THE NEED FOR THE INTEGRATION OF CLINICAL ENGINEERING& SOCIOLOGICAL PERSPECTIVES IN THE MANAGEMENT OF MEDICAL EQUIPMENTWITHIN DEVELOPING COUNTRIES
Kevin Taylor, B.Eng., EIT
Monique Frize, D.Sc., P.Eng., C.C.E., O.C.
Department of Electrical Engineering, University of New Brunswick, Canada
Noel Iverson, Ph.D.
Department of Sociology, University of New Brunswick, Canada
Christiane Paponnet-Cantat, Ph.D.
Department of Anthropology, University of New Brunswick, Canada
The proliferation of medical technology in developing countries requiresthat sound and appropriate clinical engineering practices be applied. Notonly is there increased use of technologically advanced medical equipmentin city hospitals of the developing world, but this technology is alsobeginning to appear in primary healthcare facilities at the community level.This raises the issue of servicing and maintaining a proper level of technologywithin these facilities, while at the same time considering the effectsof exposing indigenous populations to a level of technology that may conflictwith their culture and beliefs. As clinical engineers apply their expertisein technology management in developing countries, they need to rely ona multidisciplinary approach by consulting traditional healers, nationalleaders and social scientists. Those who are interested in clinical engineeringapplied to developing countries may find the approach of combining a sociologicaland engineering perspective interesting and useful.
Index Under: Clinical Engineering, Developing Countries; Equipment Management; Developing Countries, CE in.
The World Health Organization's (WHO) goal for the year 2000 is healthfor all. This seems like a monumental task when one looks at the stateof some of the more underdeveloped countries in the Third World. Can thisgoal of primary healthcare for all be achieved without running many ofthese developing countries further into debt? Can it be achieved withouthaving these cultures severely disrupted by the introduction of Westernmedicine and technology? The level of technology that should be introducedto meet the WHO's goal must be carefully evaluated because sudden introduction of Western culture and technology into the non-Western cultures of impoverishednations, although meant to be a benefit, often ends as a "poisonedgift," causing more harm than good. This, of course, can be extremelydisruptive and costly.
Since the industrial revolution, societies and cultures of the Westernworld have been undergoing modernization, resulting in highly advancedtechnology and industry. It is erroneous to assume, however, that becausethe West appears more "advanced" (that is, by its own measureof advancement) other societies need exactly what the West has. Societiesand cultures of the Third World have also been developing and changing for hundreds of years, but many of these changes have been different thanthose of the West. This is particularly evident in the highly developedspiritual and communal outlooks and practices of some of these societies.When Western culture imposes itself on such a country, introducing itsown outlook and practices, it often overwhelms that country's culture.The secular nature of Western science and technology is sometimes incompatible with the values and habits of many Third World cultures. Even developingcountries that are somewhat "westernized," or receptive to Westerntechnology, may be adversely affected by Western technology because ofthe acquisition and maintenance costs associated with it. Such importedtechnology increases the developing country's debt burden, which, in manycases, is already of crisis proportions.
Medical technology, if it is managed correctly, is one of the few Westerntechnologies that has the potential to work well with both industrializedand developing nations. This is because of medicine's unique status inWestern culture. Modern medicine enjoys a high level of technological support,and much scientific research is devoted to its development. But, it isalso still considered an art by many of its practitioners and others. Inother fields of Western development, technology often dictates how humanswill work and live (for example, computers and robotics in industry, ortelecommunication in marketing); but in medicine, humans dictate how technologywill be used (for example, acceptance of any piece of medical equipmentby physicians, and to a lesser extent nurses, is necessary for its integrationinto medical practice).
Unfortunately, technological advances in the medical environment havesometimes proven to be problematic. Medical technology is advancing ata rate that makes it too costly for many countries to purchase and maintain.Since the 1970s, even Western societies could barely meet the rising costsof new medical technologies. With the introduction of clinical engineers,medical technology management began to be efficient (Frize, 1989). In thelate 1960s and early 1970s, hospitals hired clinical engineers to monitorelectrical safety. Since then, their involvement has improved the managementof medical technology and reduced maintenance costs (Frize, 1989).
Many organizations have donated medical equipment (often without manuals,spare parts, or training [Frize, 1991]) and have left a country on itsown to deal with any maintenance or operating problems related to use.The social sciences have challenged modernization theory (a post-war theoryof development to bring developing countries to Western standards of industrialization).This way of meeting the economic and technological needs of poor nationsoften proves disastrous (Iverson, 1986) . This critique of modernizationtheory came chiefly in the form of dependency theory, which criticizedmodernization theory's proposal that developing countries embark upon apath of industrialization. Because attempts to deal with this problem haveoften met with failure, clinical engineering consultants need to becomeaware of these social science concepts, some of which have been aroundfor some time (Frank, 1975). With this knowledge, they can look for acceptablemethods of introducing and managing Western medical technology in developingcountries.
