Climate Change and LMIC Neonatal Care at a Crossroad: Self-Driven Research for Policy-Actionable Adaptation and Mitigation

1.1 Objectives

The objective of this article is to highlight my previous and current scientific investigations, interventions, and the development of technological mediations for neonatal climate-change resilience and adaptation, and the innovation of policy-adaptable technologies for the mitigation of the contributions of neonatal medicine to climate-change in Nigeria, and by extension, the LMICs.

2.1 Overview

The need to develop ideas to innovate technologies that could assist humans, and especially newborn babies, to adapt to rising global temperatures might not materialize unless the underlying pathways are discovered and subdued. Africans and the other underdeveloped climatic regions of the world have been suffering from rising environmental temperatures for a long time but without many investigations of how this had affected newborn morbidity and mortality of African neonates. The literature has rather been dominated by neonatal hypothermia (cold stress) but has little about neonatal hyperthermia (heat stress), which is relatively more prevalent in Africa than the colder regions of the world [3]. Hence, little was known about all causes of neonatal hyperthermia, including how climate effects might have been partly responsible for some hyperthermia-associated morbidities and mortalities.

The high fever accompanying neonatal hyperthermia in Nigeria was always blamed on ‘possible disease process’, and hence, often ending up on prescription of prophylactic antibiotics whilst laboratory results were being awaited. The climate was never suspected, investigated, or implicated for neonates presenting with hyperthermia in Nigeria until my studies of 2010 was published in the literature [4]. The lack of adequate knowledge of climate-change on the wellbeing of the Nigerian neonate, has thus plunged many to the devastations of wrong antibiotic prescriptions and administration, and perhaps, eventual death.

2.2 Discovery of neonatal evening-fever syndrome (EFS): Ilorin 2010

I served as a Visiting Consultant Researcher at the neonatal intensive care unit (NICU) of the university of Ilorin Teaching Hospital in Kwara State Nigeria between 2005 and 2011. During one of my visits in 2009, a compelling phenomenon drew my attention. This occurred during the extremely hot months of 2009.

The splash-back of one of the wash sinks in NICU was finished with a set of beautifully decorated ceramic tiles. I had loudly admired the beauty of these tiles the previous day as I worked with one of the nurses. However, whilst I was consulting the next day, I discovered that one of the tiles had cracked in full length. I was displeased and requested an answer on who it was that broke the tile. The ward-manager replied that ‘self-cracking of tiles in the NICU’ was an acknowledged occurrence and happened from time to time, especially during hot weather; hence, no one was responsible. I left the Unit very much troubled as to what was going on. If the weather had done this to the tiles in the NICU, what else is playing out and how could this be affecting the incubators and the neonates? I questioned myself in my thoughts. Hence, I ordered and designed a study to scientifically investigate how the incubators were responding to whatever it was that cracked the tile. This research lasted one full year revealing the compromise of incubator functions owing to high sunlight intensity [4].

Therefore, I hypothesized that the neonates who were being nursed in the incubators and cots in Nigerian NICUs could be suffering from unknown or undisclosed capacitance-effects of high sunlight intensity in the nurseries. There was an urgent need to investigate this with a specially designed study protocol. An ethical assessment application was submitted, and approval was obtained for this study at the Federal Medical Centre Nguru—situated at extremely hot climate region of northeastern Nigeria (Yobe State) in 2011. The preliminary results revealed a disturbing high neonatal morbidity owing to climate-induced neonatal hyperthermia, which incidentally and characteristically disappeared after sunset each day [5]. I codenamed this phenomenon “The Evening-fever Syndrome (EFS)” as submitted to the World Health Organization global forum on medical devices in 2013 [6]. The need for possible solutions became inevitable.

