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Introduction
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The impact of physician emigration has been experienced by all medical specialties in Ethiopia. Historically, physicians in Africa who were interested in neurosurgical specialization trained abroad. Tadios Munie, who completed his training in the U.K., brought neurosurgery to Ethiopia in 1991. Zenebe Gedlie Damtie, who pursued his neurosurgical training in Cuba, later joined him. Four neurosurgeons currently practice in Ethiopia, caring for more than 70 million residents. This ratio of 1 neurosurgeon per 17.5 million inhabitants is in stark contrast to the approximately 1 neurosurgeon per 338,000 inhabitants in North Africa, and 1 neurosurgeon per 81,000 inhabitants in the United States (2).
Providing quality neurosurgical care directed toward reversible pathologies is an attainable goal for developing countries. FIENS has been instrumental in the development of neurosurgical residency programs, particularly in underserved regions. In June 2006 a neurosurgical training program was initiated in Ethiopia through the strong collaborative efforts of local leadership and FIENS. Under the auspices of FIENS, authors A.V., S.W. and S.F. volunteered in Addis Ababa, participating in all aspects of patient care and resident education.
The immediate goals for the training program include adequately preparing trainees to handle the neurosurgical conditions commonly presented and increasing the access of both rural and urban populations to neurosurgical care. In the longer term, maintaining a training program in Ethiopia may serve to counterbalance the continued emigration of local talent. In this review, we describe the neurosurgical service and residency training program in Addis Ababa and ascertain current needs as well as future directions.
Neurosurgery Service at the Black Lion Hospital
The four neurosurgeons of Ethiopia all are located in Addis Ababa. The rest
of Ethiopia is without trained neurosurgical care. In order to be evaluated
and treated, patients often must travel more than 300 miles, a nearly insurmountable
feat given their generally poor access to transportation, particularly in
rural areas.
The general surgery department at BLH encompasses all surgical services with the exception of orthopedic surgery. The workday at BLH begins with a morning report of the general surgery department, during which admissions from the previous 24 hours and cases of patients seen in the outpatient department are reviewed. Hospital rounds are performed before clinic or proceeding to the operating theater. The department averages 15 patients, including those admitted for trauma and neurosurgical consults, children, and those awaiting operative time.
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| Figure 1 Neurosurgical Cases Performed at BLH July 2006-February 2007 |
Patients are recommended for admission to BLH after evaluation in either the outpatient department or in the neurosurgery clinic, where both pediatric and adult patients are seen. The cases from clinic are prioritized as emergent, urgent, or elective cases, and their subsequent admission to the hospital is contingent upon bed availability. Admissions from the outpatient department also are subject to bed availability. It is not uncommon for a patient requiring surgical intervention (including emergent neurosurgical intervention) to be transferred to another hospital due to lack of bed space. If a patient has financial resources to pay for a private room, or has some personal connections to the hospital, the admission process may be expedited.
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| Table 1 Training Objectives for
Neurosurgical Residents |
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The neurosurgical residency training program began in Addis Ababa in June 2006. The program is supported by BLH, the only hospital in Ethiopia that provides neurosurgical care to the more than 90 percent of the country’s population of limited or no means. Residents receive their training at both BLH and the affiliated MCM, which are located in Addis Ababa.
Medical residents in Ethiopia are financially supported by a hospital or university. The neurosurgical residents are funded through AAU, and neurosurgical staff also is supported by AAU, with monthly salaries ranging between $300 and $500. Neurosurgeons often must supplement their income through private practice, which can increase monthly income to between $2,000 and $5,000. Medical services outside of Addis Ababa are focused on gynecology, general surgery and primary care, and neurosurgical care is not supported. The limited availability of government and hospital funds has precluded investment in the neurosurgical unit at BLH. Donations of operating theater equipment (Mayfield headrest, microinstruments) and supplies (bone wax, hemostatic agents) have supplied the training program.
The postgraduate training program consists of a four-year surgical fellowship awarded to certified general surgeons. The curriculum consists of a minimum of 36 months of neurosurgery and three months each of neuropathology, neurology and neuroradiology. Dr. Tadios and Dr. Zenebe lead the neurosurgery service at BLH. Ethiopian-born Gabriel Lende completed his neurosurgical training in Bergen, Norway, and returned to Addis Ababa to lead the neurosurgery service at MCM. The learning objectives for the Ethiopian neurosurgical residents have been based on the North American training model (Table 1), although many of these objectives cannot be fulfilled given current resource limitations. Trainees also are expected to display a breadth of physician competencies based on the CanMEDS model: collaborator, communicator, manager, health advocate, scholar and professional. Four residents were initially recruited into the program, but two of them left for personal reasons within the first six months of the program.
Resident teaching sessions include a Wednesday morning radiology conference in which cases from any service can be presented and management options discussed. In addition, a neurosurgical curriculum tailored to the most commonly encountered pathologies has been established by the training program. Every week MCM and BLH jointly hold a neurosurgery conference based on this curriculum. The conference consists of a didactic session followed by case presentations.
