Initial Pictures and Stuff

As strange as my return to  America has been, its equally strange looking back at all the pictures I’ve taken. A lot of the sights and sounds from this trip feel so foreign, and yet I know I was there last week. Here’s a quick snapshot of some stuff I wasn’t able to share earlier on Tanzanian internet.

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Giraffe at Lake Manyara

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My Awesome Safari Group: Farah, Bob, Ruvi, Andrew, and Myself

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The stream I walked by everyday to work

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Simba

I’ll post a link to an album shortly. Lots of small things to take care of at home; driving my brother, DUMUNC, meeting friends, and just getting back to not speaking Swahili (its surprisingly tough!)

Thanks to everyone who read my blog, kept in touch this past summer, and kept me feeling at home!

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Karibu Nyumbani

I’m Home.

Its a strange feeling sitting in my living room with my family, talking about Tanzania as if it were a million miles away; less than 24 hours ago I was living there.

Coming back, I feel great to see familiar faces and services, but it doesn’t feel right. This must be the reverse culture shock they warned us about. Hopefully it doesn’t last too long, I’m ready to get on with my life.

Of course,that doesn’t mean the end of this blog. Many of you have requested photos and such, so I’ll be shortly posting a bunch of pictures and what not as I get over my jet-lag and some work I need to get out of the way.

Kwaheri Tanzania (Good bye Tanzania)

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A Broken System

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.

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A Rollercoaster Ride

Less than one week left. I woke up this morning feeling really excited about finally coming home next week, then I almost felt like crying, because this would be my last week here in Tanzania. But its too early for a reflection post, there is still too much to do!

This past week we had the opportunity to start wrapping up on a lot of the equipment we had difficulty with. We were finally able to find a replacement backup battery for a pulse oximeter (measuring the oxygen concentration in the blood) that was then placed into the ICU the hospital is trying to start. They still need some ECG’s and a respirator before they feel comfortable calling it an Intensive Care Unit. We are still working on developing some replacement ECG pads. We have two working machines, but no pads. Disposable parts are a huge reason why a lot of the machines that have been donated don’t get used. Because the hospital can’t afford the machines, they generally can’t afford money on disposables, and so there are some projects working on developing pads that can be built from local materials. Unfortunately, ours haven’t worked out so far.

Larry (our professor) and Gordon (his British friend) also made another stop at our hospital this week to help us with some of the equipment that we couldn’t finish ourselves. We looked at a heat therapy machine, laundry washer, and a surgical bed. Unfortunately, we went 0-3. As sad as telling the staff we couldn’t repair the machines was, internally, I felt good knowing that Nabil and I had developed a good sense of what we could and could not repair with our knowledge and that we had been able to work pretty self sufficiently up until this point. While its a shame that Larry and Gordon couldn’t help us finish repairing all the equipment, an important part of this trip has been learning my limitations given my knowledge, tools, and time.

After their short stop at the hospital, we had a chance to swing by Moshi to pick up wire for our intercom system. After spending the day bouncing from shop to shop, following strange little boys who told us their older brother had exactly what we wanted (I heard that one, one too many times), I was extremely pumped to start putting this intercom system up across the hospital. Its the project we have spent the most time on, mostly because the hospital was really small and didn’t have a ton of machines in general. Also, because last year’s group probably did an awesome job, most of it was working, so our time has been spent working on this secondary project.

Friday morning I jumped out of bed, really excited to start wiring the hospital (ok, I wasn’t excited to do the physical wiring, but was excited that our project was going to start wrapping up). When we got there, I had to make a quick tour of the hospital, testing an sterilizer with a broken pressure gauge and looking at a water bath that wasn’t boiling, while Nabil finished installing the little Barbie buzzers we found in town into the phones. Surprisingly, things like simple buzzers and wires are not easy to find, and a store like Radioshack would have made this project a joke. But alas, we don’t have all those luxuries. As Nabil and I like to say, Karibu Tanzania (welcome to Tanzania).

When I got back to the office, we started to test the wire, before we put it up. Half the wire couldn’t short from one end to the other. So half our money spent on this wire was now junk. We would have to cut open the wire to find that opening. Not fun. OK, with the wire we do have, let’s test how loud the buzzer can get. We set up a mini system in our office, with wire going all over the place. We press the switch and….nothing. We test all the wiring again and try again…nothing. Turns out the wire had too much resistance over its entire length. This meant that someone on one end of the hospital could not phone someone on the other side, because the wire would eat up too much power for the speaker to work. AAARRRGGH (insert random expletives here).

Things were starting to look down for us, when the canteen manager walked into our office. Babie (pronounced Bobby) was actually a local hotel owner. I didn’t believe him at first, because he looks like he is 24 (he’s actually 26), but he inherited it from his mother when she got sick; leaving school in Nairobi, Kenya early to do so. He took over the business of running the canteen at the hospital as a project to expand. He told us the hospital then started changing the rules on the contract, increasing rent, changing regulations, and doing things to the point that it was running a loss each day it was open. So our canteen, where we had lunch every work day for the month, would be closing our last week on the job. AAARRRGGH (insert more random expletives here).

