Hello from Blantyre! It’s crazy to think that over half the summer is over already. Becky, a Rice alum and current medical student, just left Malawi yesterday after spending a month working at Queen’s. Her departure made realize how much time has gone by.

I’ve spent these past two weeks in Blantyre, working at Queen’s. Although I miss traveling and seeing all the different parts of Malawi, it’s been nice spending time with the people at Queen’s, the other interns, and some other friends we’ve made who are also working in Blantyre. Last weekend we (including our new friends) took an excursion to the beautiful Lake Malawi where we went snorkeling and ate some great food.

But I’ve spent most of my time these past couple weeks in front of a computer, coding. I’m trying to build a program that will generate summary reports from all the CPAP data we’ve been collecting, and while I’ve never programmedd in before, it’s been a fufilling experience learning how to code while working on a meaningful project. All the data we’ve been collecting is stored online in a CSV file. CSV stands for comma separated value, which means that every element of data for each patient (name, hospital, days in hospital, days on oxygen, etc.), is separated from each other by commas. My job is to build a java application that allows the user to parse through this immense amount of data and generate a summary report for each hospital.

As I mentioned in my last blog post, we want to be able to give every district hospital specific information that will help them use CPAP more effectively. By knowing specifically how many babies were put on oxygen or CPAP, the most common diagnoses for those babies, and how many of those babies passed away or were discharged, we think that the hospitals will be able to tailor their practices to be more effective. If there is a large discrepancy in outcome in babies with birth asphyxia who were put on CPAP vs not being put on CPAP, for example, the doctors and nurses will know to place higher emphasis on getting CPAP to asphyxiated babies sooner. As an applied mathematics student, I am a firm believer that good data is an invaluble tool, especially in low-resource settings, because this data can guide the use of limited resources so that they can be the most effective. I think having a program that lets hospitals obtain this data easily can really help improve outcomes.

I’ve also been working with Emily on giving demos of the prototypes we’ve brought with us to the staff at Queen’s. Today we brought an oxygen flow-splitter to the wards. Even though Queen’s already has flow-splitters that work very well, we think that our device can be helpful in other hospitals that can’t afford such nice flow-splitters. Flow-splitters are important because they allow multiple babies to recieve oxygen from one oxygen concentrator by “splitting the flow” and diverting it to multiple tubes. Oxygen concentrators are very expensive and, as we’ve found out, break easily, so the more babies that can benefit from fewer concentrators, the better. Our device allows for up to five babies to recieve oxygen from one concentrator, each being able to get a maximum flow of 2 liters/min. Compared to flow-splitters being used in the US, our device meets the standard for only $5 USD. However, our device isn’t perfect: it leaks and doesn’t regulate the flow very precisely, but the doctors and nurses we’ve shown so far seem excited by the concept.

I’ve spent many hours in nurseries and maternity wards across Malawi these past two weeks, traveling to nearly ten different hospitals with Shannon, Carol, German, and Carissa to collect data on the hospitals’ use of CPAP. At the risk of sounding trite, I return to Blantyre humbled and in awe: the nurses and doctors I met have seen and learned to deal with countless problems, treating babies diagnosed with everything from sepsis to birth asphyxia to severe arrhythmia, often without the proper tools. It felt wrong, almost inconsiderate, to see how they could do better.

But at many of the hospitals we visited, few babies were being put on CPAP, despite having symptoms that provided a clear mandate to do so. Walking into the nursery at one hospital, I could see the CPAP machines tucked into a corner, untouched. The nurses knew about the machine, however, and even about its benefits. They pointed us to the extra supplies and helped us find the patient records that gave us information about its use. And, as I mentioned earlier, the nurses and doctors were clearly not lazy. Everything, from the hours they put in to the conditions they endure demonstrate how much they care. So why in the world weren’t the CPAPs being used?

We hear a lot about how technology can solve all of our problems. Nearly every start-up company, whether they have developed a low-cost diagnostics tool for HIV or have built an app that erases photos five seconds after being seen, proclaims that they are in the business of “changing-the-world.” But often, and especially in the developing world, just having the technology does not guarantee better results: the CPAP is only one example. Even educating the nurses and doctors about its use does not guarantee success, as I’ve seen these past couple weeks. Unfortunately, real solutions to these problems do not go viral.

So what can we do? One thing is to stop making general statements for the hospitals. While some hospitals were struggling, others were doing extraordinarily well. And even at the hospitals that struggled, many have different problems. One had frequent power outages that interrupted continuity and created more pressing problems. Another had just gone through a staff rotation. We need to look at each hospital individually and not expect a one-size-fits-all solution.

Another thing is to build better relationships with more of the nurses. During our monthly visits to each hospital, we meet with one doctor or nurse, appointed the “CPAP coordinator” for that hospital. We come in, check the equipment, count the supplies, record the data, and then leave. If our coordinator isn’t there, few others know who we are. We are strangers.

We hope that by building better relationships with more of the nurses, we will give them more ownership over the CPAP project by making them more involved. Right now we collect data and give some criticism to a few people. We’re the faceless administrators from the outside that come and give directions. The more people we involve, the more, we hope, they will understand our mission and feel a part of it themselves.

