Two years ago, however, his life took an interesting new direction when a charity supplying medical equipment to hospitals in Malawi told him it required precisely his skills. Here he recounts some of his many interesting experiences repairing and maintaining equipment in Africa.
Ihave been in the X-ray industry most of my working life; for 42 years this year, in fact. Following an electrical contracting apprenticeship at the start of my career I went to work as a maintenance electrician at the Royal Infirmary in Oldham, which was subsequently demolished to make way for the town’s sixth form college. While there I became interested in X-ray equipment when asked if I would try to repair a dental X-ray machine. Fortunately the fault was easily repaired, but my interest in X-ray equipment grew. A radiographer introduced me to the service manager of a major equipment supplier, and I applied for a job. I subsequently worked as a service and installation engineer in three major companies before deciding on a change, successfully applying for the X-ray engineer’s post at the North Western Regional Health Authority (NWRHA), where I could maintain my interest in equipment, but no longer in a hands-on role. Gradually getting used to the hands-off approach, I still missed the practical aspects and continue to keep a workshop, and build and maintain various electrical and mechanical items, just “to keep my hand in”. Following Government changes in 1995, the NWRHA, and all the other regional health authorities, were closed, and the section I worked in was bought by a private company, which two years later closed us down, making all the staff redundant. At this point I started my own consultancy business providing similar services to those provided by the NWRHA. Since becoming an independent consultant I have worked on quite a few major capital schemes, and various smaller jobs within the NHS and private sector. I decided to close my business in 2009 when I was 65; I wanted to retire from the consultancy side, but not necessarily to stop work entirely.
Telephone call from Scotland
Early in 2007 I received a telephone call from the Raven Trust in Scotland, which had been seeking an X-ray engineer and had found my website. The Trust is a charity set up by John Challis and his wife Sue to collect and ship items for projects in Malawi. John Challis had been involved with the dismantling of an X-ray machine from a clinic in Scotland, which had then been shipped out to Malawi and re-assembled. The equipment was installed in the hospital at Ekwendeni near Mzuzu in Northern Malawi, where it had provided good service for many years. When some building work had to be undertaken, the equipment was removed to a store for safekeeping. Following the works, the equipment was returned to its original location, but unfortunately no longer worked. Local engineers had unsuccessfully tried to repair it, and it was at this point that John Challis decided to seek out an X-ray engineer in the UK. I agreed to help, and asked him to send me some photographs of the equipment and its circuit drawings so I could familiarise myself with its workings.
Re-installed ‘brick by brick’
On his last visit to Malawi he had taken a printed circuit board out of the equipment, as some of the components looked to have overheated. This board, and photographs of the equipment, were posted to me, along with the news that the hospital had never had any circuit diagrams. The equipment had been removed and re-installed “brick by brick” using labels on wiring photographs and hand-drawn diagrams. When the PCB arrived I found it working, apart from some slightly swollen capacitors, which I replaced. It became apparent that this board was not the fault’s cause. There is an organisation in Malawi, CHAM (Christian Health Association of Malawi), which provides medical and technical support to Christian charity hospitals. CHAM has medical technicians who try to maintain all medical equipment in their hospitals. When John Challis next returned to Malawi he took one of the technicians to see if he could repair the machine using some advice sheets I had sent him. Unfortunately his attempts were unsuccessful. We even tried using a satellite telephone but, due to a tropical thunderstorm, just a few words could be exchanged. The equipment thus remained broken. The main purpose of John Challis’ visit was to install another piece of X-ray equipment at the hospital in Livingstonia, 150 km north of Mzuzu. Not only were John and the local workforce installing the equipment, but they also had to construct the building to house it. The equipment had been acquired by a UK charity, and was complete, including the lead protective screen and the lead doors for the X-ray room. The new building was to house the X-ray department, a pathology laboratory, and a blood transfusion laboratory, plus offices and staff toilets. This work progressed well, and was eventually completed in late 2007.
Reduced to a basic unit
Unfortunately when the X-ray equipment was switched on it would not complete its start-up, showing an error code, reducing the hospital to using a very basic mobile unit to provide its X-ray service. In the meantime I had shown colleagues in the X-ray industry some of the photos of the original broken piece of equipment to see if we could identify it, and possibly acquire some circuit diagrams. Although supplied by a British company (no longer in the medical X-ray business), we were all convinced it was Italian in origin. One colleague not only discovered the Italian manufacturer’s name, but also the fact that the company was still in business, and willing to send us a set of drawings and a manual. The manuals duly arrived, were scanned, and emailed to Malawi. I didn’t realise at this point that the telecommunications infrastructure in Malawi is not particularly good, and that most dial-up email, and the power supply in many places, is unreliable. We did get some drawings sent, but it became obvious that a more hands-on approach was required.
