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In 2016, Paraic Behan boarded a plane bound for Ethiopia.
Some 12 hours later he stood in the busy, engaging and eclectic capital Addis Ababa, a melting pot of peoples, creeds, cultures and traditions often described as the ‘rumbling heart of Ethiopia’.
The senior cycle medical student at the RCSI had dreamt of regularly volunteering as a medic in areas of the world such as Ethiopia. His experience started in earnest on a six-week placement with the RCSI elective programme in Africa.
Ethiopia COSECSA Elective Students 2016: Ross O’Grady, RCSI; Paraic Behan, RCSI; Aoife Casey, RCSI; Edward Tyrell, RCSI; pictured with Kent Grosh, university of Pennsylvania, US
The healthcare setting was “very much resource-limited” but the attitude of the medical staff was inspiring. “It’s an uplifting place when things go well but it’s also a place which brings you down to earth on occasion,” he recalled.
Some five years earlier, RCSI had seized the opportunity to set up a formal elective programme with their partners, the College of Surgeons of East, Central and Southern Africa (COSECSA) within the RCSI/COSECSA Collaboration Programme.
Looking back on his trip of intrigue in the Ethiopian capital, Mr Behan believes the RCSI/COSECSA elective programme provided valuable insights into the provision of healthcare in a beautiful and diverse city that is nevertheless hugely challenged by resource deficits.
He added: “Personally, the placement allowed me to develop my clinical acumen in order to become a more competent, judicious and conscientious clinician… indeed, this elective gave me the impetus to commit to effect positive change on healthcare outcomes in resource-limited settings in the future.”
Mr Behan’s elective was at Tikur Anbessa (Black Lion) Hospital, Addis Ababa, the largest hospital in Ethiopia with 800 beds and the only tertiary referral centre in a country with a population of over 91 million. He was based in the departments of Anaesthetics/Intensive Care and General Surgery.
It was a “fascinating facility” caring for a very diverse mix of patients. They often attended with advanced disease, which he found very challenging at times.
Mr Behan recalls that there was a sizable number of junior doctors enrolled in the RCSI/COSECSA surgical training scheme. He was impressed by their competence and learned a great deal from them.
“Many of them were actively enrolled in the RCSI/COSECSA surgical training scheme. The doctors and surgeons spoke very highly of the programme and were interested to hear what it is like to study and practice medicine in Ireland.”
Despite the lack of medical resources and certain technology at the hospital, Mr Behan learned valuable lessons, particularly in the intensive care unit (ICU).
While on his anaesthetics rotation, he spent a lot of time in the ICU. “Though the technology was not as advanced as in Ireland, this allowed me the opportunity to take clinical measurements such as central venous pressure manually. This was really useful in understanding the physiological basis of interventions which are made in ICU.
“At Tikur Anbessa, I learned to rely more heavily on my basic clinical acumen because expensive and complex diagnostic tests were either unavailable or the time taken for the result to return was too long. I found this aspect to be very helpful.”
Overall, he gained an authentic, first-hand insight into a medical system which, despite operating under very difficult circumstances, provides a critically important service to its patients.
In 1963, Prof Krikor Erzingatsian entered the medical school in RCSI Dublin. Some 53 years later, in 2016, he was awarded an Honorary Fellowship by the College in recognition of his huge contribution to surgery. During Prof Erzingatsian’s early years in the RCSI, he befriended Prof Gerry O’Sullivan, now sadly deceased, a friendship that would span almost half a century.
In 2007 Prof Erzingatsian, President of COSECSA, invited his friend and then President of the RCSI Prof O’Sullivan to visit COSECSA. Following Prof O’Sullivan’s trip to the COSECSA region, both Presidents established links between the colleges that resulted in the signing of a Memorandum of Understanding.
Orof Krikor Erzingatsian
This subsequently led to the implementation in the same year of the RCSI/COSECSA Collaboration Programme. Its principal aim was to increase the provision of quality, essential surgical and emergency care in the COSECSA region, particularly at district level.
A decade on, Prof Erzingatsian, COSECSA Honorary Registrar, acknowledges the substantial in-kind contribution from the RCSI. “The most important [aspects] which have been demonstrated by our collaborating partner colleagues have been integrity, generosity towards the underprivileged and professionalism.
In 1996, Prof Erzingatsian became a leading figure among a group of visionary surgeons in Africa in recognising the need for a formal structure of surgical training, which led to the creation of COSECSA. The quality and quantity of surgical services available to people within the region were inadequate, and all surgeons had to be sent abroad for training purposes.
