace. New parts straight from the manufacturer are often unreasonably expensive (for example, a manufacturer-provided battery replacement on a machine we were repairing cost $1000, but could be obtained at the market for $20), but finding suitable substitutes requires some electrical background knowledge that the hospital staff often don’t have. The better solution is to put the transformer within the device itself, so that the machine can be connected straight to the AC wall voltage with any old power plug. If the cord is lost or damaged, they’re easily bought at the market for around $10.

There are many features of design that are hard to consider without seeing the context or talking to clinicians directly about what devices they do/don’t need, and what they do/don’t like about existing devices. Designing so close to QECH this internship has given us the opportunity to develop our technologies in line with what the hospital needs, as well as given us a far better foundation from which to design new healthcare technologies in the future.

 

 

What makes you tick? Why do you do the work you do? What motivates you? They’re questions that seem like they should have definitive answers. The time-worn wisdom of the Disney Channel would have you believe that everything you do should lead you to your dreams. After all, what nobler thing is there than to work towards your passions? But as the more hard-hearted economists explain it, a lot of our behavior is motivated by a complex set of incentives (salary, social status, familial expectations, competition, etc.) that can be both intrinsic and extrinsic. In the context of low-resource health settings, the misalignment of these incentives can often be a pillar that props up inefficient systems or less-than-ideal practices.

The Good

I’ve seen several examples of incentives working in favor of the Malawian healthcare system. One example is the health passports, which I talked about more extensively in an earlier post. These passports are a good example of incentives in action. They ensure that doctors will be able to give the patient a high level of care since clinicians can gain full knowledge of a patient’s medical history.  Since families want the best care for themselves and their relatives, they have strong incentives to take care of their health passports and bring them to medical visits.

In another example, the MoH under the administration of Peter Mutharika increased salaries for doctors. It was certainly not an easy decision to make in a country that has a limited budget to dedicate to healthcare expenditures. However, in practice, this may attract more students to the medical field. Higher salaries will hopefully be a good first step in addressing the dire shortages of doctors and medical staff that Malawi currently faces.

The Bad

One obvious example of bad incentives stems from the dominance of public sector healthcare in Malawi. Since the government is largely in charge of acquiring and distributing drugs, equipment, and other medical supplies, there is little to no incentive for private companies to enter the market for these goods. There are private hospitals sponsored by NGOs or religious organizations (see Renata and Nkechi’s blogs about St. Gabriel’s), but even these hospitals often get supplies from the Ministry of Health. What isn’t acquired from the MoH is usually donated by foreign organizations. This system has crowded out the private market, leaving very few opportunities for private medical supply stores to pop up. We visited a medical supply store called Bioclinical Partners, and the owners and managers explained that business was hard to come by. This is largely due to the overwhelming dominance of foreign aid and government-sponsored healthcare.

The Misaligned

CPAP Nurses and Coordinators are a hugely important part of the bCPAP implementation in Malawi. The people involved in this effort are extremely dedicated, hardworking, and passionate about the cause. Nurses like Chrissie and Florence champion CPAP regularly while ministry officials like Norman and Alfred train new CPAP Nurses and disseminate information. However, some of the nurses in district hospitals have less regular interactions with the CPAP project and have less intrinsic motivation and passion for the project. This is not to say that they don’t do a good job–the CPAP project would be lost without them. It’s just that they have little incentive to fight inefficiencies in the system to get good data or correct their colleagues in order to establish better CPAP-related practices. This isn’t necessarily a problem of bad incentives, though. Instead, it’s a problem of misaligned incentives. If there was some additional extrinsic motivation, say a competition for CPAP Coordinator of the Month or achievement-based certificates, it’s possible that CPAP officers in the districts would push for the program just as much as its champions at Queens and the MoH.

Intaneti-“Internet”

I would like to take a moment to say how genuinely impressed I am with the internet here in Namitete. For a rural community, they have some decently fast internet. It’s even better than that in my pretty rural town of Saint Francisville, Louisiana. In fact, there was a point where I wanted to talk to my parents but I couldn’t because their wifi wasn’t working for a week.

 

The system for internet is genius. It has 4 steps.

• Buy an internet dongle or a wifi router. Inside of the dongle is a sims card that connects to cellular data. If Renata or I had thought to bring a wireless router, we could have connected multiple devices to one sims card. Some dongles and wifi routers come preloaded with internet.

  

• Insert the sims card into your cellphone. That’s right, you can buy internet with your cellphone. Anywhere, anytime.

  

• “Top off” your sims card with airtime. The company we are using (Airtel) sells airtime at most street vendors. We can find of airtime in Namitete or Namitondo. This is a good system for those living in rural communities. Airtel is not just in Malawi, but all across Africa and India.

