Mwanza to Mwanza

Due to some political instability in Kenya (a sham of a Presidential election and subsequent deadly protests), I ended up not visiting Lwala. While I was really disappointed, I ended up being able to visit Malawi instead. In order to do so, I had to make the two day bus journey from Mwanza, Tanzania back to Dar es Salaam on the other side of the country before taking a flight to Blantyre, Malawi. When I arrived, I hopped into a car for the three hour trip to Mwanza, Malawi.


My reason for visiting Malawi was inspired by the work of Dr. Rebecca Richards-Kortum, a bioengineer at Rice University and a MacArthur Genius Fellow. Inspired by her visit to Malawi, she set up Rice360, the global health focused arm of Rice.  Her goal is to find ways to leverage biomedical technology to address the needs in low resource regions. This challenge is bigger than taking fancy new medical equipment from the US and putting it into hospitals in Malawi. It does not take into account the resource gaps, clinical needs, and limited human capital in low resource settings. Rice360 is helping to bridge these divides, identify country and region-specific needs, and empower local doctors, nurses, and engineers.

A critical component of the team's efforts is the Newborn Essential Solutions and Technologies, or NEST360. In Sub-Saharan Africa, over 1.1 million newborns die every year, many from what in the US would be considered treatable causes such as jaundice, respiratory distress/apnea, and hypothermia. The kicker is that medical devices that can easily help treat these conditions have been available for decades in the United States. However, because medical device companies lack incentives to market or sell their devices in the region (and hospitals cannot afford them), they simply aren't available. 

Enter NEST. Rice is currently in the process of distributing NEST with the goal to ensure that every district hospital in Malawi has these essential technologies. At an approximate cost of $30,000 per package (or $1.48 per birth), these device bundles are significantly cheaper than and just as effective as their counterparts in the States. It was to help deliver and observe how NEST is being introduced that I went to Mwanza.

NEST Overview

Introducing NEST into every district hospital is a monumental undertaking. There are around 30 hospitals with varying levels of resources, infrastructure, and capacity across the country. At many of these hospitals, the NICU was almost nonexistent or severely underequipped, requiring significant renovations. Once the space is set up, equipment must be transported, assembled, and tested. Hospital staff must be trained on how to properly use the devices and maintenance must be trained on how to address potential issues with the equipment. Follow-ups have to be conducted to ensure that equipment is being used safely, fix larger issues, and to collect data on equipment usage. These efforts are only possible through continued communication and coordination with a large range of stakeholders that must have a sense of ownership in these large scale external efforts. 

While the initial efforts were led by mostly English speaking foreigners, the program has transitioned to a local staff to lead training, outreach, and data collection. George, seen below rocking a designer Galivn Klein t-shirt, leads the assembly and maintenance efforts while also presiding over training sessions in the local language of Chichewa. Although most hospital staff can speak at least a little English, it has made training sessions more inclusive and allows for staff to ask questions and get clarification more easily. 
Galivn Klein Jeans, a universally recognized leader in designer clothing

The Equipment

The equipment selected for inclusion in the NEST bundle is a selection of cost-effective technologies that respond to the unique clinical challenges in the region. Consider jaundice. Many babies in Malawi are born with neonatal jaundice, often because the are born pre-term. In fact, about 60% of babies have some degree of jaundice and it is the most frequent cause for readmission to the hospital. Also known as hyperbilirubinemia, the condition occurs because the baby's liver is not fully developed and has trouble processing a natural bodily by-product called bilirubin. The buildup of bilirubin leads to the signature yellowing skin seen in these babies. Severe or prolonged jaundice can lead to a condition called kernicterus that causes brain damage or death.

While prolonged severe jaundice is deadly, the treatment for jaundice is remarkably simple: sunlight. Leaving the infant exposed to sunlight leads to the natural breakdown of bilirubin into an oxidized water-soluble product that can be excreted. While this treatment works well for mild cases, it is better in more severe cases to use blue light phototherapy because blue light is the specific wavelength of light that is actually causing the chemical reaction. While phototherapy devices have been available for decades in the US, they are expensive and not suited to the needs or environment in many African countries.

Enter D Rev, a SF based globally-focused engineering design group. Led by Vandy(!) grad Krista Donaldson, they are focused on designing, implementing, and optimizing solutions that cater to the constraints of working in low resource settings. One of their major design solutions is the Brilliance, a low cost, durable, intuitive, long-lasting, and elegant solution to one of the most ubiquitous challenges in improving global neonatal health. As compared to the phototherapy devices that cost upwards of $6,000 in the States, the Brilliance is price-capped at $400. It has built in measures that allow for paired use with other life-saving technologies like infant warmers as well as the ability to correct for potentially incorrect usage.

Neonates also are sometimes unable to regulate their own body temperature, leaving them susceptible to hypothermia. Infant radiant warmers with automated negative feedback mean that babies can be monitored less frequently while receiving necessary care through devices like the Brilliance. In line with the trend I noticed in Tanzania, both of these devices are made in India.

Explaining how radiant warmers work

Brilliance Phototherapy Device Training
Randomly selected to test her knowledge (she was perfect)

The Pumani cPAP is Rice360's baby (pun intended). An idea originally conceived by Rice students, this simplified cPAP has empowered NICUs across Malawi to effectively respond to instances of respiratory distress due to infection and apnea in babies. Continuous Positive Airway Pressure, or cPAP, essentially means that air is blown into the baby's lungs and airway preventing them from collapsing. In essence, your lungs collapse when the pressure inside your lungs is less than the pressure outside your lungs. In most people, your muscles and lungs are strong enough to recover when the pressure outside your lungs is greater. Thank god, because that occurs every time you breath...

In the case of neonates, the cPAP provides a little extra (aka positive) pressure inside your lungs to keep them open and let your muscles relax, grow, or allow your body to focus on fighting an infection. Bubble cPAPs, like the Pumani, use water pressure as the source of this extra pressure. The cPAP designed by the Rice team in conjunction with the team in Malawi is available at 1/15th the cost of a comparable device in the States. At the same time, it is more amenable to the resource limitations that are present in Malawi.

Oxygen is another critical need in hospitals throughout Sub-Saharan Africa. It is critical for patients with respiratory conditions, neonates, and well, just generally since we breath it. However, high concentration O2 is rarely available in more rural settings. NEST includes an oxygen concentrator for this reason. This device essentially takes ambient air and runs it through a nitrogen scrubber (thanks ChemE degree). Air is about 78% nitrogen. If you flow this air through a molecular sieve under the right conditions, the nitrogen adsorbs, or sticks, to some mineral before being separately pumped out back into the air. Then, you are left with mostly oxygen (anywhere from 85-95% pure) which is good enough for clinical use, especially compared to the 20ish percent you started with. NEST also includes a flow divider allows for this purified oxygen flow to be divided among as many as 6 babies.

Inside an O2 Concentrator

Together, the Brilliance Phototherapy device, infant radiant warmer, Pumani cPAP, and Oxygen concentrator (among others) allow NICUs to provide the care needed to meet the ambitious goal of reducing neonatal deaths by half.

The NICU setup at Chiradzulu District Hospital. O2 concentrator in the bottom left, syringe pump above the drawer, Pumani cPAP left of the infant warmer, flow divider on the shelf in the back

What are the translational challenges that I keep talking about?