Trip ‘the only solution’
In April 2008 the Raven Trust asked if I would travel to Malawi and attempt to repair and set up both X-ray units. I discussed the idea with my wife, Judith, and we decided it was the only solution, even though it could prove fruitless. I contacted John Challis, and it was agreed I would travel to Malawi on 18 May for 10 days. We had originally both planned to go as, if the equipment repairs were successful, Judith as radiographer could undertake some radiography and some training for the local staff. However we subsequently decided this may not be a good idea, since the equipment might not be repairable. As the trip’s purpose was to repair and/ or set up equipment I had to acquaint myself with one particular piece of Siemens equipment I has seen in operation, but had no idea how to set up. A friend and colleague recently retired from hands-on X-ray engineering spent some time, and many emails, explaining the electronics and service procedure. Fortunately the manuals, diagrams and service software had been sent out with the equipment. I had a set of drawings, and a small bag of spare parts, for the original Italian equipment, which I was also hoping to repair. On arriving in Lilongwe, Malawi, we were met by John Gulule, a local CHAM technician, who took us to the organisation’s headquarters, where we were shown the workshop and introduced to Fergus Khonje, his boss. We subsequently set off for the country’s northern capital, Mzuzu, where we were to stay overnight before visiting our first hospital. Following a four-hour journey up the “M1” (which runs the full length of Malawi and is similar to a small UK “A” road), we arrived at the Raven Trust’s house in Mzuzu some 28 hours after leaving home.
Wonderful scenery
The next morning we were collected by the CHAM driver and set off on our journey to Livingstonia. (named after David Livingstone, although he never actually went there). The journey took us through some quite wonderful scenery, passing interesting sights at almost every turn. Many places look similar to the wilds of the UK, until you pass a village, where the houses are made of mud or local bricks. The houses are normally roofed with grass, but in some cases with a tin roof. You occasionally find local birds and monkeys by the roadside. During the journey we passed a local coalmine (some coal is exported). Seeing miners in shorts, tee shirts and Wellingtons was a little unusual. Shortly after the mines we arrived at a small village on the shores of Lake Malawi. Here we left the M1 and travelled the local dirt road to the hospital. The road was built by a Victorian engineer called Gould, and its proper title is the Gould Road, but, due to pronunciation problems, it is called the Gorodi by the locals.
Hairpin bends
The Gorodi was built to allow traffic (originally horse and bullock-drawn carts) to reach the mission station and hospital at Livingstonia. The road is approximately 15 km long, and rises 1,000 metres. There are 21 hairpin bends, and it is mainly constructed from earth and stone. John Challis is engaged in a project to refurbish the road to improve its surface and prevent it being washed away in the rainy season. The Gorodi is an unforgettable experience, and I was amazed the that X-ray equipment had travelled this way to the hospital. Eventually we reached the top, and arrived at Livingstonia. The settlement was originally moved from the lake shore in Victorian times to get away from the mosquitoes and the associated malaria problem. It is also cooler than it is at the lake. The settlement has schools, a hospital, and a university, plus houses for the staff and others. We were taken to meet several members of the hospital staff and then shown to our room in the doctor’s house – a wonderful old brick and timber building built by Dr Robert Laws in the early 20th Century. The hospital is one of the oldest, if not the oldest, in that part of Africa, is built mainly from local brick, and has tin roofs on all its buildings and walkways. The X-ray department is part of a new build project. The new building, known as the Macnair Institute, was built recently by local labour, and project managed by John Challis of the Raven Trust. It also contains a laboratory and other facilities, the X-ray department, and the darkroom. The X-ray equipment had been shipped from the UK and re-installed in a purposebuilt room. Radiation protection has been provided in the construction, and the room has lead-lined doors. In addition, a new three-phase supply had been provided. To my knowledge the equipment is the only ceiling-suspended X-ray unit in the charity hospitals in Malawi, and the building had had to be specially constructed to accommodate it. No mean feat for the team, as the members had no prior knowledge of how it should be done. I was pleased to see that the room, and the equipment, were almost ready for use. The equipment would switch on and go through its switch-on test routine, but the console then displayed an error code. I had this information before I left the UK and, with the photographs I also had, was able to talk through the possible causes of the problem with my retired Siemens colleague. Within a short time we had found the problem. A cable feeding the motor in the X-ray tube had not been connected. The cable was duly reconnected and the equipment switched on again. This time the error codes had disappeared and the equipment worked. As with all things, it’s easy when you have experience and a great deal of advice from others.
