Each Friday for the next three weeks, the Tanzania EWH team will work at Mount Meru Hospital just outside the heart of Arusha.
The Tanzanian health care system consists of larger referral/consultant hospitals such as Kilimanjaro Christian Medical Center, regional referral centers covering several districts, and smaller hospitals covering one district each such as Karatu Hospital.
Mount Meru is a regional hospital with departments for obstetrics and gynecology, pediatrics, surgery, out-patients, and units for ophthalmology and dentistry. The hospital also has a laboratory and an intensive care unit. The hospital typically sees 500 patients per day on an outpatient basis and admits approximately 250-290 patients every day.
Reaching Arusha on the highway in Tanzania – On the way to Arusha 2
Reaching Arusha on the highway in north of Tanzanai- On the way to Arusha
Generally there is a fee to be seen by a doctor at Mount Meru; however, as a public hospital, they are obliged to serve all people, and will provide free health care to those who cannot afford it.
The typical population served by the hospital consists of farmers, pastoralists or industry workers. These are families that earn a low to middle-class income. Some of those who work in the outskirts of the districts covered by Mount Meru Hospital (for example people coming from Ngorongoro or Longido district) have nine hours travelling time to the hospital. Others simply can’t afford the cost of transportation. As a result, acute patients, especially pregnant women and children, often reach the hospital too late for doctors to do anything.
Images from Mount Meru Hospital grounds
Images from mount meru Mount Meru Hospital grounds 2
Image from Mount Meru Hospital grounds and biomedical engineering Technician Mr. Sharif
According to hospital staff, the largest barriers to provide health care services in Tanzania are lack of capacity to handle all, but especially acute patients, lack of funding and lack of accessibility to medicines, supplies and health care technologies. These issues are more or less apparent in all across governmental Tanzanian hospitals from the district level up to referral/consultant levels. Handling acute cases is a particularly large problem at district hospitals, which is why regional hospitals like Mount Meru experience a very high occupancy rate and a high number of patients, that do not reach the hospital in time for an ideal outcome of their treatment.
At Mount Meru Hospital, one challenge in meeting the demand is the large amount of donated equipment of which only about half is currently functioning. The entire region has just one biomedical engineering technician (BMET), Mr. Sharif Rajabu Kishakali.As of early 2015, he is the first ever BMET at Mt. Meru Hospital. He is currently working on a preventative maintenance program for the hospital’s equipment. The attached pictures are a collection from the projects he is currently working on.
USAID is also active at Mount Meru
Dental Chair from Denmark #3 Broken equipment at Mount Meru Hospital #17
Dental Chair from Denmark #2 Broken equipment at Mount Meru Hospital #16
Dental Chair from Denmark #1 Broken equipment at Mount Meru Hospital #15
Mr. Sharif and donated baby warmer – Broken equipment at Mount Meru Hospital #13
Donated baby warmer – no temperature probe – Broken equipment at Mount Meru Hospital #12
Suction pump Broken equipment at Mount Meru Hospital #11
Beds – Broken equipment at Mount Meru Hospital #10
Baby warmer in storage room – Broken equipment at Mount Meru Hospital #9
Storage room #2 – Broken equipment at Mount Meru Hospital #8
Storage room – Broken equipment at Mount Meru Hospital #7
Microscope – Broken equipment at Mount Meru Hospital #6
Centrifuge – Broken equipment at Mount Meru Hospital #5
Autoclave – Broken equipment at Mount Meru Hospital #4
Blood gas lab equipement Broken equipment – at Mount Meru Hospital #2
Blood gas – Broken equipment at Mount Meru Hospital #1
As described extensively on this blog, working in a developing country hospital is not always easy.
In effect, it always results in a great sensation of success, when one suddenly finds a hidden stash of valuable – yes – cables. Exactly that happened when our group found the ECG’s cables and power supplies shown in the pictures below.
Box of Cables
In a storage room at the emergency department of the hospital we found 7 vital signs monitors, 7 Power supplies, 2 pulse-oximeters and 3 ECG cables in woking condition. Unfortunately, all remaining cables for the seven machines were broken, an example of which (an SPO2 sensor/pulse-oximeter) is shown here.
Pulseoximeter with broken connection
Pulseoximeter with broken connection #2
Becca Cleaning Cables
ECG cables broken.
From all the parts we had an fixed we managed partially assemble 5 working Vital Signs Monitors: Two of them were put back in to service with pulse-oximetry and ECG working, 3 of them with ECG only. Unfortunately the department didn’t have any compatible blood pressure cuffs, so we would have to buy new ones, just as we wouls need additional pulseoximeters and ECG cables.
