Collaborating Across Continents

In hospitals with plenty of resources, infants in the neonatal ward are connected to separate oxygen tanks where the gas flow is carefully regulated, ensuring that they receive proper oxygen therapy for any breathing problems they may have.

But this was not true at the ward in Mulago Hospital in Kampala, Uganda, where newborns with breathing problems are given oxygen by a haphazard daisy chain of tubes all connected to a central oxygen canister. The only way to control the flow of oxygen is by opening and closing the valve on the top of the tank, that may or may not include a flowmeter. In this arrangement, the newborn closest to the regulator got too much oxygen, while the child farthest away barely gets any.

In a classroom in the back corner of Hudson Hall at Duke University, four biomedical engineering students flashed through an in-class presentation showing their plans to create a simple system to produce a controlled “split” of oxygen from a single line to multiple infants in the neonatal ward.

A student in the class raised her hand, “How do you ensure that this will allow newborns to get the needed amount of oxygen?”

The group flipped back to images of their project, showing a panel with separate plastic regulators to control each patient’s oxygen supply, each of which was connected in parallel to the central tank. This allowed the same gas pressure to be applied to each regulator of the panel from a single oxygen tank. The design was also easy to create and replicate, they said, and it wouldn’t require the hospital to order expensive parts when things broke down.

“This doesn’t solve all the problems that they encounter in the ward,” said Meredith Lee, a BME master’s student and one of the presenters, “but it’s starting to address a big one.”

Engineering a New Perspective 

Creating workable solutions to real-world problems is a key part of the novel Duke-Makerere University BME Partnership, a collaborative program between Duke University’s Department of Biomedical Engineering and the new BME program at Makerere University in Kampala, Uganda. Spearheaded by William (Monty) Reichert, the Theo Pilkington Professor of Biomedical Engineering, the partnership was created to encourage biomedical engineering students to approach engineering problems with cost-efficient and practical solutions that can be created in resource-limited settings­­.

Reichert developed the program after spending the 2014-2015 academic year as a Fulbright Scholar at the university in Uganda. During his time at Makerere, he worked as a professor in their newly created BME program, teaching engineering classes in biomaterials, tissue engineering, drug delivery, BME design and even environmental engineering while also spearheading a major revision of their BME curriculum.

At Makerere, Reichert noticed that while the engineering students in Uganda were just as driven to solve problems as their Duke counterparts, they were limited by the technology they had at their disposal. They could develop a theoretical knowledge of biomedical engineering, but they were hard pressed to gain practical experience without sophisticated tools or labs. Other issues persisted as well.

“One of the main challenges we face—and continue to have—is a shortage of staff to support the training of students,” says Dr. Robert Ssekitoleko, acting head of Makerere’s BME Program. “That is being handled in part by the volunteering team that has been retained as teaching assistants, but these trainers cannot be officially recognized because the minimum qualification for recruitment at Makerere is a master’s degree.”

In 2014, Reichert returned to Duke for the Christmas break and met with Ashutosh Chilkoti, the chair of BME at the university. Chilkoti encouraged Reichert to think of creative ways to build upon his stay in Uganda.

“Given the connections Monty had made at Makerere University, I though this provided a unique opportunity for Monty and our department to do something meaningful in Uganda,” Chilkoti says.

In response, Reichert devised a proposal to create a unique partnership between the schools. This collaboration would allow Duke students to work with their Makerere counterparts to create much-needed, practical medical tools, and Chilkoti enthusiastically offered his support.

“Western engineering doesn’t always apply to problems that people face in places where resources are limited,” says Reichert. “Everyone’s experience in health care is drastically different depending on where you are, and as engineers at a research intensive BME department we have the ability to address that.”

Reichert worked with Ssekitoleko to create the Duke-Makerere partnership in 2014. Together, they aimed to create a program that would give Makerere students practical experience, and provide Duke students with a unique perspective on how they can efficiently design tools and technologies that are made with resource-limited settings in mind. They also arranged for the first of six Ugandan engineers, Kenneth Rubango and Henry Kiwumolo, to come to Duke on full scholarships to work towards master’s degrees at Duke’s BME department, preparing them to return to Makerere as instructors in BME.

“There is no shortage of problems in resource-limited settings that need engineering solutions, and they don’t always need particularly sophisticated ones,” says Reichert. “If you’re looking to see how your work is relevant on a human scale, then there is great value in understanding and devising solutions to these challenges.”

During the school year, students in Reichert’s class at Duke pair up with groups of students at Makerere to design tools that can be used to solve common problems at hospitals in Uganda. To collaborate, the students communicate via messaging apps and email, where they continually refine and discuss their designs and work to ensure that their tools are cost-effective and practical.

But the students aren’t limited to online communication; each semester the teams from Duke travel to Kampala to meet with their Makerere peers face-to-face and conduct research in the Mulago hospital to improve their designs.

“I learned how to work on a global team,” says Jawad Hoballah, a master’s students in BME who participated in the Spring 2017 Duke-Makerere program. “We worked through different time zones, gained insights into our Ugandan teammate’s interests and culture, and together we built a device that can have a meaningful impact on local communities in Uganda.”

With his family spread across the globe, Hoballah has had numerous opportunities to see the differences in access to healthcare across the world. For this reason, he says that Reichert’s course was a key reason for why he decided to attend Duke.

“If you’re going to succeed as an engineer, you need to take a different approach to solving problems around the world,” says Hoballah. “An issue we face in America is not necessarily an issue they face in Uganda, and we can’t just apply a bandage to the situation and say it’s fixed.”

During his time in the program, Hoballah’s team helped create a project that addressed neonatal jaundice, a common condition that occurs when the baby’s liver can’t adequately remove a substance called bilirubin from the body. The standard treatment includes light therapy, in which the baby is placed under specialized blue lighting that can help break down the bilirubin molecules. But many hospitals in Uganda don’t have access to this treatment, or even incubators to house the children during the therapy.

