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
Editors Note: Michael Kosteljanetz is Senior Consultant, Dr. Med. Sci. at the Department of Neurosurgery at Rigshospitalet University Hospital in Copenhagen. On several occasions, Michael has been working and teaching in Rwanda and Ethiopia, where his expertise in his profession is an urgent needed. Michael here describes his experiences with the challenges of working at a hospital in a ressource-poor setting. This article was originally written for students at the Engineering World Health Chapter at the Technical University of Denmark to prepare them for working in developing country hospitals, however it is highly interesting material for anyone with just a slight interest in developing countries!
It would not be fair to judge the entire developing world based on personal experience which stems from a brief stay in Addis Abeba, Ethiopia, where I worked at a private Christian hospital and a large public university hospital and three stays in Kigali, Rwanda, where I have worked for a total of 6 months in a public, teaching hospital as participant in a large American-Rwandan project. My daily work takes place in the hospital’s surgical department.
Rwanda’s situation may be different from the situation in other African countries, because the shortage of health personnel here largely is a consequence of the genocide in 1994, where approximately one million people were killed, and among them a great number of health workers. Besides, a great number of people fled to the neighbouring countries and Europe or America.
In many ways Rwanda is a well organized country, partly because of its small size, approximately 2/3 of Denmark. It is very densely populated, almost 11 million people live there. There is a network of roads, the main roads are paved and there is a well developed network of buses that takes you almost anywhere in the country. Mobile phone penetration is around 50% (in 2012), internet approximately 10%.
In my specialty, neurosurgery, there are two neurosurgeons that serve the population, both work in the capital Kigali, where one million people lives. One works at a private hospital, the other at the university hospital. The two departments are affiliated and patients can be transferred from one hospital to the other under certain circumstances.
The hospital where I worked is one of 3 or 4 greater referral hospitals. The country has a great number of health centres, more than 40 district hospitals, most of them run by nurses and general practitioners, who can perform a limited number of operations, e.g. caesarian section. In a few district hospitals there are surgeons who can perform ”neurosurgical” operations e.g. shunts for hydrocephalus.
Although the economy is growing, the country is still poor, the average income being 1/30 of that in Denmark, which of course has major influence on the quality of healthcare delivered. More than 90% of the population has a health insurance, which is very uncommon for an African country. In most cases the patients have to pay 10% of the expenses, which in a poor country like Rwanda may be more than they can afford, even though it amounts to what we would consider a minor expense, say 50 or 100$.
The University Hospital of Kigali, Rwanda was originally built almost 100 years ago and almost all buildings which are pavilions are more than 70 years old, which means that facilities and logistics are far from satisfactory. Most rooms have 8 or more beds. Washing and toilet facilities are of course very scarce.
There is one CT scanner at the university hospital, however, it may not always work. X-ray films are not always available, so most often it is not possible to get print-outs of the scan. Even if one gets one it will only depict a fraction of the entire examination; as a consequence not all aspects and angles of the disease are depicted, sometimes making it very difficult for the surgeon to make a professional decision based on the CT, just as surgical and treatment planning may be challenging. X-rays and scans cannot be transmitted electronically, so in order to discuss a case with a colleague, say when a transfer is considered, one has to take a photo of the scan on one’s smart-phone and send it and again, for which reason the image quality is a challenge. If the patient needs a MR scan they have to go to the private hospital where the only MR in the country is, but the same remarks that apply for CT goes for the MR as well.
The Operation Theater was built in 2009, but in spite of that it is already worn down, most likely because it was built with the poor materials. Many of the tiles in the floor are broken, so that water can collect in the small cavities that have been formed, the humidity has penetrated the ceiling in the theatres so that there is visible mould in most operating rooms. Because of the humidity, but probably also because of poor quality, whatever that can rust has become rusty; the wheels on most tables, where surgical instruments are placed during surgery are broken so hardly any table can roll. Legs of tables and stools are broken or at least most times broken so that they stand askew. The Danish ”Arbejdstilsyn” (Danish Working Enviroment Au- thority, red.) would immediately close the operating theaters due to the electrical installations. Electric lines and sockets runs across the floor even though it is regularly wet from the cleaning and sockets in the walls are faulty. Many of the lights and the operation lamps do not work properly and 1 or 2 out of 4 bulbs often do not work. The doors to all operating theatres are broken, so that they can neither open or close, meaning that they are more or less open most of the time, also during operations, which is practical because the personnel tends to come in and out of the room. Since the sun shines most of the time the room gets hot, and the ventilator switch cannot be reached by most people of average height. The windows have no shadow so the sun shines and sometimes blinds the surgeon.
