Project Time
Last week was a particularly busy week, with much to be done about the projects. I visited two government hospitals to assess the need for the bili-lights and searched for carpenter woodshops that might be interested in helping us build the incubators. One hospital that the doctors recommended to try was RFM (Raleigh Fitkin Memorial) located in Manzini, Swaziland’s industrial center and its biggest city. Baylor has a small satellite “clinic” –a room—in the hospital where the PAC doctors could see the HIV patients who would otherwise had to travel far to Mbabane for appointments. Dr.Erin is the main physician in charge of the clinic, so I was fortunate to catch a ride with her.
RFM is much nicer than MGH. The structure of RFM reminds me much of a Spanish villa with its palm trees and arches. It takes a great memory to maneuver through the maze of winding walkways through arches and rose bushes. I particularly liked that the design of the hospital allowed patients to wait in open-air hallways encircling a court yard, thus lessening the impact of body odor on the nose and possibilities of air-transmittable diseases. The services offered are the same as MGH, although I think RFM might be better-off than MGH.
RFM is definitely a different type of hospital than MGH; even though RFM is technically a government hospital, it is also funded by the huge Christian group Nazarene in Swaziland. Nazarene, from what I understand, is sect of Christianity started by Swaziland’s first white settlers. The Nazarene pastors built churches, schools and villages and thus are deeply integrated into the society. The state’s official religion, Christianity, is serious here. Most people go to churches on Sunday (four hours) and almost no stores aside from grocery and movie rental stores–which we are grateful of—are opened on that day.
I only had a brief meeting with the head SMO on my first day to introduce my project—a literal five minute introduction before he had to give a tour to prospective donors. Despite the hurried timing and the meeting being my first with someone so important, his affable air—with his scholarly glasses and benign smile—eased my nervousness. He was wonderfully interested in the bili-lights and the incubator, even offering to discuss the details of cost. Oh course we were not selling them (no yet) but it was great hear that there enough interest for monetary involvement. He offered me a chance to formally present the idea on that Thursday at the pediatric department meeting.
I also met with the head of pediatrics, Dr.Getshu, that day to give a sort of “heads-up” about the presentation, to test out the waters and gain his voice of support, if needed on Thursday. He was extremely enthusiastic about the cost of the incubator and the bili-lights, which are thousands of rand below what they are paying now. For them, an incubator costs about thirty thousand rand, which may not be a lot if in dollars but is a substantial amount considering the standard of living here. He is a very scientific man—the only person who delved into questions about the electronics—who liked to share his enthusiasm about the new devices. He actually took me to the neonatal ward and demonstrated it to the nurses, which also gave me an opportunity to tour around the unit. I had learned earlier from Erin during the ride that the hospital is currently trying to improve their infant mortality rate so the beefing up of their neonatal equipment was expected. The hospital has about five incubators, but Dr.Getshu admitted that the high-tech units are not permanent solutions because they have no means of fixing the incubators once they malfunction in a few years. In terms of jaundice treatment, RFM uses two units of the portable blue-lights that can be rolled from crib to crib and one interesting innovation. It resembles in shape and mass to a chemistry fume hood. The neonate can be placed on the table and directly above him is a row of the long tubed, blue fluorescent light spaced lengthwise. It is the most economically suited device for the hospital; the florescent light can be replaced for a few hundred rand every year (every year!). Unfortunately it is not feasible to have more than one of this machine because of the sheer bulk that not only takes up 1/3 of the room but also prevents it from being portable. I think I was very fortunate with the timing; RFM, despite being relatively well-funded, is still facing the same healthcare issues such as high infant mortality as the rest of the country. The bili-lights and the incubator would be a great part of a cost-effective step to improving care and conserving resources.
While the advantages to the bili-lights and incubator were obvious, I knew that convincing the hospitals to test the devices might not be easy. I am essentially asking the hospital to use two devices that have not been approved by any recognized safety agencies. Even though both devices are undergoing CE certification, the current lack of safety backing by trusted organizations is the Achilles’’ heel of the project, so it was understandable that at the Thursday’s meeting with RFM pediatricians, there was hesitation about the devices. The doctors were all very fascinated with the technologies’ simplicity and novelty, but the missing certification stamp hung like a dark cloud on their conscious and also made the confirmation process with the government difficult. I found it interesting that our safety discussion was almost completely centered on the bili-lights, whose safety depends on a background knowledge of scientific and physiological principles such as irradiance, wavelength and bilirubin breakdown that they were not entirely familiar with. It is a bit ironic that I have probably done and set more safety tests and regulations on the bili-lights than they have on their currently used devices. I doubt they have measured the wavelength of the florescent bulbs to see if it is near the optimal range for bilirubin breakdown. I fear they are also using the lights dangerously. They have neither heard of the standards on irradiance nor do they have the equipment to measure it. I have seen phototherapy lights being placed very close to the infants, but without a bili-meter, there is no way of ensuring the baby is not experiencing over-exposure of the radiation. Overall the discussion was much like running my head first against the wall because the baseline was: I do not have an official safety approval. I was glad I had the SMO and Dr. Getshun’s understanding and support. They see the potential of the devices for not only the hospital but for the rest of the country in terms of improving primary neonatal health care. They realize that in order to obtain certification, the devices need to be first pioneered in a few hospitals. In return for their trust, I compiled a manual of all the tests and scientific reasoning involved in the design and operation of the bili-lights for their review. I am meeting them this week to have their final opinions on the project.
I also meet with the SMO from MGH on Friday. I was actually initially warned by Stephanie that this meeting might be difficult because Baylor does not have a close relationship with the current SMO. I had a taste of the infamous “no urgency” syndrome prevalent here and in the various areas of the developing world I have traveled to such as in Mexico and China. We made the appointment for 8 ‘o clock, but Stephanie and I had to wait outside for 30 minutes, partially because the SMO didn’t arrive until 8:15 and then failed to call us in after she saw us because she had to peruse the daily newspaper for another 15 minutes. Time just has a different meaning here. Despite the inauspicious start, the meeting progressed in much the same tone and format as the one with RFM with safety of the bili-lights being of most concern. Her attitude was cool, but I hope the manual and Dr.Akingba’s –head pediatrician–warm support will be enough. I am scheduled to meet with her this week to see if we can make any progress.
Swaziland is a much richer nation than Lesotho and Malawi, two countries that are using the projects. The government provides enough funding to the hospitals to buy a few units of necessary medical equipments. The doctors thus can afford more doubt and uneasiness on unconventional technologies. However, that does not eliminate the need for more cost-effective and resource-appropriate devices. I am learning that it is one thing to introduce the project and another for the projects to be used and used correctly.
On another note, Dr. Michelle Adler, who also works at the Baylor Clinic, has introduced me to EGPAF which may be a great partner for the projects if the incubator and the bili-lights reach the mass-distribution stage. The acronym stands for the Elizabeth Glaser Pediatric AIDS Foundation that is dedicated to fighting pediatric AIDS through funding research, launching global health programs and advocating for children’s health. The Foundation works in many African countries including Rwanda, Mozambique, Uganda, Tanzania and Zimbabwe and countries BTB has contacts with such as Swaziland, Lesotho and Malawi. Michelle thinks it may be possible to gain its support as EGPAF sometimes fund equipment for maternity wards as part of their PMTCT (prevention of mother to child transmission) support. I have contacted the coordinator for the Swaziland division and I hope I can have a chance to meet with him before I leave (in a week’s time).