Not-for-profit Grarbet Eye and Ear Hospital in Butajira, Ethiopia, offers free surgical services to patients with ear disease. This hospital is fully funded through donations to its nongovernmental organization, Grarbet Tehadiso Mahber. For many years, the Grarbet Eye and Ear Hospital focused on medical and surgical treatment of eye disease. Patients with ear problems received medical care but only started to receive surgical intervention in the last seven years. In that same timeframe, an ear surgeon from the capital city has attended to local patients one weekend a month, and surgical teams from countries such as Spain, Japan, or the United States have come for a total of one week a year on average.
In 2012, Miriam Redleaf, MD, professor of otology at the University of Illinois Hospital and Health Sciences System, began weeklong surgical instruction and assistance every six months. The relationship between the University of Illinois and Grarbet hospital developed by chance when a personal friend of Dr. Redleaf's invited her to help at Grarbet. Since that time, the number of patients operated has increased by 200 percent, and the mission of the surgical camps has expanded from patient care to include education and training of the local surgeons.
To prepare for these surgical camps, ear patients are seen by nurses, audiologists, and a primary care physician all year long to identify surgical candidates. The surgical camps are managed by the hospital's staff, nurses, and the Ethiopian otolaryngologists who perform the actual operations. The University of Illinois professor of otology is present in the operating room to assist in any operative matter.
The length of the surgical camps is being expanded to two weeks every six months, and the Spanish team is also increasing their visits to twice a year. The current mission of this collaboration between hospital, local otolaryngologists, and visiting professor is:
1. To provide hearing health services to the indigent population.
2. To increase the skill set and confidence of the local surgeons.
3. To promote the realization among the local people that Ethiopians can provide their own otologic services.
THE PATIENT PROFILE
During two recent surgical camps, all patients were interviewed to identify their demographic profiles and to clarify their opinions and expectations about the services they were receiving. The interview questions were developed by native Ethiopians who understood healthcare concerns of the population. The interviews were carried out in semi-public settings with family members and other patients listening in, as is the custom there. (Isolating individuals for private conversations is viewed as unusual and uncomfortable.)
These interviews were presented as optional activities as patients waited for their surgery. What emerged from these 73 interviews are the characteristics of patients who seek these services, their hopes, and their satisfaction with the entire process. We felt it was important to learn more about the patients we were trying to help. And surprisingly, the patients were impressed that Grarbet was making efforts to understand them better.
Thirty-five females and 38 males underwent operations in July and December 2014. Ages ranged from 12 to 45 (average=20 years). Sixty-one patients (70%) had come for their first ear operation ever; nine (12%) had a previous ear operation at the same hospital.
Figure 1 demonstrates the patients’ professions as well as the professions of the patients’ families at home. Most of the patients were in school, and most of their family members at home were farmers.
Figure 2 shows the distribution of distances that the patients had to travel to arrive at their surgical services site; the distances ranged from 0 to 906 kilometers, with an average of 107 km. Grarbet hospital has an outreach program that sends its workers all around the country to educate people on health, disease prevention, and the specialized services available for them at Grarbet hospital. Therefore, some of the patients traveled from the areas of outreach.
Transportation was by van, bus, or small open-air taxis, called badjadj. In most of the homes, more than one language was spoken: Amharic language had 62 speakers, Oromifa 17, Silti 15, Gurage 13, Meskan eight, Adiya five, Dobi two, Afar one, and Wolaytta one speaker.
ARRANGEMENTS FOR THE SURGICAL VISIT
Most patients had planned for their surgical visit for six to 24 months. All patients came the first day of the surgical weeks, which was Sunday, and stayed until the day after their operation, making the latest discharge the following Saturday. Men's and women's dormitories were provided, as well as meals. Total cost of surgical services for each patient was approximately 3000 Ethiopian birr, or $150.