Materials and Methods
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| Table 3 Adult Neurosurgical Cases Awaiting Admission to BLH,
July 2006-February 2007 |
To gain insight into the dominant pathologies presenting to BLH, we reviewed the neurosurgical operative registry as well as the charts of patients awaiting neurosurgical admission. The operative registry was reviewed for the eight months after the inception of the training program, July 2006 to February 2007. The neurosurgical procedures performed and the patient diagnoses were tabulated. The list of outpatients awaiting neurosurgical care consisted of 438 adults and 338 children. For adult patients, age, diagnosis and date when recommended for admission were recorded. For pediatric patients, age at presentation, diagnosis, interval to neurosurgical evaluation, and date when recommended for admission were recorded.
Results
In the eight months between July 2006 and February 2007, 194 neurosurgical
cases were performed at BLH. Procedures for head trauma comprised 50 percent
of the total number of operations (Fig. 1). Among the head trauma patients,
46 percent of patients had depressed skull fractures. Of patients who presented
with a depressed skull fracture, the predominant mechanism of injury was
stick fighting (more than 80 percent). The remainder of the operative depressed
skull fracture patients presented after auto-pedestrian accidents or other
motor vehicular accidents, and kicks by farm animals. Because BLH does not
have a working CT scanner, the other 54 percent of head trauma patients either
underwent exploratory burr holes based on clinical suspicion or craniotomy
if a CT scan was brought from an outside facility.
Eleven percent of operative neurosurgical cases involved a brain mass. In 55 percent of these cases the brain mass was due to infection, and the dominant pathology was tuberculosis. The remaining 45 percent of intracranial masses included meningiomas, gliomas and other brain tumors. Spine trauma comprised only four percent of the operative cases, although spine trauma is an extremely common pathology presenting to BLH. The reason for this discrepancy is the lack of appropriate instrumentation for realignment of the spine. Consequently, many patients with spinal cord injuries and significant deformities are treated with bed rest.
The average time that adult neurosurgical patients waited for admission was 242 days, while the average time for children was 447 days (Table 2). Of the adult patients awaiting admission, degenerative spine disease comprised the majority of the cases (71 percent). Patients with brain tumors, including skull base meningioma, sellar masses, and posterior fossa tumors, comprised another 9 percent of cases. The composition of the adult neurosurgical waiting list is detailed in Table 3.
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| Table 4 Pediatric Neurosurgical Cases Awaiting Admission to BLH, July 2006-February 2007 |
Children with myelomeningocele and children with hydrocephalus together comprised 70 percent of the pediatric population awaiting admission (Table 4). The average interval from initial diagnosis until completion of evaluation by the neurosurgery service was between two and three months. However, once a patient was recommended for admission, there was a significant interval until a hospital bed became available to admit the patient for surgery. The other commonly seen pediatric cases included encephaloceles (9 percent), craniosynostosis (5 percent) and brain tumors (4 percent).
Discussion
Constraints Faced in the Delivery of Neurosurgical Care In
beginning a neurosurgical residency program, Ethiopia is making significant
progress toward overcoming one major obstacle to the delivery of neurosurgical
care: the critical shortage of trained surgeons. However, many other administrative
and social factors continue to constrain the country’s ability to provide quality
neurosurgical care. The following three scenarios encountered during our stay
in Addis Ababa demonstrate some of the key issues that are repeatedly faced.
1. Limited Operating Time
R.M. is a 40-year-old HIV-positive man who
presented to the clinic with a two-week history of progressive headaches, nausea
and vomiting. A CT scan revealed a right thalamic mass with significant obstructive
hydrocephalus. He was listed for emergent admission, but he was not admitted
due to lack of bed space.
The situation that R.M. faced unfortunately is not an unusual one. Numerous adults with treatable pathologies and children with ruptured myelomeningoceles or hydrocephalus must wait months for bed space to become available. The critical factor is the limited operating time available. Currently there are three days per week of dedicated operating time for the neurosurgery service. Further, the operative day begins at 9 a.m., after morning report, and the anesthesia team is reduced to emergency staff after 2 p.m. As a result of this limited schedule, inpatients often spend three or more weeks waiting for surgery. The ultimate result is the inability to admit patients emergently for neurosurgical intervention. Further, during the evenings and weekends, a single nurse anesthetist is available to provide anesthesia support for all emergency operations. Because BLH is a tertiary referral center caring for all parts of Ethiopia, there are often multiple emergencies during the night, forcing a triage of emergent operations among all the surgical services.
2. Blood Donation
T.H. is a 24-year-old man admitted to the SICU after a stick fight. On presentation
he was localizing to painful stimulus bilaterally. Soon after admission,
his right pupil dilated, and he developed left hemiparesis. No blood had
been prepared for the patient, but the decision was made to proceed with
surgery regardless. A large epidural hematoma was found, and he lost a significant
amount of blood intraoperatively. However, no blood was available for transfusion
until the family donated blood.