By the time I got to Malawi, I had started trying to formalize what I think are the key translational challenges in the region. Roughly, they are the 5 Es. Equipment, Education, Engineers, Entrepreneurship and Efficiency. I don't know if someone else has come up with this dorky mnemonic, but its helped me try and synthesize my experiences. It certainly isn't all-inclusive or all correct, but its my attempt to identify shared themes in my conversations, observations, and actions.

Equipment is a rather obvious one. If you don't have it, you can't use it. However, equipment also includes the underlying infrastructure. Anesthesia machines are great, but if the hospital only has electricity half the time, then you might want to fix that before you put a patient under general anesthesia and the machine turns off midway through a procedure. This mindset extends to the spare parts needed to fix problems with the equipment. For example, in Malawi, there are basically three-four main types of screws available. Most medical equipment is not designed with that consideration in mind because it is such an unremarkable design parameter. But in Malawi, its reality. As another example, all this talk about blue phototherapy for jaundice is great, but it turns out that blue LEDs are not available in Malawi.

Education is similarly obvious, but also multifaceted. Medical professionals are increasingly being afforded access to more information and better teachers but there remains great disparity in the quality of care that one can receive in more rural areas as compared to increasingly global African cities. The same is true for nurses and complementary members of the healthcare system. Gaps continue to exist regarding technical education and, more notably, among the general public. Advocating for vaccines, reconciling with alternative narratives of medicine and health, and responsibly introducing Western medicine and technology are much easier with greater education. As it stands, medical technology is usually a means to image, diagnose, or treat a patient that is already sick. Education about maternal health, hygiene, diet and nutrition allows for these technologies to be better utilized.

Engineers are a critical piece of the puzzle. The spread of Western medical technology has for the most part been a simple transfer of equipment from resource rich to resource poor settings. The technicians and engineers that operate and maintain this equipment are few and far between in such settings. Although there is a tech-savvy young generation that uses Facebook and Instagram and is looking for ways to leverage their sudden access to a treasure trove of information and opportunity, higher educational opportunities are limited and do not prepare students for the rapidly progressing world of technology. The few coders I met in Dar were all self-taught and had formed a community after seeing the lackluster educational opportunities available at the top technical schools in the country.

Opportunities for "biomedical" engineers are all but nonexistent because the subject doesn't really exist. In many ways, it feels like the US in the 1970s, when the first biomedical programs were just getting started. The subject is taught in a very piecemeal manner. Electrical and mechanical engineers with little to no background in biology try and teach a subject that they don't fully understand. The end result, unsurprisingly, is students that don't understand either. Practical experience with seeing, testing, and designing devices is also rare, meaning that the first time an "engineer" might be fixing a device will be after they are hired as part of the maintenance staff at the hospital. What use is knowing that Voltage = Current * Resistance if you do not know what to do when you discover that the voltage is zero?

I am obviously biased here, but it is my belief that a key missing component of many globally oriented public health initiatives is the lack of engineers directly involved in the process. Having the ability to navigate technical obstacles, retrofit solutions to the parameters in which they must function, and train others to also be able to do this can help create a greater sense of local ownership in a way that other professions sometimes are not able to do.

Entrepreneurship is the component that is most lacking. As has been the case in almost every country I visited, medical technology is almost always manufactured somewhere else. Even basic medical supplies like syringes come from other countries. The medical technology market has a high barrier of entry due to start-up costs, more rigorous safety and manufacturing standards than other industries, and a higher level of prerequisite industry knowledge. Then, there is the market. Malawi is one of the poorest countries in Sub-Saharan Africa. Supplies are procured at the national level before being allocated to each facility. This kind of system is similar to what I saw in South and Central America. In addition, there is an overwhelming reliance on donated equipment. That means that there really isn't room or the ability for local companies to enter and compete in the market.

Even if you have all these pillars in place, the system quite simply is not efficient. It is not time efficient as bureaucracy, out-dated procedures, technology and indifference are present at every juncture. It is not cost-efficient as insufficient infrastructure, under-trained staff, and corruption hamstring the ability of providers to deliver quality healthcare.

Things are far more intricately connected and complex than just these five factors. There are powerful and often conflicting geopolitical and sociocultural narratives (using the word geopolitical and sociocultural automatically makes me sound smart) that are hard to reconcile with the disruptive forces of Western medical technology. Disruption is certainly not bad. HIV can now be diagnosed and managed rather than being viewed as a curse by angry spirits and a death sentence. That's good.

However, technology changes faster than minds. Rural portions of Sub-Saharan Africa are faced with inconsistent electricity and water access, yet people have 4G internet on their phones. Phones and cell plans are surprisingly cheap and setting up a Facebook account is easy. The notion of health, on the other hand, is far more central to people's identity. Changing how one thinks they can be healthy, what can cause one to be sick, and how to get better is not straightforward. Delivering healthcare is not easy.

Back to RICE360

Going out into the field with the team was insightful, but it was what Rice is helping do back in Blantyre that was more interesting personally. Addressing the education and engineering gaps in the country, Rice is helping set up the country's first biomedical engineering program at Malawi Polytechnic University. Engineering is about more than just learning in the classroom, and there is also a design studio set up at Poly. Queen Elizabeth Hospital, one of the best hospitals in the country, is right next door, hopefully setting the stage for future collaborations between the two. 

The studio and the program are still in their infant stages as the projects being pursued are reminiscent of mechanical and electrical engineering more than biomedical engineering. I was able to be present during the final Design Day presentations put together by the graduating students from across the disciplines. As I know next to nothing about telecoms, many of the presentations did not really strike a cord with me. However, there were also some biomedical projects that teams had been working on. Promising ideas could be taken to the next stage by a Rice Graduate Fellow.

For example, the oxygen concentrators are a critical need in District Hospitals, but because of the dusty environment, the filters needed more frequent cleaning and the device lifespan was significantly decreased from 3 years to 3-6 months. For a device that costs ~$1,000-1,500 dollars, repeated procurement costs add up quickly and are unsustainable. The challenge for the students was to find ways to cheaply and safely retrofit the concentrator such that the device's core function (delivery high sat oxygen) was not compromised. Now, a fellow from Rice is taking over and further prototype, test, and evaluate the ideas proposed. 

One particularly interesting project going on at the studio is an idea by students that don't even go to Poly, but makes extensive use of its resources. Chia (in the VT hat)  and Sanga are working on a prosthetic hand that can be controlled using electrodes that attach to muscle groups in the upper arm. While they had taken it apart while I was there, he had videos that blew me away. They had plastic printed the joints of a hand and were using small motors that could pull the strings on the hand and make it contract. Whenever the biceps contract, there is a small but detectable amount of electrical activity. Chia's idea was simple: when there is a certain amount of electrical activity, the motors would be turned on causing the hand to close. The activity could all be run through an Arduino microprocessor.


However, they were having some issues with control that I got to help provide feedback on. In doing so, we inevitable ventured into understanding the physiology of muscles. The abbreviated experience was suggestive of the progression of the biomedical engineering program at Poly. While the hand would initially contract in response to the contraction, the hand did not remain closed. In addition, activation of the motors was based on the continued contraction of the upper arm muscles, meaning that if you had to hold something for an extended period, your upper arm would get fatigued. It was easier why these problems occurred once Chia and Sanga understood what could cause them. In addition, it empowered them to use that knowledge and consider alternative means of establishing controls. 