During the years of the RCSI/COSECSA programme, there has been a very substantial increase in the number of surgeons trained across the countries of Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe in the COSECSA region.
In fact, research has shown that 93 per cent of surgeons who have trained under the programme in the last 10 years work within the COSECSA region, the majority in their own country.
COSECSA has graduated 158 specialist surgeons, with 391 current surgical trainees (as of September 2016) in 94 accredited training hospitals. There has been a standardisation of surgical training in the region through the training and development of 300 surgical trainers, including 28 master trainers.
Additionally, 27 ‘surgeon basic scientists’ completed a three-year training programme and they deliver short courses in basic science for surgeons.
Moreover, fellowship-level seminars have been held in orthopaedic surgery and general surgery.
“Data from a January 2017 programme evaluation report confirmed the rapid increase in the number of trainees from about 70 in 2010 to just under 400 in 2016. It is reasonable to predict that, with the successful continuation of the programme, the resources will be available to increase graduating numbers of surgeons and compensate for the increased demands on resources which population growth entails,” added Prof Erzingatsian.
The Lancet Commission on Global Surgery (2015) estimated that 93 per cent of people in Sub-Saharan Africa did not have access to timely and effective surgical care.
The major shortfall of surgeons in the COSECSA region has seriously hindered access to safe surgery in rural areas, which is frequently practised by General Medical Officers (GMOs) who have no structured training apart from peer training and support systems.
In response, the RCSI/COSECSA programme set about challenging this predicament and in turn reducing the number of referrals from district hospitals to already overwhelmed regional hospitals by introducing Essential Surgical Training (EST) in rural areas.
RSCI/COSECSA and the World Health Organisation Emergency and Essential Surgical Care (WHO EESC) programme produced an open access e-learning tool based on the WHO EESC Emergency Trauma Care Course, which is used in the delivery of EST.
Over the last four years, the EST programme has trained a total of 164 GMOs in rural areas of Zimbabwe, Rwanda and Zambia.
Conducted by experienced senior-level COSECSA surgeons, the training covers the management of surgical emergencies in various specialties which include trauma, general surgery, paediatric surgery, cardiothoracic surgery, neurosurgery, urology, orthopaedics, obstetrics and gynaecology.
Ms Avril Hutch, Assistant Programme Director, RCSI/COSECSA, spoke of the positive impact on the three countries which introduced EST.
“With such a shortfall of surgeons in the COSECSA region, the Essential Surgical Training programme is designed to improve access to safe surgery in rural areas,” she said.
“The benefits of EST include improved local treatment options for patients and a reduced number of referrals from district hospitals to already overwhelmed regional hospitals. Trainees also report increased confidence in undertaking basic surgical procedures and some EST trainees have even transitioned to full surgical training following the course.
“For now we would hope (funding dependent) to continue the successful programmes in Zimbabwe and Rwanda. The Ministry of Health in Rwanda has also expressed an interest in co-funding EST in the future — this will help ensure the sustainability of the training programme.”
She continued: “People travel from other COSECSA countries to undertake EST training, ie, the Rwanda trainings were also completed by trainees from Uganda and Burundi. There is an online, interactive learning tool (Emergency Trauma Care — ETC), which was developed by the RCSI/COSECSA programme in collaboration with WHO and is used in the delivery of the EST trainings.”
Women in surgery
In 2015, the then RCSI President Mr Declan Magee travelled to Blantyre in Malawi to attend the inauguration of Women in Surgery Africa (WiSA). While in attendance, Mr Magee announced a bursary dedicated to WiSA in recognition of RCSI support in training female surgeons in the COSECSA region.
Dr Faith Muchemwa, Chairperson of Women in Surgery Africa-East Central Southern Africa (WiSA-ECSA), commented: “WiSA’s efforts in promoting and facilitating gender issues in surgery training and service provision has benefitted immensely from the support given by the two colleges, COSECSA and RCSI, whose collaboration in addressing surgery needs in Africa has been directly supported by the Irish Government.
Dr Faith Muchemwa, WiSA Chairperson (fifth from the left in the front row) pictured at the WiSA Annual Meeting 2016
“The COSECSA/RCSI collaboration helped with the establishment of WiSA and the two colleges assist us in our daily endeavours in addressing and highlighting challenges and mentorship needs of female surgeons working and training in the COSECSA region.”
As a peer support group, WiSA assists female surgeons, trainees and medical students with an interest in surgery to actively seek out mentorship relationships, while also promoting, facilitating and enabling women to take up leadership roles and positions in surgery.