We also hope to bring the CPAP coordinators from all the hospitals together for a day to discuss best practices, hopefully motivating each coordinator to have his/her hospital perform as well as all the others.

These solutions will take time. There is no quick fix. There is no “app for that.” But despite seeming otherwise, these laborious, individualized solutions are the only way for the CPAP project to be scalable in the long-run.

 

Muli Bwanjee! Greetings from Blantyre, Malawi. Emily and I arrived Wednesday afternoon, where we met up with Jacinta, Carissa, and Caleb at the Beit International Cure House. I’ve finally unpacked, and so far our stay has been great. Our house is equipped well: there is a kitchen where we cook most of our food, a living room, a few bathrooms, bedrooms, and an outdoor porch. Plus, there is a great café right next door where I had lunch yesterday (and tried Nali, a super tasty but SUPER spicy Malawian hot sauce). I’m going to make sure to bring some back with me.

So far since I’ve been here, I’ve been able to walk around Blantyre a bit. Yesterday I went to the local strip mall where I bought a SIM card, exchanged money, and bought some groceries. The big grocery store nearby is called Shoprite, and they sell fresh, homemade bread everyday. I think the five of us have polished off 5 loaves since we’ve been here. Apparently there’s a huge market nearby as well where the other interns have purchased fruit, vegetables, and eggs, but I haven’t been able to visit yet. I was also able to walk by the Polytechnic of Malawi, where Jacinta, Caleb, and Carissa have been working this past week to develop their BIOE curriculum and fix some broken phototherapy lights for QECH.

However, I’ve spent a lot of my time here so far at Queen Elizabeth Central Hospital where I was able to shadow doctors (more on that later) and meet Shannon, one of the directors of the bCPAP project here in Blantyre. For the next few weeks, Shannon, Carol (another person working full time on the bCPAP project here), Carissa and I will be traveling to many different hospitals around Malawi to collect data on how the bCPAP is being used at those locations so we can see what is going well or not-so-well.

Which brings me to some thoughts on sustainability. While I was taking an engineering design this past year at Rice, where I built a prototype of a dosing meter to be used for the phototherapy lights, the emphasis was always on building new technologies and introducing them to the hospitals in Malawi. But now that I’m here and I understand the work that needs to be done, I realize that most of what I will be doing this summer is on the back end, with implementation. When Carissa and I travel around to the various hospitals in Malawi, we will be collecting a lot of data on how often the hospitals use CPAP and with what diagnosis, training nurses to use CPAP in their hospitals, and trying to understand what the most common failures with the machine are and teaching people how to fix them. This work will take up the majority of my time this summer, while introducing the new technologies will take up much less.

I think what a lot of people observing from the outside fail to realize (including me until recently) is that the hardest part of implementation comes after the introduction. It’s maintaining and ensuring the quality of the machines that takes the most work and makes the bCPAP machines sustainable, even though the work is less glamorous. I think the same can be said about the implementation of many things in different fields: we’ve seen in the Arab Spring that revolution isn’t enough to ensure democracy or that solar panels aren’t enough to ensure clean energy. This may seem fairly obvious in hindsight, but I think that because most of the attention is focused on the front end, many people end up surprised when technologies or causes with enormous potential fall through.

Zikomo (for now)!

As I write this post on my flight from Cleveland to Houston (the first leg of a 3 day journey that will take me to London, South Africa, and then Blantyre, Malawi), I am finally able to appreciate the privilege I have to work with Rice 360 and Queen Elizabeth Central Hospital in Blantyre. As Jacinta, Caleb, and Carissa have mentioned, these past few weeks have been extremely busy with preparations – I have been doing everything I can to learn about the various health technologies developed by Rice undergrads so that I may help put them to use at QECH and at other clinics nearby.

Later today I will meet up with Emily, and together, we will bring the rest of the equipment and supplies (and Oreos, lots and lots of Oreos) to the international CURE house, where we will join our other awesome interns Caleb, Carissa, and Jacinta who will already be working on developing BIOE lab courses that they will teach at the Polytechnic.

I am so excited to have the opportunity to learn from the amazing people I will get to know in Malawi, from the doctors at the clinics to the people I will meet at the market, from BTB associates working full time in Malawi to my fellow interns. My main projects will be to help administer the clinical survey for the Bubble Continuous Positive Airway Pressure device (bCPAP) and to work on getting feedback for a tablet program that records vital signs for neonates and for DataPall, a palliative care records database. Caleb and Carissa did a great job explaining these specific tasks in detail in their first blog posts, so I won’t go into too much detail here, but the broad goal is to obtain information that will tell us how effective our devices are and to use this data to improve the devices. We hope that if we can show that our devices are successful, we can encourage other area hospitals and public officials to adopt the technologies as well.

Vital Tracker (a link to a poster that describes the features for a tablet program that takes vital signs for neonates at point-of-care)

However, despite all the preparation we have been doing, we fully expect things to change and for some projects to fall through. Design constraints we might not have realized existed could cripple a project, and unaddressed needs we did not know of before could spur new ones. Such problems are inevitable, as we spend most of our time working 9168 miles away. But we ready and willing to adapt.

Although I’m a little weary thinking about spending 23 more hours in a plane, I cannot wait to arrive and get to work (and to finally learn the proper pronunciation of the few words I’ve learned in Chewa)! Tionana!