We also considered how to model these phenomena in Labview, a powerful software that I had used at Vanderbilt. Rather than simply explaining the way in which muscles contract, we were able to graphically see the electrical activity. Just as well, setting up such simulations provided a good introduction to how programs could be designed, the way in which signals could be modified, and the form of various bioelectric signals.

Simple LABview simulation

Reflections, Criticisms, and a Small Dose of Optimism

What Rice360 is trying to do is no small endeavor. The USAID overview on Malawi highlights the broad range of challenges.

"High rates of HIV/AIDS (10.6 percent), fertility (5.7 children per woman), infant mortality (66 per 1,000 live births), child mortality (112 per 1,000 live births) and maternal mortality (675 per 100,000 live births) are exacerbated by a severe shortage of health workers, unhealthy behaviors, chronic malnutrition, frequent outbreaks of communicable diseases and limited access to quality health services, especially for the most vulnerable."
When I first got to the hospital in Mwanza to help assemble the NEST equipment for the new NICU, we were met by a power outage. The staff had to roll out the backup generator and a 50ft extension cord just so we could put together and test the equipment. No one was the least bit surprised. If that can happen when we are assembling the equipment, it sure as hell can happen when there are neonates that are relying on this equipment to stay alive.

At first, I chalked this up to being out in a more rural part of the country away from the main urban centers. I was in for a rude awakening when I got back to Blantyre. I was rather surprised to discover that I had family in Malawi, so I was staying with a cousin in one of the wealthier parts of Blantyre. As he was quite busy and I wanted to thank him for his hospitality, I decided that I would cook for us that day. It turned out they had no electricity that day. Because there was no electricity, the water pump was not operational and there was no running water either. No flushing the toilet. No showers. No refrigeration. No charging your phone. No street lights. No Wi-Fi. No fans, let alone air conditioning.

I ended up cooking over a coal fire, using my hiking headlamp to provide light while I cut vegetables. It was not fun. We ended up going to sleep at 8pm because there really wasn't much else to do. This continued for two straight days. By the end, my phone was very dead and my birthday had come and gone in the least eventful manner possible. If you know me well, you know that I never do anything for my birthday. This was somehow less than that.

This was really where I felt the most privileged. For most Malawians, not having electricity for long spurts (or ever) is normal. The country relies heavily on hydroelectric power, but after the dry season, almost everyone faces outages for at least some portion of the day. This situation is exacerbated by the recent droughts in the region and general incompetence of the country to build the infrastructure necessary to meet demands.

The combined challenges of droughts, the dry season and reliance on hydroelectric power are understandable reasons why most of the nation lives in darkness for a portion of the year. Malawi is a small land-locked country without the capital to invest in large scale wind and solar farms like other nations have done. People all over the world cling to the hope that next year will be different. That the rains will return, temperatures will stabilize, and that man-made climate change is some bullshit leftist conspiracy.

Instead, in Malawi people say things more like this: “Lol power cuts? I wish we had that problem. We just don't have electricity.” The numbers speak for themselves. Of the 19 million people in the country, about 15 million don't have electricity. That's about 90% of people. Even based on a rural/urban breakdown, the numbers are 4%/32% respectively. The people that do have electricity don't really have it that great either, as they are constantly faced with outages like those that I saw in Blantyre because of necessary load shedding. My cousin just kind of shrugged and started complaining a little more loudly when our power outage hit day 2. He could always turn on the diesel generator if he needed to, a luxury that not many can afford due to high diesel costs.

The situation isn't likely to improve any time soon. Malawi generates about 90% of power from hydroelectric plants by Lake Malawi and the Shire River, and droughts don't tend to suddenly disappear overnight leaving things as they were before. Instead, they often lead to extreme weather swings between drought and flooding. Hydroelectric power generation usually relies on steady and manageable water levels. A mismatch made in heaven.

As a country, Malawi generates about 300kW of electricity, which is scary low for a country with 19 million people. Here's just a rough calculation of how little that is. The average American family uses 897kWh/month. That means in 1 hour, an American home uses 897,000W*h/(24h*30days) =1245W. In Malawi, that level of electricity consumption would mean only 240 homes could be powered at any one time. The inability to meet demand has led to a 7% loss in GDP, which is significantly higher than the 2% average in its neighboring countries.

This capacity has hardly grown despite billions of dollars invested by a number of development oriented entities. On the other hand, the population continues to grow, increasing by nearly 7 million since 2000. Skyrocketing demand and stagnant supply has led people to adopt a variety of alternative fuel sources with greater environmental consequences, like coal and wood. Most families in rural areas rely on wood burning stoves that, in enclosed kitchens, leads to respiratory issues for women and young children. Deforestation is also steadily on the rise, which leads to more soil erosion and decreasing water levels. As you drive across the country, there are countless people selling (and buying) huge bags full of charcoal. Never before have I seen a more animated argument about whose coal is better between two competing businessmen. That's mostly because I've never seen an argument about coal, but still...

While there are policies that prioritize institutions like hospitals and schools in the face of load shedding, power outages are still common. As most of the lifesaving equipment provided by Rice runs on electricity, you can see where there would be a problem. It isn't the place of Rice to cause a ruckus about this, but the success of Rice's initiatives are certainly impacted by the woeful inadequacies in the underlying infrastructure.

Effective Partnerships

This was one of the most morally-challenging aspects of my experience in Malawi. I know it will sound like I am generalizing a problem and blaming people, but I am just trying to highlight a challenge. Emphasis on trying.

Whenever new equipment is introduced, it is important to train providers on how it should be used. Throughout my prior stops, I was always met by an eagerness to learn. While there were people that may not agree with the who and how, there was a consensus that the what and why were more important. In Malawi, I was surprised to find that nurses and doctors were provided cash compensation for attending training sessions. Many people were also on their phones and texting during the sessions. Nurses are chronically underpaid and underappreciated. However, when equipment to save babies is being introduced that will make their jobs easier, it would be fair to expect people to be invested. While people were able to show proficiency in using the equipment immediately after the training, the real question is how well the knowledge is retained long term.

In one such follow up visit to a recent NEST recipient hospital, we found that the infant radiant warmer was being used on three infants at once. While this is usually discouraged, it is understandable that an under-equipped hospital would try and maximize the equipment they have. However, one of the things stressed during the training had been the importance of alternating the temperature sensor onto each baby under the infant radiant warmer (which should be two tops but we'll let that slide). This temperature sensor is key because it automatically determines the duration and intensity of operation of the warmer. However, the needs of every baby are different. If only one baby is used to provide feedback, another baby could not be receiving as much heat as needed (sustained hypothermia), or they could be receiving too much and become overheated. These conditions are hard to diagnose without constant monitoring. Both hypothermic and overheated babies may become non responsive rather than crying to signal discomfort. Another confounding issue is that the radiant warmer does not equally distribute heat across the entire coverage area. Thus, it is important to alternate the sensor among each baby. Because the machine was in automatic feedback mode, no one was paying attention.

An oversight like this highlights a challenge of medical technology. It is a critical tool in improving the ability to aid, diagnose, analyze, treat, and improve health. But with great power comes great responsibility. Medical technology can and is used incorrectly all over the world. However, in Malawi (and the region at large) I found there to be fewer checks in place to independently identify potential issues of improper or under-use. In terms of technology I found there to be two common opinions. First, there was a distrust of technology because of repeated failed attempts at use, negative patient experiences (that usually would not have been different with or without technology), or because technology disrupted the status quo. Second, I found a reverence for technology as a panacea for the chronic challenges faced by healthcare providers.

