So this post isn’t meant to be directed at anyone at particular, but is more of a recollection of some conversations I’ve had with people over the past week or so about this whole trip I’m on. I don’t mean to sound angry or apologetic, just trying to get what I understand out onto the web. I’m sure there will be some people in EWH or DukeEngage who may disagree with my analysis, so don’t think that they have brainwashed us to think like this.
EWH Summer Institute program is meant as a way to bring together eager engineering students who want to work for one summer in the developing world (and all the cool experiences that come with it) with hospitals that have lots of broken equipment. Our purpose isn’t only to go and repair the equipment, but also train the staff in how to properly use it while working with the fundi to help him continue the work we do after we leave. This is to work towards removing the dependency these hospitals have on NGO’s coming in and fixing their stuff. We strive to create self-sufficient hospitals by doing things all locally, that’s why I haven’t just ordered an intercom system off of Amazon.com (which has been really tempting) and spare parts from other medical stores.
So how do we help create a system of sustainability? I think the first step has to be with the staff of the hospitals, teaching them how to properly use all this donated equipment. All too often, I’ve seen staff members either abuse the stuff to the point where I’m surprised it still works, while at the same time watching staff cower in fear of pressing a button they haven’t been taught to press. Some of the work Nabil and I have done is training staff in order to maximize their use of the equipment. Whether it’s through basic maintenance or troubleshooting, we have always tried our best to explain what we discovered the problem to be, and what to do if the same thing happens again. Whether or not the staff understands will be seen by next year’s group and the amount of equipment they have to look at again.
After the staff, we were instructed to work with the fundi (what they call the engineers/technicians, anyone with technical skills). Some of the hospitals have fundis that have been working closely with the EWH volunteers, and I’ve heard some great stories of how their combined efforts have solved previously abandoned problems. I really wish we had someone to work with, but our ‘fundi’ Evans has been basically nonexistent. Before today, I had seen him at the hospital about 2 weeks ago. Throw in the fact that he has been a driver most of his career and learned some electrical work that got him promoted, he doesn’t have the expertise or the interest in working with us, so unfortunately a lot of our work has been flying solo. It isn’t unfortunate that we had to work alone, Nabil and I work great together and have had a ton of fun, but unfortunate that a lot of basic skills that could have been taught or developed are now lost.
Finally, there has to be a mindset in the hospital to create an environment where equipment is essential for patient care. For Marangu Lutheran, the fact that they don’t have a real fundi is a big reflection on this idea, you can make your own conclusions.
Marangu Lutheran is part of the ELCT, Evangelical Lutheran Churches of Tanzania. This group is HEAVILY supported by a German charity organization, and so we see nearly 95% of the equipment at the hospital being donated (and German). Because nearly all the equipment is donated, its old. We recently repaired something that was manufactured in West Germany. That’s before the Berlin wall fell. Before I was born. It’s OLD.
So out of this system of the charity donating equipment to the hospital, you can lay a lot of the problems you see in the hospital to either side of this relationship. The donor groups often don’t do a good job donating (I’ll expand on this later), and the hospital doesn’t take care of what they do get.
I’ve already elaborated on a lot of the problems the hospital has with equipment maintenance, repair, and training. You need more fundis, and you need to create an environment where equipment is necessary for patient care. We don’t have that environment where the doctors respect the equipment, and you don’t have the hospital willing to spend any money on maintaining it. There are two traveling fundis (one of whom we worked with today, GREAT guy with lots of insight; a lot of what I’ve written is biased by his observations) that are hired by ELCT to go around to the hospitals to repair the equipment, very similar to us. They do offer maintenance services, but the hospitals either can’t afford it or don’t want to spend money on it (I’m not really sure which it is, I’ve seen too much evidence for both cases). The fundi, whose name eludes me, was only at the hospital today because the German organization paid for him to go to the hospital and fix some of the stuff the hospital wanted donated again. Perhaps I’ll relate the awesome fix we did later.
So apart from the hospital having issues with money and culture, the donor groups aren’t completely in the clear either. Marangu Lutheran is fairly lucky that their equipment comes from Germany, because Germany has very comparable voltage/frequency as Tanzania (except for the random power outages and power fluctuations). A lot of stuff donated by American hospitals comes as is, which means that the equipment would get fried by the 220 V trying to power a 110 V system. Usually you only need a single step down transformer to convert the voltages (you can’t change frequency, but except for motors, many systems aren’t heavily affected by a different frequency), but hospitals are almost never supplied transformers and don’t want to buy them.
So, problem 1 from the donors is ignorance of the operating conditions. Its not entirely their fault, because it is a donation after all, but a lot of stuff gets left in the storage closet as a result, and you almost create a black hole of medical equipment as a result. Problem 2 would best be characterized by disposables. Recall the last time you were at the doctor’s office. For almost every thing that came into contact with the human body, you have something that needs to be tossed out. The cover for the ear lamp, the needle for the injection, etc. A lot of the advanced equipment, like ECGs, have similar disposable parts (disposable pads), but disposables are almost never included with the donations. As a result, you either have something that can only be operated for a few weeks, or something that never sees the patient. Very similar to problem 1.
Finally, all these machines come with manuals. I’ve tossed too many of them out in all my electronics shopping to believe otherwise. However, when you ask for a manual when trying to troubleshoot a machine, you rarely find one. And if you do find one, its an User’s guide that gives rudimentary instructions on how to operate the machine. We encountered a dryer last week that kept giving an error, Drive System Fault, which really means nothing to me (or Nabil, Larry, and Gordon). The user’s manual had no section on troubleshooting error messages, and the internet had nothing. A lot of fixes could be easily remedied by supplying these manuals; but rarely do they make it to the benefactor. There are now organizations that have created manual libraries for this purpose, but we don’t have a fundi that would have the initiative to contact them.
This system is clearly broken on both sides. The donations are often incomplete or missing a critical component that can’t be readily acquired. The World Health Organization wrote up some guidelines on donations back in 2000, but clearly they haven’t been followed, and there is no real effective enforcement of these ‘guidelines’. What equipment the hospitals are able to get, they don’t know how to take care of it, and sometimes it feels like they don’t really care. From EWH, they are getting free labor (the hospital really hasn’t provided us anything, DukeEngage, through EWH, has paid for basically every aspect of our visit here. Thanks!), and the ELCT fundi only comes when ELCT pays for it. There is reportedly a year old invoice for the hospital that the fundi is still trying to get paid for.
Perhaps its the job of people like me to fix these problems. Perhaps they are beyond my control. All I know is, this system is creating a dependency for Africa that won’t help them develop further. I’ve heard that in parenting, if you realize a child is dependent, you take it away and help them cope. But these organizations would be hard pressed to simply stop donating equipment, because then the patients would suffer. And these hospitals have been chanting “No money” for years. I was looking at a broken infant incubator that is powered by lightbulbs. I needed to replace four, and asked if the hospital had any. “No money”. I went to town that afternoon and spent 1000 Tsh (less than $1) for four lightbulbs that now allow the ward to use this machine.
This is an incredibly complicated problem, with no clear solution. The days when these problems bog me down, I walk into the wards and see some of the machines I worked on being used to help a patient. That makes this entire trip worth it. But for how many patients it can serve after, that is the problem that worries me.