Why it’s so hard for a hospital in Tanzania to fix broken incubators

At Arusha Lutheran Medical Centre in northern Tanzania, there are six neonatal incubators sitting in a storage container, unused. The models, which are anywhere from 15 to 30 years old, have a range of problems. Some need spare parts that are impossible to find. Others have broken probes and sensors or software so old that manufacturers no longer support it. In Tanzania, neonatal disorders were the number one cause of death in 2018, and Sub-Saharan Africa has the highest neonatal mortality rate in the world. In other words, it’s a region where every wasted incubator can be consequential. But many of the devices can’t be easily fixed.

“I’ve been to so many hospitals where I’ve seen warmers and incubators all just shoved in corners, broken, dismantled — some rather expensive — because they don’t have the right piece for it, and no one knows how to repair it,” said Dr. Stephen Swanson, the medical director of Arusha Lutheran’s neonatal intensive care unit. His hospital recently received a donated incubator from the United States, but it had to be retired. The device needed a new electrical board, but there wasn’t any way to make the upgrade, and it was too expensive to buy new circuitry. 

The broken incubators in Tanzania are part of a global trend that experts say has made it increasingly difficult for consumers to fix a wide range of electronics, including not only medical devices but everything from iPhones to John Deere tractors. Over the past few decades, corporations have begun restricting access to spare parts, imposing prohibitive warranties, and using software locks, which make independent repairs nearly impossible. Critics say the tactics allow companies to unfairly control a device even after it’s been purchased and also harm the environment — since many people discard devices that can’t be repaired.

Advocates for the so-called “right to repair” are pushing lawmakers in the United States and Europe to pass regulations that would force manufacturers to make manuals, tools, and other repair information freely accessible. The movement attracted renewed attention during the coronavirus pandemic, when fixing broken ventilators became an urgent concern. But even in normal times, anti-repair restrictions can be devastating in places like Tanzania, where people often rely on secondhand electronics imported from other countries.

“A 7-year-old refurbished laptop is still really new to a lot of the world, and in a lot of emerging markets, the technicians there are like wizards,” said Nathan Proctor, the director of the Right to Repair Campaign for U.S. PIRG, an advocacy organization. “The problem is that, if you can’t access the schematics, the documentation for how to do that repair, it becomes impossible.” 

Despite having a graveyard for broken incubators, Swanson said that Arusha Lutheran survival rate for premature babies is 93% and infants less than two pounds often survive, a rare event in most African hospitals. The facility has nine other functional incubators for more serious cases, but Swanson said his staff often prefer what he describes as “low-tech” treatments, such as kangaroo care, where a mother carries her premature baby with skin-to-skin contact. 

Swanson said that medical staff sometimes aren’t trained in how to use an incubator correctly. But more often than not, the devices malfunction or lack necessary maintenance. “These incubators, dare I say, maybe do more harm than good,” Swanson said. “A biomedical engineer who doesn’t know how to repair the machine is invariably going to mean that the machine is not operating at the intended standard.”

Experts who spoke to Rest of World said that incubator manufacturers have intentionally made it difficult for medical professionals like Swanson to get the repairs and upgrades they need. Some of the industry’s biggest players, including Dräger, General Electric, and Hillrom, are part of the trade association AdvaMed, which spent more than $3 million lobbying federal lawmakers in the United States last year, including on right-to-repair legislation. “To ensure patient safety, third-party service providers need more than just a repair manual to properly fix and maintain sophisticated life-saving medical technologies,” Scott Whitaker, president and CEO of AdvaMed, said in a statement. “Until there is evidence of an actual shortage of properly trained service technicians, the movement to lower medical device repair standards remains a solution in search of a problem.”

But manufacturers also stand to suffer financially if independent repairs were made more widely accessible. “They realize that there is a large amount of money to be made,” said Kyle Wiens, the cofounder and CEO of iFixit, a company that promotes do-it-yourself repairs by providing tools and guides. “They have an opportunity to use their unique position as the seller of the original equipment to monopolize that service business.” 

Melanie Kamann, a spokesperson for Dräger, told Rest of World that, “while a reasonable balance between ‘right to repair’ and other regulations is of course challenging, some limitations to the accessibility of product knowledge for [the] safety [of] relevant products seem [like] the right thing.” Howard Karesh, the vice president of corporate communications for Hillrom, said that the company sold its incubator business a decade ago. “We do still train third parties, though I can’t speak to Tanzania specifically, and parts are available,” he said in an email. A spokesperson for General Electric said that the company doesn’t sell secondhand or refurbished incubators in Tanzania. (In an email sent after publication, Swanson said he wasn’t aware of secondhand incubators from General Electric being sold in the country, but noted that a representative offers other equipment through third-parties.) 

New incubators are often built with password-protected software, which can be accessed by only an authorized repair professional. Deocres Protace, a biomedical engineer at Arusha Lutheran, said the restrictions force him to spend thousands of dollars bringing in company representatives from Nairobi or Dar es Salaam, if the manufacturer even has one available. Farmers in the United States who rely on John Deere tractors have faced a similar problem: The company uses draconian software locks that can be removed by only official dealership employees. That leaves farmers dependent on repair professionals who must travel to rural or remote areas for relatively simple upgrades. Some farmers have even begun using bootleg firmware from Eastern Europe to avoid the trouble. 

Even when hospitals try to do repairs by the book, it doesn’t always work out. Swanson said that in August, his hospital paid an authorized Dräger distributor in Dar es Salaam over $25,000 for two incubators, which included access to a dedicated repair person. The devices were supposed to arrive in October, but, Swanson said, the dealer has since disappeared and stopped returning his calls and emails. Dräger told Rest of World they were following up on the matter and couldn’t comment further in time for publication. (In a follow-up email, Swanson said the representative has since gotten in touch with him, and he expects the incubators to arrive in May. He blamed the delay on procurement challenges.)

The incubators that Swanson’s hospital does have are over a decade old, but he prefers it that way. The doctor said his ideal model is the Dräger C2000 from over 15 years ago. Its features are not outdated, and it can still be easily repaired. Also, it’s more user-friendly for hospital staff.

When people in Tanzania repair medical equipment on their own, they must rely on a patchwork of different resources. Sometimes, companies give in-person training on how to repair their machines, and in other cases, people rely on unofficial YouTube tutorials or manuals they find online. Frank Weithöner, a German biomedical engineer based in Tanzania, runs a website where he offers repair guides for dozens of medical devices, including incubators; iFixit also offers similar tutorials on its website. Some companies, like Phoenix Medical Systems, make videos of incubator repairs and instructions available on YouTube.

Bernard Mbwele, a clinical researcher and faculty member at the University of Dar es Salaam’s Mbeya College of Health and Allied Sciences, said that repairs have become much more difficult in Tanzania in recent years. As medical devices become more advanced, the divide between what he can teach his students and what they can practically accomplish grows. “There is a big barrier between the manufacturers [and the users], because everyone wants to conquer the market with additional technology,” he told Rest of World. “At the end of the day, none of the personnel can repair, unless they get specific training.” 

The issue for right-to-repair advocates isn’t just that companies are making it hard for everyday people to fix their own electronics — they’re also making it difficult for even the most resourceful technicians, like Protace and Mbwele’s students. Swanson said that Protace is among the best biomedical engineers he’s worked with in Tanzania, but even he isn’t capable of fixing the incubators that languish in his hospital’s storage unit. 

“Most manufacturers right now are trying to keep the passwords and supportive materials just to make sure that they are the only ones who are connecting the maintenance and the service,” Protace said. “That way, they can keep making money.”