Vital signs monitors are fairly simple pieces of medical equipment, however the cheapest completely refurbished set found on eBay that is corresponding to these machines is $3.503.
Thus having these pieces in working condition would have an extremely high value to Roosevelt Hospital. Meanwhile the cheapest prices on eBay for replacement parts, that we need to put all of these vital signs monitors back into service, are found for $24 (SPO2) + $54.50 (ECG) + $12.5 (Blood pressure cuffs).
In “How to repair shielding on ECG cables and leads” I described how we we repaired three sets of cables. The fixes were good, but not perfect in that we did make the cables work, but the signal was still somewhat noisy, for which reason the machines couldn’t have been used in surgery and detailed diagnosetics – rather they were useful for general “simple” monitoring.
Considereing the fixed cables as being in working condition (a somewhat noisy signal is, after all, better than no signal at all), we now just needed 2 ECG cables, 5 SPO2 censors and 7 blood pressure cuffs to make all of these machines work.
The total cost of this according to the prices on eBay would be just $321, although with used parts.
Considering that a completely new refurbished set on eBay costs 3.503, the value of these equipments reach $24521 in order to buy seven of these machines.
By repairing these machines our team achieved 79x value for money (even though the fix wasn’t perfect).
Now, I thought this story would end here, when, out of the blue, I received an email from Mr. Juan Fernández at Spacelabs Healthcare in Latin America, who wrote that they would be able to send the broken parts to us — free of charge! We could now make all the machines work perfectly (with no noise on the line). My collegue in Guatemala, biomedical engineer and expert technician Mr. Joe Leier will receive and bring this donation to Roosevelt Hospital as soon as possible.
I want to thank the people, that have been a part of saving these machines: my collegues Ms. Rebecca Avena and Mr. Joe Leir and Mr. Juan Fernandez at Spacelabs. We at EWH and Roosevelt hospital we are extremely thankful for this donation, which now means that Roosevelt hospital has 7 fully refurbished, high quality patient monitors working in their emergency department.
Discovering that the monitors and power supplies work
Global Medical Aid (GMA), an aid organization from the Capitol Region of Denmark, was given broken medical equipment and therefore forced to spend their resources separating life-saving medical equipment from useless machines. Unfortunately, not all organisations perform this vital quality control: many donations end up as nothing more than piles of junk at the world’s poorest hospitals.
Medical equipment is extremely valuable and has the potential to significantly improve health care in developing countries. In an effort to aid the world’s poorest health care systems, western hospitals often donate used medical equipment when updating their inventory.
Unfortunately, donations often don’t have the intended positive impact. An example of how donations can end up causing more harm than good was featured on the main Danish news channel DR1:
The news story was on national Danish television and radio.
It is described how regional politicians of the Capitol Region of Denmark did not set aside resources for testing of equipment donations before the machines were given to Global Medical Aid (GMA). GMA had to spend a large amount of financial and human resources on separating useful pieces from broken ones — resources that should have been spent on the transportation of equipment to developing countries. (See translation of the full story at the end of this post).
Not all aid organisations pay third parties to test the quality of their donations as GMA does. Many aid organizations simply ship malfunctioning equipment directly to developing countries without any quality assurance whatsoever.
An example of this is illustrated in the pictures below from Roosevelt Hospital in Guatemala City, taken on the the 30th of December 2014. I am currently working at the hospital with Engineering World Health as part of a six person team of students and professionals from Rochester Institute of Technology, George Mason University, Marquette University and the Technical University of Denmark. We are based at Roosevelt Hospital in Guatemala City with the aim of placing broken donated equipment back into service.
Already during our first day at the hospital we found vital medical equipment out of use: 14 haemodyalisis machines, 7 vital signs monitors, 4 anaesthesia machines and an incubator. The well-meaning donations are left as junk in the “equipment graveyard” in the back of the hospital.
Another example of failure to target donations properly is shown in the following picture from the same hospital, featuring the pictured dental chair, which is still partly contained in the original wrapping, indicating that the chair has most probably never been used.
Unfortunately, the problem we are facing at Roosevelt Hospital is not unique. It is seen in developing countries around the world. Leslie Calman, CEO at Engineering World Health, summarises the issue as follows:
“The donation of medical equipment is a generous and well-meaning outpouring of aid, intended to strengthen health care systems, reduce human suffering and extend life-saving remedies to millions. But if not done with care and attendtion to local conditions — including the capacity of local hospitals to install and maintain the equipment — the generosity may not live up to its donors’ good intentions. The Secretary General of the United Nations has stated that as much as 70% of essential medical equipment is not functioning in the developing world. Coupled with equipment donations should be an investment in training a local workforce to maintain and service the equipment. This would create local jobs, build skills, improve the environment, and create the conditions in which healthcare can be safely delivered.”