2.3 The politeshield antidote – A pattern: Nguru 2013

This is a unique pattern of climate-mitigating Nursery Building Features as the antidote for ameliorating neonatal condition of Evening-fever Syndrome (EFS) in the Nigerian neonate as was discovered in my earlier studies in 2012. Nursery building in hot climates such as Nigeria may be contributing to the process of unintended overheating of newborn babies—iatrogenic neonatal hyperthermia. This is a condition of periodic fever that overcomes the neonate in the mid afternoon and early evening hours, which has been studied to be climate-induced and propagated via heat transfer mechanisms through the walls of the nursery building. This is otherwise called neonatal evening-fever syndrome as I code-named it in 2012.

I hypothesized that the process of transmitting the climatic heat of high sunlight intensity to overheat a neonate inside a nursery building may only be truncated via specialized building features that are designed to mitigate the EFS.

3.1 Concept

My concept of the features of the EFS-antidote design—which has since been in use in Nigeria for over 10 years—stems from the studied mechanisms of the propagation of the EFS as explained below.

1. It is natural for the sun to rise with quick attainment of high sunlight intensity in Nigeria.

2. It is also natural for the striking sunlight to heat up the exposed walls of the nursery building depositing much of its heat energy.

3. It is natural for the walls to conduct the heat through to the inner surface of the nursery walls and hence release the heat through radiation to the babies inside the nursery, thereby initiating the EFS against the neonates.

Therefore, my concept was to create a design with features that could truncate this chain of events, thereby limiting the delivery of the sunrays’ deposited heat to the neonate being nursed in the open nursery hall.

The concept seeks to achieve a naturally cooled nursery room without the need of an air-conditioner unit through three mechanisms: by

1. limiting the radiant heat transfer from the charged outside-aspect of the nursery wall into the inner aspects of the nursery building as depicted in Figure 1 (left)

2. naturally tapping any environmental coolness into the inner aspects of the nursery building (such as lowering the inner floor below the ground level) for producing a thermal counter effect against any heated air within the nursery as depicted in Figure 1 (right)

3. integrating a heat-exchanger module across the inner walls of the nursery: This is a single or double channels of crisscrossing 10 mm copper pipe around the perimeter of the nursery. The heat-exchanger pipe runs continuously from its entry port, where it is connected to an overhead water tank supply, snaking top-to-ground level continuously across the perimeter of the inner walls until its exit port, from where it discharges its relatively warmer water into an underground tank (Figure 2). The natural water pressure-head enables cool water in the overhead tank to travel via the pipe, absorbing the heat already transferred to the copper pipe from the walls through conduction across the aluminum-sheet overlay (component D, Figure 2). Hence, the discharged water at the exit of the heat-exchanger pipe would be relatively warmer than the temperature of the water at the inlet port. This aspect of the design targets to remove the heat already entrapped on the inner walls of the nursery building before this radiates into the open space of the nursery impacting the neonates.

3.2 Brief description of drawings

An effective tropical climate-resilient nursery should be able to stop, divert, or minimize the heat transfer process from the outside-building environment to the inside environment of the nursery building as demonstrated in my design, shown in Figure 1.

The building system was so-created, hence, diverts and truncates the heat transmission across the walls, thereby limiting the reach of the negative impact of high climatic temperatures on the nursery inmates [8].

3.3 Summary

This is the first of this kind of building features for the protection of neonates from the effects of climate-change and evening-fever syndrome (EFS). The innovation is adoptable by LMIC policymakers and is suitably built to operate in the urban and rural parts of equatorial regions of the world where ambient temperatures soar too high necessitating the high demand for air-conditioning units which further adds to the complications of global warming. This is a proven technique of natural cooling of a Nursing-Bay which has been shown to naturally keep the Hippolite-FMC Nguru laboratory Nursing-Bay at maximum of 32°C during an outdoor environmental temperature of up to 46°C (Figure 3) [8].

3.4 Nigeria adoption, versions, and policy impact

In the last 10 years, the clinical knowledge and diagnosis of evening-fever syndrome (EFS) have received the attention of the Nigerian Society of Neonatal Medicine and widely considered during practice across the Special Care Baby Units (SCBUs) nationwide in Nigeria. This has enabled clinicians to query and rule out the climatic-effect in any presenting neonatal fever before the prescription of antibiotics or arrival of lab results—which often arrive late. This awareness is revolutionizing neonatology-based clinical decisions for patient care. This has also widened the knowledge of neonatologists and their suggestive inputs during the planning and design stages of new nursery buildings in Nigerian hospitals.

