Urgent rethink needed in use of medical devices in world’s poorest countries

JustMilk prototype
JustMilk prototype

Up to 75% of medical devices in the world's poorest countries are left unused due to the fact they have been designed for use in the West. A historic IMechE conference has looked at engineering solutions to this global issue.

75% of devices in developing countries, from ambulances to x-rays, lying unused

7 September 2011

Leading engineers, health practitioners, donors and charities today looked at some of the most innovative medical technologies specifically designed for the developing world in a first-of-its-kind conference by the Institution of Mechanical Engineers.

The World Health Organisation (WHO) estimates that as much as three quarters of all medical devices in the developing world do not function due to the fact that the vast majority are built specifically for Western markets.

Expensive and difficult to replace parts, the need for a constant electricity supply, a lack of trained operators or their unsuitability to rough terrain are all factors preventing the use of these devices in the developing world.

Dr Patrick Finlay, Medical Division Chairman at the Institution of Mechanical Engineers, said:

“For years many hospitals around the world have been forced to rely on inappropriate hand-me-downs from richer countries, but what use is an ambulance to a village with no paved roads, or a dialysis machine to a clinic with no mains electricity?

“Health clinics in the world’s poorest countries have no choice but to turn to these Western medical technologies simply because there are so few devices that have been designed specifically for them.

“Simple, inexpensive technologies engineered for use in the developing world have the potential to save thousands of lives. It’s now up to the engineering and development communities to get these technologies out of the workshop and into the world’s poorest countries.”

Professor Chris Lavy, an orthopaedic surgeon who spent years working in Africa and who will be speaking at the Institution of Mechanical Engineers conference, said:

“One of the newest hospitals in sub-Saharan Africa was built with infrared sensors to turn the taps on in the operating theatres.

“Wonderful idea but is it really appropriate in a country where there are no other infra red controlled taps and no engineer to fix them? Within a year most of them had failed, some in the off position and some in the on position.”

The ‘Appropriate Healthcare for Developing Countries’ conference hosted presentations by ten inventors of revolutionary technologies for the developing world:

Just Milk

What is it?

•   A nipple shield for HIV-positive mothers that could deliver antiretroviral drugs to the infant for prophylaxis against infection or release an edible microbicide into breast milk that directly reduces HIV infectivity in the milk. Other potential applications include nutritional supplements and paediatric medicine delivery. More info at http://justmilk.org

Why is it needed?

•   Approximately 200,000 babies acquire HIV every year through breastfeeding, accounting for 40% of mother-to-child HIV transmission cases.  The WHO advises that HIV-positive mothers should breastfeed, unless formula feeding is acceptable, feasible, affordable sustainable and safe. However, breastfeeding has many benefits, as it provides complete nutrition and strengthens a baby’s immune system.  WHO also recommends antiretroviral (ARV) treatments for the HIV-infected mother or HIV-exposed infant. This drug delivery method facilitates the supply of ARVs to infants.

Who came up with it?

•   The JustMilk concept was conceived by a team of students and researchers from Malawi, the USA and Cambridge University at the 2008 IDDS conference at MIT. The team has now expanded into a major international collaboration between several groups at Cambridge University and other universities and charities.

How far along in development is it?

•   Engineering World Health (EWH) Cambridge – a student group based in Cambridge University Engineering Department - has worked with teams of Masters and PhD students at Cambridge to identify the best route forward.  Stephen Gerrard (one of the inventors of the technology) and Arron Rodrigues (President of EWH Cambridge) have found academic and technical collaborators and are trying to secure funding for further prototypes and trials.  Stephen is a PhD student in the Chemical Engineering & Biotechnology Department, working on the JustMilk project under Professor Nigel Slater.

For further information, or for clarification of any details, please contact team@justmilk.org

eRanger

What is it?eRanger

•   The eRanger Ambulance is a sidecar stretcher for a motorbike, developed to provide transport to and from local health-centres in areas where the terrain can be rough and unsuitable for four-wheeled cars. Able to safely and comfortably carry one patient and an outreach medical worker, plus emergency supplies for on-site treatment, it can greatly reduce the time taken to get essential and urgent medical assistance to remote communities.

•   Each ambulance has a specially-designed suspension system that ensures the patients get a comfortable ride over even the roughest terrain. A novel hinged section allows easy access, and means it can be folded into a chair position for the walking wounded and expectant mothers.

•   As well as the eRanger ambulance, they have also developed a mobile clinic, mobile education unit and water purification unit for developing world use.

Why is it needed?

•   Four-wheeled ambulances are not only impractical, they are well out of most developing world health clinics’ price range. The versatile eRangers can be produced for a fraction of the cost, are easy to maintain and can handle almost any terrain, meaning remote areas are not cut off from treatment. In Malawi’s Dowa district, maternal mortality rates dropped from 480 deaths in 2004-5 – the year before eRangers were introduced – to 240 deaths two years later, a drop of 60%.