The magnitude of harm caused by faulty equipment donations goes largely unnoticed. To illustrate this, consider the following: According to World Bank, the Danish health care expenditure in 2012 was 11.2% of Danish GDP, accumulating to $6,304 per capita (the corresponding number in the United States is 17.9%). This means that $6304 is spent on health care for every single one of Denmark’s 5.6 million citizens.
$34.65 billion is spent on health care in Denmark every year. Contrary to popular belief, this money is not spent on the high salaries of doctors. Based on the average yearly physician’s salary in Denmark of $85,000 and nurse’s salary set at $54,000, only 18% of the Danish health care expenditure is spent on salaries. The major part of the remaining $28.14 billion is spent on hospital infrastructure and the extremely valuable medical equipment.
My point is not that poor hospitals don’t need equipment donations. Rather, the important aspect to realise is that the donation of advanced technologies is extremely complicated. Resource-poor health care systems are in need of expertise from professionals who understand advanced health care technologies and the logistical complexity behind donations.
The fact that a vast amount of broken equipment is sent off to fill up the words poorest hospitals without ever being used is ethically irresponsible and indefensible. It is essential that local health care workers, departments, and hospitals ensure that well-meaing donations actually end up fulfilling their life-saving purpose.
Translation of the original story:
Danish hospitals donate used medical equipment to alleviate poor countries. However, aid organisation warns that the equipment may be dangerous to use.
In a corner of Global Medical Aid's storage halls in Birkerød you'll find more than 30 infusion pumps. They are donated from hospitals in the Capitol Region and should have been sent to poor countries in Africa, but as it turns out, this equipment is completely defective.
The relief organisation Global Medical Aid sends hospital equipment to poor countries around the world. They are now accusing the Capitol Region for using them as a landfill.
The reason is that the organisation has been given an abundance of used medical equipment that does not work at all. Everything from anaesthesia machines to infusion pumps and defibrillators have turned out to be broken.
"We have obviously been treated as if we were a landfill site, where hospitals could get rid of the equipment they have been storing in basements for years" says Hans Frederik Dydensborg, the president of Global Medical Aid (GMA).The politicians of the region have now decided that medical equipment is to be donated in an ethically responsible way. According to GMA, it is directly unethical when hospitals donate equipment that doesn't work. GMA has incurred large expenses in separating working pieces from broken ones -- money that should have been spent on bringing the equipment to the world’s poorest countries."We have had large amounts of unnecessary expenses, with the consequence being that we haven't been able to send off the containers as expected" says Hans Frederik Dydensborg.In the Capitol Region, the chairman of the IT and debureaucratisation committee, who is responsible for recycling medical equipment, is concerned about the fact some donations have proven to be useless."Of course the equipment must have a certain standard, and of course it to be in a condition such that it can be used" says Lise Müller (Socialist People's Party).To avoid faulty donations in the future, the Capitol Region is now creating a storage hall in order to collect used equipment from hospitals and check it up for errors and deficiencies before they are sent on to aid organisations.In the region of Mid-Jutland, they have good experiences with a corresponding scheme."I am sure that we can find people who could find use of the equipment. If they don't, we will have to throw it out. But of course we have to learn from this, that the equipment we donate is of the right quality" says Lise Müller. The new storage halls will cost about DKK 2 million (USD 330.000) a year to maintain and the money will be found in the 2016 budget of the capitol region.
During our first day at the hospital we’ve been working on two projects:
The Vital signs monitors.
The emergency department of Roosevelt hospital has received seven vital signs monitors as donations. They suspect the machines should be working fine, however the cables for measuring oxygen saturation, ECG and oxygen saturation are broken. Unfortunately we cannot test these machines as the power supplies are missing.
Furthermore only managed to collect one set of cables in condition good enough for them to be reapaired and unfortunately buying new ones would cost hundreds of dollars per machine.
For now the strategy will be to get a DC power supply for the machine as quickly as possible (18 V, 2,7A) and then we will try to get just one machine up and running.
The wire shielding was completely tangled up so we had to removed it.
Unfortunately we can’t currently test the machine as we need a power supply. We should be able to buy thit on day 3 at the hospital.
The manual showing which power supply is needed for the machine.
The 13-17 dialysis machines
I have seen thirteen machines with my own eyes, some say however that the hospital has 17 Dexter 1550 type dyalisis machines. We started out trouble shooting two of the machines that looked as if they were in a proper condition.