The original trial of this innovation between 2011 and 2013 presented two laboratories—LAB1 with all features for a freshly built nursery and LAB2 with fewer upgrading features for an already existing nursery. These versions have been discretely adopted and implemented at various places across Nigeria, some preferring the adoption of Lab-2 over Lab-1 for minimization of policy risks on cost.

In a representative large-scale policy application, the Yobe State government of Nigeria initiated a unique Statewide healthcare delivery project relying on the lessons learnt from the EFS neonatal laboratories. Hence, delivering their own version of the Neonatal Rescue Scheme [9], and constructing new regional complexes for newborn care after the pattern of the EFS Lab-1 features as showcased in their 2023 documentary [10]. The relevant aspect of this documentary can be accessed from this YouTube clip – https://youtu.be/5Vvc6Cvc4So. Some other new building complexes adopted this as showcased in “Inside Africa” documentary of CNN International [11].

3.5 Conclusion

The deadly effects of climate-induced EFS could be minimized in tropical LMICs if the choice of the site and positioning of the nursery apartment within the neonatal building complex is made with full evaluation of the predictable interactions and impacts of sunrays as the sun rises from the eastern cardinal direction and sets at the western. The neglect or ignorance of EFS mitigation would lead to daily neonatal hyperthermia, complications from needlessly administered antibiotics, and neonatal thermal-shock from practices that attempt to rapidly force-down the neonate’s body temperature, which could lead to death [3, 12]. The EFS discovery and my innovation of its antidote have been a bold response in pushing back one troublesome aspect of climate-induced morbidity on humanity (Figure 4(a) and (b), respectively).

4.1 Overview

It was a sudden realization—as I was concluding the 2010 Ilorin study on the impact of high sunlight intensity [4]—that the climate could be inflicting enormous amount of damage on the Nigerian neonate. This ignited in me a long-drawn storm of reflections on how the age-long activities of humans could have adversely compromised the conducive climate our Nigerian ancestors enjoyed. This consciousness became a driving force for my subsequent creations and implementation of climate-friendly neonatal technologies in my Nigerian neonatal practice.

The rising global temperatures—if unchecked—with its possible impacts on our reproductive physiology leave us with the uncertainties of what could become of humanity’s ability to reproduce quality offspring in the future. As I built fences to protect the Nigerian neonate from devastating climate-change consequences such as the EFS, I was compelled to join in the footsteps of other scholars studying to understand why our climate was changing. I realized that our high carbon footprint as humans, which has negatively impacted the climate, has not exonerated our other activities to keep the sick neonate alive. The enormous use of electric power in pharmaceuticals and entire healthcare delivery systems—including neonatology which I practiced—might have been a contributor to the damage to our climate. Therefore, I concluded that I must find ways of cutting back on the carbon contributions of the neonates in my African practice. Effective actions could be radical, extraordinary, and particularly unconventional—hence, I needed enormous determination and courage to significantly push any boundaries.

The major interventions in neonatal care are implemented with machines that require to operate continuously using mains electricity—national grid power or fossil fuel generators—for as many days as the neonate remains on admission. This constitutes a huge amount of environmental carbonization. Therefore, I felt the urgent need to begin to think of how I could strike a balance between keeping our neonates alive and saving the planet for them as they survive to grow up to meet the devastation we have caused. This is a serious matter as neonatology in the present context could, therefore, be classified as an electric power-guzzler in healthcare terms owing to the numerous electrically operated life-support machineries and gadgets that MUST run simultaneously and continuously for several weeks – nonstop – just to keep the neonate alive. These are the incubator, the ventilator, the phototherapy machine, the patient monitor, etc.—electric power guzzling machines which must necessarily run without a break for 2 to 4 weeks or more until the neonate is ‘out of the woods’ or goes to ‘the world beyond’. We need to keep them alive, but we even more need to preserve the planet for them.

