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In this episode, Dr. Stephen Swanson shares his journey of establishing a neonatal intensive care unit (NICU) in Arusha, Tanzania. He emphasizes the importance of addressing medical culture and involving nurses, doctors, and families in the care of critically ill and premature babies. Dr. Swanson highlights the success of a low-tech approach, including the use of blended, warmed, and humidified CPAP, and the importance of attention to detail, thermal regulation, respiratory support, nutrition, and infection prevention. He also discusses the challenges of relying on donated equipment and the need for innovative biomedical engineering solutions.

Dr. Swanson also highlights the need for appropriate training and skill development for healthcare providers, as well as the importance of collaboration and sharing of best practices. He shares his experience in organizing the Tiny Feet Big Steps African Neonatology Conference, which aims to provide practical skills and knowledge to healthcare professionals in Africa. Dr. Swanson also discusses his vision for the Institute for Child Healthcare Africa, which aims to promote quality pediatric care and build a mother and child hospital in Tanzania.

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Resources mentioned in episode:

Tiny Feet Big Steps conference: https://tinyfeetbigsteps.com/

Institute for Child Healthcare (ICHA): https://www.tanzanianchildren.com/

Every Breath Counts: Lessons Learned in developing a training NICU in Northern Tanzania: https://www.frontiersin.org/articles/10.3389/fped.2022.958628/full

Contact: swan0027@umn.edu

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Short Bio:  Dr. Stephen Swanson is a pediatrician and infectious disease physician. He is the Director of the Neonatal Intensive Care Unit at the Arusha Lutheran Hospital in Arusha Tanzania. He is also an Associate Professor, Division of Global Pediatrics at the University of Minnesota Medical School and a Founder, Institute for Child Healthcare Africa (USA, Tanzania). Dr. Swanson, welcome to the podcast. 

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July 2024 Episode Transcript -Dr. Stephen Swanson

Shelly-Ann Dakarai (00:01.427)

Hello everyone. Welcome back to another episode of the Global Neonatal Podcast. I'm Bozu. How are you doing today?

Mbozu Sipalo (00:08.456)

doing well Shelley Anne how are you doing?

Shelly-Ann Dakarai (00:11.091)

Good, enjoying the start of summer. Glad that it's getting warm. Yes, yes. So today we have with us Dr. Stephen Swanson, and we are so excited to have him on the podcast. He came highly recommended. We got a lot of emails about getting him on the podcast, and we're so happy that we were able to make it happen. And so in the interest of time, I'll just give a brief introduction. Dr. Stephen Swanson is a pediatrician and infectious disease physician.

Mbozu Sipalo (00:13.928)

Yes, amazing.

Shelly-Ann Dakarai (00:38.131)

He is the director of the neonatal intensive care unit at the Arusha Lutheran Hospital in Arusha, Tanzania. He is also an associate professor in the division of global pediatrics at the University of Minnesota Medical School and the founder of the Institute for Child Healthcare Africa. Dr. Swanson, welcome to the podcast.

Dr Stephen Swanson (00:57.934)

Thank you so much, Chellianne and Bozu. I'm really excited to be here. And I'm actually at the moment in the United States, just wrapping up a speaking tour and working with donors and fundraisers, fundraising. In 48 hours, I'll be on a plane flying back to Tanzania, which has become home to me. And I can tell you, I'm eager to get back and I'm eager to see our unit and to touch base again with our wonderful team of Tanzanian.

doctors and nurses that I get to work with every day.

Shelly-Ann Dakarai (01:32.019)

Great. So I'm so glad that you could fit us in. So let's just start kind of at the beginning of your journey in Tanzania and kind of start there and talk about what led you to Arusha, Tanzania. That's not where you're from. So kind of talk about the roads that led you there.

Dr Stephen Swanson (01:51.758)

Well, I sort of wind back the clock a bit. I went to medical school very much with the explicit desire of becoming a pediatrician. I had the privilege as an American of growing up in Asia. And so I lived in Taiwan for my entire life until I was 18, 19 years old. So moving back to America as a expat, having lived their life internationally,

I felt very much like an American, but not an American. My heart was international. And, and so I looked for ways and options to bring myself back internationally. And one thing that was very clear to me is that he loved kids and that I, had a natural love of science. So by and by I opted to go to medical school, but there was no one in my family on either side that had done anything medical or science related.

And so the decision to go into medicine was a later life decision in my mid late 20s. From there, it was clear I was going to do pediatrics and I opted to do pediatric infectious disease fellowship, breaking that up between a chief residency year in pediatrics and a PEDS ID fellowship by working as a NICU hospitalist at Stanford University Hospital for a year. In my core,

I knew a couple of things about myself and so much of our life is it not is trying to understand what we're good at, what we love, how can we use it for the betterment of the world. And that journey still doesn't end even in my late fifties. What I knew is that I loved kids and I wanted to be internationally and I particularly loved babies. But at that point I had had enough international experiences that I felt a natural door to.

work internationally was going to be through pediatric infectious disease. Because at the time it was communicable diseases, malaria, TB, HIV, that was diarrheal diseases, pneumonia that were the largest burden on children. And it would also be epidemiology, which I was interested in. And so I pursued the track of and spent with pediatric infectious disease. I spent a couple years doing epidemiology with the CDC as an epidemic intelligence service officer.

Dr Stephen Swanson (04:15.726)

And I just been waited for about 10 years looking at every opportunity. I was in 2012, I took a team of young doctors from the University of Minnesota residents to do a global health elective at Salyan Lutheran Hospital in Arusha. And by the time I was getting ready to leave six weeks later, the founder of that hospital had written a job description to bring me back to Tanzania.

And my wife was on board. Our three children were not on board. They did not want to move to Africa. And they were seven and 10 and 13. But we accepted the invitation and we found a way to fund ourselves through the Lutheran Church in the United States. And in 2013, we took the plunge, moving mid -career, life, family, three children to Africa. And then...

Our kids went to Tanzania at age seven, 10 and 13, because we promised each of them a dog if they would come to Africa with us. And they were like, well, why not? So they all got a dog. We were an animal loving family. My daughter is starting veterinary medicine school now. And 10 years have passed, more than 10 years since we made the move to Arusha. It's been an amazing.

and wonderful journey and a difficult journey with a lot more highs and lows than I could have ever possibly envisioned. And sometimes those highs and lows collapsed into the span of one day or even hours. But it's a journey that I wouldn't undo. And I feel that I am a better physician, a better clinician, a better human being because of the privilege of having

been able to work in East Africa the last decade.

Mbozu Sipalo (06:17.288)

Thank you so much for sharing that, Stephen. It's a beautiful story of just triumphing through the African space. For those who are not familiar with Tanzania, can you please explain more about it and a bit about Arusha as well?

Dr Stephen Swanson (06:38.318)

So Tanzania is a country that sits right below the equator on the Eastern coast of Africa. It's a country with a relatively large landmass. So you could fit, for example, the state of Washington, Oregon, California, and Minnesota, where we're originally from, into the square miles or square kilometers of Tanzania. It has...