  

• On your cellphone, buy mobile internet. 4GBs of internet here cost about 6,600 MK, or about $14USD. With work, we go through about a gigabyte per week, so this amount is perfect.
• Put your sims card in your dongle and you have internet!

  

  

 

This system is an example of technology designed specifically for a global setting. The majority of Malawi is rural, so it is important that cellphones and internet work in these areas. SMS is even used in Saint Gabriel’s Pallative Care Center as a means to contact volunteers spread across the hospital’s service hours (that’s a good 60 km in any direction).

 

I might tell my town to take note.

 

You know that thing that Netflix or Kindle does that goes something along the lines of “If you enjoyed this title, here are some other suggestions that you might enjoy”?

I mean, it’s not like I’m super familiar with the message at the moment, as life in Malawi is Netflix-free. But you get my drift, I hope.

 

Well, what we’ve been figuring out in our free time (like this weekend) is that there are some things that you simply MUST do if you visit Namitando. Some of them are pretty obvious components of the experience, while others… not so easy to discover. So much like Netflix, pushing indie versions of your box box office favorites, I’m going to share some of my Namitando suggestions. Whether you’re a BTB intern hopeful, or are simply interested in learning a bit about village life, I hope this paints a better picture of our home.

 

***Note: EVERYTHING on this list is worth doing! I’m just pointing out the less obvious suggestions.

 

If you enjoyed: Visiting the Namitando market

You may also like: Taking a walk through local villages

Although the market gives some perspective on local life, it doesn’t tell you everything about life in rural Malawi. Especially given the relative privilege of living in houses near the hospital compound, it can be easy to lose sight of what ‘home’ means to our patients. Lucky for you, this one is pretty easy to remedy. Setting off in along any of the roads branching off before/after you reach the Namitando market will take you into small villages interspersed with maize fields and bush lands. Look around: the homes, the people, and the daily tasks all speak to public health conditions for the villagers. Just head out and prepare to get (somewhat) lost in pockets of village life that surround the hospital. Things to bring with you include a cell phone (in case you get too lost), a smile, and basic Chichewa vocabulary words (you need to say “Mwadzuka bwanji” to EVERYONE you meet!)

 

If you enjoyed: Getting groceries from the supermarket in Lilongwe

You may also like: Finding (almost) everything in the back market of Namitete and Namitando

The first time that we went to Lilongwe for groceries, we nearly broke the bank. This past time, we just topped off on a few imported products. The major difference between the two occurances is our familiarity with the local market system. The markets in Namitando and Namitete are both lined with small brick shops, usually advertising Airtel or TNM phone service and generally having a name like “God’s Favor Shop”. Although it’s easy to disregard these establishments, they actually present a fairly impressive variety of goods. After looking closer, we’ve managed to find everything from staples like bread and eggs to fancier items like toiletries, biscuits, and peanut butter. Some shops even sell chichenges (the colorful fabric that constitutes 75% of female fashions and tools in Malawi) at very reasonable prices! The main thing to keep in mind here are that it’s always okay to poke around and explore, whether that means doing a double take inside a small shop or going down the back alley to find a new part of the market.

 

If you enjoyed: Playing with kids around the Zitha house

You may also like: Teaching the kids something

A lot of the local kids are children of hospital workers or their friends from the village. I don’t like to brag, but I’ve developed quite the posse over the past few weeks- I’ve made it quite clear that I want to be friends, and after a hard day’s work, there really is nothing more fun than goofing off and acting like a kid for a few minutes (or hours). Because we’ve started to be better acquainted (read: I’m on first name terms, they only call me ‘azungu’ sometimes), I’ve started to take advantage of their friendliness. One day, I came home as usual and sat on the front porch of the guesthouse. Sure enough, not five minutes later I saw a10 little pairs of hands grip the wall and pull themselves up. This time, I was ready. I put on some music and started my best dancing (note: I’m using the term ‘best’ very loosely here). Chortling, the kids joined in. After I’d done the Chicken Dance, Macarena, Hand Jive, and Egyptian, I’d pretty much ran out of ideas. So I laced up my running shoes and started to do exercises. Although the sight of the crazy azungu doing crunches was even funnier than the dancing, the kids’ curiosity soon got the better of them. I showed them bicycle crunches, jumping jacks, suicide sprints, chair dips, planks, and tons of other fun exercises. Each time, I’d demonstrate, then my posse would immediately join in for a few sets. Although I didn’t necessarily think of it as anything more than a fun experience, a few days later I met one of my friends on the road to the hospital. He immediately dropped in the dirt and did bicycle crunches. Just goes to show that even demonstrating healthy habits can be a party!