PROBLEMS FACED BY CLINICAL ENGINEERING
To comprehend the nature of these past and, often, present-day failuresin medical equipment management and use in the developing world, it isuseful to look at a few examples. In one incident, a diagnostic ultrasoundmachine was donated to a hospital; the cost of transportation was morethan $1,000 and upon arrival it was found to be damaged. It was an oldmodel that was complicated to operate, and there was no physician interestedin learning how to use it. Also, more modern and easy-to-use ultrasoundequipment was available locally (Mridha, 1992). In another situation, amammograph was given to a hospital that did not have properly functioninggeneral X-ray equipment. Again, the cost of shipping the equipment wasexcessive, and there was no one properly trained to install or maintainit (Frize, 1994). A common mistake is the donation or purchase of equipmentthat is of the wrong voltage (that is, 120V@60Hz versus 220V@50Hz, or viceversa) or uses a type of gas unavailable in the country (Mridha, 1988).Fundamental errors that overlook the present-day needs of the developingcountries and the state of their hospital facilities are still frequentlymade today.
The availability of spare parts and the harsh physical environment (thatis, high temperatures, humidity, and irregular electrical supply) alsoplay a major role in rendering much Western medical technology too costlyor useless to developing countries (Wang, 1991; Mridha, 1988; Frize, 1991).These problems often occur because of the Western attitude that "ifyou simply had what we had, you would be like us." By trying to forcedeveloping countries to catch up too quickly with medical technology (orany other form of Western technology), the West tends to overlook detailsthat may seem small but are nonetheless critical in the steps of development.These steps of development could be social or technical. The adaptationof a culture's work ethic as it accepts a new labor-saving device is agood example of a social change required before an innovation can be fullyaccepted. A technical example is the development and exploitation of electricity,a commodity easily accessible and reliable in the West, which allowed computersand many other devices to be developed. Thus, if a developing country hasan unreliable source of electricity, computing devices, although beneficial,will only be reliable after the country has developed a more dependablesource of electricity.
Not all problems arise out of a lack of technology or the West's ignoranceof the level of technology in developing countries. The underutilisationof technical expertise is a problem that occurs, in part, at a "grassroots" level. For example, when biomedical technicians are trainedin the maintenance and use of high-technology medical devices, they mayleave the hospital environment and seek more lucrative jobs in industry(Frize, 1991). This may be a direct result of the "Western capitalistmentality" that extols a free market and encourages occupational mobilitypropelled by career enhancement. Because these technicians are often trainedin or by Western countries, they have ample opportunity to absorb someof these values. Thus, it would be beneficial for technicians to be trainedin their own countries to avoid this problem and to focus their attentionon local technical problems (that is, medical equipment problems that areunique to their environment) (Machado, 1993). Many countries do not havea sufficient number of trained technicians to replace the ones leaving.Nor do they have the resources to continually train new technicians asreplacements.
Another reason for the underutilisation of technical resources is thatthe few trained technicians in these countries sometimes feel little compulsionto observe a nine-to-five work schedule. Some technicians will work ona neighbor's or friend's equipment before they will service their employer'sequipment. Their sense of community may be a stronger force in their livesthan the demands of employers (Johnston, 1992).
An interesting sociological problem occurs when medical technology enterstraditional ethno-medical domains. Ethno-medicine is the medical practicesof indigenous peoples. The leaders are often referred to by the West aswitch doctors, shamans or medicine men. These leaders apply traditionalmedicine that often encompasses a strong spiritual and religious element(Coreil,1990). A simple example of this is the introduction of sophisticatedobstetric equipment in an effort to improve maternal and child health.This may happen as equipment is upgraded in a country's larger city hospitals,and older but still sophisticated equipment trickles down to the primaryhealthcare facilities (Frize, 1993). The introduction of new obstetrictechnology and Western medicine into indigenous populations often disruptsthe decision-making power of the ethno-medical leaders (Coreil, 1990),placing the indigenous population at odds with the newly introduced westernizedmedical facility. Without the support of the local indigenous population,the new medical technology is wasted because the improved primary healthfacilities will not be fully utilized. Waste of this kind is no different,in its effect upon costs, than medical devices that are idle for lack ofspare parts or proper maintenance.