At present, over 65 million people. It's experiencing one of the highest population growth rates in the world. It is one of seven countries that's going to contribute 50 % of births in the next 20 years to the world. And it's a country that is a very beautiful country. It's unified by a common language of Swahili.

It's a country that's very peaceful. They've never gone through a civil war or a conflict. And it's a country that is known for having Kilimanjaro, the Serengeti in Goringora Crater, some of the most magnificent mammal viewing in all of Africa. Where we live is in Arusha. It's a city of probably over a million people. We don't really know the exact numbers, but we serve a catchment area, our hospital.

of between five and 10 million people. So we have a really large referral base. And Arusha is in Northern Tanzania. It's a bit of a tourist destination because people come to Arusha when they go, want to go to the national game parks in the Northern part, including the Serengeti, which is about four hours from our house. On a clear day, we can see Mount Kilimanjaro as well, which is two hours to the east of us. And so we arrived into that country.

And the thing that I was immediately became aware of was how different it is when you go to stay versus you go to visit or as a short -term volunteer. You know, I had resigned from my job at the University of Hennepin County Medical Center in the University of Minnesota. I had packed or given away or sold virtually everything that we had.

Dr Stephen Swanson (09:00.782)

And we had taken our children out of their public school and we had moved to Tanzania. And suddenly things that I would normally see and think, well, this is just part of the new reality of working in a different country, different healthcare resources. Those things, when they began to reoccur time and time again, particularly what I deemed to be sad and preventable deaths of children, those things.

became our new reality. And I didn't have a plane ticket back home. And so therefore it became much more close and personal. And I, in my first year experience of extremely high number of newborn and pediatric ward deaths. And after about a year into it, I made a trip to Kenya to see,

a mission hospital called Kajabi Medical Center, saw their NICU. Kajabi was a hospital I had worked at briefly in the late 1990s. Came back to Arusha and said, we can start a NICU in this hospital. Why not? Because we had only a small room with few nurses, often rotating out. And the death rate was very, very high. One out of every

three to one out of every four babies that would go into that small room that they called a NICU, but it was anything but a NICU, one out of every three to one out of every four babies would not leave that room. We had almost no hope of saving a baby that was extremely low birth weight, less than a thousand grams. We struggled in the early years because the equipment wasn't working well. It was a single ill -equipped room.

sort of added as an afterthought to the obstetric ward because hospitals get built, they focus on maternity and then they realize, we have a problem of small, sick and unprepared babies. What do we do with those? Most of our equipment was donated. It was largely broken in the unit. We were struggling with makeshift CPAP using 100 % oxygen. Our nurses were rotating through the unit every three months.

Dr Stephen Swanson (11:26.19)

as is often the case in many African hospitals based on the conviction that nurses should be able to competently care for all patients with equal ability. And therefore, any nurses we were training, we're soon after learning procedural skills and familiarity with newborn conditions would be rotated out of our unit. And we didn't have written protocols, we didn't have trained doctors. And it was a small room that was a room that,

was frankly, I had a hard time walking into day in and day out. So I set about to, with a team of Tanzanian colleagues, to develop what we determined was a NICU. And that was because I was developing this growing realization that all of my training in pediatric infectious disease, thinking that was the number one cause of childhood death,

I had gotten it wrong. The landscape had changed. It was now newborn mortality, neonatal mortality that was the leading cause of under five death. And in Tanzania, neonatal diseases primarily comprise of the, what I call the unholy trinity of prematurity, birth asphyxia and sepsis. These three conditions alone were contributing to more deaths in Tanzania than

any other disease or condition, irrespective of age or gender. That meant that there was more babies dying than malaria or tuberculosis or HIV, car accidents or heart attacks or strokes in Tanzania. And so we needed a NICU and we needed that place to get started. And so we launched that journey.

And now I get into the story of, if it's all right, telling you what happened because that journey was several years in the process.

Shelly-Ann Dakarai (13:28.595)

Yes, please do.

Dr Stephen Swanson (13:31.682)

We doubled and later quadrupled the space that we called our NICU in the hospital by adding on new rooms. We got in donated equipment. We wrote practical protocols. We ended the practice of our hospital rotating our nurses out every three months for fresh new batch of nurses. We began to invest in our doctors and training them. We got new medicines and...

And yet our death rate didn't budge. Despite having what any government official or hospital administrator would walk into and go, wow, this looks like a really lovely NICU. All of that kept our death rate the same. And that makes a point that a protocol, equipment, a shiny room, and doesn't always change death rates.

And around that time, I began to recognize that if we were going to improve our NICU, we were going to have to tackle the problem of medical culture and that building a NICU had to start with our nurses. And so I went to administration and I improved the ratio of our nurses from one to 15 babies to one to four babies. And we...

screened and invited some experienced NICU nurses from the USA and Canada to come out to help build skills and knowledge. We discouraged these NICU nurse instructors from being there short term. We wanted them to stay on average four months and they needed time to learn the hospital. They needed to be in an accompaniment role, not removing work duties from our Tanzanian nurses, but being there and walking alongside them.

loving on them, encouraging them and finding an opportunity to teach. And it was during one of those early moments when we had two NICU nurses from California embedded in our unit teaching our nurses that a little baby that I'll call Corrine rolled into our NICU. She weighed about 780 grams. She had been alive for

Dr Stephen Swanson (15:51.694)

at a local hospital 45 minutes away for two weeks. We don't know what her birth weight was, but I'm guessing that she was about 28 weeks gestation. And at the time that she came in, she was under 800 grams, 780. Corrine rolled into our NICU because a nurse had decided from that local hospital to transfer to Arusha Luther Medical Center. And when Corrine rolled in, our nurses looked at her and said, she's not going to survive. She's going to die.

that often becomes self -fulfilling. And by God's grace, we happen to have those two lovely California nurses in our, NICU nurses in our unit teaching. And they said, let's just practice everything we have been working towards. Remind you, I remind the audience again, at that moment in time, we had no hope of saving a baby under a thousand grams. I mean, our survival rate was on, was

probably about 15%. So, Corrine, we warmed her. She was in acute kidney failure. She was significantly dehydrated. She was in respiratory failure. She was showing clinical signs of sepsis too. So we warmed her. We started her on stronger antibiotics. We put her on bubble CPAP that was humidified and warmed. We started to correct her renal failure.

