ENT Outreach in Africa: Rules of Engagement

Abstract

To address inequality of access to ear, nose, and throat (ENT) care, there must be significant and sustained investment in education and training of surgeons, audiologists, speech therapists, clinical officers, anesthetists, and specialized nurses engaged in ENT in sub-Saharan Africa and other developing nations. Outreach by ENT surgeons from developed countries is essential if we are to address the critical lack of access to ENT care in SSA. However, it should be based on mutual respect, shared values, aspirations, a desire to create a durable and sustainable impact, and internationally accepted best practice. In this article, we propose rules of engagement for outreach projects in SSA and other developing countries to optimize their contributions by making them useful, sustainable, productive, and developmental. These proposed rules of engagement are based on our personal experiences and observations—good and bad—of outreach activities in our countries.

On May 30, 2017, the 17th World Health Assembly adopted a resolution about prevention of deafness and hearing loss that called on governments to integrate strategies for ear and hearing care within primary health care programs; to establish training programs for health workers; to implement prevention and screening programs for high-risk populations; and to improve access to affordable, cost-effective, high-quality assistive hearing technologies.¹ Nearly 90% of people with hearing loss live in low- and middle-income countries,² and it is predicted that by 2030, 70% of cancers will affect people in developing countries.³

Yet, >95% of the population in sub-Saharan Africa (SSA) does not have ready access to safe, affordable surgical care,⁴ and there is a desperate need for ENT (ear, nose, and throat), audiology, and speech therapy services.⁵ Therefore, from a global perspective, the greatest challenge facing delivery of hearing and cancer care is not high-technology and high-cost medicine but the lack of access to even the most elementary ENT care.

To address inequality of access to ENT care and to work toward achieving the hearing-related goals outlined by the 17th World Health Assembly, there must be a significant and sustained investment in the education and training of surgeons, audiologists, speech therapists, clinical officers, anaesthetists, and specialized nurses engaged in ENT in SSA and other developing nations. Many individuals, organizations, and companies are already engaged in outreach activities in SSA. While many such outreach projects are building sustainable clinical and teaching capacity, others may (perhaps inadvertently) be less effective or even counterproductive to the well-being and development of the host countries.

All of the authors of this article live, practice, and teach in SSA countries and have been on the receiving end of such outreach programs. In this article, we propose rules of engagement for those participating in outreach projects in SSA and, by extension, other developing countries to optimize their contributions by making them useful, sustainable, productive, and developmental. These proposed rules are based on our personal experiences and observations of outreach activities—good and bad—in our countries.

What’s in a Name?

Humanitarian mission refers to humanitarian aid that provides material or logistical support for humanitarian purposes, typically for humanitarian crises (eg, natural or human-made disasters). The primary objective of humanitarian aid is to save lives, alleviate suffering, and maintain human dignity. We consider the term humanitarian mission/outreach to be inappropriate when referring to outreach activities other than for humanitarian crises, as it reflects negatively on the efforts of local health care workers to provide services, often under difficult circumstances. We prefer terminology such as outreach when referring to a specific educational/training outreach project. The same applies to humanitarian committees of ENT societies; terms such as global education and training and global surgery are considered more acceptable, as they capture the primary mandate of rendering services, training, and development when such projects are executed.

Objectives of Outreach

• Focus on the long-term improvement of health care delivery in the host country.

• Build and strengthen local capacity by training local educators.

• Establish local centers of clinical, teaching, and research excellence.

• Benefit the hosts, not the visiting team members.

Establishing an Outreach Project

• Always engage medical professionals in a host country, as individuals or through universities, hospitals, or professional medical societies, to identify areas of need that may benefit from outreach.

• Avoid organizing outreach programs through nonmedical people, such as politicians.

• A formal partnership agreement or memorandum of understanding is essential.

• Such a partnership agreement should be in line with international best practice.

• Outreach is not a training opportunity for visiting trainees; rather, it should be conducted by qualified, experienced clinicians.

• Registration requirements, as prescribed by the host’s medical and dental council, must be complied with.

• Personal medical malpractice insurance should be applicable in the host country.

Patient Selection and Management

• In underresourced settings, appropriate patient selection for surgery is complicated and must be done in conjunction with the hosts.

• Patients should be selected that support the objectives of teaching and training.

• Provision should be made for follow-up of surgical patients.

Interaction with Hosts

Good preparation and planning between host and collaborating institutions is essential. This requires

• Mutual agreement about objectives

• A clear understanding of the host’s capabilities and constraints—for example, by not demanding investigations that are not readily available or affordable

• Clearly spelled out sources of funding, to not financially disadvantage the host

• Mutual respect, to not undermine the status of the hosts among their colleagues, community, or political leadership

• Avoiding the duplication of locally available efforts/services

• Allowing the hosts to be hosts, even selecting a restaurant of their choice

Donating Equipment

SSA is littered with donated diagnostic or therapeutic equipment that is inappropriate or cannot be maintained due to a lack of technical support—therefore,

• Check that equipment conforms with the host institution’s requirements.

• Confirm that the voltage of US-sourced equipment is compatible with that of the host country.

• Confer with the host that donated equipment is compatible with existing equipment (eg, drill bits for mastoid drills).

• Do not donate equipment that cannot be serviced due to a lack of technical backup.

• Budget for the costs of customs clearance.

Research

The primary objectives of research outreach should not be to benefit the researchers of the outreach institution but to build research skills and capacity in the host country, improve clinical outcomes of patients in the region, and assist local doctors with their academic career advancement. This requires that local researchers do the following:

• Be engaged in identifying research ideas.

• Be engaged in obtaining ethics approval from their host institution.

• Be engaged in planning and execution of the research.

• Be coauthors of publications emanating from the research.

• Be offered funding assistance to present the research in international fora.

Avoiding a Culture of Dependence

The ultimate measure of successful outreach is when transfer of skills makes the hosts self-sufficient—be it in terms of clinical service provision, teaching, research, or running courses (eg, temporal bone or head and neck dissection courses)—and the outreach team can move on to a new project. Not to have this as a primary objective can establish a culture of dependence on the outreach team for clinical services, teaching, or research.

Measuring Outcomes of Outreach

It is inappropriate to measure success of outreach by the number of surgical cases done or hearing aids fitted, as it reflects short-term, nonsustainable outcomes. Rather, outcomes should be determined in terms of

• Transferring skills to host surgeons

• Providing diagnostic and surgical equipment

• Developing resource-appropriate protocols/guidelines

• Building research capacity in the host country

Conclusions

Outreach by ENT surgeons from developed countries is essential if we are to address the critical lack of access to ENT care in SSA. Outreach should be based on mutual respect, shared values, aspirations, internationally accepted best practice, and a desire to create durable and sustainable impact.

Author Contributions

Wakisa Mulwafu, conception, drafting and revising it critically for important intellectual content; Johannes J. Fagan, conception, drafting and revising it critically for important intellectual content; Kaitesi Batamuliza Mukara, drafting and revising it critically for important intellectual content; Titus S. Ibekwe, drafting and revising it critically for important intellectual content.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.