In the earlier years of my African practice, I was embattled with the well-known Nigerian epileptic power issues. The unwell neonate cannot do without power, such that in the sudden failure of grid energy as is often the case in Nigeria, the caregiver must necessarily force some hundreds of kilograms of carbon into the atmosphere, continuously running fossil fuel generators—where this is available—to keep the neonate alive. The balance must lie in lowering the carbon-footprints from the use of all these essential technologies for neonatal care by innovations that would mitigate how the interventions contribute to climate-change. Hence, I faced another challenge of innovating methods of tweaking the operational systems of existing neonatal devices, developing tailored designs, and creating alternative green energy techniques to make the neonatal devices and facility-lighting to become less dependent on mains electricity. The tweaked technologies must be efficient in power consumption management to ensure 24 hours/day reliability and sustainability. The journey to achieving zero-carbon emission in my neonatal practice seemed impossible, but this had to start with a review of my existing technologies.

4.2 Decarbonization of the power-banking-system

Leading up to the year 2009, I was simultaneously engaged with over 12 tertiary and university teaching hospitals across all regions of Nigeria as a Visiting Consultant, supporting their neonatal thermoneutral research and interventions. Sudden power failures in Nigeria were rampant. The often-long waiting time in-between fossil-fuel power changeover at the Special Care Baby Units (SCBU)—where I practiced—retarded the progress of thermoneutral care leading to the loss of lives. Hence, I introduced the power-banking-system (PBS), which used 48-volts 800AH gang of batteries and 4 KVA load-capacity inverter modules to bank-up mains electric power to later utilize this to run the incubators and facility lights during the power-failure waiting time. The PBS functioned like a UPS that could deliver up to 4 hours of power support—a great deal of welcomed development at the time, especially by 2014 when I had perfected this art, applying it at many SCBUs across the country—in southern and northern Nigeria. This became a springboard for my new challenge requiring a major shift in the source of power for all my neonatal systems at the Nigerian SCBUs. My initial small climate action was to end the recharging of the PBS with mains electricity. It was almost seamless to shift from mains power supply to a gang of photovoltaic cells (solar panels) as the means of re-charging the PBS batteries—a successful move in reducing the neonatal carbon footprint by that small amount.

The conventional technique of inverter power installation in Nigeria involves connection of the panel-battery-inverter assembly as a standby power supplier in the event of grid power failure. This technique has limitations that often create practice frustrations as was observed across my network of SCBUs applying this. Some centers explained their frustrations for the lack of sustainability of this power option, including the high cost of frequent deep-cycle battery replacement. Other centers complained of the short lifespan of the standby inverter power supply after a full charge during sunshine, which could only support facility lighting and powering of the essential neonatal machines at night for less than 4 hours before the SCBU returned to utter blackout for the rest of the night. There were explainable technical reasons for this short lifespan, including inefficiency of the installation technique that was often applied. I embarked on a scientific investigation for a more efficient way of making the banked energy stretch further to cover the power needed for an entire night shift. Hence, in my resulting publication, I proposed and tested the separation of the duo of ‘facility lighting’ and ‘sockets powering’ into two independent systems when using renewable energy as the main source of powering the SCBU [13]. The proposal demonstrated how the Neonatal Unit could be powered by two independent solar panel gangs, one supplying 12-volts to its charge controllers for facility lighting purposes and the other supplying inverter-able 48-volts for powering the equipment, respectively. The new solar-based PBS technology has been successfully applied at seven notable Nigerian hospitals, including the SCBU-1 of Federal Teaching Hospital Owerri, the Amina-Centre of General Hospital Minna (northern Nigeria) and the Neoroom of the Calabar Women and Children Hospital (southern Nigeria), enabling these hospitals to often operate on ‘all night’ solar-banked PBS-power until daylight returns the next day when the system returns to the regular supply of harvested solar power in real-time to operate the neonatal equipment.

