2012 PFIG Recipient Zodina Beiene

Career Administrator

Zodina Beiene
School of Engineering and Applied Science
Biomedical Engineering Major
2013 Graduation Year

Internship: Duke Engineering World Health Summit

Notes on the first week

This summer I am interning for two months in Arusha, Tanzania through the Duke-Engineering World Health Summer Institute. EWH is an organization that works toward alleviating the disparity in healthcare through the repair and implementation of medical equipment in developing world hospitals. The EWH Summer institute allows for university students to spend their summers repairing medical equipment, much of which is still functional yet relegated to storage for various reasons, in the developing world. For the first month in June, I will be taking classes in Swahili and medical instrumentation. For the second month, I will be working in Tengeru hospital, which is located just outside of Arusha town. My partner for the second month is Oriane Matthys and she is from Duke. During this month, I hope to apply what I have learned in a practical setting and gain hands-on experience working in the hospital. I mainly wanted to participate in this program because it merges my interests in biomedical engineering, global health, and international development. I am most looking forward to seeing the direct impact of my work in the hospital and interacting with the end-users of biomedical equipment. My goal is to extend what I have learned through BME courses at UVA and the first month of the program in order to address the needs of the hospital and ultimately, improve the quality of care delivered.

My first week here in Tanzania has flown by so quickly and I have adjusted to the new environment effortlessly. After landing at Kilimanjaro airport, I was received by my host family for the first month. Their incredible hospitality has served as the perfect introduction to Tanzania and the culture. This week marked the beginning of classes, which are held at a center called MS-TCDC (Training Center for Development Cooperation). Classes commence at 8:30 a.m. for 4 hours of Swahili lessons in the morning followed by 3.5 hours of engineering lecture and lab in the afternoon. Since greetings and proper introductions are significant part of the culture in Tanzania, emphasis will be placed on gaining a solid grasp of conversational Swahili. I really enjoy how small the class sizes are (6-7 students for Swahili class) because it allows for very interactive and productive learning in a condensed period of time. In the afternoon, the biomedical equipment course instructor teaches us (23 students in total--18 Americans, 2 British nationals, 1 German, and 1 Danish) the theory side of biomedical equipment (including the utility, possible sources of error, suggested minimal testing, possible solutions). During the lab, we practice working with different electrical components and thus far, we have made an extension cord and LED flashlight.

I am so pleasantly surprised thus far--everything from level of professionalism of teachers at TCDC to the amenities provided has exceeded my expectations. I am eager to see how the remainder of the month spans out and to begin working in the hospital thereafter.

Midway

The last five weeks in Arusha have been a whirlwind experience–encompassing everything from intensive daily Swahili lessons and biomedical equipment training to weekly visits to the local Mt. Meru Regional hospital in Arusha city center for hands–on training. The highlight of the week is on Friday when we rummage through storage and scour the wards of Mt. Meru hospital for broken or faulty equipment and spend the day repairing as much as we can. I most enjoy utilizing what I have learned throughout the week in class–soldering techniques, troubleshooting, testing, among others–and applying those skills to the equipment in need of repair or maintenance at Mt. Meru hospital. Besides serving as excellent preparation for the second month when I will be stationed at Tengeru hospital (West Meru District Hospital), it allows for the opportunity to glean out techniques only obtainable from practice in the field. As we repair equipment, our highly experienced instructor, Miguel, leads us through the process, commenting on possible sources of error and potential solutions. Repairs range from simple mechanical fixes and power supply to more complicated electrical repairs, with some devices requiring creative and resourceful solutions. With a collective effort, we have managed to repair a mobile surgical lamp (rewired circuiting), three wheelchairs (mechanically transferred wheels), three blood pressure machines (patched up the bladders with holes and calibrated pressure gauges), two oxygen concentrators (removed stripped power supply cords and replaced them, cleaned valves and mold out of the humidifiers, and tested oxygen concentration), a centrifuge (verified rpm speeds for efficacy) and finally, a hospital bed. The most gratifying part about working on the equipment is being able to return the now functional devices to hospital employees on the floor. In one instance, a nurse was even waiting for us to finish repairing a wheelchair–as an extremely busy and crowded regional hospital, I find this precisely conveys the extent of the need–and immediately took it afterwards for use in the ward! This demonstrates just how crucial every piece of equipment is in developing world hospitals and how there is little room to be selective¬–a luxury often afforded in healthcare systems of developed nations. In the context of Tanzania, and especially when looked at against the backdrop of the more recent physician strikes in public hospitals due to less than optimal working conditions, lack of necessary equipment for diagnostics and procedures, and low salaries, salvaging and maintaining as much equipment as possible seems to be more essential than ever.