In Malawi, I found that a critical component of the latter mindset was missing. Technology doesn't save lives. People empowered by technology save lives. Having a cPAP in the hospital NICU makes for a great sound bite. But what if it just sits there on a shelf collecting dust because no one feels comfortable setting it up (or plain just don't know how to)?

Pay to Play

As in other countries in the region, staff turnover is constant. Rice, like every other organization engaged in technology transfer, has limited resources and cannot train every single person ever. The onus is then on the hospital. The successful use of technology in such a setting requires there to be a pool of people able to teach and a pool of people wanting to learn. When someone else is paid to attend a training session and you are not, it doesn't take a world renowned behavior economist to realise that people who are not getting paid will be less willing to go through training, regardless of the “good” that it may provide (saving babies…).

There are certainly times when money may need to exchange hands. Staff that comes in on an off day at their own expense should be reimbursed. And I'll be the first to admit that I am less interested in day long trainings when food is not provided or subpar (TBT RA training). However, that is often not the case. The nurse or doctor is a salaried employee collecting an added bonus on top of their salary for attending a training at their workplace. The solution of providing all attendees a cash “reimbursement” is, in my opinion, the wrong approach.

In essence, you have assigned a cash value to knowledge. Knowledge about how to use devices that makes your job easier (saving babies). Knowledge that is not a perk, but rather an expectation of your job (saving fricking babies!). Knowledge that is invaluable because, wait for it, no parentheses you're saving fricking babies!!

Once you start paying (“reimbursing”) people to attend trainings, it is near impossible to go back to not paying. People come to expect it. People that don't get paid hear about it and start to demand it too. Rice actually had to increase the reimbursement amount because it was not enough and people were skipping training sessions. Again, I'm not saying that reimbursement is bad. Nurses or doctors that have to arrange for an extra day of transportation and a missed off day deserve it. However, the way the system is set up in Malawi currently didn't feel like that.


The NEST package may be cheap by market standards, but it is still quite a fortune for hospitals in Malawi. It is hard to believe that the government alone would have procured as much equipment as quickly and as effectively as Rice has done. Rice360 has build a relationship with stakeholders in government to help tackle the challenges of maternal and neonatal health, with hospitals across Malawi to build capacity, provide equipment, and train caregivers, and with public-private partners to design and build customer need-specific solutions. The undertaking is important, impactful, and impressive.

But at the end of the day, the hospitals receiving equipment bear little to no cost. It really isn't all that different than a donation. Yesterday, they didn't have the device. Today, they do.

The Pumani cPAP is one such example. Through extensive conversations, input, and feedback from staff at Queen Elizabeth Hospital in Malawi, the Rice team developed this low cost device. It is quintessentially what I want to do, and why I set off on this trip. To build relationships, learn how to have such a conversation, what to ask, and how to approach problems from a non-Western centric lens.

However, a medical device requires more concrete evidence for market approval and acceptance than one success at one hospital in one country. As such, the device was scaled up across the country, and eventually to other hospitals in the region. It was done so at no cost to the receiving hospitals but rather was to collect the necessary level of data to increase the power of their study and provide justification and demonstrate progress for further partnerships and grants.

It turned out that some of the hospitals that received the cPAP rarely used it. Sometimes, it was cast aside as “broken”. On the other hand, it turned out that hospitals that bought the device at their own expense reported much higher use. This wasn't due to a disproportionate number of neonatal cPAP-candidates. Instead, it was a mentality of maximizing an investment. Because the hospital had paid for the device, higher-ups were far more keen to justify that it was a good investment. The best way to do that, of course, is to use the device.

This leads to the sustainability of solutions. There is no shortage of great ideas that could address “the woes of Africa”. There is a limited amount of funds, however. A cPAP in every hospital and NICU in Africa is another great soundbite, but it unlikely to happen if the plan is to do so is exclusively using grant money. Such ideas fuel the misconception that Africa is just a poor place in need of handouts from wealthier countries. The reality is Africa, just like the US and Europe, is a market. While there doesn't yet exist the same amount of purchasing power as other regions, African doctors, hospitals, and countries are willing to pay for medical equipment if the price is right. 

The cPAP wasn't just a giveaway. Anyone buying medical equipment will want to see proof that it is cost-effective and will be successful in the harsher environmental conditions in the Sub-Saharan region. Proving this requires lots of data from a representative cross-section of settings and countries. "A cPAP in every NICU" is not just a PR move. It is a necessary step towards making the cPAP a market solution to a very significant challenge across Sub-Saharan Africa. 

However, the challenge is finding balance between being sensitive to local needs and building a device that is flexible enough to be used in a variety of settings. There comes a moment when design decisions shift from being responsive to prospective. There are many untold stories in which one hospital's problem has been solved by clever locals at a hospital in a bigger hospital in the city or in the town next door. Local engineers are limited by access to capital and resources. They often cannot take the next step because they cannot envision it being possible. 

For solutions to challenges in low resource settings, Western engineers hone in on a challenge, talk to local healthcare providers to learn more about the unique constraints in the region, and (hopefully) work in conjunction to design a solution. When done one think about the scalability of the solution? Design decisions are certainly influenced by economics, feasibility, and market constraints. A client-centric approach may be most accommodating to the needs of the local partner, but may not work for other partners. Seemingly silly things like certain sizes of plastic tubing may be cheaper and more readily available in Africa. Spare electronic components that are available at a local electronics shop as compared to being shipped from the States can make a huge difference. If the decision to make your design a market solution is made after the solution has already been designed, it can force you to pay higher prices, make concessions, or lead to the realization that your design is not actually appropriate after all.

This was the first place I really started considering that a successful design doesn't just have to work. It has to sell. There is a global market for resource-constrained technologies that is much bigger than I expected, and profit-seeking and low-cost are not mutually exclusive. However, finding a balance between the two requires engineers to be aware of more than just the problem at hand. For every successful low resource device, there are innumerable others that fizzle out even though they are great ideas. It seems like there is no blueprint to success.

That Dose of Optimism

In many ways, I left Sub-Saharan and East Africa very jaded and pessimistic. The deck was stacked against us. Africans that were hungry for change were hamstrung by bureaucracy, infrastructure, and scarcity. It seemed like being a biomedical engineer was a luxury and not a necessity. I couldn't strengthen the power grid and ensure oxygen and clean water would be available. If I couldn't fix the underlying challenges, what's the point of medical devices? If a mother in labor couldn't get to the district hospital because the roads were too bad, wasn't it better to focus on that than building a NICU?

As I've had more time to reflect, I am much more confident in the direction of the countries I visited. Reading the book "The Bright Continent" by Dayo Olopade has helped provide me clarity and led me to synthesize my experiences differently than I had done before, where I felt very Afro-pessimistic. While not universal, there is a vision that is shared by many of the most amazing people I met over those two months. Clever innovations that happen because the situation demands it. Cell phones and internet have changed the game completely, connecting the large, young population of the region with each other and the world. Things that I underappreciated like the informal private transport system, mobile banking and mPesa, and the strong social support systems are unique cultural phenomenon. While the formal social structures and bureaucracy can be frustrating, meeting people who work day in day out to move forward has been rewarding. Numbers are only half the story. People are ready to make a difference, and that is all the more important.