Operating tables cannot be adjusted electronically as they could when they were new and even to adjust them manually is difficult. Suction equipment which you need to suction away blood during an operation is faulty. The main reason being that the disposable suction tubes, like many other disposable consumables are used not one but several times leading to a change in the stiffness of the tubes, so that they collapse, when suction is activated.
Since the surgical instruments themselves often are robust, made by steel, they are usually working but even simple instruments may not be available.
Now, while you can perform a great number of abdominal operations with a very limited number of instruments, neurosurgery is for the most part a hightech area. Scissors and scalpels almost always work, especially when they are sharpened. Most surgeons use suction, which I have described and a bipolar, which is a kind of electrical tweezers that can burn tissue in a very limited area and thereby induce coagulation of vessels and stop bleeding. Contrary to other surgical fields, bleeding in neurosurgery cannot be stopped by ligature of the bleeding vessel. Our bipolar has been repaired with adhesive tape, so that it works most of the time, which it did not the year before.
Essentially problems related to the operating theaters can be divided into:
Lack of equipment. This can be divided into large, high-tech equipment, which is very expensive to purchase (operating tables, surgical microscope, special aspirators etc) and lesser like normal surgical instruments, hooks etc.
Lack of maintenance.
Lack of sufficient knowledge about the function of the equipment, leading to faulty usage and maintenance.
Lack of renewal/exchange.
Lack of daily consumables that is sutures, gauze, patties (small cotton pieces to protect the tissue, e.g. the brain during surgery).
Lack of special consumables needed for certain operation (e.g. shunts, ventricular drains).
Logistic problems, including storage facilities.
Irregularities in water and electrical supply (rare).
Lack of skilled personel (scrub nurses and anaesthetists).
Lack of facilities for postoperative care and observation (that includes the rooms as well as the personel).
Logistic problems include poor planning and surveillance of the daily surgical plans. If one wanted to be sure that the cases one had planned would be brought to the OR, it was mandatory to be present in the OR, meaning that one could not leave the OR for rounds or seeing patients in the out–patient–clinic while waiting for the preparations for the operation. Because of the long and awkward routes from the wards to the OR (among other things), waiting time before and between operations were often 2-3 hours. Part of the waiting time could sometimes be explained by shortage of a consumable that had to be procured or instruments that were not sterilised.
Roughly the above mentioned can be divided in a) shortage of fundings for buildings, including repair and maintenance b) shortage of skilled personel c) lack of resources for training and education of personel e) logistic problems.
To which extent one or more of these issues are more important than others cannot be concluded from my non-scientific observations, neither can I conclude which means are most appropriate to solve the problems. This will demand further analysis. Considering that Rwanda is a country where the economy is steadily growing there is a chance that some of these problems can be solved because of improved funding but other problems could be dealt with in the meantime.
Note: Neurosurgery is the specialty that deals with the surgical treatment of diseases and congenital conditions and injuries in the central–nervous–system, that is the brain, the nerves, the spinal cord and the surround- ing tissue (meninges and skull and verter- bal bodies). The neurosurgeon removes e.g. tumours, haemorrhages, aneurysms. Some neurosurgeons mainly operate on the spine.
Authored by Michael Kosteljanetz, edited by David Kovacs. Published by the Engineering World Health chapter at the Technical University of Denmark.
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!
Antigua, Guatemala: Site of the Engineering World Health Winter Institute in 2015. The coming two weeks 15 engineering students from around the world are going to put broken medical equipment back into service to aid the Guatemalan health care system.
Getting to Guatemala was probably the longest flight of my life. The trip started in Copenhagen at 3:30, went through Amsterdam and Atlanta to finally reach Guatemala Airport at 8:30 in the evening. Once I arrived in Guatemala I had been on the way for 24 hours exactly.