And a baby that I thought would probably pass away within a few hours lived to the end of that day. And the next morning she was a bit stronger and the next day a bit stronger and next year a bit stronger. And to make a long story short, Corrine was discharged from our NICU with a weight of about 2 .3 kilos. She came back at 10 months at one year at three years of age. And when our nurses saw that their

anticipatory proactive steps could save a baby and that this was not written in stone or God's will, that this was a baby that they could save through attention to detail and being anticipatory. And it's like a fire was lit in them and there was no holding them back. At that moment, our NICU changed and it changed

Dr Stephen Swanson (18:17.134)

and our survival rate started to take off. And we went from a 20 % EOPW survival rate to today we're over 80%. Our VOPW survival rate is approaching 90%, provided the child doesn't have an underlying congenital anomaly and arrives into our NICU with a recordable body temperature. Those are the caveats. And that became clear to me that

As important as any equipment or protocol or staffing ratio, it's culture. We have to get the nurses, and I'll come to the doctors in a moment, to think differently about medicine and their role and the survivability of these babies and the effects of being proactive and anticipatory. We made other than changes with our nurses.

we began to assign them the babies because before that, every nurse was every baby. Every baby was every nurse's responsibility, but everybody's baby is nobody's baby. So we basically told the nurses, these are your babies. We involved the nurses in our rounds and we encouraged input and questions from them, which was radical because in our hospital, I don't think any nurses had ever joined Dr. Rounds.

or ask questions or wait in on how a baby was doing. We modeled, I modeled to our young doctors that the nurse's opinion was important and that they should review doctor's orders. Doctors are not infallible. They make mistakes. We had had examples before that of nurses knowing that the order or the drug dose was definitely wrong, but not feeling courageous enough to bring it up to the doctor.

And so from that, what we were doing is we were elevating the status of our nurses. We were giving them worth, we were investing in their training. We were making them an important part of the team. And today, I believe more than anything that hospitals rise and they sink based on the level and quality of nursing care. That it's actually more important than the doctors because they're there 24 seven. And

Dr Stephen Swanson (20:43.438)

So that was the first thing that we did that turned our NICU around. Then we focused, or simultaneous and parallel to, on accompanying the doctors. We needed to address the dysfunctional hierarchies that are there. You know, as a legacy of colonialism and out of cultural respect for elders,

young doctors just generally don't challenge authority. They don't challenge or ask questions or disagree. And so I had to encourage our young doctors to speak up, to look up facts, to not memorize. And even when they would ask me a question as a professor of pediatrics, even if I knew the answer, I would say, that's a really good question. Let's look it up together to model.

that it's okay not to know, and that they should double check and look things up, including drug doses.

As part of accompanying doctors in this journey of becoming a true skilled clinician, we had to model listening to the nurses and we had to on the other side encourage our nurses to speak up and have a voice. We began to be more transparent about our mistakes, doing it in a safe environment where doctors were not shamed or humiliated because all of us at some point have to have the training wheels taken off of our bike. We're going to all fall.

And so let's discuss these mistakes and actually learn from them rather than bury them and deny them out of a fear of being shamed in a shame honor culture. I had to encourage our doctors and our nurses to pay a lot of attention to detail. The details matter. Small changes in a baby matter. And that's hard because Tanzania, I would say, has so many cultural strains.

Dr Stephen Swanson (22:44.814)

in terms of its warmth and its friendliness and its value on community. But attention to detail is one that is, you know, is something that's not really reinforced much in the early schooling years. And so our doctors, we had encouraged the attention of detail nurses to synthesizing clinical information, recognizing their own clinical and personal cognitive biases. Boy, talk about a new topic for our doctors.

It was trying to teach them about our cognitive biases, you know, of attribution bias or just the biases that we go into in when we look at a sick baby. And helping the doctors form a coherent assessment and plan, not memorizing facts. This was a journey. But once we started to do this with our doctors, really in effect teaching them,

and modeling clinical thinking, critical thinking, and not memorization. Our Tanzanian doctors just excelled. And within about a year or two of this, I had young Tanzanian doctors who had just finished their internship, worked with me as a medical officer for two years, who could manage a 700 gram baby, as well as any African neonatologist.

that I had yet met. It was astounding to me how if you love on them and you water them, how quickly they were going to bloom. And that changed my thinking. I stopped referring to Africa or Tanzania or our hospital as a low resource hospital. I don't believe, I don't use that term, at least not intentionally any longer. Africa has...

plenty of resources. And I realize Africa is not a country, it's a continent of 1 .3 billion people. But let's not call it low resource. The resources are there. We just have to discover them and support them. And we meaning the collective body of medicine. And when we started to do that, our doctors excelled. So we worked on the nurses, we worked on the physicians.

Dr Stephen Swanson (25:13.39)

But that wasn't enough. We had to partner with our families. And this was actually before KMC was starting to become in vogue. I had recognized that in many of the NICUs I was seeing in that country and other countries, moms were basically allowed in the unit only at the time of feeding and otherwise were being kept out. Fathers would rarely step foot into a NICU to see their children.

And there was a lot of looking through glass windows at babies on the part of the mothers. So we really opened our doors to get the mothers into the NICU. Of course, we had to teach them how to do hand washing first, but I became convinced that the mother is as important a nurse for her baby as the designated nurse for that shift is.

So we taught the mothers how to express their milk, how to fortify it, using regular formula to boost the calories and nutrition, how to feed their babies via NGT -OGT. We started doing skin -to -skin very early. We would have 700 grammers less than 24 hours old, still on CPAP, doing skin -to -skin with their mothers. We asked the moms to join rounds. That's still difficult to get moms to come in, but we would ask them to come in around the time of rounds.

so they could listen to and contribute to rounds on their baby. And by involving and partnering with families, we were moving our unit towards a more compassionate model that was less physician -centric. And then we had to tackle one of the biggest beasts in the room, and that was the problem of technology. We were dealing with our nurses.

We were changing the culture of our doctors. We were partnering with families, but we had the problem of technology.

Dr Stephen Swanson (27:16.238)

And if you can give me a few minutes on the issue of technology. I've discovered over a dozen plus years of living and working in Africa and another equal number in Asia. People want a machine to leapfrog into the next generation of healthcare. There is this pervasive deep seated view, especially in many hospitals in Tanzania.

that if I can have a piece of equipment, I can become like the West. Well, let's set aside that whole question. Should we even become like the West? The goal should be to create an African hospital that runs really well, not to reproduce a British or American hospital in Tanzania. That was never my goal. It should be none of our goals. Equipment, in many instances, actually contributes to death rather than saves babies.

I know of one major hospital in Tanzania that received several new NICU ventilators. And for the first two years, 100 % of their babies put on the ventilator died because they didn't have the blood gases, the portable x -ray, the experienced nurses, the suctioning of ET tubes, the protocols. Meanwhile, more babies who would have lived on good high quality bubble seat pap were neglected because that

machine, the ventilator was there to save them in the minds of the nurses and doctors. So equipment, incubators included, can contribute to death rates rather than help them. And so much of equipment in Africa today is donated, and it's a mismatch of equipment and what the NICU really needs. And then of course, you have the problems of local heat and humidity and electrical surges that damage the equipment.

You have a lack of parts, perhaps biomedical engineers that are unavailable. You have various manufacturers of this donated equipment, each piece of equipment having its own spare parts and protocols or manuals. And all of this contributes to equipment graveyards. And 70 % of donated equipment by some estimates ends up in an equipment graveyard today. It could be as high as 90%. So we adopted a very conscious approach that

Dr Stephen Swanson (29:39.886)

we were not going to rely on a machine to save a baby. That we would rely on the nurses and doctors and that our use of technology would be judicious. And today our premature baby survival rate, if you're 26 weeks and greater, our overall preterm survival rate in our NICU is above 90%. And as I said, it's above 80 % for EOBW babies. And we do that without a mechanical ventilator.

