Stories From the Field:

UGANDA

OB/GYN in Mbarara, Uganda

Adeline Boatin, MD MPH

I’m now almost at the end of my first trip to Mbarara Regional Referral Hospital. It’s been quite the whirlwind and time always flies so fast.  As I’ve gotten to know this hospital and in particular the obstetrics and gynecology department I have realized there is a trail of hospital equipment that tells the tale of visitors past and perhaps present.

On the antenatal ward for example I came across two digital fetal doppler machines. These are handheld, very portable and useful in finding and listening to fetal heart tones in utero. They are essentially a digital replacement of the pinard (fetal stethescope).

As handy as the digital dopplers are, their portability and attractiveness were their downfall when it came to their use on the antenatal ward. Concerned about their inherent, “walkability”, the donors/department created small metal cages, with no openings and attached to the metal IV to host the handheld devices. Unfortunately this has meant that the devices cannot be cleaned, or the batteries changed, so now the devices simply sit there, tugged along whenever the IV pole is in use, but unable to perform their ascribed function. Fixing this issue seems a simple undertaking, but perhaps it is a measure of their lack of desirability by local clinicians that the dopplers continue to sit there, literally gathering dust, and the pinard continues to be the preferred mode of auscultation. Indeed although it may seem like the digital device is an improvement, this very scenario prompts me to question if there is any evidence that demonstrates one is better than the other and if such evidence is relevant in the local setting.

This picture of forlorn and non functioning equipment is seen again and again all over the hospital. Most often, it is not a simple matter to fix the equipment – the expertise or the parts needed are simply not available. In the medicine department for example, there are several donated light boxes with a similar fate. Each is made up of a box, with a white screen and a light bulb to illuminate – technology that is seemingly simple and therefore easily transferrable from one setting to another. Unfortunately these boxes are manufactured with specialized light bulbs with unique sockets and shapes that are unavailable locally, rendering the light boxes unusable once they burn out. Another example is seen in the operating rooms where I noticed several electrocautery machines sitting quietly in corners. They are handy when available, but clearly not essential, and without any local expertise trained in fixing them and almost no hope of company technicians coming out to fix them,  more than likely they will go on sitting in the corner -too expensive to discard, and yet not essential enough to find a solution to.

This is not to say that such equipment is unnecessary or fated to be relegated to an iron cage. I also saw several examples of machines both donated and bought integrated successfully into clinical care.  Nonetheless, the trail of quietly forgotten equipment should remind us to be careful in what we wish for or even in some cases introduce as visitors. It’s very easy to think that x instrument or y machine would make such a difference and let’s do what we can to get it here. It might even work for 6 months or perhaps 1 or 2 years, and perhaps that is worth it, but often it appears that they don’t even make it that far and clinicians revert to their known and perhaps more reliable methods.

Perhaps a more exciting and more sustainable approach is that taken by new institutions like CAMtech. Its stated goal is to “to improve and accelerate high-quality, affordable medical technology development for low- and middle-income countries (LMICs)”. CAMtech’s very first innovation lab is currently growing roots in Mbarara, Uganda.  I had the opportunity to see it in action when I went in search of their first engineer.

I was lucky enough to meet Patrick Ssonko.  He recently graduated from engineering school and just this past summer was hired as the engineer in house at CAMTech.

I was very impressed and encouraged by his enthusiasm, creativity and zeal. During my visit, he demonstrated his self developed heart rate and temperature monitor and even let me test it out. The instrument is in its early phases but the potential is huge. He plans to build in a component that can relay the values to a separate screen and more importantly have the ability to send text message alerts to clinicians.

The potential for this kind of enterprise to positively impact clinical care in MRRH is huge. First of all if engineers like Patrick are connected to and collaborate with physicians and nurses working on the ground in Mbarara , devices created are much more likely to be directly applicable to the clinical setting within which they work. Home grown devices also likely mean cheaper components and more importantly that the replacement components and the local expertise on how to replace them are available.

Adeline Boatin, MD MPH
OB/GYN Global Health Fellow