4.3 Invention of the PLB: A solar-based technology to decarbonize facility lighting

It is literally impossible to do modern healthcare delivery without power for lighting the environments of the healthcare facilities especially during the night. It is required, by standards, that a healthcare facility does not practice in the dark—adequate high illumination of environment lighting is a ‘non-negotiable’ in neonatal care delivery. The enormous air pollution from fossil fuel generators to keep the nursery unit’s high wattage bulbs alight endangers health as well as contribute huge amount to climate-change, hence requiring some scientific mitigation.

Independent lighting system: In Ref. [12], authors reported that typical inverter power in Nigeria is wired into the existing nursery power distribution lines using ‘switchover gear’ controls via chosen fuse-lines. This technique enables them to select specific fuse-lines for power sockets and gangs of lighting points to be energized by the inverter. However, all the conventional high voltage appliances along the prioritized lines are automatically enabled. “Therefore, the inverter system is subjected to supply energy to all installed conventional light bulbs on the prioritized fuse lines”, most of which are rated up to 100 watts [12]. I had previously reported in the literature—from my experience—that the inverter system installed in this manner would readily get drained of its battery reserve in quick time, and that low wattage bulbs, such as 5 to 12 watts had been tried but these yielded insufficient illumination intensity for critical aspects of clinical works, such as ‘neonatal line-setting’ in the night. Therefore, we innovated the ‘polite-light-bank (PLB)’ system, which was a successful response to the need of making the solar power option to sufficiently last an entire night with high intensity of illumination throughout [13]. The PLB was a separate low-voltage wiring—independently distributed across the walkways and rooms of the nursery building, applying Light-emitting-diode (LED) technology. Hence, the lighting system so-demonstrated was a standalone 12-volts system, which relieved the inverter system from the power-draining high-wattage light bulbs. The application of the PLB technology as an essential system for high illumination lighting of the neonatal facility, hence, presented a major shift and a win for my decarbonization agenda in neonatal healthcare delivery (Figure 5). The applying facilities gave an average overall satisfaction rating of 98% in their performance assessment over 4 years of applying this lighting technology [13].

4.4 Solar-adaptation, decarbonizing existing neonatal devices and new inventions

The PLB technology was one huge neonatal decarbonization success that I needed to exploit further for the Nigerian and LMIC neonates. Its low-voltage and low-power consumption characteristics—requiring no intermediary inverter module—make it an extremely low-cost item of essential technology for neonatal care in addition to its zero-carbon pollution quality. Therefore, beyond 2020, I began to research and trial how the PLB technique could simultaneously power some essential neonatal devices that otherwise rely on grid or fossil-fuel power. The conscious elimination of the ‘inverter module’ where possible, has the general advantage of lowering maintenance and operational costs of the power system—inverters cost much to acquire and are prone to unavoidable and avoidable failures that could shutdown life-support devices until maintenance engineers and required spare parts arrive and repairs carried out. These could take considerable amount of time—days to weeks—to happen with the consequences of loss of lives.

Individualized power-buffer station: The “individualized power buffer station” was conceptualized to create independent low power reserves for all applicable neonatal devices in the SCBU. Typically, in our concept, a pre-processed energy from the PLB solar panels is split and channeled to a few “buffer stations”, strategically located around the inner nursery ward where two incubators could access the same buffer station for energy without being moved around. Unlike the PBS, which is fully installed in a separate ‘power room’ in the nursery complex, an individual buffer-station is attached to the equipment or located near the devices within the room [12]. The buffer stations are 12-volt 150AH-battery systems linked to the 12-volts solar-panel gang supply of the facility’s PLB and recharged via a dedicated MPPT charge-controller, each delivering outputs of 12-volts DC via cigarette lighter sockets, and 230 volts AC via a dedicated 2.0-3.0 KVA power inverter.

