By Mercy Asiedu

Engineering is the backbone of medical advancement, in that it equips medical professionals and hospitals with tools necessary for diagnosing and treating medical conditions as well as enabling medical professional to do their work more efficiently and accurately. However, there are disparities in availability of technology between clinics and hospitals in higher resource settings and in lower resource settings. The presence or absence of necessary medical equipment can affect the quality of medical care and affect global health indicators such as years of life lost, years of life lived with disabilities, etc. On November 16th, we heard Dr. Malkin talk about engineering and its presence in global health. He touched on several topics including ineffective donation of medical equipment to developing countries, potential ways for improving the technology deficits and methods his work had taken to tackle these disparities.

First, we heard him talk about ways in which equipment donation was actually harming health care in developing countries instead of helping. He mentioned an experience where he and other organizations had donated several pieces of equipment to a hospital in Nicaragua. However, during a visit to the hospital, he realized that none of the equipment was being used. As a matter of fact, a lot of money was being used to store all the unused medical equipment in a large rental space. As Dr. Malkin pointed out, over ninety percent of medical equipment in developing countries are donated from high income countries with about seventy-five percent meeting that same fate of disuse or misuse. Some of the reasons for this include donations of broken equipment, lack of trained technicians, lack of dependable electricity, etc. Dr. Malkin disputed the idea that initial low capital investment cost and complexity requiring training were problems for this. Since most of the equipment is donated, initial capital costs are the most prominent issue; in actuality donors prefer to donate equipment with higher capital costs. Additionally, research has found that complexity of equipment is also not a problem and that after training, most medical personnel are able to effectively use highly technical equipment. The bigger problems with the use of the equipment is availability of initial training, long term costs including need for expensive, unavailable consumable components as well as long term maintenance and fixing of broken equipment.

This raises an interesting issue in the ethics of medical equipment donation. Recipient hospitals have a responsibility to use the equipment donated to them where and as needed. However, donor hospitals should also have the responsibility of ensuring that the equipment they donate are in full functioning order and can be used by the hospitals they donate to. It can also be argued that donors should also be responsible for providing initial ground training to the hospitals accepting the equipment since these might be not the standardly used equipment in the recipient hospital settings. There is also the need to ensure easy access to consumable components of devices. Blind provision of medical equipment, anywhere in the world, whether in high income or lower income regions, without training or without access to consumables will inevitably lead to disuse. However, this might be seen by donors as too much responsibility and eventually lead to decrease donations. This might also raise the issue of “beggars can’t be choosers” and that “some help is better than no help at all”..

Some potential reasons for the disuse of medical equipment that Dr. Malkin did not touch upon are political and cultural barriers. Use of medical equipment needs to be approved by the ministries of health in most countries hence, the government has a responsibility to ensure that medical equipment being donated are in the best interests of their countries. With the excess flow of donations, the government of the recipient hospital could decide to choose which donations to take and reject and could instill guidelines for both donors and recipients of the medical technologies. Governments also have to ensure that the necessary training and technical assistance is available for the use of these equipment. Donors could work with governments of the recipient country to ensure that this is available. However, this does not overcome resource restraints such as lack of dependable electricity. Another issue is cultural perception of use of the equipment. It would be interesting to see how much acceptance by the medical personnel according to their work flow culture and acceptance by patients affects use of these equipment.

There are several angles of looking at the problem of lack of or disuse of medical equipment in lower resource settings and Dr. Malkin pointed out some of the ways in which he had tackled this problem. Through organizations, he has started such as engineering world health and the global public service academies, he addresses training of on-the-ground technicians to use and repair medical equipment. His research also develops medical devices designed for use in developing countries. He ends on the note that different type of technology, not low quality technology is the way to address some of these disparities.

Discussion question

  • What are some political and cultural barriers you can see affecting use of donated medical equipment in developing countries?
  • Do you think it is the responsibility of the donor, the recipient of the medical technology to ensure its full use and why?
  • Describe other ways in which disparities in engineering technology between developed and developing countries can be overcome;
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