Dayo Olopade explained my Afro-pessimistic perspective as a product of formality bias. Basically, it is this idea that the best avenues to create change are formal social structures. If you want to improve the nation's power grid, you start at the top. You lobby politicians, provide technical support and investment, and craft policy that leads to growth. If you want to improve maternal health, you identify stakeholders, highlight the challenge, propose solutions, and implement solutions or provide resources/training accordingly. If you want to share why you think gun control is important, you write a letter to your congressional representative.

As people are discovering in the US, sometimes these formal structures are not the most receptive vehicles for change. They are lethargic (or outright dysfunctional), controlled by special (or self) interest, and characterized by unfulfilled (or empty) promises. A project that goes from conception to execution to completion in anything close to its originally projected timeline and cost is an anomaly. However, this system has worked for the most part in the West. The situation in every country I visited in Sub-Saharan and East Africa are more characterized by the parenthetical characteristics.

It is hardly surprising that Western organizations, ideas, and initiatives tend to hit a roadblock in the region. There are so many ways in which development work as it is structured is misaligned with reality. This is because so much of life is informal. The informal economy accounts for anywhere from 30-60% of a nation's GDP in the region.

When we say a meeting starts at 10am, it starts at 10am. In Tanzania, I had a meeting at 10am which turned out to be at 12 noon. After a couple days, I realized that going in to the hospital at 8am was really more like 9:30am. When I called an Uber, I expected that it would take at least 20 minutes and multiple phone calls to confirm, even if the driver was sitting 5 minutes away. Riding the local bus system was less about looking at a timed schedule and map and more about just going out to the main road and listening. When a small 15 seater microbus, or daladala, passed, I hailed it down based on what the young man with his whole torso out to window was shouting. When I went to the airport to see how much a flight from Dar es Salaam to Zanzibar cost, I haggled with the cashier and walked away when I didn't like the price. Crossing the street at a crosswalk if you could find one was laughable at best and impossible at worst. Drivers swerved in and out of traffic, onto what was the "sidewalk" and sometimes into direct traffic in order to get from point A to B. I once bought some apples through the window of my cab stuck in traffic. I also could have bought clothes, shoes, any other produce, umbrellas, lottery tickets, phone cases, chargers, headphones, tobacco, and literally anything else you can think of. In Malawi, you could buy 50kg bags of charcoal and there would be people holding live chickens along the side of the road for some extremely fresh meat.

Hopefully, this helps shed light on how things are different. Because of lacking or poor infrastructure and transportation, things just don't happen on time. Think about the Tokyo Metro that apologizes when it leaves 20 seconds early. I've arrived at destinations 4 hours late and no one was surprised. For all my complaints about the national grid in Malawi, people in rural areas of the country are using solar microarrays to power their cell phones, connect with each other, and with the world on their own dime.

In the US public transit is woefully inadequate and laughable at times. Throughout the region, savvy private citizens have built up an impressive intra and intercity network. It isn't perfect, but there was a need and someone is meeting it.

In the US the racial wealth gap continues to grow because Black Americans were given subprime loans by the banks we are supposed to trust. People in Africa turn to their community, cooperatives, and extended family to secure funding and grow their business. Banks just aren't willing to lend to these individuals, but without the strong social networks that exist in the informal sector, loans necessary to generate more wealth wouldn't be possible.

Transportation, commerce, and banking/credit are often informal because the formal sector fails to meet a critical need. People need to move, they need/want things, and they need to be trusted to create more. The most important thing is that Africans aren't sitting on their asses waiting for the US,Europe, or their government to solve their problems. In healthcare, these challenges are certainly daunting, but it is this attitude that I know will be the true impetus for continued progress.

Fun Times

Enough serious questions. I love tea, and Malawi had surprisingly good tea. I could spend hours walking amidst the tea plants. Unlike many other places, local tea planters cannot afford pesticides, so this tea is damn good (and relatively cheap). I also went to Lake Malawi, which was one of the most beautiful lakes that I have visited. More pictures and videos to come!


Hakuna Matata and my identity crisis

Flying from Lusaka, Zambia to Dar es Salaam, Tanzania was an interesting ordeal. Leaving from Lusaka, we flew to Harare, Zimbabwe, Blantyre, Malawi, Lilongwe, Malawi, and finally to Dar. Basically, within 5 hours, I was in 4 African capitals (although technically Dar isn't the capital. It's Dodoma. But that hasn't really caught on). Maybe not a record, but definitely an interesting future fun fact.

Dar es Salaam means Abode of Peace in Arabic. It may once have deserved that designation, but today as the largest city in one of the largest countries in Africa, it most certainly is not peaceful, but rather chaotic. Rapid growth and poor (aka no) urban planning set the tone for my stay in the area. The city does not have a sterling reputation for safety, but I didn't really feel unsafe. This feeling was one that I had throughout my stay in East and Sub-Saharan Africa. Most of the countries I visited in the area had a pretty significant Indian presence. It was something that I was aware of, but really hadn't understood the scope of until I was there.

There were Indian temples in most every city I visited from Cape Town onwards. Dar actually had an entire Indian part of town where it seemed more people were speaking Hindi and Gujarati (a language spoken in one state of India) than Swahili or English. As such, throughout my time in the region, I could be treated as an Indian rather than an American. I rode the crowded minibuses, walked through town relatively unharassed by peddlers, and could often secure lower prices for services than other "Muzungus". Muzungu is a Swahili/Bantu word that draws from the legacy of Europeans that visited and colonized the region. Today, it more generally refers to tourists, particularly white people.

Undoubtedly, my upbringing and social norms are more Muzungu, but I often found it convenient to co-opt a more Indian identity. Rather than talking exclusively about what I did at home, I talked about experiences in India more because it afforded me more unfiltered access to the places and people I interacted with. At the same time, when I met with doctors and hospital officials, being an American trained biomedical engineer afforded me tremendous access that might otherwise not have been extended. The whole exercise revealed a previously unexplored layer to the Indian-American identity that I have struggled with to fully embrace.

Dar is much more glitzy than people think

I sat in an Uber for two hours the first day. Then I walked the next day. I saved an hour

I didn't see a road named for Trump for some reason

But enough free association. I called this section Hakuna Matata, not just as an ode to one of the best movies ever, Lion King, but also to recognize that it has very real meaning for a great many people in the world.
"It means no worries for the rest of your days. It's a problem-free philosophy."
Timon and Pumba are like real-life Zanzibar. This beautiful and historic island is a three hour ferry ride off the coast of Dar es Salaam and one of my favorite places I visited. The people of Zanzibar are overwhelmingly Muslim. Around 99%. It also has a rich history as a critical port for trade between East Africa and India, especially slaves and spices. The historic center of the area is called Stone Town, a UNESCO World Heritage Site. The area is characterized by extremely narrow alleys between buildings, big beautiful wooden doors, and the never-ending presence of men and women sitting outside and chatting along these narrow streets. The rich smell of Swahili, Arabic, Malay, and Indian cuisine can be found exuding from the various street food fixtures along the water front and the larger alleyways. It was a wonderfully relaxing time before heading back to the chaos of Dar.

Fun fact: the walls of Stone Town are actually more coral than stone, meaning they are breaking down due to acidifying rains

Muhammad made me that banana leaf tie and hat.

This tortoise is from the Seychelles, the second oldest living after Galapagos. Only 150 yrs old.  