We do early surfactant administration. We'll do bubble CPAP. We focus on thermal regulation, respiratory support, nutrition, and infection prevention, but we're not trying to reproduce the West with expensive equipment. We tried a ventilator in our unit and it increased our mortality rate because the nurses would watch the one baby on the ventilator and neglect the other 10 babies on bubble CPAP.

these were the challenges that we faced and these, this was the result of, of, you know, I've compressed maybe five years into 20 minutes, but that was, that was our journey. And once we, we got going, we just watched every year, our survival rate increasing, nudging higher. We started to cast a larger and larger net. We would have.

Babies coming from as far away as eight hours after birth, sometimes as little as 600 grams. And we would have babies coming in wrapped against their mothers on the back of motorcycles driving two hours, or on the back of grandmothers, I should say. We were approaching 30 hospitals sending us their babies, and we were a relatively small mission hospital. Our NICU is only 24 beds. That includes the KMC unit and the intermediate.

And it came out of that and the book that we wrote detailing our protocols that we locally print, but it's called Every Breath Counts, the manual for neonatal care and drug doses. It's about a 400 page manual that really was us distilling down what we had learned into practical protocols. That book and our experiences led us to...

Dr Stephen Swanson (32:06.574)

Start the Tiny Feet Big Steps, Advancing Care of Critically Ill and Premature Babies in Africa Conference, which this year will be our fourth year.

Shelly-Ann Dakarai (32:21.907)

Thank you so much for going over that. That's pretty amazing and inspiring work that you've been able to do in, although it's been 10 years of doing work, the amount of progress that's been made, it's a short time for neonatal mortality. If you look at some of the papers that look at how many years it takes to go down a notch and then down a notch again. So that's pretty amazing work and pretty inspiring.

You talked a little bit about how you had to get the nurses, you talked about the buckets, the nurses, the doctors, the technology, and I appreciate you kind of putting that all into perspective, but it sounded like you started by changing nursing assignment, and I wonder how you were able to do that. How were you able to get buy -in from the admin folks at the top when that was not something that was something that they thought was necessary important back before you asked for that?

Dr Stephen Swanson (33:18.19)

Yeah, good question, Chellianne. And that is, you know, the importance of good administration, good leadership in the hospital and governance is so important. We could not have done this without, at that time, the buy -in of hospital administration. I think they recognized the desperation of the need for NICU. We were attracting a higher and higher

population of high -risk obstetric patients, a larger and larger population of high -risk obstetric patients. And the leadership knew that because I was constantly bringing it up to them that neonatal diseases is the next frontier. We have to challenge it and address it. And we can't purport to have a good hospital focused on with quality obstetrics if there's no NICU.

And so I had to basically convince them two things. One, we need more nurses. Two, when we train nurses and give them the skills and the knowledge of newborn conditions so that they recognize when a baby is having reflux versus vomiting or when a baby's condition is changing and showing signs of sepsis.

we can't take those nurses and rotate them out. And so I really had to work hard with the nursing matron and with the head of the clinical department, the director of clinical services. And I also had to do that for the doctors because we had the same problem on the physician side of things. We would, you know, in the Tanzanian system, you go to medical school, then you go to internship. Internship covers four domains.

medicine, obstetric surgery, and pediatrics. At the end of internship, doctors generally get a posting as a medical officer. We call them registrars in Tanzania, but it is these registrars or medical officers were being asked to cover every department. And I was saying to the administration, no, we need two, three today. We need seven because we've grown, but we needed doctors posted exclusively to pediatrics.

Dr Stephen Swanson (35:41.646)

We could not train a doctor to intubate and deliver surfactant or to stabilize a baby or to occasionally and rarely put a central line into a baby like a UBC just to see them leave and go to say orthopedics. So we managed to stop that practice of rotating medical officers and nurses and that along with pairing them with people who...

came with more experience to teach in a loving and long -term way. We're not talking short -term volunteers, but long -term volunteers. That really changed so much of our results and our outcomes. Again, I come back to people don't always talk about medical culture and hospital culture because it's ambiguous and hard to quantify and define.

But culture is real and it exists in every institution. Believe me, I know that having done my medical school at Harvard and then training on the West Coast and then the Midwest and then Washington University, every institution has its own culture. Every country has its own culture. And medical culture as a whole is among the slowest, most resistant to change of any culture I have ever come across. If the world of technology changed as slowly as

as medical culture does, we would all be still using a typewriter rather than a computer. And so we had to really push for a change in that culture. And part of that change of culture was involving the parents and speaking kindly to the mothers. And as I said, elevating the voice and the status of our nurses.

Mbozu Sipalo (37:41.352)

Thank you so much, Stephen, for sharing that impactful account of how you worked on the medical culture and how it's really something that needs to be worked on. Just to highlight the low tech approach that you brought up to reduce the neonatal mortality in Arusha, what advice can you give other resource limited settings on how they can optimize low tech care? For instance,

At Arusha Lutheran Medical Center, you use blended, warmed and humidified CPAP. And in other centers in Africa, for instance, where I worked in Lusaka, we tend to improvise on the CPAP, which compromises really the care for that sick baby. How do you think we can improve that? And how do you think other centers that may not be mission hospitals can work around really working on?

how to improve that low -tech care.

Dr Stephen Swanson (38:44.334)

Yeah, I am. That's a great question. And I would say that one of the reasons why we have such a high survival rate is that over 70 % of all of our NICU admissions, irrespective of gestational age or birth weight, over 70 % will end up at some point on bubble CPAP. We basically put all of our birth asphyxia babies on it. Most of our...

septic babies end up on bubble CPAP to just augment their respirations. We are now pioneering a use of a NIPPV device that runs some nasal intermittent positive pressure ventilation is called NeoVent that is been designed from a doctor with experience out of Nepal and India who's based in the United States and runs without electricity. And,

because respiratory support, being the lungs for the baby or helping to be the lungs for the baby is so important. CPAP, I think, as well as our emphasis on thermal regulation and nutrition, trying to really boost nutrition and get our babies back to or above birth weight within a very short window of time and see them gain weight thereafter, those have been the mainstays of our high survival rate.

We have an advantage in our hospital that we have an oxygen plant. It sometimes breaks. It doesn't always work well. But we have an oxygen plant that was put in at the foresight of the man who built our hospital. And an oxygen plant was helpful. But then we had to put in a medical air compressor, which I raised the funds to do ourselves. And then we had to get blenders into the country. And that was a difficult thing, getting them through customs as a piece.

because they didn't understand what that was. And then we had to figure out a way to warm and humidify it. So today, our entire CPAP system costs us under $200, but we have the benefit of an oxygen plant and medical air, without which hospitals are really forced to run bubble CPAP off of a cylinder or an oxygen concentrator, delivering 100 % FiO2 or 95%.

