Abstract
At first glance, we may be inclined to think that the life cycle of hybrid bodies ends when wired heart cyborgs die. However, during my fieldwork, I learnt that pacemakers removed from deceased bodies are reprocessed to be used in new bodies. This chapter therefore traces what happens after death. Adopting the path creation approach, I describe how creating a second life for pacemakers requires the building of new infrastructures because it concerns other geographical spaces. Whereas new pacemakers are primarily implanted in the bodies of citizens of wealthy, industrialized countries, the advocates of reuse try to reach people in poor economies in the Global South. My account of the path creation process of reuse of pacemakers in the Global South illustrates that vulnerabilities and resilience are not necessarily restricted to humans. This chapter argues that any understanding of the work involved in creating resilience to vulnerabilities, including health risks and unintended use of technologies, should include the building of resilient devices and infrastructures.
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Notes
- 1.
Nederlands Uitvaart Museum Tot Zover, De Nieuwe Ooster Begraafplaats, Amsterdam. Visited 12 February 2012.
- 2.
Unlike internal heart devices, replacement hips and the reconstructed knee joints of deceased people are not implanted in other bodies but used for recycling their metal components, including the expensive and increasingly rare titanium. In the past decade, recycling artificial hips and knee joints has become a booming, although not very lucrative, business, particularly in wealthy, industrialized countries where cremation rates and artificial joint implantations are high (Williamson 2016). Local crematoria collect the metal remains from cremated bodies and ship them to companies specialized in the recycling and separation of metals.
- 3.
During the cremation process, when temperatures may reach 1300 °C (2400 °F) for 90 minutes, the iodine in the battery creates a gas that expands very rapidly and causes the case of the device to burst. A chemical reaction with the melting lithium also causes an explosion, which releases the energy of the battery (Gale and Mulley 2002, 353).
- 4.
Website Decorated Urns. https://decorative-urns.com/cremation-blog/about-cremation/cremation-pacemaker-removal-death/. Accessed 30 May 2017.
- 5.
Website Neptune Society website. https://www.neptunesociety.com/cremation-information-articles/why-a-pacemaker-should-be-removed-prior-to-cremation. Accessed 30 May 2018. Website Decorative Urns. See endnote 6.
- 6.
Although the removal of pacemakers and ICDs is compulsory by law or required by the management regulations of crematoria in many countries, removal to avoid environmental pollution is only regulated by law in some European countries, including Sweden and the Flemish region of Belgium (Heuverswyn et al. 2013; Erven and Smit 2010).
- 7.
- 8.
Websites of the Neptune Society and the Decorative Urns company. See endnotes 5 and 4.
- 9.
Website Neptune Society. See endnote 5.
- 10.
During my research, one of the relatives told me that the private nurse who witnessed the removal of the pacemaker from his father’s body had experienced the surgery as rather disrespectful because it was done rather hard-handedly (Interview Andrew, 2013).
- 11.
Website Neptune Society. See endnote 5.
- 12.
Because most reutilization programmes concern pacemakers, I do not include ICDs in my analysis. Although defibrillators are collected for reuse as well, their shock functions are switched off before implantation because of concerns about inappropriate shocks, and the refurbished devices thus function only as pacemakers (Hasan et al. 2011).
- 13.
Although a number of other organizations are involved in making explanted pacemakers available in the Global South, I have selected Project My Heart Your Heart because it is an initiative that aims to make the process of recycling a legally and morally accepted part of mainstream health care. In the US, the non-profit organization Heart to Heart has been involved in collecting and distributing explanted pacemakers in countries in the former Eastern Europe and South America since 1994 (Pace4Life 2013). In contrast to Project My Heart Your Heart , Heart to Heart restricts its activities to collecting explanted pacemakers and shipping them to the recipient countries, which are responsible for the sterilization of the devices (Anonymous 2009a). Heart Beat International, a charitable organization founded in 1984, has been involved in the distribution of pacemakers close to expiration in terms of sterility that are donated by manufacturers in the US. This organization works through pacemaker banks established by local Rotary International divisions and has established local partnerships with public hospitals in Central America (Baman et al. 2010). In the UK, Pace4Life, a charity organization founded in 2012, aims to provide explanted pacemakers to ‘underprivileged people in the developing world’ (Pace4Life 2013); it can be considered as a sister organization of My Heart Your Heart .
- 14.
Founded in 1953 to support Korean War orphans, World Medical Relief provides mostly non-governmental organizations with medical aids such as prescription drugs, medical equipment, liquid nutrition, and bed pads. Over the years, the organization has expanded its mission by providing medical devices to low-income people in the Detroit area as well (Greene 2018).
- 15.