No test equipment to hand
We next decided to make sure the equipment was producing X-rays. Because there was no test equipment available, we resorted to the oldfashioned, simple method. Normally this would be a simple exposure of a suitable item, car keys or tools. The film would be developed and checked. The darkroom had been set up, but unfortunately, despite it having been ordered and expected soon, there was no X-ray film. We blacked out the X-ray room and exposed a piece of fluorescent screen from the inside of an X-ray film cassette. A healthy blue glow brought much relief, as the equipment appeared to be working. We spent several hours tidying up cables and making some alterations to get the best use from the equipment. Eventually some film arrived and we tried the first film on the new equipment. During our trip from Mzuzu we had stopped at the bottom of the Gorodi for a rest, and a drink, and, while there, the local butcher had given us the leg from a goat deftly removed with an axe. These bones were used to provide our first film. We then spent the remainder of the time at Livingstonia tidying the equipment and sorting out some other minor electrical problems. At Livingstonia it is customary for anyone new to be introduced at the Wednesday morning meeting/service in the hospital’s chapel/meeting room. This turned out to be quite a pleasant experience. The service and singing are undertaken in the local language, and my introduction was translated. The staff were very welcoming, and made us realise why Malawi is known as “the Warm Heart of Africa”. Time to move on again: this time back to Mzuzu via the Gorodi and the M1. We arrived back late in the evening just in time to eat, chat and go to bed. The following morning we drove to Ekwendeni Hospital in the Raven Trust’s pickup truck. The hospital is about 10 km from Mzuzu, and the location of the original equipment I had tried to repair by email. I was introduced to the maintenance manager and the hospital electrician and then taken to the X-ray department. As I had spent so much time looking at the photographs and drawings of the equipment it was like meeting an old friend. However the equipment didn’t work, and would not switch on without blowing a fuse. I asked the local technicians to disconnect all the peripheral circuits to the X-ray table and we put in new fuses. The equipment was switched on, and the fuses did not blow, but nothing else happened, with no displays or lights showing. Further investigation showed that all the printed circuit boards in the control panel had been pulled out while the technicians were looking for the fault. We switched the equipment off and pushed all the PCBs back into their slots. The console subsequently sprang back to life. Displays came on and lights flashed. As all the external wiring to the X-ray room was still disconnected, it was apparent that the fault lay in the wiring from the control console to the X-ray room. We tried to find the fault, but unfortunately the wiring was very untidy, and all the same colour, with labels made from zinc oxide plaster on the ends.
Heat and humidity
As Malawi is extremely hot and humid at certain times of the year the labels had faded and some had fallen off. I asked if the hospital had a roll of 1.5 mm threecore flexible cable so we could start afresh and rewire the unit. At this point I realised this was like asking for the moon. Due to a lack of finance the hospital does not have much in the way of spares and materials, with most of its resources going towards patient care. John Challis went off to Mzuzu to try to find some three-core cable, and we set about removing the old wiring, which was, of course, recycled by the hospital electrician. The equipment control room and X-ray room each have a junction box, and it is these that had to be rewired. We had circuit drawings for the console, and the junction box wiring was numbered, so that made the rewire easier. John Challis arrived back carrying a roll of 2.5 mm three-core cable, which it transpired was the last and only size available in Mzuzu. While John Challis had been out looking for the three-core cable, I set about looking around the X-ray department. The dark room was very small, and the processing of films was carried out using a wet processing system, probably last used in the UK in the mid-1970s. Fortunately my early training included wet processing, so at least I could develop films if the need arose.
Plate glass offered no protection
A similar setup was in place in the previous hospital at Livingstonia. I also found a very small Siemens mobile X-ray machine in a cupboard. When I asked if it worked the radiographer said no. Investigations showed a fuse had melted, but when this was replaced the unit worked well. I also discovered the doors to the department were standard interior doors incorporating no lead protection at all. The “lead glass” in the control cubicle was in fact plate glass, and afforded no protection. John Challis is arranging for both lead sheet and lead glass to be sent out to Malawi, and the local joiners will make lead doors. We believe the walls provide adequate protection, but some measurements are planned to check if this is the case. John Gulule, the local electrician, and I, set about rewiring the junction boxes wire by wire. Following several hours’ work we had completed a rewire. We switched the system on again and this time no fuses blew and the console appeared to work well. Unfortunately, when we tried to make an exposure, nothing happened. Further investigation showed that the motor in the X-ray tube was not working. We investigated, and found some wiring was not properly connected, and, having corrected it, the motor worked and we managed to make an exposure. The end of another successful day, but we still had a long way to go.
