an excerpt from my journal…

Day 50:

A few weeks ago, I wrote about how hard it was to believe that we were halfway through this internship. Now, looking out the window of one of my four flights back home, I can say it is even more difficult to accept that our time in Malawi has come to an end. 

This morning felt just like any other morning: I woke up, showered, and watched the sunrise while drinking my morning tea. Soon after we finished dragging our luggage up the stairs, Mr. Richard appeared with the bus to drive us back to the Lilongwe airport. While loading the suitcases, we joked about how it was just like the day we first arrived in Malawi, only now he would put the bus in reverse. 

It was then time to say goodbye to Kabula: the kitchen where we cooked all of our meals together, the terrace where we soaked ourselves doing laundry, the place we all began to call home as time went on. Soon after that, it was time to say goodbye to Blantyre, then our friends from Tanzania, and finally Malawi. 

One Week Later:

The past week has been full of quality time with friends and family. Due to the time difference between Michigan and Malawi, it was difficult to keep everyone fully updated throughout the course of the internship. As a result, I often share my stories starting from day one, using my journal entries and photos as guides to what I was seeing, thinking, and feeling. In day-to-day conversation, I’ve noticed myself begin to repeat a phrase: “When I was in Malawi…” I’ve said it while driving down the road and cooking dinner, comparing my experiences here to my time abroad. I’ve even said it while going under for oral surgery, sharing that we had gathered feedback in Malawi on a locking mechanism for the IV that was feeding into my arm.

In my downtime, I’ve also been working on finishing a book I started reading at the beginning of the internship. “Don’t Let’s Go to the Dogs Tonight” is a collection of personal narratives from the African childhood of Alexandra Fuller, some of which take place in Malawi. Reading through them at a time when I am also reflecting on the past few weeks has given me a lot to think about, and one quote, in particular, has stuck with me…

When describing an English guest to their house in Zambia, Fuller writes about how people like this man never last long, and then they return to their homes and say “when I was in Africa” for the rest of their lives. Coming across this similar phrase, I couldn’t help but compare myself to the foreign man. We too had spent a short period of time in another country, seen both its beauty and its challenges, and then returned to the United States to share our experiences. 

Thinking through this comparison, I began to once again flip through pictures of our work, and eventually the differences became clear. I saw our very first hospital visits, our ideas at every stage of the design process, and the final prototypes that came out of it all. Continuing to flip through my camera roll, I soon came across our speeches at the internship’s closing dinner. As I played the videos, I heard Nana talk on living with people of diverse cultures, personalities, and mentalities. Hannah highlighted the similarities between each of our lives, despite living on opposite sides of the world. Foster recounted an interview question that we all received: “Are you able to associate with people of different backgrounds?” Tebogo then gave the answer, saying that the studio would not feel the same once we all returned home. 

Finally, I began to play the speech of Dr. Ng’Anjo, one of the professors who welcomed us to the design studio when we first arrived at the Polytechnic. To the room of interns from three different countries, he said, “Keep the course. Whatever you have learned, don’t just say: Oh, it was an experience. We were in Malawi … Blantyre … a lot of dust.” The room laughed. Smiling at his own joke, he continued: “Amidst the dust, amidst the noise, amidst all that you have experienced… say this is the knowledge that we got, and I’m going to run with this knowledge.” 

Listening to these words once more, I am reminded that while our time in Malawi has come to an end, the experience is not confined to a single summer. The names of my fellow interns do not simply stay on the pages of my journal, they light up the screen of my phone. Despite the distance, ideas continue to flow. I receive updates from my teammates as they gather feedback from district hospitals on our training model and application. As progress is made on the MUST Design Studio, suggestions are shared from what is done at the OEDK and the Poly. 

When I was in Malawi, I found something that I want to continue to be a part of for years to come. As Dr. Ng’Anjo put it: “by working on these types of projects, you serve life itself.” I chose bioengineering because it lies at the intersection of technology and people. I wrote this statement when I applied to Rice. Last year, I used it as motivation whenever I was struggling with a problem set in a physics or math class. This summer, I had my first opportunity to understand what this statement truly meant. 

– Alex 

I would also like to thank all of the donors and supporters of this internship program for making this possible. Without you, our newfound community of engineers from Malawi, Tanzania, and the US would not exist. 