Bursary recipients are chosen based on their expressed interest in surgery, potential leadership qualities or research contributions to the field of surgery and can use the grant towards travel costs to attend a WiSA event or related conference.
The late Prof Gerry O’Sullivan
In January 2008, Irish Aid granted start-up funding for the RCSI/COSECSA Collaboration Programme to begin and pilot the initiative. Having completed a successful development phase in the first year, RCSI/COSECSA has had continued support from the Government’s official aid programme.
Mr Eric O’Flynn, RCSI/COSECSA Programme Director, commented: “The majority of the funding for the collaboration programme has come from Irish Aid. RCSI’s largest contribution is in-kind, making staff, material, resources and office space available. The collaboration is fortunate to have in Irish Aid a partner that understands the long-term nature of the type of institutional strengthening undertaken by the collaboration programme, and the very significant and long-lasting impact this is having across the entire region.”
RCSI’s continued support for COSECSA examinations includes a joint development of examination standard operating procedures, collaboration on delivery of pre-exam seminars and MCQ writing seminar, support for the establishment of COSECSA Court of Examiners and the annual exchange of examiners and external examiners since 2009.
“Initial support for COSECSA examinations involved examiners travelling from RCSI to examinations and related events held in Africa. This has evolved into a mutual exchange of examiners in each direction; every year, two examiners from each college travel to the other to examine. We see this a maturation of the relationship and a sign of mutual respect between the colleges,” Mr O’Flynn added.
Despite the dawn of the Internet and access to travel, Mr O’Flynn also touched on some of the challenges and constraints they face on a daily basis.
“There are a number of challenges, including the sheer size of the COSECSA region. For example, Maputo, Mozambique to Addis Ababa, Ethiopia as the crow flies is further than Lisbon to Moscow and travel is significantly more difficult. Internal flight connections in the region are infrequent and often expensive. The COSECSA region has over 320 million people. While the Internet has improved immeasurably in recent years, video conferencing, for example, remains a challenge.”
He added that COSECSA training is “appropriate to the context in which trainees and surgeons work. This places much less emphasis on the use of advanced diagnostic and surgical technology than equivalent training in Europe or North America, for example, as this is generally not available in practice.
“Familiarity with the context, conditions and resources available is a reason why the collaboration programme feels COSECSA trainers often offer far more valuable training than could be offered outside the region. While the collaboration programme does work with COSECSA on providing some courses employing more advanced technology (basic laparoscopic courses, for example), this is not a core focus.”
The collaboration programme aims for the long-term sustainability of COSECSA. “To ensure this, it is vital for COSECSA to increase its internally-generated revenue and the collaboration works with COSECSA on this in a number of different ways. COSECSA’s income is increasing and we hope to keep this positive momentum going.
“We’re looking to help COSECSA build an institution that will build vital surgical services in the region for many, many generations to come.”
A personal view: Former RCSI President Mr Declan Magee
Mr Declan Magee, Immediate Past President, RCSI, is an instrumental figure in the development of the RCSI/COSECSA Collaboration Programme. He shared his thoughts on the programme’s achievements.
Mr Declan Magee
“While not exactly a moment, what has really excited me has been to witness the incredible achievements of our COSECSA colleagues over the past 10 years and to know that we have made a significant contribution to their success,” Mr Magee told the Medical Independent (MI).
“I think these achievements have been listed by others but they include the development of reliable training programmes and assessments across almost all surgical specialties and across 10 countries; ever-increasing numbers of trainees; the establishment of a capable executive and infrastructure; and the genesis of Women in Surgery Africa (WiSA)”
Mr Magee attended the launch of WiSA in Blantyre, Malawi, in his capacity as RCSI President.
At the event, Mr Magee announced a bursary dedicated to supporting the training of female surgeons who are members of WiSA.
“At its launch in December 2015, Patricia Numan, Past President, American College of Surgeons, favourably contrasted the timely establishment of WiSA with the protracted and arduous recognition of women surgeons in the US,” said Mr Magee. “One year later at the Mombasa meeting, witnessing the talent, energy and altruistic vocation of the young African women surgeons was certainly a stand-out moment for me.”
He continued: “Other standout moments have been to see our COSECSA colleagues recognised at international meetings and at the WHO for their commitment and their achievements and the contribution they can make to the global agenda.”
Mr Magee said it was a particular honour to be conferred with an Honorary Fellowship of COSECSA.
“Finally, a personal special moment was in December , when COSECSA conferred me with their Honorary Fellowship. An honour that I was happy to accept in the knowledge that it had been earned by the effort and hard work of very many colleagues.”