Dr Stephen Swanson (41:02.286)

And we all know about the negative effects of oxygen toxicity, especially on the very small babies and preterm babies. But this is where we need new innovation coming into play. Because what we do, when I say we focus on low tech, we're not putting in, I mean, we have phototherapy lights, we have monitors for babies to monitor their heart rate and stats. We have IV pumps.

to deliver safely the fluid at a steady state and medicines. And we have bubble CPAP. And those are the mainstays of what we are doing. But we're not relying on total body cooling for berth asphyxia or as I said, ventilators. How do we get bubble CPAP to work in Africa? We use a ram candela and that was...

developed by Professor Ram out of, based originally out of LA Children's Hospital. Ram cannulas, which are spelled R -A I love, I am the biggest fan of them because they go on the face and they can be easily secured. You can transition the baby on a Ram cannula to nasal cannula. You can position the baby, put him prone, put him skin to skin with moms. You don't have to have a hat. You don't have to worry about it coming out.

It doesn't damage the nasal septum at the same rates. It was a game changer for us using ram cannulas as compared to the previous types of cannulas, Hudson and others that we had struggled with and never worked well. And I'll just tell you that we have babies as our smallest survivors, 350 grams with bubble CPAP. Now that was an outlier, but you know, for us, if we get an 800 gram baby on bubble CPAP, it's warmed and humidified.

And we can do early surfactant if they show signs of severe RDS. We have a very high survival rate. Our babies that do end up dying in our NICU actually die of sepsis, late onset sepsis. And that's one of the big, what I call it for us, the four legs of our NICU success has to be the fourth leg being infection control and prevention. The other three, thermal regulation, respiratory support, and nutrition.

Dr Stephen Swanson (43:25.326)

So how do we help African hospitals with it? Well, there's a need for innovative biomedical engineering that really works for the African context. And there are a lot of devices that are out there on the market being pushed into African hospitals. And I'm just going to be very frank with the audience and say, they don't work well. They're junk. They may have studies to show the survival rates. They may have done large.

trials in certain countries like Malawi, but when you actually go there and you live and work in the trenches, these devices are not working. They're problematic. They're causing desiccation and drying out of the noses. Babies are stopped breathing because they can't breathe because their nose is so dried out because the unit doesn't know how to warm or humidify. They're noisy. You can't have some of them more than three or four in a unit without increasing significantly the decibels and

That has a negative effect on your development of babies to make it loud. Are Nick, if you walk in there, you could hear a coin drop because we turn everything down, the monitors and the alarms, everything is very quiet. so we need to find new solutions to blend oxygen with ambient air off of concentrators, use Ram cannula technology, I believe is probably the best out there and employ this in a way that is affordable.

and make it locally produced within the African continent. It can't be shipped on a container or it'll be held up by some government official awaiting some documentation to show that this meets their local compliance and you'll have to pay importation, middlemen, taxes, et cetera. I mean, today, one of our biggest challenges, having tackled the problem of nurse,

and doctor abilities aren't one of our biggest problems, just getting supplies, consumables and equipment into Tanzania. It needs to be locally produced. And we need to do this in a way with local input. And I have to say, these products that are being used and pushed into, and I see them on the ventilator side and I see them on the CPAP side being pushed into the African hospitals, they don't work.

Dr Stephen Swanson (45:54.926)

or they work very poorly. And this is, I think, inappropriate equipment developed by siloed Western developers who go to Africa and people will say, yes, they like it. But yes doesn't always mean yes in Africa. There's a yes, but they're shaking their head no. And you have to realize that.

Dr Stephen Swanson (46:26.062)

that they may tell the developer or the researcher what they want to hear. But the moment that team leaves, they revert back to not using it. And it gets, there's dust and is broken. And how many of these devices have I seen cast aside? Now we've introduced our bubble CPAP system to well over 150 hospitals. And we get reports back that they love it, but we have one problem.

Our bubble CPAP system, which still lacks, in our hospital we can blend it because we have medical air that is coming in with a blender, but it lacks the ability to blend it with ambient air. And we have to find ways to do that. There are people out there like Bayou that are developing it, but they don't use the right cannulas for the nose. These have to be adapted to ram cannulas.

So one of the huge needs in the African setting, and this would be, is innovative, locally produced, warm, humidified, blended bubble CPAP with appropriate cannulas that are easy to attach and position babies with, created for the African hospital.

We need that desperately and that is one of the things on my agenda that I want to work with biomedical engineers and local manufacturers and get it produced in centers throughout Africa so that it can be exported and received without having to come on a container held up in a port in some city for six months with an exorbitant tax on it.

Shelly-Ann Dakarai (48:21.043)

Yes, thanks so much for sharing that perspective. I do want to, before we switch gears and talk about the conference, which we definitely want to get to, I did want to piggyback on a lot of what you talked about with that respiratory management and doing what is necessary for your context, because there is a unit that I know in that does not use bubble CPAP, but their reasoning is because of.

the equipment that they have and they do have ventilators and their nurses are trained. And so the wastage of changing the circuits between Bubba CPAP if the baby fails and needs NIPPV and they have good outcomes. So, because it works for them, you know, so it's interesting that, and I appreciate you talking about, you know, doing what works for.

your unit if you have the data to support that you're making improvements, a lot of times what we write about in the evidence sometimes doesn't quite come down in the practical setting as to getting it to work, getting your nurses comfortable, getting all the other things that have to go with that. But I did want to quickly ask about surfactant because I feel like that's often the missing piece. Many units may have bubble CPAP. They may even have some access to blended oxygen, but the surfactant piece is often missing.

Can you speak a little bit about how you were able to get surfactant in your unit and how you deliver that since you don't have ventilators? And then we'll quickly move on to talk about the conference, which I think is important for us to spend some time on.

Dr Stephen Swanson (49:43.982)

Yeah.

Okay. Thanks, Shelley. And I do want to come back to, I am not anti -technology. I think we just have to create what we have to figure out a system that works in our particular NICU and not try to imitate or replicate what is being done in Canada, United States or other countries in the West. And there will come a time when we have ventilators that we will be using in our NICU. We're just not ready for it yet.

Shelly-Ann Dakarai (49:57.427)

Mm -hmm.

Dr Stephen Swanson (50:16.558)

surfactant. So in the early years of my time in our hospital, surfactant was not a recognized or licensed medication in Tanzania. The government was very, very slow to approve of it. And we spent over eight years trying to get it approved and licensed for use in Tanzania. In the early years, I had to import it through Nairobi. There was no local distributor in Tanzania for surfactant.

Shelly-Ann Dakarai (50:16.819)

Right.