He was closing shop for the day and was waiting for a final sit down with hospital administration, so we spent the next hour talking. Nothing in particular, but enough so that he invited us for dinner that night at the hotel. Things started looing up. After a little more brainstorming for our intercom system, we headed home, hopeful that the night would make up for a really frustrating morning. We got to the lodge (Babylon Lodge) and had a few drinks, talked for another good hour, and headed down for dinner. Because we were dining with the boss, Nabil and I got the full treatment, with a 3 course meal, waiters there for our every whim (we didn’t have any though, so it was kind of a waste) and a great conversation with a young Tanzanian man, really hoping to change the community around him. It was really refreshing to talk to someone who had hope for the country that wasn’t trying to sell us a hike to Killimanjaro or get us into a taxi. I felt at ease, and the western dinner he made us felt almost foreign to my mouth. Delicious.

It was an interesting day that started off extremely hopeful, dove into failure, but finished off real nicely with a new friend. Almost like this entire trip, I could talk another couple paragraphs about the parallels of the day to culture shock. But, now I’m off to Moshi to see what we can do to get this darn intercom working. I’m almost tempted to buy them walkie-talkies and call it a day. Who knows what will come out of it. With less than a week remaining, I gotta make every day count.

6 Days Left!

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Hitting our Groove

Sorry for the lack of updates, but as I stated last time, life has been moving fairly slow here in Tanzania, once the initial shock of living by ourselves was over. Days have become fairly routine, but that doesn’t mean we haven’t accomplished much. Over the past week or so, we have been able to repair:

Furnace: There was a tiny furnace in the dental lab, which they told us was used to melt metals. When we got it, it wouldn’t turn it on, so Nabil and I took it apart, couldn’t find anything wrong, and put it back together. Tada! Working furnace. Then we sat around for an hour watching it get up to 900 degrees Celsius (!), just to make sure it wouldn’t blow up or anything. I appreciate the fact that sometimes, all the thing needs is a little maintenance, which most of the time means tightening a few screws and readjusting a wire here and there. No big deal.

Curtains: There were some curtains in the general wards that had broken wheels. Among the two that we found, both had separate, but irreplaceable issues. So we used the parts for one and were able to the other. One working curtain is better than two dead ones.

Suction Machine: During Inventory, we found another suction machine in the major operating theater. Turns out the knob for the vacuum power needed to be tightened. The sad thing is, they didn’t want to touch it; so while it was a simple fix (and we taught them what to do if it happened again), we were needed for that one.

Mercury Sphygmomanometer: It was missing the little bulb used to pump air into the cuff. Found another bulb in storage. Good to go.

Just a couple of the things that we did. Notice, none of these took incredible engineering skills. Just a screwdriver, some patience, and the courage to take something apart you have never seen. It makes me realize a bit about why technicians are so difficult to find here. The stuff that we do isn’t high skilled labor, but there aren’t people who want to do that for a living. Anyone who does learn the technical aspect of it will probably continue their education and either work in a bigger hospital (I hear KCMC, the biggest hospital in the region, has a team of 20 technicians), or will be intelligent enough to find their way into administrative jobs where they get paid more. The current technician at our hospital is just a electrician, who used to be a driver, but somehow got the job of electrician. Puzzles me as well.

On the more technical side, we were able to come up with a solution to the intercom problem the hospital gave us. To those I haven’t mentioned it to, last year’s group installed 6 telephones in order to help different hospital departments communicate with each other. Unfortunately, when they pressed the ringer for one, the entire hospital would start ringing, so they wanted us to install something which would signal only one other person. We came up with a pretty simple solution, but we needed 30 switches and about 250 meters of speaker wire. We were basically going to run a separate wire on each phone and some switches. I’ll put up a diagram sometime this weekend.

Anywho, we had a huge problem finding these simple switches; with no DIY culture here, things like Radioshack (or I think they have changed their name to ‘The Shack’) don’t exist, and the normal hardware/electronic stores here have the standard wall switches and what not. We had already spent a day in our town of Marangu looking for them with no luck; and had wasted a day last week fruitlessly looking. Yesterday we went to this one store we had become friends with, owned by a Mr. Shah. Mr. Shah (his parents were Gujurati -or Indian-, but he we brought up in Tanzania) was a pretty nice guy with a lot of good stuff in his store for us, and yesterday he basically closed down his shop and walked with us around town, taking us to the shops of all his friends to find us the switches we need. After about an hour, we found 17, which should work for now.

That’s one of the things I will miss about Tanzania in the US, is that when you can’t find something in one person’s store, they will gladly walk you over to someone else’s store to help you find it. Whether they end up getting a little commission on it, I don’t know, but it still has been extremely helpful, especially when we aren’t adept at the language. Sometimes, they end up leeching onto you and won’t let go of your hand (guys feel comfortable holding each other’s hands while walking down the street, one part of the culture that hasn’t grown on me), but for the most part, people here want to help you.

Today we are going to finish up a couple fixes with the supplies we bought yesterday, and hopefully start figuring out how we are going to get this intercom system set up. Only 2 weeks left in this country, so I gotta make it count!

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