Like many other developing countries, Ethiopia has faced cultural barriers, such as fear of contracting HIV or of developing medical illness, to the development of a strong voluntary blood donation program. Consequently, before proceeding with surgery a patient’s family or friends must donate the amount of blood necessary for an operation. This poses a dilemma for all emergent cases and particularly for neurosurgical emergencies, for which outcomes often are related to expeditious operation.
3. Limited Diagnostic Modalities
G.A. is a 19-year-old man who presented to the hospital after a motor vehicle
accident. On presentation he could intermittently follow commands but was
very lethargic. As there was no CT scanner at BLH, G.A. was transported unmonitored
to another facility for a CT scan. The imaging revealed a large, right-sided
intraparenchymal hematoma with uncal herniation. Upon return to BLH four
hours later, G.A.’s exam had deteriorated to decerebrate posturing, and the
family elected comfort care.
Only basic diagnostic tests such as plain radiographs, ultrasonography and myelography are available at BLH. CT and MRI devices are unavailable in the hospital. Consequently, the patient must be transported to another facility to undergo neuroimaging. As in G.A.’s case, the significant delay in treatment can lead to preventable morbidity. However, for most people in Ethiopia the cost of neuroimaging is prohibitive. A CT scan with contrast in Addis Ababa costs 1000Birr ($113) and an MRI with contrast requires 2500Birr ($284). If financial resources allow, however, there is capability within Addis Ababa to perform MRI, MRA, CT, and EEG.
Areas for Further Development
Pediatric Neurosurgery
Hydrocephalus remains a significantly undertreated pediatric health concern
in Ethiopia. BLH has no neuroendoscope, and the cost of a ventriculoperitoneal
shunt is approximately 2500Birr ($284). In a country where 78 percent of the
population is living on less than $2 per day, this cost is prohibitive. Ugandaâs
experience with ETV can serve as an excellent teaching model for Ethiopia.
In his time with CURE Children’s Hospital of Uganda, neurosurgeon Benjamin
Warf led significant research evaluating ETV as a treatment option for infants
with hydrocephalus. His work has shown that ETV is particularly effective in
patients older than 1 and in patients younger than 1 with both postinfectious
hydrocephalus and aqueductal stenosis (6). Further, in patients younger than
1, ETV combined with bilateral choroid plexus cauterization yielded a higher
success rate than ETV alone (7). Developing competency in ETV in Ethiopia can
serve to free part of the dependence on costly shunt assemblies, making treatment
of hydrocephalus more accessible.
Postgraduate Training
Residents in Addis Ababa are exposed to a diverse set of pathologies, including
pediatric, oncologic, spine and trauma cases, providing a rich environment
for a postgraduate training program. However, system-wide resources significantly
limit resident exposure in the operating room to an average of only six cases
per week at the primary teaching site. Further, although the operating theater
at BLH is outfitted with basic instruments such as a Hudson brace, Gigli
saw, punches and rongeurs, there are critical deficiencies that limit resident
training and patient care. The addition of a headlight, neuroendoscope, intraoperative
radiographs and ultrasound, and intraoperative frozen section are essential
for the development of the neurosurgery service.
Due to these limitations, the program’s learning objectives (Table 1), which are modeled after those of North American training programs, may not be realistic today in Ethiopia. Although they do represent a target toward which the Ethiopian program should strive, a more immediate goal may be to focus training on the commonly presenting pathologies using the resources available. With trauma representing half of all operated cases, neurosurgical training should be extended to those general surgery trainees rotating with the neurosurgery service because they represent the practitioners who likely will be managing head trauma outside of Addis Ababa.
The long-term goal of the program is the development of world-class neurosurgical care in Ethiopia. Providing world-class neurosurgical care is not necessarily predicated on access to the latest technology. Neurosurgeons in developing countries must be aware of the latest techniques and technology but must simultaneously optimize the appropriate technology available (5). A consistent supply of international volunteers with a strong interest in neurosurgical education, such as those being supplied through FIENS, can serve a critical role in augmenting the practice of neurosurgery in Ethiopia.
Conclusions
While Ethiopia’s journey to improve access to neurosurgical care begins in
Addis Ababa, the road is a long one. The development of neurosurgery services
in rural areas is decades away-but this is the ultimate vision. As the infrastructure
of the healthcare system in Ethiopia develops, the delivery of quality neurosurgical
care must progress as well. Integral to this process is the success of the
residency program in Addis Ababa. The strong collaboration between local
neurosurgeons and FIENS has provided a solid framework. It is now up to the
international neurosurgical community as a whole to ensure continued success.
Acknowledgements
Our housing accommodations were supported by BLH, and our visit to Addis Ababa
was made under the auspices and with the support of FIENS. We extend special
thanks to Merwyn Bagan, MD, and Gail Rosseau, MD, of FIENS for assistance
in coordinating this volunteer experience, and to Raymond Sawaya, MD, and
the Department of Neurosurgery at Baylor College of Medicine for their support.
REFERENCES
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