Dr Stephen Swanson (50:46.414)

We didn't have blood gas as we do have them now. And so we had to create some criteria based on FIO2 and work of breathing and how many centimeters of CPAP, how many hours old of using surfactant. Once we started using surfactant, it was like we had partially solved the problem of death by respiratory distress with bubble CPAP. But there was still a 20, 30 % group of babies that were not going to survive. They were not going to improve.

and ZPAP alone without the benefit of surfactant. And so we started, once we were able to procure surfactant through Kenya, and later it became licensed in Tanzania, we were able to administer it. Here's the problems with surfactant. Number one, for very, very small babies, it requires a skill level to intubate them and appropriate sized ET tubes.

and laryngoscopes at work. And I've witnessed a great deal of trauma done in hospitals that do not understand how to intubate a small baby. Often doctors will bring in the anesthesiologist who is no better than a medical officer at intubating a baby of this size. So we had to develop the skill set and our interns, or not our interns, but our registrars, our medical officers got so good at intubating small babies that

they could get it on the first, maybe second attempt. We would never think to invite anesthesiologists in to do it who are adult focused. But we had to find ET tubes that were properly sized and laryngoscopes and keep the bulbs working. And that was a challenge. About five, six years ago, we started a pivot towards delivering surfactant by laryngomask airway, which is called the salsa technique. And we have,

To my knowledge, we were the first hospital in Africa to do LMA -administered surfactant. We have done it very successfully, down to one kilo. And there are new LMAs that will be developed and emerging soon that are going to be sized for five and 600 gram babies. It avoids the trauma. It is very effective. It is easy to use. It doesn't require replacing and buying

Dr Stephen Swanson (53:12.206)

equipment like laryngoscopes and getting the proper size blades and ET tubes. It's easy to teach and we teach that at our tiny feet, big steps, African neonatology conference, the salsa administered technique, and they're using it a lot now, a friend of mine in their hospital in Ethiopia. But here's coming back to the surfactant. It's expensive. Hospitals want to give it and expect that that baby will miraculously live.

without proper warm, humidified bubble seed pap, without proper nutrition, without proper nursing care, without proper suctioning of the nose from time to time, the nares. Surfactant is not going to save that baby. It's a tool in your toolbox, not a miracle drug. And what we saw happening in Tanzania was hospitals ordering large amounts of surfactant, but having none of the other pieces in place. And then that surfactant either expiring,

or being given to babies who then still went on and passed away, to which the families and the hospital administrators blamed the surfactant as the cause of death. And suddenly we went from surfactant being available to now it's quite hard to get again, set aside the pricing issues, which is expensive, because hospitals said, well, we tried it, it didn't work. Well, you tried it.

in the wrong sequence. You have to first put the building blocks of your NICU in place and then you add the surfactant. I believe that surfactant is important and helpful in a substantial percentage of, for sure, EOBW babies and even a number of BOPW babies, but it has to be done correctly without causing injury at the right time with the right ancillary supports and levels of nursing care.

and it has to be subsidized. African families can't, by and large, with only some exceptions, afford surfactant. So either it has to come down in pharmaceutical cost, or we have to find a system to make it available cheaper, because it costs us about $230, $250 for one vial.

Dr Stephen Swanson (55:37.774)

which is good for one kilogram baby. And that $250 could represent a month of wages for a family or more.

Shelly-Ann Dakarai (55:53.683)

I see. So the families are paying their hospital bill and that's included in it, but it's somewhat subsidized through your hospital. Am I getting that correctly?

Dr Stephen Swanson (56:02.606)

Well, we have a foundation of fund that I started that allows us to provide surfactant free of charge to every baby who needs it, whose family can't afford it. We ask them to contribute where they can, but we don't withhold it based on the family's ability to pay for it. And some private insurance will pay for it, but most Tanzanians don't have private insurance. But in other hospitals that lack that ability,

to support the NICU through external donors, they would probably have to charge it. I don't know if government insurance pays for it in most places in Tanzania, government insurance does not pay for it. And so it becomes quite expensive and it's distressing to a family to have it given and then to have their baby pass away. And then again, they will sometimes blame the surfactant when it was other factors.

Shelly-Ann Dakarai (57:01.267)

Thanks so much for sharing that.

Dr Stephen Swanson (57:01.294)

And I'll just throw up, I'll throw a plug in for, you know, skin to skin and good nutrition. Those things reduce RDS and not over hydrating these small NICU babies, not flooding them with fluids. So they need to do the other things of nutrition, careful fluid management, skin to skin, thermal regulation. I mean, I've been in hospitals where they looked at me and said, well, this baby needs surfactant. We should give this baby surfactant.

Shelly-Ann Dakarai (57:08.755)

Mm -hmm.

Dr Stephen Swanson (57:30.67)

and I took a temperature on the NICU baby and they were 32 degrees or 33. And as soon as you warmed them back up, lo and behold, their quote unquote RDS improved dramatically. This was hypothermia. So again, coming back to the attention to small details and making sure everything else has done well, surfactant thin is the next step. And I believe that...

Ella Mae administration of surfactant for at least the babies that are, you know, above a kilo is a way to do it without expense or trauma to the baby.

Shelly-Ann Dakarai (58:12.403)

Yeah, I agree. So let's switch gears since we've been talking about you brought it up earlier, the conference, and we kind of switched gears and took you on another path. But I want to kind of go back to that. You talked about that conference and how it came from the lessons learned in building your unit. So let's talk a little bit about that. How did the conference get started? And tell us a little bit more about that.

Dr Stephen Swanson (58:34.997)

So in 2020, we decided after having an exhausting year of visiting public admission hospitals and running two to three day conferences, we decided to host a conference in Arusha. And we, and so we were advertising it and it was for Tanzania. Three days before the conference was to start,

COVID hit and the world shut down. And so we had to cancel that conference in March of 2020. And we waited and we held our first one in October 2021. And that conference was three days long. And we had over 160 African doctors and nurses attend from five different countries in Africa, mostly East Africa. And the response was so...

wonderful about this conference that we decided, well, let's do it again in 2022. And then in 2022, we extended it from three to five days. And we ended up going from five countries to nine countries in Africa that attended and getting close to 200 nurses and doctors to come. And then we did it again last year. And now we were closer to 230.

nurses and doctors from 15 countries across the African continent and USA and Nepal. And the amount of lectures and workshops grew from in the low 40s to now we're approaching 80 lectures and workshops at a five day conference. So we will be doing it again this year, October 21st to 26. We're going to make it six days instead of five, because we still feel like there's more material.

And so it's a six day conference held in Arusha at a lovely five star hotel called Grand Malia. And we're projecting because we're hoping to partner with the African Neonatal Association. We're projecting probably 20 plus African countries and maybe 300 doctors and nurses attending this year. To my knowledge, the conference has become the largest clinical neonatology training conference.

Dr Stephen Swanson (01:01:00.142)

in Africa. What's unique about it, and this reflects our team and my team's core belief, is that we're training nurses and doctors from the same hospital together. Last year, we had 94 hospitals that attended from across the 15 countries. I believe that it's not okay to just send doctors to a conference, why not bring the nurses? But if the nurses are there, why not have the doctors too? Because we add to the

the richness of the conversation. So they sit in shared lectures and then they break away for different workshops. We focus it on being very hands -on skills -based, practical lectures that are short, 20, 30 minutes, practical skills, how to do surfactant by an LMA, how to position babies, how to do neuroprotective measures, infection control, how to place an IV, how to secure an IV, how to make sure...