If you enjoyed: Learning basic Chichewa phrases

You may also like: Getting Chichewa lessons

To live in a village or work at a hospital in Malawi, there are a few key phrases that you simply have to know:

good morning, good afternoon, how are you, have a good day, what’s your name, how much does it cost, your baby is cute (1), etc.

With your Malawian friends, however, you need a completely different vocabulary: Are you tired? What’s up? I’m confused, Do you like to dance?

You know, typical friendship stuff.

Having each of these vocabularies is pretty important, but you develop them in drastically different ways. For the former, it will suffice to skim past intern blogs, run some Google searches, and maybe pick up a trusty Chichewa 101 book (2). For the latter, you need to dig a little deeper. Sometimes that means asking a friend how to say something that’s relevant to the situation. Other times, it means taking advantage of some free time and trading snacks for Chichewa lessons at the hospital cafeteria or in the Zitha House kitchen.

Having started to develop the latter Chichewa vocabulary a little later, I’m still finding it to be tremendously helpful. Learning someone’s language is a great way to become a part of their world, even if you can only string together a maximum of 3 words. It’s the effort that supports the development of a relationship.

If you enjoyed: Going to mass at the Catholic church

You may also like: Going to mass at the Catholic church… in a chitenge!

I bought my first chitenge last week (!!!) and have been itching for the opportunity to wear it. However, my enthusiasm has been tempered by the knowledge that it’s very much a cultural symbol, and wearing it with respect is of utmost importance. For example, wearing a chichenge to work or the supermarket= pretentious foreigner.

At church, however, the chichenge reigns with sartorial ubiquity. As God’s house, the church is the place in Namitando that likely has the greatest respect for tradition and modesty. As such, putting a chichenge over my dress was not viewed as inappropriate. Rather, a Malawian friend told me that wearing a chichenge was sending the message that I love Malawi and appreciate its culture; that I respect its traditions and desire unity with the community of believers at the church. He told me it was a sign of loyalty.

Well, I’m not entirely sure if that’s all true, but I believe that my chichenge-wearing was well received. I definitely had more Chichewa conversations before and after the service, and I shook a TON of hands during the sharing of the peace. I was also a definite plus that chichenges are gorgeous and fairly comfy (when you can keep it wrapped tightly enough to stay put).

 

(1). I’m not a creep, I promise! When you pass mothers carrying their children almost CONSTANTLY in the hospital, it becomes a better alternative than just smiling at their kid.

(2). Neither BTB nor I is being paid to endorse Chichewa 101. It’s just the only Chichewa book on Amazon at the moment.

 

Since we’ve been spending a hefty portion of our time at St. Gabe’s in Hospice, I wanted to take a few minutes to introduce you to some of the palliative care team. Because even if I’ve said it before, it definitely bears repeating: the hospital workers are AWESOME! I feel like I’ve been reminded of this in 3 distinct scenarios this week. Yeah, it’s been a busy one, and a particularly Morphine Tracker-heavy one to boot.

 

Thursday was one of the hospital’s biweekly outpatient palliative care clinics, and we had the opportunity to observe and assist Alex, the palliative care nurse and resident Superman of the Family Centered Care Unit (FCCU). We popped over to the FCCU as soon as morning meeting was over (around 8 AM) and found that the benches outside were already FULL of people. Inside, a line stretched down the wall, all the way to the treatment room. As we met up with Alex, he didn’t even bat an eye at the people cueing up. Instead, he got straight to work. Now, when I say work, I mean it in the truest sense of the word. This guy does everything: read patient records, perform exams, collect vitals, write in the patient’s health passport, provide injections, count pills, dispense medications, schedule follow-up visits, and keep records for the pharmacy staff. That day, he enlisted our services to help pack pills, track down one of the hospital’s 3-4 functional blood pressure cuffs, fill out pharm records, and greet patients (woooo, Chichewa practice). After an endless stream of heart failure, sickle cell, Karposi’s sarcoma, and stroke cases (among others), lunchtime hit and the clinic was finally over. As out last patient shut the door, I couldn’t help but exclaim “Alex, why didn’t you tell us that you’re a SUPERHERO!” The man seriously does it all, and the fact that he can navigate the busy clinic solo and maintain the sensitivity required for hospice care just goes to further highlight his incredible contribution to the hospital.