It was also revealing. The family I stayed with through Airbnb was extremely open and shared the struggles of raising a child with intellectual deficits. There story was tragic, and perhaps more tragically, not the only such one I heard. Following multiple trips to the National hospital in Dar with differing and incorrect diagnoses, the family finally had to take their son to India where he was diagnosed with cerebral malaria. However, the swelling of his brain for extended periods had done irreversible damage, making him reliant on round the clock care from his parents. I came away in awe of their strength, and just in much in shock of the failure of the healthcare system, a feeling that I never truly was able to shake.

Surgery and Policy: A Deep Dive

My visit to Dar Es Salaam was primarily in order to meet with a contact provided by one of the team members in Macha. Safe Surgery 2020 is a public health initiative working in cooperation with Harvard School of Public Health. This was a different aspect of the project that I had less experience with, but surprisingly, one that I now find to be the most important.

In exploring the connection between medicine and technology, the aspects of Western medicine that have spread more quickly are those technologies that are easiest for users. Swallowing a white pill when you have a headache is relatively easy (In Guatemala, people preferred syrups rather than pills which they were unaccustomed to swallowing). An RDT can be reliably administered and interpreted by a rural health worker with minimal training. But what about surgery? Things ranging from C-Sections and hernia to cancerous tumor removal all require a trained individual and equipment, both of which are in short supply in lower and middle income countries (LMICs).

I had heard briefly of the challenges from Dr. Spurrier in Zambia, but here in Tanzania, I got to explore the challenge more fully than before. My contact was Desmond Jumban, a native of Cameroon, that had been working and living in the US for the past few years. He shared with me some of the shocking numbers that had led him to focus his efforts on surgery.

Around the world, almost 5 billion people (shiiiiit) lack access to safe surgery, despite it being one of the most effective treatments we have for a wide range of conditions. That is, at least one (usually most) of the following is lacking: trained surgeons, anesthesiologists, nurses, equipment, oxygen, and the ability to provide adequate and responsive peri-operative care.

Like many other countries in the region, inadequate human capital has led to reliance on task sharing. In some arenas, this has been hugely impactful and beneficial. Consider community health workers. Managing the HIV/AIDS epidemic or malaria in the region would be near impossible if the only people that provided healthcare and medication were trained doctors. It takes too long, costs too much, and is inefficient to rely on trained doctors to ensure that patients are doing relatively simple things, such as taking their antiretroviral medication. Rather, local workers and volunteers who are provided basic medical training are able to perform such tasks.

Perhaps more importantly, they are able to do at just as high a degree of success and efficacy as a doctor. In addition, there are some pragmatic reasons why CHWs are effective. Because they are often locals, CHWs are able to gain the trust of the community more quickly than a doctor, even if they are Tanzanian. There are dramatic differences in culture, customs, and language across the country, and you're far more likely to believe a community member than random doctor that might not even be from the country. Similarly, CHWs are less likely to move away and leave their community drained of precious human resources. Doctors, on the other hand, often leave for more Western countries, or at the very least for wealthier cities within the country leaving large swaths of the country as what can best be described as healthcare deserts.

The challenges are further exacerbated by the overall lack of quality healthcare providers. Focusing on just surgery, there are only 2 surgeons for every 100,000 people in LICs as compared to 9 in high income countries. When it comes to anesthesiologists, there are only about 20 anesthesiologists in all of Tanzania (that's 1 per 2.5 million!). As compared to the global recommendation of 20 surgeons, anesthesiologists, and obstetricians per 100,000, Tanzania has only 0.46.

This leads to the more dangerous facet of task sharing: its blurring with task shifting. Undoubtedly, there are benefits to task sharing. It allows for the creation of a more robust healthcare delivery apparatus than would otherwise be possible, where systemic needs can be more efficiently matched to the system's ability to address those needs. In the tiered systems of many African countries, CHWs and Community Health Officers (CHOs) at a local clinic or hospital serve as primary healthcare providers. They are usually found in rural communities, and can deal with basic injuries, run RDTs to test for potential cases of malaria, and are complemented by CHWs that may be engaged in grassroots education, point of care testing in the field and healthcare awareness efforts. For cases that cannot be handled, patients are subsequently referred to secondary, tertiary, and occasionally quaternary hospitals based on each level's ability to handle the case.

Tanzania's Healthcare system (similar to other's in the region)

The numbers speak for themselves, however. When there are not sufficient numbers of trained practitioners at the top of this pyramid, tasks are shifted down to individuals that may not have the skill or training to do so safely. However, in doing so, the credibility of CHOs, doctors, surgeons, and Western medicine is undermined at large. Doing so creates long term damage and sets back efforts by countless other individuals and organizations. The prime example of the tragic consequences of this limitation is found in obstetrics. 

Imagine (for many this is a reality) an individual with between 3 months-year of basic surgical training leading your wife's, sister's or mother's C-section in a primary level district facility. In addition to the lack of a clean working environment, the instruments and protocols employed may not prioritize infection control measures as possible due to lack of supplies or awareness of risks. The nurse anesthesist (forget having a trained anesthesiologist) will usually administer ketamine because it is cheap, can be administered without machines requiring oxygen or electricity, and therefore requires minimal training. However, due to the lack of formalized dosing and delivery protocol, underdosed patients may still move on the table while under the knife, leading to additional and unexpected surgical complications. Overdosed patients, on the other hand may never wake up (euphemism: dead). Assuming there are no complications during the procedure that an inadequately trained individual cannot handle, the mother is at risk for a variety of complications, including uncontrolled hemorrhaging, infection, and sepsis. Infections are so common that mothers are frequently put on a regimen of antibiotics post-parturition for a week.

No wonder they use ketamine. The prerequisites for anesthesia are usually lacking.

These systemic deficiencies highlight the global disparity in maternal mortality between high income and low/middle income countries. While the US does not have a stellar reputation with nearly 14 maternal death/100,000 births (Western Europe is between 3-8/100k), Tanzanian mother's die 400/100k births. In other words, a mother is 25 times more likely to die during the perinatal period as compared to a mother in the States. Mind you, I haven't even talked about infant mortality yet. 

This sad reality leads to the tragic calculus by mothers to forego the care of a (supposedly) trained professional in favor of traditional birth attendants (TBAs). TBAs are important members of the healthcare system, but they lack the training to address complications as well as are not equipped to deliver babies in cases where HIV transmission mother-to-child is possible. However, with maternal mortality so common, many choose to take the risk and, at the very least, be able to die at home rather than in a hospital. With Western medicine implicitly associated with the dark prospect of death that is promised under the guise of better care, you can hardly blame one for being resistant to change.

I am not painting a bleak picture to reinforce a stereotype, but rather to acknowledge the complicated nature of the problem. To understand the role of Safe Surgery, I had to temporarily put aside my engineering cap and don my policy wonk hat. Safe Surgery is invested in bringing relevant stakeholders to the table and craft a comprehensive policy that defines for the first time the requisite skills, roles, and limitations of those within the healthcare system tasked with the delivery of surgical, anesthetic, and obstetric services. They identify six facets that need to be successfully addressed to meet the surgical burden of Tanzania: (a) service delivery, (b) infrastructure, (c) workforce, (d) information management and technology, (e) finance and (f) governance.

With most doctors found almost exclusively in the large cities of Dar, Arusha, and Mwanza, the primary question is who is going to deliver medical services. Only 27% of dispensaries, 33% of health centers and 51% of hospitals which provided surgical care had the correct personnel and equipment to provide safe surgical services. In many cases, that effectively is a death sentence. Without the ability to diagnose cancer due to the lack of equipment and experienced personnel, there is no reason to refer a patient until it is too late.

