Wednesday, September 24, 2014

Building emergency medicine in Ethiopia

Ethiopia faces a critical gap in emergency medical care. Canadian experts have paired with Addis Ababa University to develop a national research and training facility and graduate the country’s first emergency medicine specialists.
In Ethiopia, average life expectancy is just 58 years, with communicable diseases such as tuberculosis, malaria, diarrhea, and pneumonia taking a heavy toll. Over the last decade, there were roughly four doctors for every 100,000 people in Ethiopia — less than half the level recommended by the World Health Organization. Canada, in contrast, has 210 doctors for every 100,000 people.
In 2008, Ethiopia’s Ministry of Health declared emergency medicine to be a top priority. Faced with an ongoing exodus of trained staff, and with no qualified emergency practitioners or teachers, the country reached out. Since 2010, Addis Ababa University (AAU) and the University of Toronto (U of T) have worked together to meet the country’s training and research needs through the Toronto-Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM). From 2012 to 2014, IDRC has supported this unique teaching and research collaboration through a Canadian Partnership grant to the University Health Network (UHN).

Starting from the ground up
Dr Megan Landes, a physician with the UHN Global Health Emergency Medicine Group and co-director of TAAAC-EM, recalls some of her first impressions of emergency care in Ethiopia:
“The emergency room was lacking the organization we would consider essential. Triage was just being implemented, and given the volume, very sick people were waiting a long time to be seen. In a place where there are few seatbelts, few sidewalks, and a lot of traffic accidents, the amount of trauma was tremendous.”
Dr Biruk Germa, Senior Emergency Medicine Resident at Addis Ababa University, also attested to the lack of resources. “We have a shortage of rooms, a shortage of staff, a shortage of medications, and a lack of investigation modalities in the hospital.”
For Dr Landes, the dilemma was where to begin: “How do you develop an emergency medical system when there are no trained specialists?”
From bedside teaching to distance education
To tackle the challenge, TAAAC-EM has taken a comprehensive approach that includes curriculum delivery, clinical teaching, operational research, training in research methods, distance education, and mentorship. Four times a year, a Canadian medical team comprised of U of T faculty members, a senior EM resident, and a registered EM nurse have travelled to Addis Ababa for intensive month-long residencies, teaching and practicing at Black Lion Hospital, the country’s largest public hospital. Together with AAU partners, they developed a three-year emergency medicine curriculum that meets both Ethiopian and international standards.
At the heart of the program is hands-on teaching through bedside supervision, case review, and clinical mentorship. Each AAU EM resident is mentored by a member of the U of T faculty. Between visits, email helps to bridge the distance, and regular video conferences allow for ongoing learning and problem solving.
To better equip AAU to address emergency medicine policy priorities and operational challenges, TAAAC-EM is also building research capacity. AAU and U of T faculty identified three initial topics related to emergency care, and developed a protocol to facilitate collaboration and shared learning in the research and writing approach. Five other research projects were developed by the first cohort of Ethiopian graduates, overseen by faculty from both universities.
Ethiopia's first EM specialists
As a result of the partnership, the first Ethiopian emergency medicine specialists graduated in October 2013, with a second cohort expected in October 2014. By then, 10 new specialists will be practicing – roughly half in the nation’s capital, with the others taking their expertise to regional centres across the country.
TAAAC-EM hopes to match the tremendous success of an earlier partnership in psychiatric medicine that dramatically increased the number of psychiatrists in Ethiopia. Moreover, nearly all the graduates remain in the country.
Looking forward: A growing network of expertise
While Ethiopia is enjoying a much-needed injection of expertise, TAAAC-EM’s achievements will have a global reach.
An open-source Internet platform will make peer-reviewed EM teaching resources widely available and will eventually support North-South collaboration in other low-income countries. As of June 2014, some 50 Web-based teaching modules were in development.
Meanwhile, a growing body of knowledge is emerging on the practical challenges facing EM departments and health systems in Ethiopia. Two first studies — looking at the causes of early death in emergency departments, and cases of head trauma — are being presented at conferences in Canada and Ethiopia in 2014.
Canada is also seeing benefits. Through TAAAC-EM, a growing network of Canadian educators and trainees has gained experience in global health emergency medicine. More than 20 faculty members have been involved in curriculum development; over 100 have worked on teaching modules; and 15 more have been involved in designing and carrying out research. Many have developed a lasting commitment to this ongoing relationship.
“For those of us involved in this project,” says Dr Landes, “it changes us tremendously. I know that I am a better doctor because I practice in Ethiopia.”
Mary O'Neill is an Ottawa-based writer.