The machines are quite old old but some of them are in a surprisingly good condition. Currently the haemodialysis department is renting machines from an external company, which is expensive, so it is our hope that we can help the hospital by getting their own machines working and thereby save some expenses.
Unfortunately we are currently in doubt whether or not the consumable products are necessary to use the machine are available.
For now however, we are still testing the machine!
Stay tuned for the coming updates for the continuation of these projects and the initiation on the baby-bottle project!
We would reach Chitwan on the evening of the first day of our trip. We had a meeting with Professor Harish Chandra Neupane, Chairman and Managing Director of Chitwan Medical College Teaching Hospital. His staff helped us create a logo and the hospital donated medication to a value of approximately 10.000 NPR for our project.
Morning view from Chiwan
Morning view from the roof of the Baniya Family’s house
The IT Engineerof CMC helping us create out logo (which is also used to watermark these photos)
Donation of medicines from the CMC
Mr. Paresh of CMCTH, Dr. Justin, Dr. Saujan and myseld.
Dr. Saujan and Dr. Justin busy getting everything ready before proceeding to Rukum.
Exchanging contact information.
And agreeing to collaborate in future projects.
Hand-written receipt for the medication we bought.
A short break before proceeding to Rukum, Jumlikhalanga.
At AHCN we wish to thank Sunil Baniya and the Baniya family in Bharatpur for welcoming us so wamly in their home and accommodating us. We are ever so thankful for Mama Baniyas great cooking skills.
Ever since the first time I was in Nepal, I’ve been yearning to go back and really do something for the people I met there. It might have been the parents who lived too far away to bring their sick children to a hospital before it was too late, or maybe the mothers who are in constant fear that they will become pregnant, a condition that should be joyous, but instead is all too often lift-threatening in Nepal. Then there were the others, those who were left without treatment, sometimes to die, simply because the hospital was too busy on that day — or because the family couldn’t afford the necessary treatment. They died due to lack of medication, lack of equipment and lack of funds. It all comes down to a lack of access to healthcare.
With the small and newly founded association Acces Health Care Nepal (AHCR), we have arranged our first project starting on sunday, the 26th of november 2014. Our team consists of Dr. Justin Jung Malla, Dr. Saujan Shreshta, photographer and MBA Finance Mr. Rajkumal Siwal, nurse Ms. Ashmita Malla, and myself (B.Sc Biomedical Engineering). Together we have created AHCR. Our first mission a health camp in Rukum District. Rukum was one of the sites of Maoist insurgency in Nepal and is today one of the poorest and most neglected areas in the country, where access to health care is either scarce or completely non-existant.
You can help us with a donation of your choice at http://gofundme.com/g1mdns. Your help will be greatly appreciated by the people in need of health services in Rukum.
With us we bring medication and basic means of treatment. Our doctors will to treat the patients we meet. Equally importantly, we will document the health care situation in Rukum in articles, that will be shared on this blog as a launching point to reach as far as we possible. As biomedical engineer, I will write a technical report about the health care situation in Rukum with suggestions to projects, that may benefit the health care sitution in the area.
Below are some pictures from previous health camps I have attended in Nepal.
Shortly before we left the KCMC this August, we found out that it was not rare for hospitals to be lacking various equipment in paediatric size. In consequence it would not be possible to measure the oxygen saturation and blood pressure of children. In some cases lack of paediatric size tubes made it impossible to intubate children in need of a ventilator to assist their breathing.
Most of these products could probably be made pretty easily with a bit of creativity. This should give ideas for some design projects for most biomedical/design engineers.
We had a small budget for our various projects from the EWH and we decided to spend what we had left to buy blood pressure cuffs in paediatric size and clip-on pulse oximeters for the paediatric department at KCMC.
Around the world LEGO Company is famous for inspiring creativity through play. Nowadays LEGO is also being used widely for educational purposes. In Tanzania, I found a new use of LEGO that I would have never imagined possible.
This summer I was one of six students from EWH DTU participating in the annual Engineering World Health Summer Institute in Tanzania. We brought 27 kgs of LEGO bricks from LEGO Charity with us. During our stay, we found schools and orphanages to which we could donate the LEGO bricks.
In one case, however, the LEGO bricks could be used for purpose more serious than pure entertainment. I was fortunate enough to meet Dr. Marieke Dekker, currently the only paediatric neurologist in all of Tanzania – a country with a population of almost 50.000.000.