Antigua is like a small and very romantic town. It could have in Spain apart from the fact that’s it’s surrounded by volcanos(!) Very cool. Have a look at the Gallery! It gives a quite nice impression of small and romantic Antigua.
On the way to the Central Park
The Central park #1
The Central park #2
The Central park #3
The Central park #4
The Church at the The Central park
The Central park #5
The Central park #6
In Antigua there’s a Volcano at the end of the street!
AHCN and davidkvcs (author) is back after an unpleasantly long break due to a December exam-period.
Starting tomorrow you can expect 20+ updates on behalf of Access Health Care coming to you directly from Nepal.
From February you will find updates from Guatemala, where I will be working with Engineering World Health from December 28 – January 20.
davidkvcs.com has been growing rapidly these past six months, and I am looking very much forward to the upcoming year. Overall I will have a large range of exciting articles and posts coming up about developing countries, culture, health care and international development.
I can’t wait to share all this content with you all!
The featured image above is a labour bed. This is where mothers of the region give birth – if they go to the hospital at all.
At Access Health Care Nepal we believe that health care is a human right: Everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment.
After seeing the current state of the Salle Bajjar District Hospital however, we had to conclude, that if one of us was a patient in this region, we would avoid all contact with its health care system if possible at all. Looking through this gallery speaks for it self. You don’t have to ask yourself whether or not you would like to be admitted here to know the answer. This is the largest public hospital in Rukum and the condition of it is devastating for the people.
After an initial meeting with the doctors of the hospital we were given a tour of the hospital. A quick inventory (made during the tour) showed that more than 66% of the equipment is out of order – and we were not counting the piles of broken equipment in the storeroom as the storekeeper was on leave.
The hospital has 15 beds and an occupancy rate at all time of at least 150% – and 200-300% is not uncommon. The hospital has no biomedical engineering staff and in consequence they have no preventive maintenance program. If something breaks, a request for new equipment is made to the government. Whether the request is met or not is completely unpredictable.
During the Maoist insurgency Doctors Without Borders were active in the region and the hospital was quite well off. However, since activity of the Maoists came to an end around 2011, the activity of Doctors Without Borders did the same, and today the hospital has become completely neglected.
At a hospital like Salle Bajjar District Hospital, the presence of Access Health Care Nepal as well as Engineering World Health would not only be helpful, but would be a part of fulfilling every individual’s fundamental human right to health care.
A central aim of for Access Health Care Nepal is to create awareness of the health care circumstances in rural Nepal. You can help us by sharing this article.
Labour bed in Salle Bajjar District Hospital – in use.
Before proceeding to Rukumkot, we had a meeting with Mr. Bharat Sharma, the Local Development Officer of Rukum, to talk about the health care needs of the district, and about and how AHCN and possibly also EWH could help the region. We agreed with Mr. Bharat Sharma to arrange a visit to the Salle Bajjar District Hospital that very same day (post about the visit coming up tomorrow). Furthermore Mr. Bharat Sharma ensured that it would be possible to bring EWH volunteers to the region and we agreed to collaborate in phase 2 and 3 of the AHCN effort in Rukum.
AHCN and the Local Development Officer Mr. Mr. Bharat Sharma
Explaining about the mission of AHCN
And explaining about the possibilities of bringing EWH volunteers to the health care facilities of the region.
Mr. Bharat Sharma
Mr. Bharat Sharma, David Kovacs and Saujan Shrestha
Dr. Saujan Shrestha
Talking about what types of donations, if any, would be beneficial for Salle Bajjar District Hospital
It is now a little more than a week ago that I returned from and unforgettable journey to Africa. It’s been such a journey that expands horizons, gives new perspectives, creates new visions and changes beliefs and values. During my stay I worked for a month at local hospitals, an experience that was different in so many ways from what I had expected.
Prior to our placements at local hospitals the students of the 2014 EWH summer institute (myself included) took part in a month-long educational course on “Engineering in the Developing World” and an introductory Swahili course – a program which proved to be of considerable advantage as we were soon to develop a trusting relationship with the departments we would come to work for.