Assume now that a health center realized that it was ill-equipped to handle a case and referred it to a hospital. There is then the issue of inefficient communication between these centers to properly hand off patient medical information. Getting the patient from one place to another is similarly difficult, with ambulances being scarce and poorly maintained at best and public transportation and roads being inadequate as well. There is also the challenge of overcrowding and resource constraints at frequently-referred hospitals with little to no horizontal referring of patients to private hospitals.

Infrastructure and IT and management are key components of this puzzle, and perhaps the most frustrating as a biomedical engineer trained in the West. In most cases, the technology to help patients exists. However, the road to go from here to there does not, both literally and metaphorically. Anesthesia machines that are specifically designed for the tough low resource environment exist, but they still require electricity and/or water. However, only 52% of hospitals have a reliable water source. Electricity is a fickle thing that comes and goes in most rural settings, and usually cannot meet the loads required by a hospital, meaning trade-offs have to be made.

Effectively managing patient information requires time investment and coordination among government entities that are more concerned with aggregating power than working together (a problem that certainly is not unique to the region, but far more consequential). Every hospital I visited, from Muhimbili National Hospital in Dar down to a rural clinic outside of Mwanza collected all information on paper, leaving it nearly impossible at worse and unbearably tedious at best to accurately collect information on patient outcomes, surgical procedures, and surgical facilities. Without this information, identifying critical gaps and accurately measuring progress cannot happen. Again, even if the value of collecting this information is recognized, there is insufficient human capital to manage such a system.

Governance and finance are expected, but no less frustrating, challenges. You can hardly blame countries in the region for being distrustful of European and American organizations meddling in state affairs. Putting aside that elephant in the room, there are multiple departments that need to cooperate. As you can guess, they usually don't. The Health and Education ministries have different priorities and visions of how to achieve goals. Surgery is not as popular a health topic as malaria and HIV/AIDS, so getting people to the table is contingent on convincing them that a problem exists.

I would also argue that the challenge of safe surgery is a much more local challenge. In other words, it is not as simple as securing a Gates Foundation grant to buy some mosquito nets that some white people can distribute on their spring break. Creating a safe environment for surgery is contingent on local development at large. The local hospital needs clean water and electricity. Patients in dire need of surgery must be able to get to the hospital on decent roads. Surgeons and doctors must be available, meaning that there must be experienced individuals that can teach them over a number of years. Logistics to ensure that surgical supplies and anesthesia are affordable and available must be considered. The list goes on. Organizations like Safe Surgery can beat the drum, but their success is contingent on state, regional, and local buy-in to a greater degree than other public health efforts. That also means local investment. In the case of Tanzania, that remains the biggest challenge going forward. The Chinese are glad to pitch in and build roads across the country as part of Xi Jinping's Belt and Road Initiative (aka 21st century economic imperialism). The National Hospital in Dar was actually built by by the South Koreans. Cuban anesthesiologists work in Dar because of the dire shortage. Healthcare expenditures by the Tanzanian government are extremely low because someone else is glad to foot the bill. The question is at what cost?

An interesting quirk to the situation in Tanzania is that the country actually has a huge problem with unemployed doctors! Almost 2,000 doctors are without work despite the dire need for health professionals across most of the country. Up until 15 years ago, most doctors in the country were trained outside the country in South Africa, Kenya, Uganda, or Europe. The ones that came back to Tanzania found themselves overwhelmed by the demand in the country. Then, the government invested in educating healthcare professionals and established 8 medical schools across the country. Come 2017, the country churns out nearly 1,000 doctors a year. The problem is that doctors are employed by the government, which doesn't have the money to pay that many doctors. At the same time, there is a dire shortage of doctors in more rural district level health centers. Creating incentives for doctors to work in more rural settings remains a significant challenge.

My elegant solution

Medical Equipment

In addition to spending my time meeting with doctors to talk about policy changes necessary to establish nationalized surgical protocols, I also explored the technical challenges faced in the region with regards to medical equipment. In more cases than not, that led to me trying to fix instruments in a challenging and humbling environment. When I visited Kilimanjaro Christian Medical Center (KCMC) in Moshi, I was struck by the state of affairs. There, I met their lead engineer. He was one of the few people that I met that I could describe as an engineer during my time in East Africa.

Tasked with the maintenance and management of equipment, he bluntly outlined the challenges he faced at work day in day out. An important aspect of this was medical donations. As a Christian-affiliated medical center, KCMC was significantly better off than other hospitals that I visited, as there was a Dutch team of doctors and engineers there delivering equipment.

The maintenance center.

This was an important takeaway message for me. The majority of equipment I saw at even the largest hospitals in the region were secondhand. In Mwanza, I found myself trying to fix a Siemens patient monitor that had had its last software update in 2002!! The device itself was older than me.

People feel good when they are helping all the poor people in Africa that don't have all of our wonderful gadgets and gizmos. Thinking that they are being altruistic, they send over their old medical equipment thinking that they are doing everyone a service. However, for the most part, this is done irresponsibly. From the day the device arrives until the day that the instrument ends up locked in some room collecting dust because it doesn't work, the process has numerous flaws.

Many of these problems are logistical. No organized system to log equipment when it arrive, track preventative maintenance schedules, or collect instruction manuals is in place. The typical procedure I encountered was a young secretary from intake comes and writes down the device serial number in a huge spiral notebook along with a brief description. The device is now "logged". The question then becomes what to do with the device. Where should the patient monitor go? Well, pediatrics has been complaining about how they don't have enough, but when the engineers walks through urology, a nurse complains how they don't have any that work (she cannot bother to have notified the maintenance department through the procedure in place). Fine. The monitor goes to urology. It turns out that the monitor that supposedly did not work actually works fine. The nurse just assumed it didn't work or did not know how to use it. That monitor gets carted off to peds. Did you follow that? If not, maybe you can go pull out the spiral notebook where the device history is logged...

That seems like a fixable problem, right? There are computers with Excel that could go a long way in improving this problem. A centralized list of equipment as it arrives is possible to create, and there are people that know how to do it. The engineer I talked to was all for it. However, his boss was not. This frustrated me to no end. As I made my way around, I was often pawned off to junior maintenance workers after meeting the senior brass. It turned out the younger staff was just as frustrated as I was. As a generation that had grown up and been able to learn in better technical programs, they were usually more tech savvy and creative than their superiors. However, they had one major problem: they were young. Talented individuals were limited by the bureaucracy and office politics. Promotions were almost always a matter of "experience" rather than talent or capability. Even an idea as simple as logging equipment by Excel was met by resistance because it was a challenge to his authority. Shifting away from paper logbooks to a system that a young tech savvy individual could manage suggested that his pencil-pushing job was irrelevant as it was currently performed. I know that I am being harsh, but I wasn't alone. As one engineer put it, "we just have to wait until they retire or die". Dark.

Then, there is the usual problem that the equipment that hospitals get is old, meaning that it comes with myriad other implicit challenges. Older equipment breaks more often, and is certainly not helped by the dusty conditions and frequent power cycling due to inconsistent electricity. When a device breaks (already broken devices are also given), fixing it is often not possible. That's because that biomedical technicians, let alone engineers, are few and far between. Most "engineers" are usually people that got a certificate at a university and learned basic theory about electronics. With no better alternative, they are the people most often tasked with fixing devices. Unsurprisingly, they are often out of their depth. For example, the idea of preventative maintenance often fell on deaf ears. Simple steps like clearing the filter weekly that could extend the lives of critical equipment were neglected.