The past two weeks can be summarized by two words: rapid prototyping. Everyday, we walk into the studio with ambitious goals of finishing multiple attachments to our model, but somewhere along the line we’ll hit an obstacle. One 3D print’s dimensions are incorrect. A ball and socket fails to replicate the range of motion of a human shoulder.  Our elastic strings don’t properly simulate muscle tension. But once a prototype falls short, its life is not over. We immediately begin shaving away extra material, cutting new holes, and taping on components to test potential directions that our next iteration could take. After a new low-fidelity prototype has been created from the remains of our previous failures, the cycle begins once more. We arrive at obstacles, meet to discuss the shortcomings of a design, and a new design is born. It’s kind of like the Circle of Life (sorry but I’m listening to the soundtrack of the new Lion King movie as I write this).

By the end of Friday, we had completed all neuromuscular attachments to our training model, and with only one week remaining, our focus shifted to developing the assessment app. In the last half hour of work before the weekend, my team grabbed a huge white sheet of paper from the back of the studio. We then began to create a flowchart, outlining the basic progression of screens within our app. Once we decided on the placement, text, and purpose for a component, I would draw it onto our plan with a vibrant red marker (I found this part super satisfying). Not only did this process help us produce complete idea of what our app would be, but every member of our team left the studio visualizing our app in the same way. In engineering design courses back at Rice, it was always stressed that a crucial step in any project is making sure all of your team is on the same page. This helps avoid any major misunderstandings later on while prototyping.

On Saturday, we drove to the Satemwa Tea plantation, the first fair trade registered tea plantation in Malawi. We began the morning with a tasting at the factory, where we each tried a spoonfuls of 18 varieties. I never knew this, but apparently even without flavoring, the different methods of rolling tea leaves have a large impact on the taste. My favorite teas were the white hibiscus, red hibiscus, green verbena, and the green mint. We then went on a walking tour through bright green rolling hills of tea plants, some of which were close to 90 years old. In the evening, we had dinner with some previous 360 interns from Malawi who had worked in Houston last fall. It was neat to compare experiences between the two different internship locations and hear about their time at Rice.

Sunday morning, Shadé and I woke up early to put finishing touches on the Clean Machine. With the craziness of prototyping our own projects, recreating this technology was a responsibility that we had pushed to the side. Taking it home to Kabula and working on it over the weekend was a good call, but looking back, we definitely had to get a little crafty with some components. For example, we completely forgot to bring the pulley’s counterweight from the US, and not being at the Poly, there was no clear replacement or way to attach the counterweight to the belt. Still wanting to test our work, we borrowed rocks from the garden and used some clothespins…

After working on Clean Machine and making a little progress on this blog, we began to prepare food for a cookout we were having with all of the interns. We underestimated the amount of time it would take to chop all of the veggies, cook the hot dogs, and fry all of the chips, samosas, and spring rolls. As a result, dinner was delayed a little, but boy was it worth the wait! I think all of us were surprised at our ability to create such a spread of food.

Returning to work on Monday, our team began to develop our simplified assessment app for the Ballard Score. Looking at our plan, we started with the simple stuff: creating different screens and adding in buttons. Once that was done, we had to think a little more on how we wanted to program more complicated things like our sliding scale. Being that I was the only one who had done something like this before, I initially felt as though I had to serve as a resource for the rest of my team, but this didn’t last long. I remember the moment we tested our work on a phone emulator for the first time. At that point, we had only made the buttons that switch between screens. Still, the feeling of seeing your work come to life is thrilling. Everyone soon began to practice with the program on their own time, and our team began to fly through developing the rest of the app.

Since last Thursday, we have been testing and tweaking our work. You can find our most recent version attached below. If you are viewing this blog on an android smartphone, simply download, open, and install the file to try it out!

Download SimpleBallard App

Early Friday morning, I hopped in a taxi to Queens for a meeting with Prince, a nurse who frequently collaborates with Rice360. He was able to give plenty of useful feedback for the Clean Machine prototype and even had the time to look at our new Ballard Score training model. After talking with him, I arranged to observe in the NICU for a few hours until work started at the Poly. Heading into the ward, I was very concerned about my presence becoming an obstacle for nurses to work around. This was the last thing I wanted, so I began by sitting in the corner towards the back of the room. After a short while, Sarah, a fellow at Rice 360, tapped my shoulder and told me that something was happening on the other side of the room that I might be interested in seeing. A new baby had been admitted into the high-risk section of the ward. From a distance, I saw nurses quickly retrieving equipment from all around the room. The level to which every nurse is able to work with one another is incredible. Their communication is clear, quick, and their collaboration is efficient. Observing led me to better understand the role in which an engineer could contribute in this setting.

