I have been involved in the Gambia-Swansea VISION 2020 LINK now for more than 16 years. I hope that this article will be of some interest to anyone considering volunteering overseas, as part of a LINK or in any other capacity.
The VISION 2020 LINKS & Networks Programme has been operating since 2004. The Gambia, the smallest country in Africa – half the size of Wales – sought to improve their country’s eye health (particularly paediatric eye health) soon after they had established the Sheik Zahed Regional Eye Care Centre (SZRECC) in 2007.
After a presentation about the LINKS programme in 2008, a steering committee was set up in Singleton Hospital, Swansea, comprising two ophthalmic consultants, two orthoptists, two opticians and two ophthalmic nurses. We were matched with The Gambia where we visited in the spring of 2008. There was a return visit from The Gambia staff to Swansea later in the same year.
In March 2009, a team of five Singleton staff visited SZRECC to try and improve paediatric ophthalmology. They concentrated on orthoptics, refraction and surgery, based on the priorities and needs identified by SZRECC. The team noticed some dysfunctional equipment and were told that the equipment in the smaller outlying hospitals was also a problem. When they returned to the UK, they asked medical physics staff if they would join them on the next visit. As I had some experience in repairing hospital equipment within Africa (albeit, some 25 years earlier), I volunteered to go with them in November 2009.
Preparation
The Swansea coordinator of the LINKS partnership had taken photos of both the working and dysfunctional equipment, including the make, model, serial number, etc. This was invaluable as we were able to search for operation and service manuals for the equipment that we were likely to encounter and also know what special tools and spare parts might be required.
Example of recording equipment details.
Many medical companies were happy to provide manuals for their equipment. Knowing the company engineers who visit Singleton, some were willing to also provide training for disassembly and maintenance. Some of the equipment was quite old or not in use in the UK. I found that www.frankshospitalworkshop.com was a useful website for manuals and information for this type of equipment. Where the manufacturers did not allow their manuals to be distributed, www.medwrench.com was also very useful to obtain information and specific advice on equipment.
"In my previous travels to Africa, I saw many well-intentioned donations that […] were configured for the wrong input voltage and far too complicated to set up and use in the hospital where I found them"
I bought and took my own tools (and subsequently donated most of them). I also took service aids such as wire, fuses and silicon grease, as well as cleaning materials (brush, abrasive cleaner, etc.). One should not expect a dazzling array of tools and spare parts and they may not be available to buy locally. I also took a short mains extension with earth leakage trip and a mains wiring indicator to ensure correct wiring. The mains electric supply can be very unreliable and often causes sensitive medical equipment to fail. The disruptions to the supply often used to blow the lamps in equipment. Sadly, although the newer LEDs are more reliable, it is now the capacitors and cooling fans in the switch-mode power supplies that tend to fail.
Servicing a slit lamp.
When to go
Timing the visit is important, particularly if you hope to travel within the country. For some of the year, some roads will be either difficult or impassable. Avoiding the hottest weather can help you work at your best. It is also worth trying to avoid religious festival periods to maximise your useful time in the country.
Repairing a field analyser.
The visit: tips for technical support
In total there have been nine visits to The Gambia that have included technical staff, and I have visited eight times. I have been made to feel very welcome wherever I have been; it is not all work.
If you have not already agreed the major priorities of your visit, then it is good to meet all staff involved to discuss this when you arrive. It is important to listen and not assume that processes are the same as in the UK; their needs may not be what you envisage. Do not expect everything to go to plan – it probably will not, but you may come to enjoy this aspect, as I have. You will need patience, particularly if you are visiting remote hospitals. You may have to wait for one person to find the relevant key to gain access to the equipment and then another person who can start the generator so that you can run the equipment.
On my first visit, apart from installing tonometers on slit lamps, most of my time was spent with the local engineers repairing broken equipment. If manufacturers have standardised on certain makes and models, then this will make things a lot easier for you. Also, if they have chosen appropriate technology equipment rather than over- complicated, microprocessor-driven modern counterparts, then you will have a better chance of explaining how it works as well as keeping it in good repair and maintained.
Wherever possible, involve the local staff in the thought process when doing repairs so as to not exclude them. You need to explain how the equipment works and also teach how to recognise the components (especially those that need maintenance or that may fail) within the equipment. Sometimes you may have to resort to repair methods that you would not use in the UK; if you do not fix it then it will likely stay broken. This balance of risks is one of the trickier aspects of working in a developing country.
It is important to document any equipment that you look at; make a list of what manuals, spares, tools and test equipment are needed. Look at how the equipment is being used. If you find equipment is suffering because of dust, perhaps storage can be improved (an old clean pillowcase, for example). I found an autoclave precariously positioned and likely to fall and so was not surprised to find other autoclaves that were bent to an extent that they were unusable. Equipment is often damaged when moving it between centres because of poor protection during transit.
Keeping equipment clean and well maintained will normally extend its life. On subsequent visits, I spent more of the time going through the techniques of maintaining equipment (especially autoclaves and slit lamps). A procedure and checklist can help you to do this in a systematic way. When staff confidence had grown, I filmed the staff doing the servicing themselves so that they had a visual aid in my absence. Once again, maintenance is much easier if there is some degree of standardisation on appropriate technology equipment. To have high technology you need a reliable electric supply, a clean, dust free, air-conditioned room and ideally a local service contract on a frequent basis to keep it working. In my previous travels to Africa, I saw many well-intentioned donations that must have been expensive to transport and were never used. They were configured for the wrong input voltage and far too complicated to set up and use in the hospital where I found them.
Failures and successes
You will not win them all. Sometimes you will need to say that equipment is not worth repairing. If the makes and models of equipment have been standardised then parts from one machine may be of use to keep another of the same model working for longer by ‘cannibalising’ parts.
I attempted on many occasions to encourage the local engineers to organise a list of what equipment was where. I tried card systems, spreadsheets, databases, but none were ever kept up to date. I also tried to encourage not only planned maintenance between my visits, but also recording the work done by completing check-sheets – I had no success with this either. Remember that probably there are a hundred and one other jobs to do; we all have to prioritise.
Communication between visits was challenging and never reached as many of the useful exchanges for which I had hoped – however, there were also many successes. Numerous repairs and services were completed, and the clinical staff were overjoyed that they had functional equipment for treating their patients. During my most recent visit this past year, we looked at a faulty operating microscope. We diagnosed that the gas spring was faulty and I sourced a replacement when I returned to the UK. A month after I had posted it, I was delighted to hear that the local engineers had fitted it and it was all working correctly. This is how you can measure success! It is the little things that make such a huge difference to lives and to the team using the equipment for diagnosis, etc.
It’s not all hard work!
Conclusion
On a personal level, my visits to Africa and to The Gambia in particular have been some of the most rewarding and memorable parts of my working career. I have enjoyed almost all aspects of my time in the LINKS partnership with The Gambia. Fundraising for our trips by organising quizzes and so on was great fun. I have made so many new friends both in The Gambia and in Swansea because of this partnership.
Our LINKS partnership has expanded my knowledge of medical equipment, not only in terms of understanding how the specific equipment works but also how it is used. Being part of a multidisciplinary team will help you when you encounter challenges, as seen while working in Africa, and helps you to think ‘outside the box’
Acknowledgement: The lead authors would like to thank the Gambia-Swansea Links Teams for their support in the production of this article.
Declaration of competing interests: None declared.