 

The second ‘ah ha!’ moment came while we were delivering a presentation on Morphine Tracker. During lunch on Wednesday, we invited the entire palliative care team (a mixture of 8 clinical officers, nurses, and other health care workers) to learn about how our software can improve quality of care for patients with chronic conditions. We overviewed the importance of keeping careful records of morphine use (morphine shortages are common, and the drug is heavily regulated by the Ministry of Health and various nonprofit donors), and then presented Morphine Tracker as a tool to make that process easier. I was encouraged by the fact that 5 team members were in attendance (during lunch, no less!), and that we had some valuable discussion on marrying the system with existing routine. But perhaps the most uplifting moment was when Collins showed up to the meeting. Collins is the first person we’ve trained to use Morphine Tracker, and he has taken to it with remarkable ease and an optimistic attitude. To get why it’s exciting, though, you need to know 2 things about Collins:

1. He’s on holiday right now. Collins is actually leaving to visit his family in Zambia next week. But what did he decided to do with his day off ?!? (a day I’d use to eat popcorn and binge watch Netflix): HE CAME TO SUPPORT US!
2. Collins is technically on the cleaning staff. He has no medical experience and little computer training. Yet, his superiors recognized his potential (rightly so!) and have designated him as one of our new Morphine Tracker data entry ‘point people’. Despite the fact that he’s comparatively low ranking in the hospital staff, he has adopted his role with Morphine Tracker to such an extent that he feels he has the agency to contribute to meaningful decisions about its use in the hospital. How incredible is that?!?

 

Our third palliative care superhero is Mary Kaminga, one of the health workers who typically is found in palliative care. Like Collins, Mary hasn’t had extensive computer training to this date. Nonetheless, our first lesson yesterday went swimmingly! After listening with a quiet consideration, Mary would be able to execute the Morphine Tracker commands like she’d been doing it for weeks. We made a fair amount of progress in our 40-minute lesson, and scheduled more tutorials for early next week. I was afraid that our earnest praise of Mary’s work was getting brushed off (she’s incredibly modest). However, my heart did a little dance when Mary stopped us on our way out of the ward that afternoon. “Hey, Mary, we’re just heading to outpatient. Do you need any help?” She spoke shyly, but with a twinkle in her eye. “I just need to learn more”. Mary has a heart of gold, and she and Collins’ dedication bodes well (I hope) for the future of morphine records at St. Gabe’s.

 

Our experiences with the palliative care team this week have only given me increased respect for some of St. Gabriel’s finest. This insight comes with perfect timing, as we have spent this past week presenting on Morphine Tracker and starting to put it into play for the ward. As we make some final tweaks, the importance of factors like ease of use and ability to quickly integrate the software into existing routines become crystal clear. After all, the superhero’s tools only help them defeat the powers of darkness if they’re handy enough to come into use.

Pamene Zimaswa- “When it breaks”

When things break in Malawi they are hard to fix. Sadly, though, I learned this lesson with my laptop. After dropping it, my laptop would turn off a few minutes after it turned on. The hospital secretary, Kathy, recommended that I give it to Everest, the guy who comes from Lilongwe to fix Saint Gabriel’s computers. He was extremely qualified, she said, and was certain that he could fix it.

 

This weekend, after three weeks of my laptop being in Lilongwe, I finally got it back. Everest tried his best, swamped with so many other computers to fix, but be it either due to lack of knowledge or lack of the proper tools, I received a phone call saying that he had “failed to fix my computer.” In fact, the problem was worse: I couldn’t turn on my computer at all.

 

When I went into town to pick up my laptop, we saw Richard, the hospital lab technician on his way to get the machine that counts hemoglobin fixed. When we saw him again in lab the next week, he said that the engineer couldn’t fix it, and that hopefully the hospital would buy a new one.

 

 

The thing about technologies is they break. Regardless of how durable you attempt to make it, sooner or later nature will take its course and your technologies will break. So either someone’s there to fix it, or it gets stored indefinitely. For example, looking at Hannah Abrams blog about the lab from two years ago, most of these centrifuges are now broken and are sitting in the lab collecting dust.

 

Or they go to the maintenance office. Here you will find Duncan and Flora, the two hospital technicians. Duncan deals with mechanical issues and Flora with the electrical. In the maintenance office, there are broken technologies piled high.

 

Duncan told us that things that should take them a few minutes or hours to fix takes them days and weeks, just because they don’t have the right tools. Flora agreed with this, and said that, a lot of times, they simply don’t have the parts or the proper tools to fix them. These are simple things like solder and proper sized screwdrivers that would be commonplace at the OEDK. The two of them together just don’t have enough time to fix everything that goes wrong in Saint Gabriel’s: a lot of times, the hospital will have technicians and engineers come in from Europe or surrounding countries in Africa to fix technologies.

 

Malawi and Saint Gabe’s just needs more: More doctors, more engineers, more tools, more parts, more machines, and more resources.