It's not an arterial IV by accident. How to mix IV fluids to create D10 .2NS or fifth or quarter normal saline because most hospitals like our own don't have these IV fluids pre -prepared. How to fortify breast milk to boost the calories to 24, 26, 28 kcal per ounce or 30 mls. How to feed babies. What rate? How rapidly?

how quickly to progress to full feeds. And we will probably have about 80 unique lectures and workshops. We are also starting to add more and more lectures around follow -up care and developing aftercare for NICU graduates. We want to start putting in more content we haven't yet about how to work with

government and hospital administrators and leadership to get support and buy -in. And what I love about the conference is that we are explicitly targeting nurses and doctors that are working in a range of hospitals with different levels of NICU. Some of them, they're just starting their NICU in say, Northern Mozambique. Others, they are...

Dr Stephen Swanson (01:03:28.398)

have an advanced NICU at a teaching hospital in Campala or Lagos, but they all come in and they all have their own problems that they're facing in their NICU. And they're all in the trenches, taking fire, seeing deaths, feeling discouraged, feeling very alone. And when they come together, nurses and doctors, they discover in this conference that they're not alone, that there are other people across the continent who are sharing the same passion.

have the same burden, facing the same struggles. Some have figured out solutions, others haven't. And there's a lot of in -between sessions and workshops in the evenings and during lunch hours where there's constant talking back and forth. And we love on this team of 200, 300 doctors and nurses, we give them great food, we give them a beautiful venue. And we want them to know that,

that they're loved, they're valuable. What they're doing is amazing. And we want to partner with them and help just move that needle a little bit in the ability of their hospital to make improvements. We send them back with materials and the workbook or the handbook that our team wrote. We demonstrate non -invasive forms of respiratory support. It's an amazing experience and I love it.

And I think that what I love about it is that I get feedback afterwards that we implemented this or we learned that in the workshop and we tried it and it's working. And our hospital now has a grandchild. You know, we've started another NICU and another NICU and you get stories of becoming a grandpa through this conference. It is...

It's African centric and we're trying to take practical skills and knowledge that you need for nurses and doctors in a low income setting. And we're trying to give them those practical skills and encourage them in the process. And it's one of the hardest things I do because I have to raise a significant sum of money to make, to pull this conference off. We subsidize every,

Dr Stephen Swanson (01:05:56.462)

African nurse and doctor on the order of 50 to 75 percent of the conference cost. We raise through donors and sponsors in order to make it affordable. Every African -based speaker, we travel, we cover their speaking travel expenses or their accommodation and travel expenses. And we work very hard to get African doctors and nurses upfront teaching it.

as an example of, you know, there are people doing it in the continent. They don't need to see a white face saying this is how you do it. They can see their own neonatologist from Nigeria standing up and teaching. And that's what my philosophy is. Yes, we bring in people from academic centers in Europe and United States and Canada to help teach. Last year we had 26 academic institutions represented in our, but we try to put...

a very strong sort of African centric focus on the teachers and trainers, nurses and doctors. And I learn everything. I learn every year at the conference, even though I'm the director and coordinator of it. It's like, I mean, it was through these conferences that I learned about a form of NIPPV that doesn't run on electricity.

Mbozu Sipalo (01:07:22.824)

Thank you, Stephen, for sharing that account of the incredible work you're doing that focuses on long -term benefits. And I love how the conference unifies Africa and unifies the unitologists. I just have a question linked to that unifying of specialists. What are your thoughts on clinicians in resource -limited settings, such as those in Africa, consolidating guidelines, protocols, manuals?

based on evidence from research across different regions and focusing on unified implementation strategies instead of region -specific protocols that convey similar messages. I find that we have common problems, meaning they could be common solutions. So just wanted to pick your brain on that.

Dr Stephen Swanson (01:08:19.95)

Dr Stephen Swanson (01:08:23.726)

I do not want us to have to recreate the wheel in every hospital. There are things that are out there that work and we need to learn from each other and we need to implement it. And I think that's important. So finding common solutions and that's what we're trying to teach at the conferences. It may not be the solution for everyone, but this is a solution that we have figured out that we have the evidence really works.

maybe you want to implement it in your unit. I'll say, for example, our feeding protocol, which was implemented well before research started to come out about early inter -feed with rapid advancement. And the fact that we get our average baby back to birth weight before two weeks of life, even our ELBW babies is astounding compared to when you go into many hospitals today in Africa and you'll find a baby.

commonly four and six weeks of life that may be still below their birth weight. So I really do think that there's a need to unify and consolidate our protocols. At the same time, I recognize that a lot of protocols are coming out and because Africa is a continent and not a country, that some protocols generated from places like say in Cape Town or Nairobi.

just don't translate well to smaller district hospital admission hospitals. And so there has to be the ability to adapt and localize a protocol. And if you think about the scene in the United States, I mean, people still can't agree on a lot of protocols. You know, do we do early PDA closure or do we take a watch and wait approach?

Should we be giving steroids to a baby to prevent RDS or should we be waiting or sorry to prevent BPD later or should we be waiting? There's a lot of disagreement. What I do think that we should come together and agree on is, and these are in my opinion, is the value of and the method of thermal regulation of these babies. The KMC works, but it doesn't work in every setting.

Dr Stephen Swanson (01:10:50.158)

We have a lot of mothers who are in the ICU or at another hospital when that baby arrives. So there's a need for in referral hospitals incubators. How do we use them correctly? But let's promote and push KMC really hard. And we've been doing KMC and our 700 gram babies from the beginning. There needs to be unification around, I think, feeding protocols and rapid advancement of feeds.

in many hospitals today in Tanzania, by day of life three, babies are still not being internally fed. They're being kept in PO. Recognizing when things are not neck, I mean, how many babies get called who are just spitting up, it's called neck and they get made in PO and they get put on antibiotics. And these constant restarting of antibiotics and re...

and stopping of internal feeds just has profound downstream effects on the baby's growth, development, and later infection rates. There needs to be unification around infection prevention and control and practical. Make it practical. Let's not try to roll out measures that just aren't going to be work in a hospital when you have crowding and you have understaffing. And so there's room to

for consensus and there's room for adapting to your own setting. And that's the kind of conversation I hope comes out of these, when we do these conferences. And the people who should be weighing in on this the most are people in the trenches in Africa. I really feel that, and I've spent my life in academic medicine before I went to Africa, that...

well intended though they may be, we have to move away from the silos of Western academia and prescribing what Africa needs and get much more local buy -in that says this works, this doesn't work. And they need to find that voice and speak up because a lot of the protocols that I see coming out, even from the WHO, is just, it's pie in the sky. It's not going to ever work.

Dr Stephen Swanson (01:13:14.094)

I mean, look at the WHO Sustainable Development Goal 3 .2 that in six years they want to end preventable newborn deaths. Is that going to happen in six years' time in Africa? It's a lofty goal, but it's not going to happen.

So let's accept the fact and still make changes without pressuring countries to artificially lower their and falsely lower their neonatal mortality rates to meet a superimposed millennial development goal or a ministry of health goal that is out of touch with the reality on the ground.