Paediatric neurologist Marieke Dekker
Dr. Marieke Dekker works with hundreds of children with serious neurological disorders in her work. As a neurologist she uses the LEGO bricks to test fine motor skills and cognition of the children. She is able to asses their development and at the same time give them a once in a lifetime gift that brings great joy. Many Tanzanian children have never seen, let alone owned, toys before:
According to Dr. Marieke Dekker, “LEGO bricks are a great success, especially here, dealing with children suffering from neurological disease. Neurological conditions are often well visible and they are known to cause stigmatisation in African society – it is a huge social problem.”
At the paediatric ward of the KCMC children received LEGO bricks as a gift.
Children were given LEGO bricks as a gift #1
Children were given LEGO bricks as a gift #2
Paediatric Neurologist Marieke Dekker uses LEGO bricks for occupational therapy at her clinic at the Kilimanjaro Christianity Medical Centre in Tanzania.
The stigmatisation of these conditions, even by family members, complicates many children’s access to care. As Dr. Marieke Dekker points out, cerebral palsy is the most common paediatric neurological disorder in Africa. The disease is primarily caused by poor perinatal circumstances and healthcare. The severeness of cerebral palsy is varying results in cognitive, behavioural and learning disabilities. Children with less severe cerebral palsy have proved to be a very successful target group for LEGO bricks.
The LEGO bricks allow doctors like Marieke to assess motor skills, as it “‘breaks the ice’ in the patient-therapist relation and the ultimate joy is to be given the toy upon going home.” says Marieke.
In many cases, the cerebral palsy can be devastating, rendering a child dependent on care around the clock. This group is unfortunately also very common in Africa, mostly concerning school-age children with spinal cord problems. Due to dangerous traffic, falling from trees (harvesting fruits, a major part of African diet), tuberculosis and other infectious diseases, a disproportionate number of children are paraplegic and wheelchair-bound for life.
“Since there is no rehabilitation medicine in Tanzania, they remain in-patients until the family cannot pay the hospital bill anymore, or until they die from pneumonia or infected pressure sores. Many of these children were given LEGO bricks. They built, rebuilt, remodelled and rearranged… it gave them and their caretakers a spark of joy in a circumstance of misery.” says Marieke Dekker.
Marieke’s patients truly benefit from using the LEGO bricks in the clinic professionally as well as psychologically. It means infinitely much to children to whom such toys would never be affordable, let alone available.
Marieke, the EWH DTU chapter, and I wish to continue this collaboration by bringing LEGO bricks with us to the Summer Institute in Tanzania in years to come!
All photos were taken and published in this article with consent from patients and parents.
KJ is teaching a nurse at the female medical ward how to use the manual suction pump – which was suprisingly challenging, not just for the locals, but also for us (had to read the manual…)
Samson from the orthopaedic department at KCMC is preparing a new piece for an infant incubator that we have been working on.
The KCMC has a whole department for creating prothesis – the department is actually a Danida donation from the 70, where approx. 70 danes came to Moshi to do development work.
We were (here KJ) teaching one nurse from each department of Mawenzi how to use the manual suctionpumpt. The main points are to put water around the lid to close it tightly and fold the tube for vacuu
Nurse is bringing back the suction pump to the department – now working – this pump is useful whenever there’s a powercut or when the electrical ones breake (which happens quite often..)
This guy spent approx. 1.5 hrs showing me around Moshi as we were lookig for a diode that we needed to fix an infant incubator. People in Moshi are reallyreallyreally helpful
Some pictures from a great day in Moshi: We fixed an infant warmer, taught nurses how to use the manual suction pump and made new parts for infant incubator with assistance from the orthopedics/prothsis department.
1: KJ is teaching a nurse at the female medical ward how to use the manual suction pump – which was suprisingly challenging, not just for the locals, but also for us (had to read the manual…)
2: Samson from the orthopaedic department at KCMC is preparing a new piece for an infant incubator that we have been working on.
3: The KCMC has a whole department for creating prothesis – the department is actually a Danida donation from the 70, where approx. 70 danes came to Moshi to do development work.
4: We were (here KJ) teaching one nurse from each department of Mawenzi how to use the manual suctionpumpt. The main points are to put water around the lid to close it tightly and fold the tube for vacuum.
5: Nurse is bringing back the suction pump to the department – now working – this pump is useful whenever there’s a powercut or when the electrical ones breake (which happens quite often..)
6: This guy spent approx. 1.5 hrs showing me around Moshi as we were lookig for a diode that we needed to fix an infant incubator. People in Moshi are reallyreallyreally helpful
Outside the engineering department of KCMC today. At first I thought they were singing as part of a celebration; it was a national holiday. Later on I realized that they were singing for somebody’s funeral and this place was just outside the mortuary.
"It needs to be done, and not enough folks are doing it."