GHA xxxx-xxxx xxxx-xxxx Global Health Action Vol. 00, Month 2009, pp. 000–000 sici xxx PUBMED Abbreviation JohanJFagan

*Johan J. Fagan Division of Otolaryngology, University of Cape Town H53, OMB, Groote Schuur Hospital ObservatoryCape Town7925South Africa+27 21 406 6420+27 21 448 8865

MarianJacobs Division of Otolaryngology, Faculty of Health Sciences University of Cape Town

Cape TownSouth Africa

Faculty of Health Sciences University of Cape Town

Cape TownSouth Africa

Global Health Action ORIGINAL ARTICLE Survey of ENT services in Africa Background: Burden of disease (BOD) is greatest in resource-starved regions such as Africa. Even though hearing disability ranks third on the list of non-fatal disabling conditions in low- and middle-income countries, ear, nose, and throat (ENT) disorders are not specifically coded for within the framework governing global BOD estimates, and in discussions about health challenges, non-communicable diseases receive scant attention. Implementing cost-effective interventions to address conditions largely neglected by global estimates of BOD such as hearing loss are important contributors to health and economic development. Objectives: Establish a database of ENT, audiology, and speech therapy services in Sub-Saharan Africa; create awareness about the status of these services; propose effective intervention; gather data to lobby African governments, donor countries, and aid organizations; determine need for Developing World Forum for ENT, Audiology, and Speech Therapy services. Design: Survey of ENT, audiology, and speech therapy services and training in 18 Sub-Saharan Africa countries. Results: There is an alarming paucity of services and training opportunities, and there is a large gap between higher technology, expensive health care in high-income countries and lower technology, low-cost practice in low-income countries. Conclusions: Lower technology and lower cost Developing World medical practice should be recognized and fostered as a field of medical practice, teaching, and research. Developing World centers of excellence must be fostered to take a lead in teaching, training, and research. A Developing World Forum for ENT Surgery, Audiology, and Speech Therapy, directed and driven by Africa and the Developing World, supported by the First World, should be established, to develop a comprehensive intervention to turn around the severe shortage of services and expertise in the Developing World. Global health policies and practices should include new norms and standards which serve the interests of the global community, and are based on current realities of global health. otolaryngology ENT audiology speech therapy Developing World Africa hearing In recent years, public health has emerged as a priority in the discourse on globalization, and the collective health of the world's people has become a subject of intense debate. The challenge of addressing transnational health problems is not new. In the mid-1940s, the threat of malaria, polio, and biological warfare led to the establishment of Centers for Disease Control with its initial focus on combating malaria by killing mosquitoes 1.Concerns about unequal development in the world underpin all discussions related to the global health agenda, with available evidence pointing to growing economic disparity. This inequity is mirrored by the burden of disease (BOD), which is greatest in those regions of the world where resources are few.Nowhere is this inverse relationship more prominent than in the African subcontinent. Yet, in discussions about addressing Africa's health challenges, non-communicable diseases have received scant attention. This has led to a current wave of advocacy for this neglected area.Hearing disability ranks third on the list of non-fatal disabling conditions in low- and middle-income countries 2. There is a broad agreement that implementing cost-effective interventions to address conditions largely neglected by global estimates of BOD such as hearing loss are important contributors to health care and, in turn, overall economic development 3. Yet, even within the framework governing global BOD estimates, conditions such as ear, nose, and throat (ENT) disorders are not specifically coded for.Against this background, a survey was done of the availability of ENT, audiology, and speech therapy services and training in Sub-Saharan Africa. 2 2.1 Establish a database of ENT, audiology, and speech therapy services in Sub-Saharan Africa. Create an awareness in the First World about the status of these services. Plan and promote effective, targeted support for these services. Gather data to lobby African governments, donor countries, and aid organizations. Determine the need for a Developing World Forum for ENT surgery, Audiology, and Speech Therapy. 3 A questionnaire was distributed by email to an ad hoc group of ENT surgeons and audiologists in Sub-Saharan African countries in which there were known to be ENT services. Participants were traced through personal contacts and the Pan African Federation of Oto-Rhino-Laryngology Societies (PAFOS) database, and proved to be challenging or impossible in some countries. Questions were asked about the availability of ENT, audiology, and speech therapy services and equipment (nil/poor/good/excellent), about training programs for ENT surgeons, audiologists, and speech therapists, about the availability of services in rural areas, and about their opinions about how to improve the situation. 4 ENT surgeons from 18 Sub-Saharan countries responded to the survey (Fig. 1). Countries with no known resident ENT services were not surveyed.