Mbozu Sipalo (01:13:56.904)

Thank you so much for that really insightful response. I think it will give us a lot to think about afterwards. I think we'll be wrapping up soon, but just to bring it all together, I'd like you to share with our listeners and with us the inspiration and the driver behind all these things you're doing. Could you tell us a little bit about the Institute for Child Healthcare Africa?

Dr Stephen Swanson (01:14:23.086)

I C H A yes. So as the Tanzanians will be calling it each up, but it's Institute for Child Health Care Africa. So a few years ago, our hospital started to run into problems with leadership and governance and financial challenges, as well as spacing challenges for our NICU and a change in the vision and direction of the hospital that I felt was not.

compatible with what we wanted to be able to do in changing the discussion and landscape around neonatology. So we started, I started along with a team of people in the United States and in Tanzania, the Institute for Child Health Care Africa. And what we want to do with ICHA is to promote and model quality pediatrics, particularly around neonatology.

through a model of outstanding clinical service, research and training. The neonatology conference this year, Tiny Feet Big Steps 2024 will be held under the Institute for Child Health Care Africa. And our in -game is actually to raise the funds and build the first mother and child hospital in Tanzania.

and one of only a few in all of East Africa. A mother and child hospital that really from the point of conception on through the spectrum of pediatrics focuses on quality care. We want to build a hospital in such a way that teams of doctors and nurses from across the African continent, not just Tanzania can come.

and do a one month attachment on the obstetric ward or in the NICU assigned to a team where they are being mentored and modeling all of the things that we talked about, the culture of medicine, how we involve the parents, how we perform skills and procedures, the way our doctors and our nurses interact with each other, a simulation and a lab and competency training.

Dr Stephen Swanson (01:16:46.158)

And I come back to that because we can give them a book and we can lead them into a conference and do a workshop. But that doesn't change outcomes as much as seeing it firsthand. I come back to that story of Kareem. When our nurses saw a 780 -gram baby within hours of dying, survive and go home and become a healthy, neurodevelopmentally normal child, it lit a fire in them that this is possible.

in our hospital, and we don't have to make excuses any longer. Can we do that through a maternity children's hospital based in in Arusha that is really more focused about bringing teams of doctors and nurses to do one month attachments or longer in our unit, and we learn from them, they can see and learn firsthand from us what works, what doesn't work. And they can develop a core set of competencies and that gets partnered with the conference. And then as

part of each's mission, we find ways to locally develop through biomedical engineering and manufacturing the very products that we are using so we can help them acquire and procure it from an African location instead of relying on it being shipped from California, for example. And so we have a model of outstanding clinical service.

training and then developing research through an institute of neonatology, an institute of midwifery. It's a big lift, but I think it's possible. And it's a way for us to continue to build on what we've done. And I've got an amazing team of 10, 12 Tanzanian doctors, two of whom are in South Africa right now, pursuing further training, two up in Nairobi.

one possibly in Minnesota, and these doctors will be the face of this. And they will be the ones running the research along with other collaborative organizations, being the face of neonatology, being one of many players in this continent, changing the narrative that small and sick babies don't survive. They can survive, and they can survive in a low tech,

Dr Stephen Swanson (01:19:12.174)

low -cost evidence -based manner. And that's what we want to try to build on our past successes and continue to grow it through a mother -child hospital.

Shelly-Ann Dakarai (01:19:28.659)

Thank you so much, yes.

Dr Stephen Swanson (01:19:29.038)

My wife says I'm a dreamer. I, yeah, my wife says you're a dreamer. I go, well, I can live with failure, but I can't live with not trying.

Shelly-Ann Dakarai (01:19:33.683)

Yep. Yep.

I think it's a remarkable goal and one that is needed and I pray for all success in that. You've made different, you know, success thus far and you have a great team and so the sky really is the limit. So thank you for sharing that with us. So we are wrapping up now and we'd like to ask one last question about, you know, there may be folks working in similar situations.

Dr Stephen Swanson (01:20:00.75)

Thank you.

Shelly-Ann Dakarai (01:20:08.915)

As you are any words of advice to help them keep going on those hard days or when they're getting pushback from their admins or you know all the challenges that come into taking care of babies in in similar situations any last words of advice before we we say bye

Dr Stephen Swanson (01:20:31.694)

I want to acknowledge that the people that are working in the trenches, including my own doctors and nurses, that they are, along with the mothers who are fighting for the survival of their baby, that they are the true heroes in this world. I know it's hard, and I know that it's hard not to get habituated and numb to the high death rates that...

many hospitals, including our own, has experienced. But I believe that they are the true heroes. And I think that that needle moves slowly and you don't always know it. It's like, you know, as a as the father of three children, you know, when you one day put your child against the wall and you mark a line to see how tall they are and you go, my goodness, they've grown four centimeters in the in the past year or less.

You don't always see that growth that's occurring. It seems slow and it's painful, but that's when you need people to come in as it happened to me and look at your unit and say, you are much farther along in this journey than you were a year ago or two years ago. Nick, you change and changing medical culture, the culture of nurses and doctors and engaging in the families and the culture of hospital administration and government leadership.

That change comes slow, but it does come. And one day you look back on it and you go, we are so much farther along than we were. And it's a fight worth fighting. It's why I gave up what I was doing in the United States to join in that fight. And I am the richer for it. And these doctors and nurses, I believe will be the richer for it.

Dr Stephen Swanson (01:22:31.566)

But I think we also have to balance that.

hopeful message that change can happen. It just takes time with the realization that it's also really hard. And they need a lot of love and support in this journey.

Shelly-Ann Dakarai (01:22:52.339)

Thank you so much for those words of encouragement and a great way to end this podcast. I'm sure people who have listened have been pretty inspired and some may want to connect with you. So as we wrap up, can you just let us know what's the best way that folks can connect with you if they have questions or want to support your work?

Dr Stephen Swanson (01:23:12.462)

So I would say the best way to connect with us if you are interested in the conference and interested in registering, it's first come first serve and we will probably close it when we get to 300 registrants from across the continent is to go to the www .tinyfeetbigsteps .com. So it's tinyfeetbigsteps .com and that will show up.

the conference information, photos, videos. We have a lot of online media about past conferences and information about it. People can go to Tanzanianchildren .com and get more information about the Institute for Child Health Care Africa. And then of course, my email address, I don't mind if you post my academic email address linked

the podcast website.

Shelly-Ann Dakarai (01:24:13.939)

Okay, great. We will certainly put all of those in the show notes as well as your article and some of the other things that you've been involved in. So thank you so much for taking the time. We appreciate it and we wish you all the best with the conference.

Dr Stephen Swanson (01:24:29.71)

Well, thank you for taking the time to do this interview. And I just want to applaud what you're doing because you're putting neonatology and a global perspective at the forefront of people's minds. And so I'm grateful too for you and for the incubator podcast. Thank you.

Shelly-Ann Dakarai (01:24:49.423)

Thank you. All right, bye. See you guys on our next episode next month. Bye.

Dr Stephen Swanson (01:24:56.654)

Thank you.