Malawi

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.

Rice360

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.

Ownership

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!