 

When the new baby was admitted, I saw Prince run to the other side of the room and grab a linen blanket. He then held the blanket up to a radiant warmer used to heat the room for at least 30 seconds. As I was reminded by Sarah, the best treatment for a cold baby is a warm blanket, warm socks, and warm hat. After the situation had calmed down, Prince came over to tell me that a useful project would be a warm storage container for linen blankets. This idea would save time in situations where every second counts. Prince’s suggestion got me thinking about ways to simplify processes, and I soon began to observe other opportunities for engineering to have an impact.

Recently, I’ve been thinking more and more about the scope of this program. As an intern, one of my primary responsibilities is needs-finding for projects at Rice. These projects are then worked on, and taken back for feedback. Looking forward into my next few years of education, I may even end up working on a need we identified through this internship. It truly is a cycle, involving every stakeholder at every stage. From nurses in hospitals across Malawi, to the students from four separate universities, to the professors and organizers that make it all possible, everyone is fully invested in a common goal. Step by step, prototype by prototype, progress is made, never losing sight of the bigger picture.

Thinking about how fast these first few weeks have flown by, it’s really hard to accept that we are halfway through this internship. Recently, I have been taking more and more pictures of regular day-to-day tasks, not wanting to forget the small things: the sunrise, the walk from Queen Elizabeth to the Polytechnic, and our home-cooked family dinners at Kabula Lodge. The following blog will take you through one day of our lives here in Malawi. I’ll walk you through decisions my team makes while prototyping, things I notice on the streets of Blantyre, and my thoughts from when I untuck my mosquito net in the morning until I tuck it back in at night. Hopefully this blog gives you a sense of what it is like to be an intern in this amazing program. 

– July 5th, 2019 –

7:26 AM

It’s become kind of a tradition that every morning as we are eating breakfast, I will set down my tea and declare the time to be 7:26. The bus from Kabula leaves every morning at 7:30, and through trial and error, we’ve discovered that in order for every intern to take their seat on time, this is when we all must begin to scarf down our remaining tea and toast. 

This morning the normal bus was out of service. Instead, we rode to work in a smaller replacement bus with fewer seats and unfortunately, less leg room. Once at Queen’s we began our usual walk along the busy streets of Blantyre: through the small market outside of the hospital, under the bright blue walking bridge, and between two tall palm trees marking the side entrance to the gated Polytechnic campus. From there, we usually have around 30 minutes until work starts, so we spend our time either reading or journaling in the sunny seating of an outdoor amphitheater.

8:30 AM

Wongani, a technician at the design studio, waves to us from the covered red walkway on his way to unlock the doors to the studio. Inside, light pours in through the 360º windows onto the clean and shiny tables, signaling a fresh start to a new day. While we wait for the rest of our project teams to arrive, Shadé and I make progress on the Clean Machine prototype. 

9:00 AM 

My Ballard Score team sits down and begins a brainstorming session for one of the training model’s attachments. For 10 minute intervals, we sit in silence, each writing down whatever comes to mind in our journals. At the end of the time, we each have several pages filled with a mix of potential solutions and mechanical components. Each one of these ideas is then shared with the group, free of any immediate criticism. As someone reveals a drawing, others build off of it, presenting their own related thoughts and combining concepts. 

Betty and I spend the rest of the morning developing low-fidelity prototypes for two of the brainstormed ideas. While we bend pipe cleaners and straws to create proof-of-concept models, Rodrick and Racheal continue work on two other neuromuscular attachments: heel to ear and the popliteal angle. With a goal of finishing prototypes for both of these attachments by the end of the day, they make final adjustments to dimensions in various CAD files. 

12:07 PM

Not wanting to waste valuable time, my team hangs back a few minutes into lunch to get our 3D prints started. With stomachs growling, we all make our way across the street to Miko’s Dessert Shop. Rather than getting their extravagant ice cream waffle cones (like we do every Friday), we instead order freshly baked cinnamon rolls. Unable to resist the smell, I finish mine on the walk to get an actual lunch from LJ’s – a small red shack across from Queen’s.  