During the fourth week, classes at TCDC ended (with a cumulative examination of Swahili) and we moved out of the comfort of our host family’s homes to begin work in our respective hospitals. For the second month (beginning mid-July), I am living on my own with eight other participants closer to Arusha city center. In addition to repairing biomedical equipment at our hospital, Oriane and I will be pursuing a secondary project (using the stipend EWH has provided us) to address some of the specific needs of Tengeru hospital. Tengeru is a public district hospital supported by the government, specifically the Ministry of Health and Social Welfare, and serves as the Arumeru district's designate hospital. As a district hospital (which is below regional hospitals and above health center and dispensary services in the pyramidal structure of healthcare in Tanzania), Tengeru is a relatively large, 120-bed facility.

For our first day at the hospital, Oriane and I arrived by 7:30 a.m. after about a 20– minute commute by dala dala–the local transportation–to introduce ourselves to hospital staff and become acclimated with our new working environment. Our knowledge of basic Swahili and greetings proved more than useful as we greeted nearly every hospital employee and explained our role and goals for the coming month. We also had a meeting with the chief director of the hospital, Dr. Aziz Msuya, where he outlined certain pieces of equipment to work on and issues to address. In the afternoon, we began our work in the storage room alongside the hospital "fundi," which is Swahili for technician. Interestingly, the fundi only speaks Swahili; so Oriane and I will definitely be putting our Swahili skills to the test this month. Despite the language barrier, I am looking forward to working collectively with the fundi in order to better understand how the hospital currently approaches the repair of medical equipment. I can tell based on our first day at the hospital and initial interactions with physicians and nurses that there is much work to be done.

Aside from classes and work in the hospital, the participants and I have spent our weekends taking in the local attractions. We spent one weekend on a two-day excursion to Ngorongoro crater, a conservation area, and Lake Manyara, a national park. Ngorongoro crater was formed by a volcano that collapsed onto itself and animals now live and graze within the crater. The views from above the crater were absolutely breathtaking–flatlands surrounded by mountains and the most puffy, cotton–esque clouds along the perimeter. We spent the entire day traversing the crater from one end to the other, stopping frequently to observe the herds of animals in their native habitat. In Lake Manyara national park, we camped at a site overlooking the entire lake and reserve–a scene reminiscent of that out of the Lion King.

A more challenging and strenuous endeavor was the group's decision to ascend the second highest peak in Tanzania behind Mt. Kilimanjaro, Mt. Meru. Mt. Meru towers over Arusha and I pass by it everyday on the way to TCDC and Tengeru hospital. The hike to the summit took three days and was no easy feat! It included a 6–hour hike on the first day, followed by an 8–hour hike up a series of endless stairs on the second day, and a grueling 6–hour night hike over steep ridges and treacherous rocks to reach the summit by sunrise on the third day. I will never forget the image of the sun rising behind Mt. Kilimanjaro at the summit and the most beautiful, striking hues of pink and orange. Reaching the summit, at 4,566 m, is most definitely one of my proudest and most memorable moments.

Final Reflections

Working and living independently the last month has provided me with the opportunity to explore the streets of Arusha and gain a better understanding of the culture of the city. It has also provided me with a dose of reality–more specifically with respect to healthcare, and the reality of services offered in Tanzania. While differences between my hospital and hospitals in developed nations abound, as expected, I did not anticipate learning and tackling some of the unique challenges the hospital faces. During our needs-finding interviews, my partner and I had some frank discussions with the District Medical Officer, Dr. Msuya, where we learned more about the specific challenges and needs of our hospital.

As only a public district hospital, Tengeru lacks more sophisticated equipment, such as an anesthesia machine or electrosurgery unit (ESU) used during operations. However, since the hospital only performs 5-6 minor surgical procedures daily, the most invasive being Caesarians, this type of equipment is not a primary need. The most advanced piece of equipment at the hospital is an X-ray machine, but when we arrived, it had been out of service for some time. For the short-term, patients requiring X-rays were referred to Mt. Meru Regional hospital. After troubleshooting the X-ray machine, we found it needed 20 replacement batteries, which cost about $35 each, an amount exceeding the provided budget. This example of the easily repairable yet still out of service X-ray machine highlights a significant hurdle the hospital faces: lack of funding and dependence on the government for necessary supplies. I admittedly found the situation frustrating because it was such a simple repair that would have had immense benefit. According to Dr. Msuya, the hospital requests and obtains equipment from the central medical store department (MSD); however, when an item cannot, for some reason, be obtained from central MSD, the hospital must dip into its own limited funds. As a result, repairs and crucial maintenance checks are delayed.