Eighteen countries that participated in survey.

Table 1 and Fig. 2 present the number of ENT surgeons, audiologists, and speech therapists per country, and compares it to the UK. The UK has the poorest ratio of ENT surgeons to population in Europe, and is intending to further improve this ratio to 1/75,000 4. Some African countries have no ENT, audiology or speech therapy services at all.

Comparisons of ENT surgeons, audiologists, and speech therapists/100 000 people, with the UK.

ENT surgeons Audiology Speech Countries Population (Million) Number Per 100,000 Number Per 100,000 Number Per 100,000 Botswana 1.7 3 0.176 6 0.353 3 0.177 DRC 55 25 0.045 0 0 0 0 Ethiopia 78 11 0.014 0 0 0 0 Ghana 22 15 0.068 6 0.027 2 0.009 Ivory Coast 21 48 0.229 1 0.005 3 0.014 Kenya 33 40 0.121 4 0.012 3 0.009 Lesotho 2 2 0.1 0 0 0 0 Madagascar 17 16 0.09 2 0.012 4 0.024 Malawi 10 1 0.01 0 0 0 0 Namibia 2 3 0.15 7 0.35 12 0.6 Nigeria 130 70 0.054 5 0.004 3 0.002 Senegal 11 25 0.227 1 0.009 2 0.018 S Africa 48 200 0.417 490 1.021 1,144 2.383 Swaziland 1 2 0.2 1 0.1 1 0.1 Tanzania 36 11 0.031 0 0 2 0.006 Uganda 28 16 0.057 1 0.004 2 0.007 Zambia 12 2 0.017 1 0.008 0 0 Zimbabwe 14 6 0.043 0 0 1 0.007 Total 521.7 496 0.095 525 0.101 1,182 0.227 UK 61 614 1.0 2,500 4.1 10,000 16.393 Table 2 presents a summary of ENT, audiology, and speech therapy training programs. Many countries have no training programs, especially for audiology and speech therapy. If one applies the current ratios of ENT surgeons, audiologists, and speech therapists in the UK to the total population (521.7m) of the countries surveyed, then the shortage of personnel in these 18 countries is as follows: ENT: 5,251–496 = 4,755; audiology: 21,381–525 = 20,856; speech therapy: 85,525–1,182 = 84,343. Medical schools ENT surgery Audiology Speech Countries Total number Number with ENT training Number of ENT surgeons who qualify p.a. Training program? Training program? Botswana 0 0 0 No No DRC 4 1 1 No No Ethiopia 6 0 0 No No Ghana 3 2 1–2 No No Ivory Coast 2 1 8 No No Kenya 2 1 4 Yes No Lesotho 0 0 0 No No Madagascar 2 1 0 No No Malawi 1 0 0 No No Namibia 0 0 0 No No Nigeria 36 19 4 No No Senegal 2 1 5 No No S Africa 8 8 6 Yes Yes Swaziland 0 0 0 No No Tanzania 5 2 2 No No Uganda 3 1 1–3 No No Zambia 1 0 0 No No Zimbabwe 1 0 0 No No In all the countries surveyed, the overwhelming majority of people depend on the state health services. Table 3 – 6 present summaries of the levels of clinical services in the state sector in the countries surveyed. ENT services are restricted to major cities (Table 3). Availability of State ENT services outside major cities Nil Very poor Poor Good 9 3 5 1 Table 4 highlights the poor access to simple, routine audiology, hearing aids and the most basic hearing restoration surgery such as ventilation tubes and tympanoplasties. Availability in State service Audiology and otologic surgery Nil Poor Good Excellent Audiology 5 9 3 1 Auditory brainstem reflexes (ABR) 13 3 1 1 Hearing screening: newborn 16 1 1 0 Hearing screening: schools 12 3 3 0 Hearing screening: industry 11 5 2 0 Hearing aids 9 7 2 0 Myringotomies, ventilation tubes 4 10 3 1 Tympanoplasty 4 8 5 1 Mastoidectomy for cholesteatoma 2 10 5 1 Mastoidectomy for mastoiditis 3 9 5 1 Middle ear (ossicular) prostheses 14 3 1 0 Bone anchored hearing aids 17 0 1 0 Cochlear implants 17 1 0 0 Table 5 demonstrates that there is very poor access even for relatively low-cost oncologic surgery, and that laryngectomees are not offered the opportunity of post-laryngectomy voice restoration. Availability in State service Head and neck oncologic surgery Nil Poor Good Excellent Total laryngectomy 5 8 3 2 Speech prosthesis post-laryngectomy 13 3 2 0 Partial laryngectomy 11 5 2 0 CO₂ laser surgery 16 1 1 0 Parotidectomy 3 5 7 3 Radical neck dissection 6 7 4 1 Modified neck dissection 5 7 5 1 Selective neck dissection 7 6 5 0 Commando resection 9 6 3 0 Total maxillectomy 6 6 4 2 Craniofacial resection 13 3 2 0 Pedicled flaps e.g. pectoralis major 9 5 4 0 Free microvascular flaps 13 4 1 0 Mini and microplates 6 9 2 1 Fine needle aspiration 3 9 3 3 Frozen section 12 3 3 0 Table 6 presents the poor access that patients have to modern sinus and rhinologic surgery, and the reliance that is still placed on open as opposed to endoscopic sinus surgery. In some countries, no sinus surgery is done. Availability in State service Sinus and rhinologic surgery Nil Poor Good Excellent Endoscopic ethmoid sinus surgery 12 3 3 0 External ethmoidectomies 