According to the FDA’s compliance policy guide, explanted pacemakers cannot be properly re-sterilized due to the possibility that body fluids may have entered the terminal leads of the pacemaker. Consequently, foreign protein material may affect the new user of the device (FDA 2015). The FDA is particularly concerned about the transmission of viruses and Creutzfeldt-Jacob-like prion deceases (Kirkpatrick et al. 2010).
- 16.
The FDA prohibits ‘the introduction into interstate commerce of any … device … that is adulterated or misbranded’ (Baman et al. 2010, 1654). The European Union also prohibits the second use of explanted devices, although reuse has been part of regular health care in many countries, including Sweden. In the early 1990s, 5% of pacemaker implantations in Sweden involved reused devices. However, this practice ended when Sweden joined the European Union (Runge et al. 2017, 297). In contrast to implantable cardiac devices, other medical devices such as catheters, endoscopes, and hemo-dialysers are approved for reuse in the US and Europe (VanArtsdalen et al. 2012).
- 17.
There exist no federal prohibitions on collecting devices explanted from deceased bodies in the US.
- 18.
Although the contributing researchers to the publications I have analysed in this chapter are affiliated with various universities in the US and abroad, I refer to this collaborative research team as the MHYH researchers in the remaining part of this chapter.
- 19.
In Africa, a quarter of the 31 countries included in the Pan-African Society of Cardiology survey did not have any implantation centres.
- 20.
Homepage website Project My Heart Your Heart. www.myheartyourheart.org, Accessed at 30 July 2018.
- 21.
The leading causes of death worldwide include cardiovascular and respiratory disease, diabetes, and cancer. In 2008 ‘almost 80% of those deaths occurred in low- and middle-income countries’ (VanArtsdalen et al. 2012, 300).
- 22.
Timir Baman, one of the MHYH researchers, as cited in Anonymous 2009.
- 23.
- 24.
Crawford , as cited in Stiles (2013).
- 25.
More advanced pacemakers that include more functionalities may cost anywhere from US$10,000 to US$50,000 (Ross 2010).
- 26.
Homepage website Project My Heart Your Heart. www.myheartyourheart.org, Accessed 30 July 2018; Gakenheimer et al. (2010); Project My Heart Your Heart. Legal consent form; Crawford and Eagle (2017, 34).
- 27.
Baman, as cited in Anonymous (2009a).
- 28.
A legalized redistribution of responsibilities is important for the pacemaker industry to assure that the original manufacturers are no longer liable for potential malfunctions of a reprocessed device (Crawford and Eagle 2017, 34).
- 29.
To gain access to the explanted pacemakers required for these tests, the MHYH had already established a close collaboration with the Michigan Funeral Directors Association and an implant recycling company in Detroit that provided them with a steady supply of pacemakers removed from deceased bodies. Pacemaker acquisition among the funeral industry involved the development of quality assurance protocols to make autopsy technicians acquainted with the necessary skills to remove pacemakers from dead bodies. This training focused particularly on disconnecting the pacemaker generator from the leads to avoid cutting the leads, which is not only risky for the technician but may cause malfunctions of the device as well (Badin et al. 2013).
- 30.
Email communication Thomas Crawford, 8 September 2018.
- 31.
- 32.
Email communication Thomas Crawford, 8 September 2018.
- 33.
My account of the path creation process of pacemaker reuse by the MHYH collective is necessarily restricted to 17 September 2018 when I completed this chapter. Developments that happened later, including the publication of the results of the clinical trial, which are expected around 2020, and a broader approval of the FDA, of which the time frame is still unknown, could not be included (Email communication Thomas Crawford, 8 September 2018.).
- 34.
Homepage website My Heart Your Heart . www.myheartyourheart.org, Accessed 30 July 2018.
- 35.
The MHYH website includes a clause that ‘the device will be used only for research and will not be implanted in a human subject without the express approval of the US.’
- 36.
During the first pilot clinical study conducted in the Philippines and Vietnam, the MHYH collective had designed an online registry to track and monitor patients implanted with a refurbished pacemaker (Baman et al. 2010, 1652).
- 37.
According to Thomas Crawford, the results of a survey of prospective users of refurbished pacemakers in Nicaragua, Pakistan, Ecuador, and Jordan will be published in 2019 (Email communication Thomas Crawford, 8 September 2018).
- 38.
Although other organizations can profit from the work of the MHYH collective, they, nevertheless, have to submit their own application to the FDA to get approval for pacemaker reuse because FDA approval is programme specific (Email communication Thomas Crawford, 8 September 2018).
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Oudshoorn, N. (2020). The Second Life of Pacemakers: Creating Resilient Implants and Infrastructures for Pacemaker Reuse in the Global South. In: Resilient Cyborgs. Health, Technology and Society. Palgrave Macmillan, Singapore. https://doi.org/10.1007/978-981-15-2529-2_9
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