After this first month of education I was moved to my placement along with my group, which besides myself consisted of a student from Duke and one from Harvard. We were to work in two hospitals: Kilimanjaro Christianity Medical Centre (KCMC) and Mawenzi Hospital, both situated in the town of Moshi, Kilimanjaro region.
The KCMC is one of the largest and most prestigious institutions in Tanzania and has a biomedical engineering department consisting of 30 engineers and technicians. Despite good will and hard work from the department, it was obvious that we could do much in both hospitals, just as we could learn a lot from them. Our group alone repaired more than 60 pieces of equipment during our stay. Overall, this year’s EWH summer program returned 4,200 pieces of equipment amounting to 8.6 milion according to the latest figures from EWH.
If I was to draw one conclusion about medical equipment in developing countries today, I would say that it simply should not be allowed to donate without informing properly about that specific piece of equipment in the local language (or in English, at the least):
In so many places we found rooms and whole warehouses filled with piles of medical devices. To our surprise, very often these devices could be put back into service by simple mechanical repairs. We even found completely new operating theatres that could not be used because they were packed full of unused equipment. I was left behind wondering if donations do any good at all – or if they do more harm than good. During our month at the hospital we slowly started to learn the reasons why these equipments weren’t in use: How were people supposed know how to use a piece equipment, if they had no manual for it? Or how could they use a machine, if the user interface was in Dutch or in German? When a repair was to be done after all, many reported difficulties and bureaucratic systems when having to acquire replacement parts, such as a lightbulb for a microscope.
The type of problem that could arise when departments were not provided information about new technologies became clear to me one day at the KCMC, when our group was asked to repair an Infant Warmer from GE. We were told the following: The department had received a completely new machine and put it into a small room where they normally observed newborns in the early hours after a birth. But when the staff began to use it, the machine heated the room up to a temperature so high, that it was unbearable to stay in there.
The solution turned out to be immensely simple: the skin-temperature sensor had mistakenly been placed under the bedside, and had to be moved to the skin of the newborn – otherwise the device would constantly work to achieve a temperature of 35.5 degrees under the bed instead of on the baby’s skin. Thus the machine was heating on and on (and on…).
After having cleared out this first misunderstanding, we explained that the machine could not, as some thought, be used to take X-rays images, but that it merely contained a tray for a detector plate so that you weren’t forced to move the baby around unnecessarily, and that the machine could not calculate an APGAR-score, but that it contains a stopwatch simply to help you with the task. The problem wasn’t lack of education or ability to understand how a machine works. It was simply the fact that people were not provided the necessary information. Even if some information was provided, it was not done properly: How is a nurse going to read a 500 page manual, while working in a ward full of women in labour? Seeing this and other similar cases, one of our main focuses became developing quick start guides in order to provide departments with a fast and simple way of knowing how to use a device.
Another typical issue that we encountered was how departments virtually never took advantage of vital signs monitors and ECG’s because they had run out of the necessary electrically conductive gel. There are a number of alternatives to conductive gel – in principle anything that contains electrolytes, for example aloe vera or ketchup, can be used. It should have been obvious however (as I did not first think of), that most doctors and patients do not want to use these methods, as they are uncomfortable and inconvenient. I remember explaining to a doctor how he could make his own electrically conductive gel using water, flour and salt. His response: “Is that really recommended?”. Imagine his reaction, had I recommended him to use ketchup. In addition, many Africans are proud people to whom one can and should not just offer anything (just as one would probably not do anyone at home). Therefore, developing a gel that is more likely to be used clinically, and in addition could be produced cheaply using local materials, would be an example of a simple and small, but valuable project for developing world hospitals (while you can find alternatives to conductive gels, I still haven’t seen one that actually looks like the gel that is used in clinics). Notably the KCMC already had the means to produce their own ultrasound gel (which is acoustically and not electrically conductive) so they shouldn’t be too far away from being able to produce their own conductive gel too.
This and many other projects are still to be carried out to make the daily life at a these hospitals run smoothly. Here I have given just two examples of what it can be like to work in the developing world. So many ways remain in which one can help this parallel world of ours, in which resources are so scarce that we are constantly forced to think in new and innovative ways to provide the best possible health care for the all people.
"It needs to be done, and not enough folks are doing it."