CLINICAL ENGINEERING SOLUTIONS
What is being done to counter these problems? Various ways of addressingthem have been suggested and introduced, but it is estimated that 40 to80 percent of medical equipment is idle in developing countries where suchsolutions have not yet been conceived (Mridha,1988). To avoid a repetitionof these errors, one must look closely at their causes and consequences.
A pyramid type model has been devised by Michael Cheng to introducethe proper level of medical equipment into developing countries (Cheng,1993). This model represents the distribution of medical equipment as itrelates to complexity. The width of a pyramid is the quantity of devicesand the height of a pyramid is the complexity. At the base of the pyramidis the first layer, consisting of the least complex devices, such as stethoscopesand weight scales. Up through the next layers would be the water baths,microscopes, sterilizers, and X-ray machines, up to ultrasounds, monitors,lasers and, finally, magnetic resonance imaging and CT scanners, whichcurrently represent the cutting edge of Western medical technology. Asthe complexity of the devices increases, the numbers available decrease.The bottom half of the pyramid (that is, stethoscopes through sterilizers)can be maintained by technicians with a minimal amount of training andcost. The top half, however, representing devices of greater complexity,requires an exponentially larger amount of resources (that is, more costsand technician training time) to properly maintain the equipment.
This model is one example of the new perspective clinical engineerscan bring to the question of appropriate medical technology managementin developing countries. If a country has sophisticated devices imposedupon it before it has obtained rudimentary medical equipment, or if itdoes not even have proper facilities to maintain its rudimentary devices,the costs can be crippling. Because most countries do not have the resourcesto handle the exponentially higher costs of sophisticated equipment, theysimply will allow such devices to remain out of service. By following thismodel's principles, a sustainable medical technology base can be introduced.As the country develops its technical support base and the training ofits technicians, higher levels of medical technology can be introducedand sustained.
Mridha (1992) recognizes another area of change that is required forsuccessful medical equipment management in developing countries: "Itappears that the problems cannot be eliminated unless the Western designedmedical technology is modified or medical devices are especially designedand manufactured for use in the developing countries." Specially designedand manufactured devices are excessively expensive for most developingcountries if they are designed in the West. It is unlikely that most developingcountries have the manufacturing base needed to design and manufacturesuch devices. This deficiency could be overcome by modifying Western medicaldevices, because the other two options are more difficult to achieve (Poluta,1988).
The continued implementation of medical equipment management models,as well as the safe and successful modification of medical devices to meetthe needs of developing nations, requires that those nations have skilledtechnicians and engineers. Project HOPE's biomedical engineering programis attempting to address this issue. These countries' needs have been summedup by Weed (1989): "The problems are not only equipment, its use andmaintenance, but also involve the recognition of the need to provide awork place, financial support, and administrative structure for BiomedicalEngineering from the hospital administration to the Ministry of Health."Project HOPE plans to develop a functioning clinical engineering repairand maintenance department in a major hospital, a training-education programcurriculum for cooperative education with a local technical university,a clinical organizational structure at the national ministry of healthlevel, and user-education for medical personnel at all levels. The keyhere is to try and maintain this infrastructure even after the Westernsupport and expertise has moved on. Unfortunately, this has not alwaysworked.
Ideas like Project HOPE's, as well as the other clinical engineeringsolutions (that is, the implementation of a medical equipment managementmodel and the modification of medical equipment), require two fundamentalconditions: full-time clinical engineers employed by developing countries'hospitals and, more importantly, a high level of political will (Frize,1991; 1992). Without the full support of a country's government, any solutionto its medical care problems will only be temporary.
The question of the proper introduction of medical technology to developingcountries goes beyond purely engineering considerations. There are caseswhere Western medical technology and practices interfere with the indigenouscultures of developing nations. Engineers and healthcare administratorsmust look beyond their scientific and engineering training to assess thesociological implications of their medical technology management plans.This means looking at cases where technology could damage a culture orwhere technology could be abused (for example, using ultrasound for thedetermination of the sex of the fetus).
The knowledge and experience clinical engineers have collected fromtechnology transfer experiences within developing countries are not new.The social sciences had come to the same assessments of past methods oftechnology transfer to developing countries. This can be seen in the writingsof Andre Gunder Frank (Frank, 1975) and others (Iverson, 1986); Frank'scritiques of Western post-war development theories, grew out of Paul Baran'swork (Baran,1957). Communication between the fields of sociology and engineeringis necessary so that the ideas proposed by sociologists can be readilytransferred to clinical engineers. The two perspectives of applied scienceand societal development need to be considered together. This may enableWestern medicine and medical technology to be more readily embraced bydeveloping countries.
