International Medical Development Project in Ethiopia
Developing Pediatric Otolaryngology in sub-Saharan Africa
Healing the Children’s Experience in Ethiopia
by Glenn Isaacson, MD, FAAP
Margaretha Casselbrant, MD
Lewis Katz School of Medicine of Temple University and the Department of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC
Stage 1 - Helping the Children
Healing the Children’s involvement in Ethiopia began with a picture. Desma Ferrell, Executive Director of Healing the Children’s Philadelphia branch, had visited Ethiopia and found a pediatric ward in Addis Ababa Ethiopia filled with sad looking children. Each of them had a tracheotomy. She wanted to find a way to help these children and let them eventually go home.
She contacted medical colleagues on her return to Philadelphia with this goal in mind. Thus began the first of 15 semiannual short-term missions to the horn of Africa.
The original intent was to help these particular children. When the team of nurses, anesthesiologists, and pediatric otolaryngologists arrived, they realized that the problem was not lack of equipment or knowledge of a particular surgical technique, but absent infrastructure -- not just medical infrastructure, but national infrastructure. These children had recurrent respiratory papillomatosis not subglottic stenosis. Their hospital had a microscope, microdebrider and a skilled surgeon to care for them. They could not go home because there was no electricity to run a suction pump.
Stage 2 - Helping the Residency
Ethiopia is the second largest nation in Africa by population with more than 96 million people -- half of them children. Realizing that a one-off medical mission would not make a dent, Healing the Children’s team decided to focus on improving quality and capacity in Pediatric Otolaryngology and Anesthesiology.
With the help of a US-trained expatriate Ethiopian pediatrician, the team was introduced to the existing otolaryngologists and anesthesiologists in the country. There were about a dozen of each, mostly located in the capital city of Addis Ababa. There were newly created residencies for otolaryngology and anesthesiology. Working with these existing programs, Healing the Children focused first on patient care and education.
Surgeries were done initially at government hospitals including Tikur Anbessa (Black Lion Hospital), the premier teaching institution in the country. The facilities were in bad repair having been constructed by the Swedish in the 1950s and maintained poorly under the recent communist government. It was difficult to do more than one or two operations in a day. This limited the potential for both education and patient care.
Fortunately, Healing the Children was introduced to another nongovernmental organization (NGO) working in Ethiopia. CURE-International had just built a small specialty hospital following an American model. Though spartan, it was adequately staffed and equipped for orthopedic and plastic surgery. This proved a more productive site for pediatric surgery and resident education.
In the first five years of recurring surgical missions, Healing the Children was able to educate the first classes of Addis Ababa University otolaryngology residents in soft tissue technique, endoscopy, and otology. This was done through a combination of didactic lectures, simulation laboratories using cadaver dissection and animal models, and clinic and OR teaching. The focus was on information transfer rather than volume surgery.
During the same period, Healing the Children also developed a relationship with the Makanissa School for the Deaf. Team physicians and audiologists cared for children with profound hearing loss at this total-communication school providing hearing aids where appropriate and medical care including tympanoplasty for those children with partial hearing losses.
Eventually, the first class of AAU Otolaryngology graduates was sent off to regional hospitals throughout Ethiopia to practice their trade.
Stage 3 - Assessing Impact
While the first years were productive in terms of patient care and basic otolaryngology education, there were obvious problems. The team was only in Ethiopia two weeks out of the year. This was inadequate for good continuing patient care and for education. Eventually, the Healing the Children team learned by word-of-mouth about other NGO teams visiting Ethiopia. We began to coordinate our activities, working together, sharing missions and resources, and developing a curriculum for residency education. Eventually, by sharing donated resources, we were able to put together the first temporal bone laboratory in the horn of Africa and to teach several courses using cadaver temporal bones.
In this third phase of development, it was important to stop and think about whether we were doing the right thing. Clearly, transmission of information to the Ethiopian Otolaryngology residents was a good thing to do. We participated in their Board examinations at the completion of the four-year residency. The students were bright and had learned much. However, while their information bases were good, there were clearly major deficiencies in surgical skills. We needed to do more.
We also wanted to know whether the surgeries we were doing produced good outcomes. As our first collaborative research project with AAU, we reviewed the pre-and postoperative audiograms and surgical results of all of our tympanoplasties. The results were comparable to those reported by developing world surgical programs, though they would have been considered inadequate in Europe or the United States.
Stage 4 - Helping the Graduates - Growing Capacity
Our most recent efforts have been focused on the graduates of the AAU residency. Several of them were assigned to regional hospitals. They tried to practice Otolaryngology and failed. They lacked local support, equipment, and confidence in their surgical skills. To correct these deficiencies, we helped them find postgraduate fellowship training both at sites in Africa, and in the United States. Through the American Academy of Otolaryngology’s visiting scholar program, AAU graduates attended the AAO national meeting and did mini fellowships at Temple University, University of Pennsylvania, SUNY-Syracuse, and Harvard hospitals. Graduates have participated in Head and Neck fellowships in Kenya, Spain, and Senegal.
The lack of surgical instruments and operating microscopes was particularly acute. Healing the Children worked in coordination with several US hospitals and NGOs to find decommissioned instruments and transport them to Ethiopia. It was possible to rehabilitate discarded operating microscopes using alternative power sources and LED lighting. Boeing Corporation and Ethiopian Airlines provided transportation for these heavy items on newly purchased commercial airliners.
The Healing the Children teams visited the hospitals and universities around Ethiopia where the AAU graduates were stationed. We worked with them to help improve their operating room flow. Our audiologists trained Ethiopian nurses to do hearing tests. We operated together with the graduates on difficult cases at their home hospitals and at CURE-Ethiopia to help them develop confidence in their surgical skills.
Healing the Children faculty have worked in coordination with Ethiopian universities and the AAU graduates to develop research skills. Together we determined the prevalence of hearing loss in normal populations and in children with treated HIV. We are studying the causes of sensorineural hearing loss in profoundly deaf children and their siblings.
Healing the Children has moved from the surgical mission model to a newer paradigm. It focuses on transfer of knowledge and technology to Ethiopian physicians. It is hoped that with continuing support, a new generation of otolaryngologists will address the huge need for surgical care in this populous developing country.