At LJ’s you get a choice of nsima or rice, a meat, and a variety of vegetables. I prefer to have nsima over rice, mainly because I think it is way more fun to eat. From what I have been taught, here’s how to best enjoy these bouncy scoops of corn flour: first roll a ball in the palm of your hand (quickly because it’s hot), use your thumb to press a hole in the center, then use the nsima as a spoon for the rest of your food. 

1:30 PM

The work ethic of the Polytechnic and MUST interns is incredible. In addition to the internship, they are still attending classes, completing homework, and working on their own side projects. I honestly have no idea how they manage to do it all. Today, Rodrick had to leave for a few hours to give a presentation. In his absence, Racheal, Betty, and I have found little ways to be productive. Racheal has begun working with the software we will be using next week to design our app. Betty continues to work on her low-fidelity prototype, and I start designing components of the training model’s arms in SolidWorks.

3:30 PM

Just as bright light pours in through the windows every morning, the warm beginnings of a sunset flood the design studio starting at around 3:30 p.m. Over the past few days, I’ve begun to notice the effect of this lighting on our productivity. This final hour truly becomes a test of our willpower to accomplish the goals we established in the morning. Today, we had hoped to finish prototypes for both of the neuromuscular attachments on the hip, but as the orange tint of the sun overtakes the fluorescent blue of the LEDs, we haven’t assembled either. 

When Rodrick returns from his presentation, I am staring with frustration at my computer screen, unable to get one dimension of an arm to change without having to start over again from scratch. Unlike the rest of us, he is somehow still full of energy. It spreads to the rest of us, and the next hour becomes a mad rush to finish at least one of the attachments.  

4:26 PM

With 4 minutes to go before the end of the day, we have completed the prototype for the heel to ear attachment. My fingertips are encrusted in a layer of solidified super glue and our table is a mess of PLA shavings, bits of elastic, and random hand tools. During the walk back to the bus, I reflect on what we were able to accomplish.

It’s difficult setting goals and then not being able to accomplishing them fully. Back at Rice, the OEDK is just a short walk away from my dorm room, allowing me to work on a project until I am satisfied, sometimes into the early hours of the morning. Here, a 15 minute bus ride separates me and the design studio. At the end of every day, we must set down our tools regardless of whether or not we have reached a natural stopping point. As frustrating as this is can sometimes be, I feel that it has helped me to become a better teammate. 

In the past, I have struggled to let others take the reins in group projects. If a calculation was being made, I wanted to double check it. If a prototyping method was modified, I wanted to be there to understand the decision. But for the first time in my life, the engineering design process has been shoved into the time constraints of a workday. With so much to do, there is no longer time for me to obsess over every detail. My group at the Polytechnic has learned to strike a balance of task-division and making sure the whole group remains on the same page.  

5:30 PM

Once back at Kabula, we all walk under the beautiful orange flowers that drape over the reception area. Having done laundry the night before, I take down my clothes from the line and begin to pack for our weekend hike of Mount Mulanje. Hannah, Liseth, and Cholo start preparing dinner in the kitchen. At the very beginning of the internship, we randomly selected four teams to trade off cooking duties. The system works well and has been a fun opportunity to learn how to make some new dishes from the Tanzania interns. For our last meal, Joel taught Kyla and I how to make nsima, or as it is called in Swahili: ugali. The process turned out to be more difficult than expected and requires a lot of arm strength (more than I have), especially when you’re cooking for 11 people.  

8:00 PM

Eggplant parmesan is ready. People slowly begin to crawl out of bed, up the stairs to the terrace, and take their seat around the dinner table. While eating, we joke about how we’ll probably die climbing the mountain this weekend. Liseth retells stories of Cholo’s misadventures in the kitchen. We laugh, talk, and eventually move into the lounge area. Some 0f us do research for our projects. Others snuggle up in a blanket to read a book. I begin writing.

