Sunday, December 17, 2017

Good Technology Bad Technology

There is a legitimate argument to be made that high-end technology does more harm than good in a resource limited setting. There are many factors that are involved in the administration of a piece of medical equipment in Zambia that donors and recipients do not take into account. It always seems like a great idea in practice. The stereotypical email I receive is as follows, "Hi Omar, we have this great (insert technology) that is being discarded at our hospital. Do you have a need for (insert technology) in Zambia?" The answer is almost always no.

The tendency is to think only about the benefits of the technology in a world that frankly does not exist. People have an image of a machine that never breaks, provides an exact diagnosis, and a patient receives a correct treatment based on the test results. There is not adequate consideration of maintenance, technical training, study interpretation, financial viability, and consequences of inappropriate use.

Within the field of global neurology there is always the temptation to introduce electroencephalography (EEG) into resource limited settings to improve the diagnosis of epilepsy. That would make sense if all that was needed to gain a benefit was turning on the machine. Unfortunately, having an any technology accounts for about 10% of what is required for it to be used successfully. The human element is always the overlooked piece. Someone must know how to use the technology and someone must know how to interpret the findings. Without these two key pieces, it is simply a case of garbage in/garbage out and can result in harm to the patient.

EEG, which measures brain waves by attaching electrodes to the scalp, is a supportive but by no means definitive test in the diagnosis of epilepsy. In other words, if you see abnormal brain waves, it can help confirm the diagnosis of epilepsy but many patients with epilepsy have a normal EEG. As a result, the diagnosis of epilepsy is still clinical and largely based on the patient history. Additionally, a properly trained EEG technician is critical towards obtaining a high-quality study that can be interpreted by a neurologist trained to read EEGs. In the U.S., there are EEG training programs lasting from 1-2 years in order to become a certified as a technician. I went through one year of epilepsy fellowship in order to learn how to interpret an EEG.

In terms of epilepsy in resource limited settings, there is something called the treatment gap. The treatment gap is defined by the percentage of patients with epilepsy who are not on treatment. In the majority of Africa, the treatment gap is > 90% The majority of these patients can be diagnosed with epilepsy by clinical history alone. It makes much more sense to concentrate on providing medicines to lower the treatment gap rather than scaling up the use of EEG.

However, I have observed that there is something intoxicating about the technology. Hooking up a patient to electrodes while brain waves appear on a computer screen makes patients and providers feel like they are participating in a higher-level care. This occurs even in the setting of rampant misuse of the technology in Zambia. There are numerous EEG units currently in use in Zambia. Near as I can tell, the only purpose they serve is to charge patients for a sham test. I have seen reports that are said to be abnormal literally copying the verbiage I use in my reports. The patients are then sent to me for further management. I manage 1 of only 2 only legitimate EEG labs in the country based on competence of the technicians and quality of the reads. It has been a great challenge to keep our lab financially viable.

The same issues exist with neuroimaging technologies such as CT and MRI scans. Everyone thinks it is a good idea without taking into consideration the heavy lifting involved in managing a successful imaging laboratory. I remember during my first visit to Zambia in 2006 naively thinking, "If only they had an MRI scanner here, things would be so much better". I even had the audacity to email the head of the National Institute of Neurological Diseases and Stroke, Story Landis, to ask how I could facilitate the purchase of an MRI scanner for Zambia. This is comical looking back now.

There are some very real instances when CT or MRI scans of the brain have done more harm than good in Zambia. The thing that should precede the introduction of CT or MRI technology are competent radiologists that can read the studies. Without properly trained personnel there are major limitations to the reports that are issued. Sometimes reports are issued by individuals who have had no formal radiology training. Providers then treat CT and MRI reports as gospel. There is often anchoring on a diagnosis without questioning the findings and patients are treated inappropriately. Complex cases don't have to be thought through. Providers can always say that they were just following the radiology report.

Another issue with a poorly implemented and utilized technology is that it may contribute to the equipment graveyard. This is the term used for useless broken-down equipment that occupies valuable space that could be better utilized. There is a non-functioning electron microscope (EM) that has been at the University Teaching Hospital in Zambia for over 10+ years. On the list of 100 things needed in this setting to improve care an EM sits at #110. Yet nobody wants to discard a piece of equipment that was worth a lot of money at one time even though it has no diagnostic utility. It continues to take up an entire room in the virology laboratory where it currently sits as the most expensive paper weight in the country.

Part of the aversion to throwing anything away comes from the context of having resource limitations. When I first arrived in Zambia in 2010, there was a large exhaust pipe that was the wrong fit to a laminar flow hood in the department of medicine laboratories. It sat in the hallway in the most inconvenient place where you were liable to trip on it more than anything else. It was a huge eye sore. When I asked the lab manager if it could be discarded he said maybe someone could use it someday. I then asked how long had it been lying there - the answer was 10 years. Despite strenuous objections, I had it removed and it has made no difference, though some people still hold on to the idea that it was wrong to remove it. I still joke about the pipe to this day.

The best ideas and technologies in this setting are simple. A game changing technology is a cell phone for a myriad of reasons. Its use is widespread. It is easy to replace. It serves as a reliable light source that can be used during surgery or cervical cancer screening when there is not steady electricity. It provides a tool for patient follow-up, study outcome, lab results, and appointment cancellations so that a patient does not spend transport money when a provider is not in the clinic. Providers in rural areas will send me WhatsApp videos of patients with movement disorders and ask for medication recommendations. I discover new uses almost monthly.

Donations of equipment are always well intended but people must consider what lies on the other side. There are consequences of equipment taking up space, serving a transient benefit, and having improper implementation. The title of an issue of the Harvard Business Review I recently read had the title: Humans are Underrated. This is particularly true when it comes to global health. Humans must come before technology.  


  1. Very well said. This love of technology applies beyond health as well. When I was in Zambia - I met with a education official, who wanted ipads for teaching in rural schools. When I pointed out that many of the schools he was talking about didn't have regular electricity (obviously essential for charging said ipads) - he said "well, just give us solar panels as well."

    1. Great example David. It is hard to combat the mindset that having a fancy technology will make all the difference.

  2. Too true. More investment in training Zambians. Less in dubious equipment and buildings to house said equipment is what is needed. There are incredibly talented and intelligent individuals to (further) train and investments in such training are the path to better healthcare and systems.

  3. Reminds me of "The White Man's Burden" by William Easterly - the key thesis there being that a thoughtless, top-down approach (in your case, large pieces of equipment or technology) is inferior to accountable, innovative approaches utilizing existing or easily available modalities, in your case driven by agents who are far more nuanced in the day to day needs at the provider-patient level. That is why your work in Zambia is so important - and incredibly challenging. From the perspective of an administration, a new MRI will always be "sexier" than the application of a group messaging system or other strategies even if the outcomes are likely to be better with the latter. -Jason Yoon

  4. Thanks for sharing. I think these kinds of gifts of technology are well-intentioned, but it is difficult to foresee how they may actually be detrimental without understanding the context in which they will be used.