Dr. Msuya also noted the need for high quality and durable equipment–with easily replaceable parts–appropriate for the conditions in which they will be used. Some equipment received by the hospital is often of low quality, partially defective as it is sold and purchased at a lower price, or even superfluous with respect to the hospital’s specific needs and specialty of healthcare services. There is also a great need for electronic stabilizers to protect equipment from surges in electricity, UPS batteries to provide back-up during power outages, and in general, more technical expertise. I was surprised to learn a great majority of the equipment breaks due to electrical surges. When the power returns after an outage, the surge in electricity often blows fuses and destroys equipment. Since there is no designated technician with the expertise to repair equipment, damaged equipment is incorrectly presumed to be beyond repair and equipment is relegated to storage. Over the course of the month, Oriane and I aimed to address the above needs outlined by Dr. Msuya. In learning this information, we were able to direct our goals and prioritize our efforts.

We had our work cut out for us these past 4 weeks–performing everything from maintenance checks, mechanical and electrical repairs, and equipment installation. Taken collectively, we put into service three surgical lamps, an autoclave, a suction pump, two oxygen concentrators, a dental drilling machine, and multiple blood pressure machines. The fixes ranged from simple–replacing a blown fuse for a surgical lamp or replacing the wall plug–to more complicated–bypassing a leaky and irreplaceable first safety valve of the autoclave. Another example of a simple repair includes a surgical lamp that needed new light bulbs. This surgical lamp was placed in storage most likely because the hospital was unable to locate and purchase the specialized light bulbs with built-in reflectors. To make use of the surgical light as an examination light, we replaced the burned out bulbs with regular, inexpensive halogen bulbs–a simple solution which used what was readily available and allowed staff to maximize operation of their equipment. Our other repairs included cleaning the air filters for the oxygen concentrators and calibrating the pressure gauges of the BP machines. With some pieces of equipment, users were simply unaware of required maintenance necessary for continued usage. For example, after troubleshooting the dental drilling machine for a considerable amount of time, we discovered the source of the problem was the water that had accumulated within the tank from the humidity of the air. After emptying out the rusted water in the tank, the dentist was then able to use the drilling machine without interruption. After our repairs we were able to stock the Major and Minor theaters each with two surgical lights, as well as an additional autoclave used for sterilizing surgical tools. Furthermore, the Neonatal unit now has a designated suction pump and oxygen concentrator and female ward its own oxygen concentrator.

In addition to repairing the aforementioned equipment, we spent a large part of the time and budget allotted starting the Neonatal unit for premature babies at our hospital. As our pride and joy for the month, we invested over half of our budget toward getting this unit up and running. Because the rooms were already fully stocked with the necessary equipment–though still in boxes and unassembled–we felt we could contribute most significantly by installing the equipment and compiling operational guides. We worked closely with our main point of contact, Dr. Msuya, who expressed setting up the Neonatal unit as the greatest current need. We assembled a neonatal resuscitation table (infant warmer) recently shipped from China, compiled operational instructions, and translated them to Swahili. We also trained nurses and physicians on how to operate the device. The training session was challenging given the language barrier, but nonetheless very effective. Because Dr. Msuya mentioned that equipment often breaks because of user tampering with the device, we made sure to spend time informing the staff on how to properly handle the device. Additionally, we cut mattresses for the bedding framework and installed a new oxygen concentrator. As part of our secondary project, we put up curtains for four windows (over 18 meters of fabric), bought extension cords, and donated some solar-powered table lights. Now, the unit is completely ready for patients! At one point soon after we completed installation, the pediatric physician even summoned us to witness our first patient–an infant with low body temperature–be placed on the resuscitation table. Luckily, his temperature rose and there was no need to use the warmer after all; but the fact that the hospital staff was making immediate use of the equipment and in doing so, meeting the needs of patients, affirmed the relevance of our work.

Despite some of the challenges I faced during my internship–language barrier, slower pace of work there, and improvising due to limited resources–I also gained invaluable hands-on experience, troubleshooting skills, exposure, and life-long friendships. I had the opportunity to interact with the end-users of biomedical equipment (physicians, nurses, patients, etc.) and contribute to improving the quality of healthcare delivered at my hospital. This past summer was truly an unforgettable experience! Thank you, Parent’s Committee, for making this once-in-a-lifetime opportunity possible!

To see photos that chronicle my nine-week experience in Tanzania, check out my blog: 
http://21intanzania.wordpress.com