A society' s development toward modern science and engineering, andits ability to produce young engineers or scientists, is the same processas the development of different types of technologies. In both cases, certainsocietal and technological steps and changes must take place before thenext development can occur. Technicians and engineers from developing countrieswho are trained in Western institutions may have difficulties readjustingto the lack of technological resources that characterize their own country.As a result, the expertise they have acquired in the West remains underutilised.Individuals who have benefited from training in the newest technology mayalso experience cultural conflicts upon their return. Many developing countriesdo not share the same "materialist/technological" approach foundin the West, especially when it comes to treating the body. Similarly,the learning processes that have produced technically trained Western professionalsare not always compatible with the outlook of a developing nation, suchas technicians not being bound by a nine-to-five routine. Unfortunately,Western technology is often perceived as requiring a Western work ethicfor its full integration. Western social scientists and engineers, workingwith technicians and engineers in developing countries, should be ableto find a socially acceptable solution to the differences between theirown beliefs and those of their hosts.
A final area of concern is the fact that Western medical scientiststend to be sceptical of ethno-medicine. But ethno-medicine does play avaluable role in primary healthcare, even if it is only the simple butimportant fact that the people believe in it (although it would be presumptuousto assume that a traditional culture' s medical arts, which have been developedover a span of many generations, would have nothing to offer in healingthe sick) (Choudhury, 1992). As more sophisticated equipment is introducedto primary healthcare facilities and consequently to indigenous cultures,their traditional medical leaders must be given a voice in gauging thelevel and type of technology to be acquired. This approach would utilizethe authority and knowledge of these leaders, to allow for the adoptionor adaptation of medical equipment or procedures that do not conform withreligious or cultural beliefs by setting up a framework for a more personaldialogue of concerns.
Western consultants working in developing countries need sound trainingin local cultural practices so that their efforts can be more beneficialto the people who most need them. By incorporating the knowledge and skillsof local traditional medical practitioners, Westernized physicians, clinicalengineers and technicians can adapt Western technology to the culturalenvironment of the patient. This will avoid the standard, yet destructive,habit of requiring developing countries to adapt to Western work ethics,along with Western technology. Incorporating local cultural attitudes intothe decision-making processes of a country' s healthcare facilities canadvance medical practices in the developing world. In addition, an integrationof sociology and clinical engineering can produce a fruitful multidisciplinaryunderstanding of developing countries' medical care.
By properly evaluating the needs of developing countries, viable clinicalengineering solutions can be found that combat the effects of the proliferationof medical technology and its associated rising costs. Some of these solutionshave been presented here and are still being developed by engineers whohave learned from previous mistakes and failures. Engineering consultantscould have avoided many of these mistakes if there had existed a betterdialogue between the social sciences and clinical engineering communities.Indeed, both fields can learn from each other. By working with one another,and with local and national leaders, clinical engineers and social scientistscan realistically address the complex problems these countries face andhelp them to achieve the goal of healthcare for all by the next century.
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Kevin Taylor received an Engineering Diploma at St. FrancisXavier University in 1989 and a Bachelor of Electrical Engineering at theTechnical University of Nova Scotia, Canada in 1992. He is currently completinghis Masters of Science in Electrical Engineering degree at the Universityof New Brunswick by specializing in clinical engineering. His interestsinclude clinical engineering, clinical engineering in developing countriesand Third World studies.
Monique Frize received her doctorate at Erasmus Universityin Rotterdam in 1989. She has worked as a clinical engineer for 18 yearsand in 1989 was appointed as a Professor of Electrical Engineering andas the first holder of the Northern Telecom/NSERC Women in EngineeringChair at the University of New Brunswick, Canada. She has worked on projectsin Bangladesh, Haiti and Morocco (1989-1994). Her research interests arein the areas of clinical engineering and critical care instrumentation.She has received two honorary degrees since 1992, and the Order of Canada.
Noel Iverson, Ph.D., University of Minnesota, is now aprofessor of Sociology at the University of New Brunswick, Canada. He haswritten articles on theory, comparative socio-economics, urbanism, themilitary, and social change. Author of Germania, U.S.A. and editor of Urbanismand Urbanization, he is presently preparing a biography of Nels Andersonand a study of obedience and military ethics.
Christiane Paponnet-Cantat is an AssociateProfessor in the Department of Anthropology at the University of New Brunswick,Canada. She received her M.A. and Ph.D. from Simon Fraser University. Herfields of interest are International Development Studies and Latin AmericanStudies. She has done research on land reform and peasant cooperativesin Peru and is now interested in fishery cooperatives in Yucatan, Mexico.