This leads to a mistrust of the maintenance department, with doctors and nurses not calling engineers when there are problems with a device assuming that they will be unable to fix the problem. Maintenance workers become similarly jaded because they often do not have the ability to fix the problem even if they can diagnose it (which they often can), or they are called when a device fails completely rather than when they could have done something. That's because spare parts for 20 year old devices are usually not available, and if they are, they far exceed the financial resources of the hospital. While Muhimbili National Hospital has the luxury of refusing all medical donations and purchasing all equipment new, that simply is not possible for most hospitals as I saw firsthand at the second and third best hospitals in the country.

Among doctors and staff, this creates complacency and a lacking sense of ownership. If something breaks, no one cares because they will get another one for free thanks to some big-hearted donor. Many hospitals had minimal budgets for equipment because they had come to rely on this unsustainable cycle of dependence. Because the hospital never paid for it and the device is second-hand, staff treat the equipment with less respect. Some of it is lack of knowledge and training on how to use the equipment. Nurses, those that primarily watch patients at point of care, aggressively yank on delicate pulse ox cables. Leaks in air pressure cuffs are ignored, compromising the basic function of the device. While training sessions are held, many choose to not attend or are shy to ask questions if they do not understand. Even if people understand, there is significant turnover and no systemic way to ensure that new staff receive the same training.

Made in Africa?

Africa is a big place. With the world's most rapidly growing population and 800 million people that are quickly growing wealthier, it seems like the next "it" place for technology. In many ways, it is. When it comes to mobile banking, Silicon Valley is second to Nairobi, Kenya as a tech hub. Innovations that have grown out of necessity like mPesa as a mobile banking platform feel like the future. When it comes to healthcare, however, that change has been slow. Why doesn't Siemens market patient monitors in Africa? The simple answer is that it isn't worth it. Western medical device companies in general have very healthy profit margins. While there is a clear need in Africa for these devices, entering the market would require significant investments in PR, customer relations, and logistics infrastructure that companies have determine exceed the potential revenue that they could make.

Consider the case of HIV antiretroviral medicine. Back in the 1990s when the HIV/AIDS epidemic was rolling into high gear, medicines that could allow patients to live with HIV already existed. However, they cost $10,000/year, so only rich people like Magic Johnson could afford it. Screw poor Africa. It wasn't until 2005 when Indian pharma companies released a generic medicine that prices plummeted to $100/yr, making it possible to scale up ART treatment and manage the epidemic.

In most cases, India remains the pharmacy of the developing world, and increasingly, is entering the medical device market. Most of the new patient monitors and large scale medical equipment I saw were made in India.

It stands to reason, however, that devices could also be made cheaply in Africa. Labor is cheap, and shipping costs would be reduced. If the manufacturing is done locally, spare parts would be more readily available. Ironically, that isn't the case. When I chatted with the lead device engineer at the National Hospital, he lamented the red tape and logistical challenges that make it difficult to bring these manufacturing opportunities to more local settings. Political instability, innumerable police checks, corruption, nightmare border crossing, lack of skilled labor, unreliable utilities and transport infrastructure, and short-sighted policy decision undermine the region's ability to be a reliable hub. Locally grown medical device companies are few and far between because higher quality Indian devices tend to be cheaper despite being manufactured in a different continent. In the short to medium term, I don't see this changing.

Doc Talk

Talking with doctors themselves gave me further insight. In professions such as orthopedic surgery, secondhand doesn't really work. Instead, doctors have a grab bag of usually donated screws and plates. One surgeon in Mwanza told me that his surgical plan often comes down to opening up a patient, determining what screws and plate are needed, telling an assistant to run over and scramble through there inventory and see if he can find it, and if he can't, to close up the patient without doing the procedure. Parts are available irregularly and in unpredictable quantities, and they are rarely logged properly because it simply isn't possible with the limited hands they have available. In addition, parts that might be available in the morning unpredictably can be used by another surgeon. Again, because it isn't logged, there isn't much they can do.

These parts have to be bought new, and every surgeon I talked to knew that European and US made parts were of higher quality. However, because they can cost 3-5 times as much as Chinese or Indian made parts (usually Indian because Chinese were total crap), doctors were forced to buy subpar parts for their patients. Quite simply the sheer quantity of patients demanded that they do so.

Personal Reflections

If you actually read everything I just wrote, good for you. I hope you learned something. There were many days where I felt helpless. This repeated experience was not good for the spirit. Walking into the ER in the regional hospital in Mwanza, I was shocked to find every single monitor beeping in error. Nurses indifferently walked past the screeching alarm as patients lay there trying to rest amidst the alarms. This was the freaking ER, where the most critical patients were brought and where catching sudden fluctuation in vital signs was a matter of life and death, and they only had 6 functional monitors for 20 beds. No one cared to even turn off the alarms. When a cartridge on a blood gas analyzer needed to be changed, I was able to do so because I read the manual. The fact that no one had bothered to tell the maintenance worker because they didn't think he could was discouraging. The fact that he actually couldn't was even more discouraging.

Even at the National Hospital, this problem was ever-present. When the hospital got a new CT scanner, they had a problem and thought that the device was not working. After they flew in a Kenyan trained engineer, they found the problem. They hadn't flipped the on switch.

Death is never far away when at a hospital in Tanzania. In Zambia, I did not have this experience (probably because of where I was), but at every large hospital I went to in Tanzania, there was a casket shop outside the hospital. Walking past it as I came and went, I was constantly hit by the fact that many others that had come had left very differently than I had. For some messed up reason, it reminded me of an Indian movie about a wedding planning business. The lead actor quips (in Hindi), "Be it recession or inflation, weddings will happen and wedding planners will always be needed". Turns out that selling caskets outside of Tanzanian hospitals isn't all that different.

The hardest part of seeing the casket everyday was that a disproportionate number were a specific size. Two or three feet long wooden caskets. For babies. For children. Distraught families would march through the hospital compound streets carrying them. They are voices and images that have stayed with me.

It's older than me...

The Blood Gas Analyzer

One corner of one room of the Medical Device Graveyard

The Sunset on Lake Victoria made the end of my day less shitty

Kilimanjaro and Serengeti

Climbing Kili and visiting Serengeti reminded me of the great natural beauty and richness of Tanzania. Two unforgettable life experiences that I highly recommend. Challenge yourself and climb Kili in 5 days on Machame Route. On the 5th day, I went from 4600m up to 5900m and then all the way down from 1am to 3pm the next day. Longest but most rewarding day of hiking in my life.

Erastus, my guide. He's like 6'6 and a total boss

First sighting of the peak

Mt Meru, Tanzania

Safari to Serengeti, Ngorogoro, Lake Manyara, Maasai Village

This was an absolutely amazing experience. GO GO GO! I went right as the Wildebeest Migrations were beginning and the animals were returning from Masai Mara in Kenya. Every year, 20 million animals make this trip. That is an absolutely unfathomable number. GO GO GO!

Watching a giraffe run is so weird

Wildebeest as far as the eye can see

Driving through Serengeti is like the cornfields of the Midwest except it doesn't make me want to kill myself

Pumba is ugly

Ngorogoro Crater