Radiography service restored
The next day we had to try to sort out the wiring in the tube stand in the X-ray room, and unfortunately we did not have circuit diagrams for this piece of equipment. It is manufactured in Italy and built to a World Health Organisation (WHO) specification. Several European manufacturers make similar units, but I could not find the correct circuit diagram from my industry contacts in the UK. I decided to try to rewire the unit, and draw out its circuit at the same time. This was not as easy as I thought, but it eventually proved worthwhile. We spent a couple of days drawing out parts of the circuit, as we rewired the unit using some of its original cables and some of the new three-core cable. We finally completed the job and, to our delight, it worked, and the local radiographer was able to X-ray his patients again. While all this work was being carried out I came to realise just how much we in the UK take things for granted, the three-core cable being just one example. During the rewire I also asked for several tools for various jobs, such as a hammer, which no one had, and Allen keys – again none could be found. I did get hold of a hacksaw, but it was home-made from reinforcing bar. Tools, test gear and spares are all in very short supply in Malawi. I had taken a simple digital multimeter, which I left with the hospital electrician, as he had worked so hard, and always with a smile. My hand-held oscilloscope was left with John Gulule, again for his hard work. I am sure these items will be put to very good use. Time had flown by and I had nearly reached the end of my visit. It had been arranged that we would travel in the lodge on the shores of Lake Malawi so that I could see some of the local sights on the way there. We passed much farmland, where the farmers grow maize and vegetables. We also stopped at a rubber plantation, and watched the latex dripping into upturned coconut shells. Most of the country is farmland with villages and settlements. Most villages have a well with a pump, and you see young girls collecting water. It is not unusual for them to carry 75% of their bodyweight of water. You can buy vegetables and foodstuff at most village markets. We finally arrived at the lodge at Nkhotakota Bay.
Clear lakeside skies
The lodge, which is attached to a pottery, is right on the shoreline of Lake Malawi. The rooms are very spacious and comfortable, with four named after the houses in the Harry Potter novels, so I found myself staying in Ravenclaw for the night. We arrived in the early evening, so it soon went dark. At this point you realise what light pollution does to the night sky at home in the UK. I have not seen a sky so clear and bright since I lived in the Middle East. John Challis, Bob Baxter and I ate in the lodge restaurant, where I had a local fish called Chambo, fresh from the lake, washed down with a Kuche Kuche beer. After breakfast the next day we set off on the final leg of our journey, to Lilongwe, where we were to stay overnight prior to going to the airport and my flight home. Lilongwe is the new capital of Malawi; the old capital, Blantyre, is further south. While most of the industry in Malawi is in Lilongwe, banking and company head offices are in Blantyre. We stayed at the Korea lodge overnight, where I saw my first TV for ten days (I hadn’t missed it at all). The following morning John Challis and Bob Baxter (the latter from Ekwendeni) took me on a tour of the local wholesalers, as they had to buy supplies for other projects they are working on. Most items are readily available for general building and electrical works if you have the money to buy them. John Challis and Bob Baxter are involved in various school and hospital projects, funded from Scotland and the rest of the UK.
Time to think
We arrived at the airport in the early afternoon in time for my return flight home. John Challis and Bob Baxter were staying on for a while to do other work. My plane left on time, and the journey was uneventful. The eight-hour wait for the connecting flight to Amsterdam was tedious, but did give me time to think about what I might be able to do next. Following my trip I decided to continue working with the Raven Trust. I had discussions with the Trust and CHAM about running a training course in Malawi for the local technicians. I also began collecting X-ray and other hospital items to be sent to Malawi. When our house started to look like a warehouse John Challis arranged to visit us and take the collected items back to the Raven Trust HQ in Scotland. The Trust sends out several containers annually, but funds have to be raised to pay for their transport. Several people and hospitals have been very generous with items, which are either currently in store, or on their way. While John was at our house we discussed the training course again, and the possibility of a second visit to Malawi in June/July this year. We agreed that both my wife Judith and I would visit Malawi for three weeks from 26 June to 17 July, with the training course running from 30 June to 2 July. Mornings were to be spent in the classroom, and afternoons undertaking practical work. Most of the equipment that had been collected would by that time have reached Malawi and would be available if required. Judith could, as a radiographer, help with parts of the course, and also help the local radiographers, some of whom have limited training. Arrangements were made for the trip, and the course, and we left the UK on 26 June. The course was well attended (by 14 technicians from across the country) and proved a success. From the feedback questionnaire we received all the attendees would have liked it to have been longer, and are also keen to undertake a further, more advanced course in the future. We travelled to four further hospitals and X-ray departments to undertake repairs and servicing, finally managing a three-night break on the shores of Lake Malawi before returning home on 17 July. From our trip we concluded that Malawi desperately needs training courses in all the engineering disciplines required in hospitals. Expertise to provide help and guidance in the installation of hospital equipment is also in short supply. I am pretty sure that the IHEEM membership, with its wealth of knowledge in these fields, could provide much of the required help. Improved mobile phone and email is making it a little easier to get information out to technicians when they need it, while enhancing communication to more remote hospitals is being investigated. We are trying to improve radiation protection by sending lead and lead glass, and are assessing local bricks and building materials for their suitability for radiation protection. My trips were certainly eye-openers, and made me realise just how well off we are with our NHS hospitals and other health services in the UK.