Connecting Gobal Health to the Creation of Sustainable Enterprises

[Jonathan Rosen]

For the past several years, I have been working with clinicians, engineers, scientists, and entrepreneurial leaders to better understand how we can develop new technologies for rural and poor communities that combine improvements in public health and health care with new entrepreurial ventures that also advance economic development in those communities.

Today, Madeline Drexler wrote a nicely balanced piece in the New York Times (Looking Under the Hood and Seeing an Incubator By MADELINE DREXLER). You can read the full article at (http://www.nytimes.com/2008/12/16/health/16incubators.html?emc=eta1).

I would be interested in discussing some of the implications of this project, alternative approaches, and how best to teach these ideas to our students through the MedTechIQ platform.

[Jonathan Rosen]

This is a remarkable tour de force post worthy of parsing into several discussion topics. Some of the issues raised are ones we are struggling with and discussions like this one will be of enormous help. We are at least aware of two good points you have raised: The article cut off Kris' response that said we are not seeking to replace KMC with ours or anyone's incubator. So one issue is whether it is possible to map the regions or even villages where this type of incubator could make a difference. We also know that bubble wrap can and does save lives and so do Styrofoam coolers with holes cut in them. But when there are very limited care givers, the time it takes to attend successfully to one baby's needs with these basic aids takes away from time to care for five others. So we believe that in some settings, a $1000 incubator that provides an elegant, safe, and efficient solution can be used effectively to help with the critical care of several patients. Finally for now, we believe that the routine cleaning, maintenance, and preparation of the incubator for the next patient can be the basis of a sustainable local enterprise. Yes, it will keep it from breaking, but it will also insure that the system works perfectly for the next patient. The education and training definitely will extend beyond this need, but this is a start. One of our goals is to design an incubator that solves the need in low-resource settings, and is such a good solution to problem, that NICU nurses in our most advanced care hospitals would prefer them to the $40k monsters that they use now, and that still require families to make quilts to keep the noise and light levels down. These are all assumptions tested with our global health providers, but not yet in the field. Each can be the basis of a valuable discussion. We welcome your thoughts.

[Adrian]

This [article] is an interesting metaphor for the problems that dog the healthcare systems of much of the developing world and attempts by the developed world to help resolve them. i think the question posed is, what is appropriate technology?
The burden of disease in most developing countries is so high, particularly in the arena of Mother and Child Health (MCH) that there will always be competing priorities. Would resources be better directed towards education to teach mum's the kangaroo method etc. Maybe so; but the most salient point in the article is that the vast majority of women in the developing world, give birth a long way from a health facility of any kind, let alone one with an incubator ( even one so innovative as the model) In Sub-Saharan Africa about 70% 0f women deliver at home, hours away from healthcare facilities. The argument that only 14% of births are low-weight babies but they constitute 60-80% of neonatal deaths, should be caveated with that fact; it is 14% of the 30% of babies delivered in healthcare facilities. There is no data on the 70%.
I agree with the commentator who argued for concentrating on improving both access to healthcare facilities and to improving the quality of home deliveries. The former, access to healthcare is the Philosopher's Stone of development and is critically dependent upon such issues as good governance, public education and population pressure. The latter is a 'clash of civilizations'. I never fail to be frustrated by the attitude of most Ministries of Health ( and often their bilateral donors) towards the issue of home deliveries by such as Traditional Birth Attendants (TBAs) They (TBAs) have been in existence for 1,000's of years, long before western scientific medicine made tentative inroads into rural communities. They are essential because women in rural areas are under-served by healthcare systems. One would expect that a pragmatic government would recognize this fact and commit resources to enhancing the TBAs ability to do the job as well as they can in the circumstances. It is sad that most MOHs I have have worked with, faced with three options to resolve the issue of quality of home deliveries through TBAs, make them illegal, train and resource them, ignore the issue in the hope it will go away; always choose the latter. Sadly this is often because of considerable political pressure from professional nursing organizations.
If we only taught and provided incentives to TBAs to recognize and refer 'at-risk mums' we would have a major impact on maternal and neonatal mortality.
Apropos the training issue, during last year's deployment of the USN COMFORT to Latin America, the Project HOPE team designed and implemented their own appropriate technology for teaching TBAs to manage complicated deliveries. It comprised an MRE box, a Cabbage Patch doll and a length of parachute cord. I have posted a photograph of it in use in El Salvador.
Finally, the issue of standard incubators and their viability in the developed world. It all hinges on training. If an indigenous medical team knows well the value of a medical equipment and how to maintain it properly, it will be used well and long. Sadly it seems that this is a global problem. Inappropriate technology, often delivered with little training or support, has a very short working life in the developing world. I too have seen sheds full of incubators, x-ray machines, anesthetic machines, ultra-sound machines and all manner of laboratory equipment, all rusting into oblivion. It is interesting to note that of the 12 MOHs the USN COMFORT worked with last year in Latin America, the number one request from every single organization was repair of medical equipment. It became such a priority that the COMFORTs medical repair workshop had to be reinforced with additional staff.
I am told the solution is not repair as such but rather preventive maintenance, teaching the users how to use and maintain the equipment to avoid breaking it in the first place. Maybe there is scope for an online preventive maintenance workshop?
I hope this rather lengthy post adds more light than heat to the discussion. i promise to try to keep future posts briefer.

[CC-Conrad Clyburn-MedForeSight]

Jonathan,

We welcome the opportunity to work with you on these initiatives. As you know, I have been a long time devotee to the "Tri-fecta" approach to medical technology development you have espoused. i.e., developing medical technology that is relevant to the funding stakeholder (often the federal government), to medicine in a hi-tech environment, and to extending access to healthcare in the developing world. We are at your service in any capacity you might find useful.

CC