After visiting Mulago hospital, the students came up with a new design for a “jaundice crib.”

This design used a box that was threaded with blue LED lights. To use the device, the baby is laid down on the bottom portion, and they are treated with light from both above and below. Because the LED lighting is also removable, when a strand breaks biomedical engineers can easily fix and replace it at low cost.

A third project, developed with Duke-Makerere Scholar Rubango, devised a solution to another problem that plagues hospitals and clinics in Uganda’s hot climate: vaccine transport. Their design features a carrier that is similar to a thermal lunch box, outfitted with a temperature sensor and stacked trays for easy vaccine access.

While the entire design is novel, the engineers took extra care when designing the trays, as they wanted to make it easier for healthcare workers to identify the vaccines without taking them out of the carrier and exposing them to warm air, thereby saving their contents.

“This isn’t an issue that we’d have in the United States, but in Uganda vaccines are often transported by bicycle,” says Rubango, who was one of the first students to graduate from the BME program in Makerere. “So spoilage is a big problem, and a simple change like this can make a big difference.” 

Donations Hurt

For Robert Malkin, understanding the context surrounding a problem is key. Malkin, a professor of the practice in BME, is the founder of Engineering World Health (EWH), a nonprofit organization that engages students from Duke and around the United States to improve health care in low-income countries across the globe. Originally, the organization’s goal was to take decommissioned hospital equipment and fix it so it could be used in hospitals where resources where scarce.

Malkin says this goal changed after a trip to Nicaragua, where he found that hardly any of the equipment that had been donated was being used. Instead, the hospital had to rent out a building to store the sea of medical equipment that had been donated from EWH and other organizations. According to Malkin, the equipment was either already broken when it was donated, or it had broken at the hospital where the staff didn’t have the resources to fix it.

“In our efforts to help, we sent this hospital backwards,” he says.

According to the Director General of the World Health Organization, only 10 to 20 percent of donated, critical equipment is ever used, and most of it requires materials and parts that constantly need to be updated. On top of that, most of the medical devices that have been donated were designed for the developed world, not places where power shortages and other limitations are common.

Essentially, he says, “If you have donated medical equipment to a developing world hospital, you have probably hurt the people you were intending to help. It’s like donating your car to a community without gas.”

Malkin shifted his goal when he came to this realization. Now, students who participate in the program are challenged to create low-cost, sustainable solutions to circumvent the issues that arise in hospitals where resources are scarce.

One of Malkin’s favorite success stories involves engineers who recognized that hospital workers had a hard time accessing replacement lightbulbs for the specialized surgical lights in operating rooms. Instead, workers were using regular lightbulbs, which would quickly overheat and even catch fire.

Instead, students devised a method to rewire the surgical lights so the bulbs from the backup lights in a truck could be used as an alternative. Their approach not only increased the longevity of the surgical lights, but it made replacement bulbs immediately accessible and affordable.

Devising Lasting Solutions  

Malkin uses his design course—Design for the Developing World—to challenge students to think outside the box for their designs, while still being realistic about cost and utility. Although the course is independent of the activities of EWH, the projects that students work on are based on previous research from students who visited hospitals through the EWH program.

Students in this course will typically create five to 10 new products a year, which are then used in hospitals in resource-limited settings.  One of the more enduring projects created through Design for the Developing World is the Pratt Pouch, a ketchup-packet-like item that contains antiretroviral medications to prevent mother-to-child transmission of HIV during childbirth.

“The problems that you solve through EWH and through Design for the Developing World extend beyond technical limitations,” says Meggie Lund, a recent BME graduate who took Malkin’s design course after conducting work with EWH in the summer of 2015. “Working as a technician in a Nicaraguan hospital offered a firsthand glimpse into equipment needs and common failure points of existing technology, which we translated into more effective, sustainable solutions in Dr. Malkin’s design class.”

In Design for the Developing World, Lund was on a team that developed parts of a device to diagnose pneumonia. In the United States, doctors diagnose pneumonia via an X-ray, but X-ray machines aren’t always available in hospitals around the globe. Instead, Lund and her team worked on an alternative — a specialized belt that loops around a person’s chest and utilizes impedance plethysmography to diagnose pneumonia, even going so far as to distinguish between bacterial and viral strains.

Given the impedance disparity between fluid and air in the lungs, a series of resistance measurements across the chest could be plugged into an algorithm to “reconstruct” an image of the lungs and make a diagnosis. The project has continued with different teams across multiple semesters, Lund and her team are optimistic about the tool becoming a viable alternative for doctors.

“We try to make sure that we’re designing equipment so that the spare parts are locally available,” says Malkin. “But we can also benefit the local economy if we can develop these products to be locally manufactured.”

Engineering World Health has grown to be an established presence at Duke since Malkin created the program in 2001, and the lessons it imparts to its students are similar to those gained from the new Duke-Makerere partnership.

And these programs continue to grow.

Since its inception, EWH has expanded to include more than 40 chapters at universities across the US, and it supports training programs in various countries in Asia, Africa and Latin America. As the Duke-Makerere BME Partnership enters the second year of the five-year agreement, Reichert is looking at ways to continue to expand the reach of the program. One idea he’s mulling over involves working with students to commercialize their products once the course is over so their work can be also be used outside Uganda.

As global-health education expands in Duke BME, Reichert and Malkin are hopeful that the students who participate are broadening not only their technical, cultural, problem-solving and entrepreneurial skills, but also their understanding about how they can use engineering to help others around the globe.

“If you really want to help the developing world, you need to be in the developing world,” says Malkin. “These programs give students an opportunity to do just that.”