5 4 7 2 Inferior meatal antrostomies 6 5 5 2 Caldwell Luc/radical antrostomy 4 4 8 2 Cosmetic rhinoplasty 14 4 0 0 Table 7 highlights the limitations to delivering a modern ENT service due to a lack of equipment. Availability in State service High cost equipment & services Nil Poor Good Excellent Flexible nasopharyngoscope (NR: 1) 9 4 3 1 Operating microscopes 0 10 7 1 Otology drill (NR: 1) 3 8 4 2 CO₂ laser 16 1 1 0 Ultrasound of neck 5 4 6 3 CAT scanning (NR: 1) 2 2 6 6 MRI scanning 12 3 1 2 PET scanning 17 1 0 0 Radiation therapy 7 6 3 2 5 In Engaging for Health (2006), the World Health Organization released a plan for global health for the next decade, and proposed the following major policy thrusts 5: Investing in health to reduce poverty. Building individual and global health security. Promoting universal coverage, gender equality, and health-related human rights. Tracking the determinants of health. Strengthening health systems and equitable access. Harnessing knowledge, science, and technology. Strengthening governance, leadership, and accountability. There has been an unprecedented global response in the past 10 years, with large increases in funding being directed at global health improvement. Recognition of the dire circumstances in Africa has placed the subcontinent at the forefront of such efforts through initiatives around AIDS/HIV, malaria, and tuberculosis. These efforts are however uncoordinated, and the disconnection between vast donor funding and lack of development of health systems is lamentable 6, for in most cases, the financial aid targets particular diseases, such as HIV/AIDS and malaria; interventions, such as ARV programs or bed nets; or a list of challenges which are unconnected to strengthening of health systems and indigenous institutions which have the potential for making a sustainable impact on health. A further reality is that the design of several of these initiatives is dominated by the wealthy world, with limited input by those most affected, leading to programs which may not serve short- or, indeed, long-term health development needs. Efforts to address specific health challenges lie in the realm of innovative, targeted interventions, based on careful analysis of the problem, and designed by those who have practical experience of, and insight into, appropriate and effective solutions.It is common knowledge that all the countries surveyed in this study have an enormous ENT-related BOD. This audit presents a disturbing picture of under-resourced, understaffed, and outdated ENT, audiology, and speech therapy services in Africa. Patients still die from simple ENT infections and curable cancers, and do not have access to the most basic hearing tests or hearing rehabilitation. The audit also highlights the lack of training facilities, critical to improving the shortage of qualified staff.This survey demonstrates the paucity of specialized services and training facilities. While we acknowledge the great importance of non-specialist ENT, audiology and speech services provided by nurses and other medical personnel, it is only through the leadership, training, research, and specialized clinical services provided by a critical mass of resident, well-trained specialists in these fields, that these services will become self-sustaining and countries may one day become independent of foreign medical assistance.What is clearly needed is a comprehensive, multipronged, multinational program to improve the quality of, and access to, ENT, audiology, and speech therapy services in Africa. Such a program has to be carefully planned to take into consideration political, infrastructural, and staffing realities, and will have to be planned jointly with local medical practitioners, academics, academic institutions, governments, and international donor and health organizations in order to be effective, cost-effective, and sustainable.Vorobiof and Abratt reported that 21 African countries do not have radiation therapy facilities 7. Hence, reliance in these countries has to be placed on a purely surgical approach to cancers of the head and neck. Our study also highlights the lack of modern equipment and reliance on outdated surgical techniques. For these reasons, ENT surgeons in poorer countries are compelled to practice lower –technology, lower cost type surgery compared to their counterparts in the Developed World. This chiasm between high technology, high-cost medical practice in the First World versus lower