Who came up with it?

•   The eRanger ambulance was initially designed by British engineer Mike Norman, a former motorbike racer and designer with over 40 years experience in the industry. The company is now based out of South Africa and counts Nelson Mandela among its patrons – eRanger South Africa was launched at Mandela’s house in Qunu in 2004.

How far along in development is it?

•   The first eRangers were successfully trialled in Zimbabwe from 1997-1999, since when they have gone from strength to strength. They are now available in 18 developing countries across the globe, and the company is now working with major international donors such as DFID in Kenya and UNICEF in South Sudan.

Heartrate monitoring via mobile phone

What is it?

•   The microphone on mobile phones is used as a stethoscope to analyse and record heart sounds. This means that a patient’s condition can be analysed remotely by a doctor hundreds of miles away.

Why is it needed?

•   For many rural communities access to qualified doctors for routine check-ups can be incredibly difficult. The creators are specifically targeting tubercolosis pericarditis, which affects around 10% of all TB patients and has an unusually high mortality rate (40%). This is largely due to the fact that the onset of symtoms is insidious and sufferers in developing countries can't get to the clinic before it's too late. Being able to pick up the early warning signs by monitoring the heart could therefore save countless lives. Half of Africa’s 1 billion population now have mobile phones, making the mobile stethoscope a simple, low-cost and easily scaleable solution to a deadly problem

Who came up with it?

•   The idea originated out of a conversation between Prof Bongani Mayosi (Head of Department of Medicine at the University of Cape Town's Faculty of Health Sciences) and Thomas Brennan, a post-doc researcher at the Oxford Department of Engineering Science, about how to bring down tuberculosis pericarditis mortality rates in a low-cost way. Working with the Wellcome Trust, they have brought earlier work by Katherine Kuan and Dr Cari Gifford together with existing mobile apps such as iStethoscope to come up with a low-cost remote heart monitor that could work in a developing world context.

How far along in development is it?

•   Brennan tested a prototype at Groote Schuur hospital in Cape Town between January and April this year, collecting phonocardiograms from 150 volunteers using a Littman 3M electronic stethoscope (the industry standard), an iPhone and a Nokia 3100 classic. The mobile stethoscope proved to be as reliable as the Littman when used with both the iPhone and Nokia, proving the concept works. The team are now planning further tests on patients with heart palpatations in rural areas, as well as developing an Android app which can effectively record and process the phonocardiogram to extract heart rate, signal quality and abnormal heart sounds.

Hearware

What is it?

•   Hearware is a hearing aid for the developing world that uses bone conduction to send vibrations to the working cochlea, bypassing the need for the ear drum. The aid is solar powered, with an internal battery that charges from 4 hours of abundant sunlight and will last for 3 days. The aid design is also easily adaptable, meaning it can blend in better with local cultures and thus reduce negative social stigma, rather than use the light pink design of Western hearing aids which are designed to camouflage with Caucasian skin.

Why is it needed?

•   Two thirds of the 250 million people worldwide who suffer from a disabling hearing impairment live in the developing world. The current approach to solving the problem of hearing loss in the developing world is for charities and NGOs to collect discarded western aids and distribute them to the developing world. These light pink hearing aids not only need expensive micro batteries which are often unavailable in developing countries, but they are designed for a different type of hearing loss to the type prevalent in the developing world. Most hearing loss in the developing world is caused by ear infections which damage the ear drum, not old age where we find a healthy ear drum and degraded cochlea. This means that, as the WHO have said, ‘where hearing aids and services are available [in the developing world] they are generally expensive and inappropriate for developing countries’.

Who came up with it?

•   Andrew Carr developed the concept while working on a Masters in Product Design Engineering at Glasgow University five years ago, after the idea of using bone conduction in a developing world environment was brought to him by Haytham Kubba, an Ear Nose & Throat surgeon. Since then he’s taken on other projects, gaining experience in product development, and is now ready to take on the project full-time with the right backing.

How far along in development is it?

•   The hearing aid circuitry has been tested and proved using off the shelf components. The next stage will be to secure backing from donors, NGOs and hearing aid companies to take the product to the mass market.

Donkey ambulances in Afghanistan

What is it?

•   The final design concept comprises a padded seat securely attached to a donkey, which allows the patient to be supported in a comfortable position during the journey, and provides suspension in the seat to make the journey a little smoother. To allow the patient to get on and off the donkey as easily as possible, the back of the seat is removable, so allowing the patient to lift her leg over the back of the animal.

Why is it needed?

•   Afghanistan has the highest maternal death rate in the world, at 1,575 per 100,000 births. Minimising delays to accessing healthcare facilities is one of the most effective ways to tackle this, integral to which is improving access to prompt, affordable emergency transport. This is especially important in mountainous regions, where bumpy tracks make motorised or wheeled transport  extremely difficult. One low-cost, sustainable and – importantly – locally produced solution is adapting seats on the donkeys locals already use to traverse the terrain.