Relying on the successful creation of power outputs from the buffer-station, applicable neonatal devices were re-manufactured or re-engineered by creating a power interface that enabled them to operate on the preserved solar-energy. Some of the decarbonized neonatal devices are described below:

1. The innovation of decarbonized incubator & resuscitaire (Figure 6a)—being the creation of the green-energy versions for my >20 years old popular invention – the RIT technology [14, 15]. In the late 1990s, Nigerian tertiary hospitals were notorious of littered carcasses of obsolete incubators—abandoned in rooms, workshops, and along walkways, breeding rodents and mosquitoes and causing environmental pollution. Beginning from 1996—when I took notice of this trend—I began a long-stretched study on possible innovations that could minimize this environmental pollution trend and simultaneously reuse the same rejects to enrich neonatal care in Nigeria. The concerted work was rewarded with my invention of the recycled incubator technology (RIT) in 2003 and the use of this technique across the entire country to reclaim hundreds of dysfunctional incubators back into functional status—up to the end of MDG4 in 2015. My climate concerns beyond 2015 inspired the new moves to make the RIT a low-power dependent technology operable via low voltage solar energy supply.

2. Invention of the politeheartCPAP v-model (Figure 6). A solar-powered neonatal non-invasive ventilator that has contributed to the survival of respiratory-distressed Nigerian neonates since its invention.

3. Innovation of solar-driven conventional phototherapy (Figure 7), involving the design and creation of a buffering interface with or without a modified phototherapy light-source to enable existing overhead phototherapy machines such as ‘the MTTS Colibri’ device to be powered by sunlight using the PLB system

4. Innovation of solar-driven syringe driver (Figure 7), involving the design and integration of a solar-buffer circuit to enable systems such as the Graseby 3100 series to run on the solar power driven PLB technology.

5. Innovation of the ‘politecontec’ patient multiparameter monitor (Figure 7), involving the design and integration of a solar-buffer circuit to enable a spot-check pulseoximeter to run as a continuous patient monitor on the low-voltage supply of the PLB via a cigarette lighter port.

4.5 The recent invention of the ‘politeultralumen (PUL)’ phototherapy device

The treatment of severe neonatal jaundice (SNJ) in Nigeria conventionally requires the often-distant travel of the neonate born in faraway places in search of the specialist—it is high risk, labor-intensive, and power-guzzling. Firstly, the mostly inadequate neonatal transport in Nigeria is associated with high morbidity and mortality risks, and secondly, the sought-after specialist gold standard intervention is a surgically invasive high-risk procedure. A non-invasive climate-friendly technique for this condition could minimize these risks. Therefore, it was necessary to turn to this third major concern for neonatal decarbonization.

The treatment of neonatal hyperbilirubinaemia—severe neonatal jaundice—in the newborn in Nigeria is conventionally carried out through an extreme treatment technique called Exchange-Blood-Transfusion (EBT). EBT is very expensive, surgically invasive, and a high-risk procedure. A badly treated hyperbilirubinemia could result in permanent brain damage, poor cognitive abilities, bodily disfiguration, etc.—associated with medical conditions such as kernicterus spectrum disorder (KSD). A lot of LMIC children are behind the doors suffering from complications of KSD. A recent non-invasive treatment technique showed that a well-organized and delivered high-intensity phototherapy irradiation—of the correct light wavelength, could treat over 80% of cases of the diseased blood in-situ, rather than surgically draining the blood out in all cases with its accompanying risks and energy consumption. The non-invasive technique such as the Firefly® phototherapy system (MTTS Asia Co., Ltd., Lane 41 An Duong Vuong, Tay Ho, Hanoi) requires mains high-voltage to operate. This is expensive, largely unaffordable and unusable in the hinterlands where electricity and fossil fuel generators are scarce.

Faced with the challenge of providing a hinterland-operable solution for hyperbilirubinemia in Nigeria, I decided to initiate the development of a climate-friendly device that could apply the principles of high-intensity irradiation to treat severe jaundice in a typical non-electrified Nigerian village. The result was the Politeultralumen device (Figures 8 and 9), Nigerian Patent (IPONMW638442007947116728, F/PT/NC/2024/11141).