10:00 PM

I finish this blog! 🙂

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This week, my team had the chance to present at the first ever Malawi Innovation Pitch Night, and after the whole experience, I realized how little I have written about my main project in this blog. As a result, the following post is gonna be a little more technical so brace yourself for some facts and figures, but I promise every one of them is important. I’m super excited about the work we’ve been doing so far and its potential impact so please continue reading! 🙂 

Around the world, premature birth is estimated to be responsible for 35% of all neonatal deaths, mostly concentrated in developing countries. In many government hospitals in Malawi, nurses lack a systematic approach to identifying prematurity in newborn babies. Instead, birthweight, an inaccurate estimate of gestational age, is primarily used. In some cases, a reliable number can be calculated from the mother’s last menstrual period (LMP), but frequently no record is kept of this information. Rather than using birthweight, and in cases where the LMP is not known, a Ballard Score assessment should be performed. The Ballard Score is a set of 12 neuromuscular and physical signs that when combined, produce an accurate estimate of gestational age. However, even in hospitals where nurses have knowledge of this assessment, it is almost never performed. 

Wondering why this was, our team traveled to hospitals all over Malawi: Mulanje and Zomba District Hospitals, and this week, Kamuzu and Queen Elizabeth Central Hospitals. From talking with nurses, we identified two obstacles that make it difficult to complete the assessment for each and every newborn…

1. Many nurses lack the necessary knowledge to perform the assessment, especially in the case of the challenging neuromuscular procedures. Some nursing students told us the Ballard Score was only a single lesson during one day of their schooling, taught through pictures of the procedure rather than hands-on practice.
2. Nursing teams are often understaffed and short on time. As it stands, the Ballard Score assessment takes 15-20 minutes to both perform all 12 procedures and calculate a final score. This is too long for many hospitals where as many as 20 babies are born per day needing individual care and attention. 

Looking at the factors surrounding these two separate problems, my team has developed two separate solutions…

Our first design, a training model for neuromuscular Ballard signs, aims to tackle the knowledge gap between the classroom and the assessment room. The model consists of a main baby mannequin with two attachment points for interchangeable limbs: one at the shoulder and one at the hip. Each interchangeable limb corresponds to a different neuromuscular sign, and can be adjusted to replicate the muscle behavior of a baby at different degrees of prematurity. 

Once fully developed, we hope to implement our model as a teaching tool for nursing schools. Imagine a classroom filled with groups of students, each gaining hands-on experience through the use of our model with different attachments. A professor could walk around from station to station, providing advice and corrections for each of the different signs as they see the motions performed right in front of them. Ultimately, the model should provide nurses with the confidence to complete the assessment when working in a hospital setting.  

Our second second design aims to reduce the time required to perform a full Ballard Score. Having not conducted years of research like Dr. Ballard, there is no way we could remove any signs from the assessment while still maintaining an accurate estimate of gestational age. Instead, we decided to cut down the amount of time it takes to record and calculate a result from the assessment while also making it quicker and easier to match observations to the score’s criteria. 

In every hospital we visited, nearly every nurse carries a smartphone. After seeing this, we determined that one of the easiest ways to roll out our design to as many hospitals as possible would be through app development. Designing an app also allows for a user interface that cuts out a lot of the unnecessary information on the current assessment chart. Numbers are cut out entirely, as all calculations are performed in the background, simply producing an accurate estimate of age at the end of each assessment. Furthermore, the use of a sliding scale takes the diagrams of each sign in the current chart and consensus them into one changing image, letting nurses easily scroll until the image matches their observation of the real baby. 

So many aspects of care for premature babies revolve around knowing their specific age. In addition to helping nurses save these precious lives, we believe our project has the potential to contribute to an even greater picture. Organizations such as Nest360º rely on accurate data when measuring the impact of their technologies on neonatal outcomes. With the most common estimate of gestational age being birthweight, reliable data surrounding premature births is difficult to obtain in developing countries. Furthermore, the paper records of many hospitals are either non-existent for individual births or difficult to sort through. Together, our training model and assessment app for the Ballard Score can become the start of a solution. 

We fully realize that any prototypes we come up with in the next few weeks will no more than scratch the surface of this issue, but it is the potential for future work that excites me. What if the app could upload each assessment to a database? What if that database could be used to assess the impact of lifesaving technologies? What if that data revealed a need that had previously gone unidentified? By creating a solid foundation for others to build off of in the future, I feel that my team has an amazing opportunity to start something that truly matters. 

– Alex 

 

 

Bonus: Here’s some pictures from the rest of this week’s adventures…