Who came up with it?

•  Design engineer Olivia Comberti worked with Engineers Without Borders Strathclyde students to develop the idea. Each concept was evaluated by the community and modelled by engineering students at Strathclyde University to test the structure. Stewart Britten, Project Coordinator at HealthProm, said: “Afghanistan has probably the highest maternal mortality ratio in the world and a major factor in this is the delay in seeking a skilled birth attendant. If a low-cost solution works sustainably, with local production using largely locally available materials, we hope that the reduction in mortality figures will lead to its replication in other parts of Afghanistan and other very low-income countries with similar terrain.”

How far along in development is it?

•   The project began to reduce maternal and newborn deaths in one remote, mountainous district in the north of Afghanistan in 2008. The design is now at the testing and evaluation phase, after which it will be reproduced locally by Afghan artisans for use in the villages. As important as developing the physical means of transport is securing the support of the local stakeholders to ensure its effective use. For example, the establishment of men’s groups to manage the journeys, and the development of local policies regarding management of animals are key components of an effective solution.

The SKUTA

What is it?

•   The SKUTA is a seated scooter designed primarily for disabled people who have limited use of a lower limb, (for example, due to Polio or trauma) and for single lower limb amputees. Its rugged construction features heavy-duty wheels, brakes and a footrest. The SKUTA bridges the gap between crutches and a wheelchair offering a practical, low cost, simple, easy to maintain and realistic solution to those with limited mobility. The seat is adjusted to a height, which allows the user to effectively stand upright, when static, and to use a simple striding action when moving forward.

Why is it needed?

•   In the developing world the ability to easily walk long distances is vital. For those with lower limb disabilities not only can long distance movement be difficult, hard and undignified, but the strain can cause wear, tear and damage on other areas of the body as it compensates for the incapacity. This can lead to further problems and loss of quality of life in later years. Wheelchairs are also often totally unsuitable for developing world environments particularly those that are more rural.

Who came up with it?

•   John Church, a retired consultant orthopaedic surgeon. Having worked for 15 years in Rwanda, Uganda and Kenya, John was acutely aware of the need for a mobility device that would address this area of disability. When working in Rwanda he saw local people making wooden scooters and from this came the idea which has brought us to the advanced prototype stage of the SKUTA.

How far along in development is it?

•   The Skuta is at an advanced prototype stage having gone through a multitude of initial designs. Initial trials have taken place in Uganda and now following some design modifications multi county, multi centre trials are being planned with start dates of early to mid October 2011.

Cooking Solutions

•   Indoor air pollution caused by cooking on a fire or a traditional stove kills a staggering 1.5 million people a year – 50% more than malaria. Practical Action, a UK NGO, have come up with a range of simple, cost-effective ways to cook food safely. Improved stoves burn fuel more efficiently, thus requiring less wood, and have improved heat transfer to the pot so it can cook food faster.  Other Practical Action solutions include safer fuel, smoke hoods, chimneys and improved ventilation within the home.

Solar-powered vaccine fridge

•   There is an urgent need to meet provide refrigeration for the storage of life saving vaccines in rural clinics in sub-Saharan West Africa. Due to inaccessibility to grid power, conventional refrigeration systems are not viable however the region enjoys year round potential for solar power. The solar-powered fridge is being presented by Qasid Safir, a mechanical engineering student at Swansea University, working with Engineers Without Borders.

Motorcycle ambulance trailer

•   This project involves the development of an appropriate, low-cost ambulance based on motorcycle technology. It is aimed at providing emergency transport between rural clinics and a referral hospital where distances may be considerable and there is a need for carers to travel with the emergency patient. It therefore uses an ambulance-trailer rather than sidecars which are also being successfully used for emergency transport. The project has evolved from a number of transport surveys carried out by the author as a consultant with IT Transport Ltd which showed that a major concern of rural families was lack of transport to medical services in cases of emergencies.
•   The concept of a motorcycle ambulance-trailer (MAT) was proven in trials in Mtwara, Tanzania, when a prototype completed over 10,000km between a rural health centre and referral hospital and saved a number of lives. The need to carry a carer was amply proven by one birth occurring during a night journey to the hospital.
•   Testing has been limited due to lack of funding but a 12 month trial is about to start as part of the African Community Access Programme (AFCAP) funded by DFID. The main aims of this project are to evaluate the effectiveness of a low-cost ambulance service in increasing access to health services and the medical impact of this and to establish guidelines for operating emergency services based on this concept.

Waste disposal incinerator, Uganda

•   Six engineering graduates, working with Welsh NGO Engineers for Overseas Development (EFOD), are planning to build a waste incinerator for Kumi District Hospital, Uganda. By delivering waste management facilities, the EFOD team intend to offer the local community a means of safely – and effectively – managing and disposing of waste material generated by the hospital, improve awareness of health and safety, give a boost to the local economy and provide additional long term skills to local workers, including awareness of more robust construction techniques.
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