technology, lower cost medical practice in the Developing World, is rapidly increasing, and will continue to accelerate. It is unlikely that the poor who live in the Developing World will ever have ready access to new, high technology, high-cost medical advances. With changing medical practice in the First World due to advances such as imaging, chemotherapy, irradiation, neuronavigation, robotics, minimally invasive surgery, interventional angiography, genetics, and pharmaceuticals etc, younger generations of First World medical practitioners have become unfamiliar with medical and surgical care appropriate to the Developing World, even though it might have been the standard of care in the First World as recently as 10 years ago. Diseases such as leprosy, tuberculosis, HIV, malaria, rheumatic fever, complicated mastoiditis and sinusitis, etc. are essentially diseases of the Developing World and are rarely encountered in the First World. Consequently, medical practitioners in Developing World countries can no longer turn to centers of excellence in the First World for guidance about sound, lower technology, lower cost healthcare.It is therefore crucial that we acknowledge the existence of two tracks of medical practice i.e. a higher technology, higher cost First World medical practice versus a lower technology, lower cost Developing World medical practice. Developing World medicine and surgery should be recognized and fostered as very important fields of clinical practice, teaching, and research that cater for >50% of the world's people. Centers of excellence in the Developing World need to be fostered and need to take the lead in terms of teaching, training, and research in Developing World medical practice.A Developing World Forum for ENT Surgery, Audiology, and Speech Therapy, directed and driven by Africa and the Developing World, but supported by the First World, should be established, and should develop a comprehensive intervention to turn around the severe shortage of clinical services and expertise in Africa and the Developing World. A key element would be to establish and/or strengthen centers of clinical, teaching, and research excellence in the Developing World. Teaching institutions in the First, but in particular in the Developing World should provide specialist training and clinical fellowships to under-resourced countries, with an emphasis on staff training at teaching hospitals.But the answers to the challenge of Africa's health and that of global health inequity also lie with global health policies and practices, including developing new norms and standards for health care which serve the interests of the global community, and are based on the current realities of global health, and which strive to advance efforts to promote health equity. The following ENT surgeons from Africa participated in the survey (some respondents requested anonymity): P.J.C. Buys, C. Chidziva, K. Difela, E Diop, U. Fröschel, A. Konney, I.M. Macharia, N.K. Mohamed, N.H. Moshi, L. Ole-Lengine, B. Olusesi, A. Rahman, F.J. Rakotovao, M-J. Tanon-Anoh, N. Teferi, G. Tumweheire. About CDC: Our history – our story [online]. Available from: http://www.cdc.gov/about/history/ourstory.htm. Para 2 [cited 1 September 2008]. Mathers CD, Lopez AD, Murray CJL. The burden of disease and mortality by condition: data, methods, and results for 2001. Table 3.12. The 10 leading causes on YLD by broad income group. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global burden of disease and risk factors. Disease Control Priorities Project. New York: Oxford University Press and World Bank. 2006, p. 45. Cook J, Frick KD, Baltussen R, Resnikoff S, Smith A, Mecaskey J, Loss of vision and hearing. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, eds. Disease control priorities in developing countries. New York: Oxford University Press and World Bank. 2006, p. 958. NajimOPowellS. So you want to be an ENT surgeon, BMJ career focus BMJ 2007334 2057 World Health Organisation . Engaging for health. 11th General Programme of Work, 2006–2015. A global health agenda. May 2006. Available from: http://www.who.int/entity/management/AGlobalHealthAgenda.pdf [cited 1 September 2008]. Garrett L. The challenge of global health [online]. In: Foreign Affairs, January/February 2007. Available from: http://www/foreignaffairs.com/articles/62268/laurie-garrett/the-the-challenge-of-global-health [cited 1 september 2008]. VorobiofDAAbrattR. The cancer burden in Africa S Afr Med J 200797 937, 939