Robert Malkin to Take Seat on World Health Organization's Executive Board

Robert Malkin, a professor of the practice in biomedical engineering at Duke University’s Pratt School of Engineering and a founder of Engineering World Health (EWH), has accepted a new role as a representative to the Executive Board of the World Health Organization (WHO) beginning in January 2008, when he will attend his first board meeting and The World Health Assembly in Geneva.

The WHO board serves in a manner analogous to the board of directors of a corporation, according to Malkin. Its member states prepare and approve the agenda for the WHO and for the World Health Assembly. Malkin will serve as a representative of the International Federation for Medical and Biological Engineering (IFMBE), a conglomeration of organizations that represents the field of biomedical engineering to WHO. IFMBE is one of about 75 such groups that serve as representatives to the WHO board, including the International College of Surgeons, The World Bank and The United Nations.

Pratt science writer Kendall Morgan talked with Malkin about what he hopes to achieve in his new position.

Pratt News: Were you surprised to be asked to take on this role?

Malkin: It was a surprise, although I've wanted to get more involved with the World Health Organization for some time. They have the potential to do a lot of good in the developing world, but they aren't realizing that full potential, particularly in my area of medical devices. I had originally assumed there would be some well-functioning technical committees that I could get involved with. But as it turns out, there aren't any such committees. So this makes sense as a place to get started, and one of my goals is to start some committees in critical areas related to medical devices.

They already have working committees in several areas related to pharmaceuticals, which have been very effective on some issues such as intellectual property. For example, the open access to drugs has moved far forward, although it is still a serious problem getting anti-retrovirals and other drugs to people in developing countries. They are at least 10 years behind in access to every common medical device, from pacemakers to lab equipment, even microscopes and light bulbs.

Pratt News: Isn’t a lot of medical equipment donated to the developing world?

Malkin: Yes, 95 percent of all medical equipment in the developing world is donated and 70 to 80 percent of it doesn't work. Mostly, this is the fault of the donors in the U.S., Europe, Japan and to a lesser extent China. We have done a poor job of quality control. Organizations often don't check the equipment before it is sent. The WHO can play a major role in moving this forward through a quality assurance program.

Pratt News: Are there other reasons that so much of the donated medical equipment doesn’t work?

Malkin: We’ve done an analysis of 2,000 pieces of equipment to determine why it breaks, so we’re beginning to have a better picture of the problems. One reason is spare parts. What happens is, for example, people send equipment that runs on 110 power to a country on 220 without the conversion parts, or the devices may not be convertible. Sometimes batteries or fuses go. We’ve found that 23 percent of all sidelined devices are the result of simple spare parts.

User training is another serious problem. Most of the time the equipment is shipped without a manual or with a manual in a language that the people don't speak, which is almost the same as sending none at all. There is also no delivery of training.

The rest of the problem relates to consumables. Twenty years ago, or even five to 10 years ago, you bought equipment and used it. Now, you get the equipment donated, but many of them need a supply. It’s like buying a color printer. The printer is relatively inexpensive, but the ink cartridges are expensive. That’s exactly the model that medical devices have taken. For example, you can get IV pumps donated, but they often need a special cartridge for each patient that is outrageously expensive per patient -- not by American standards, but for developing countries, several dollars per use is too much. Most of those hospitals have about 30 cents per patient for consumables, so a couple of bucks is absolutely not doable. Many of the supplies are not even available, so even if they had the money, they still couldn't buy them.

Pratt News: How might technology be effectively brought to the developing world?

Malkin: I don't think we can simply export our technology, drop it in the developing world and expect it to work. We have to develop new technologies. For one thing, if you consider the top 20 health problems in the developing vs. developed world, there is almost no overlap. The most significant conditions in the developing world are insignificant in our world and vice versa. For example, depression is a major cause of morbidity in the U.S. It’s not even on the list in the developing world. Traffic accidents in developing countries are almost as big a problem as malaria. In the developed world, these are not on the list. So when you look at what equipment you would send, it would be all the wrong equipment. We need to develop the equipment that makes sense for them.

Pratt News: Has your work with Engineering World Health put you in a position to understand the problems and begin to address them?

Malkin: We’re in a very unique position to do the analysis about why equipment is not working. Everyone knows it isn't working, but no one knew why. There have been a couple of analyses of individual countries, but nothing like what we've done for Central America, Africa and Asia.

Pratt News: Do you have any other goals inspired by EWH?

Malkin: Every summer in the developing world, EWH students do interviews with hospitals to ask them what their technological needs are, and surprisingly nobody knows. The WHO has no list of technological needs. They have a list of diseases, which they match with the American equipment that would be appropriate. But as I’ve said, a lot of that equipment won't work when it gets there. We need a list of needs rather than diseases. We publish the 20 top needs each summer and I’d like to see the WHO begin to do this, and then do a better job of meshing those needs with organizations who can help.

In some cases, the needs don't require research, just development and product. They can be relatively simple. Some have been solved by our undergraduates at Duke in the course "Design for the Developing World." The problems can be very small, but we need a coordinated effort to match people with funding who want to solve problems with the problems as they are expressed on the ground in developing world hospitals.

Pratt News: Given all of this, what role do you think engineers can play in improving global health?

Malkin: One of my objectives is to bring the profile of engineering higher on the global health stage. At first, it may not necessarily sound like it makes sense, but engineering can contribute a tremendous amount to global health. Technology drives health care. And other issues with health consequences have an engineering component. For instance, safe water is a civil and environmental engineering question. Traffic accidents and other injuries are a prevalent cause of morbidity. These are in part civil and mechanical engineering problems. Also, difficulties in communications and power delivery are some of the largest problems in developing world clinics and hospitals. The hospitals we visit through Engineering World Health generally have no access to normal telephones and inconsistent access to electricity. These are to some extent electrical engineering problems. Engineers have a tremendous role to play in improving the quality of health care around the world.