The majority of patients came accompanied by escorts, though five came on their own. Forty-six came with one escort, 17 came with two escorts, three came with three escorts, and two came with five escorts. The escorts were usually a male relative. Nineteen fathers came, 11 mothers, seven spouses came, one female guardian came, and two uncles came. Twenty-seven patients came with at least one brother, six patients came with at least one sister, and 11 patients came with a non-related escort.
SURGEONS’ SCHEDULE FOR THE SURGICAL CAMP
As for the Ethiopian surgeons and residents, their visit begins early in the morning, before the patients begin arriving. The majority of them reside in the capital, Addis Ababa, or in the surrounding area. The week begins with a three-hour van ride after the doctors and residents are picked up from their homes. These hours are spent chatting with each other and getting to know the foreign doctor.
Once at Grarbet hospital, they are taken to their living quarters for the week, the Grarbet guesthouse, specifically made for this purpose, where they will share their meals and downtime. It is here that the residents’ questions throughout the week will be more thoroughly answered, the workday and patients discussed, and sometimes an impromptu lecture given. When the group visiting is not tired from the day's work, they sometimes venture into town and plan group excursions among themselves.
Of note, the residency training program is new, and while the didactics are excellent, resources for surgical training are not well developed. Therefore, the residents typically have had no hands-on surgical experience. This week serves as their introduction.
The hectic workday begins at 7 a.m. and is done after the last patient has gone to the recovery room and rounds in the wards are completed, which is usually around 6 p.m. Throughout the week, the surgeons receive oral feedback on their progress.
At the week's end, Grarbet hosts a modest dinner back in Addis Ababa for all of the trainees. At this dinner, the written evaluations, along with a certificate of completion, are given to each trainee. Grarbet also keeps the evaluations on file.
PATIENTS’ UNDERSTANDING OF SERVICES
Most of these patients had ear problems since childhood, although six patients stated they only had symptoms for one year. The patients typically had spent years visiting medical centers (often closer to their homes) and searching for successful treatments before making it to Grarbet hospital.
Thirteen percent of the patients had been referred to Grarbet from other hospitals, and 17 percent were informed by family and acquaintances from the Butajira area who were familiar with Grarbet hospital. About 17 percent knew about the Grarbet hospital because they live in the surrounding area, 37 percent were informed by other Grarbet patients, and the last 16 percent were informed by Grarbet's outreach visits.
Many of the people decided to come to Grarbet because they knew a previous Grarbet patient. They explained that they had been told that Grarbet had helped others with similar problems to theirs and that they believe it to be the best hospital to go to for eye and ear services.
They were also aware that there was a chance of them being seen and operated on by foreign doctors; some said that they were specifically coming to be seen by a foreign doctor.
When asked about their preference of nationality for the attending doctors, 20 percent preferred them to be Ethiopian, 33 percent preferred a foreign doctor, and 42 percent had no preference. All patients had high expectations for the hospital because of Grarbet's reputation. In their interviews, the patients expressed their expectations of having their ear disease resolved. Once there, all 73 patients reported that they were satisfied with Grarbet's services and amenities.
SUMMARY OF IMPACT OF COOPERATIVE SURGICAL CAMPS
The last question of the patient survey was open ended, asking them whether they had any comments they would like the hospital employees and surgeons to know. Many of the patients answered that they had come because they personally knew people whose lives had been tremendously improved by their ear surgeries.
As the patient survey shows, some of them came from long distances, and their escorts tended to take an entire week for their surgical trip. For many of them, the trip involved saving money for more than a year. This indicated their determination to come and their confidence in Grarbet's services.
For the Ethiopian surgeons and residents, this was an opportunity for surgical training. By the end of the week, most residents are able to perform simple ear procedures without any assistance. They were uniformly grateful.
As the number and length of surgical camps continue to expand, it appears that more surgeons and residents are in line to have this training experience. At present, the chairman of ENT at Addis Ababa University has begun to actively adjust his residents’ schedules so that more of them can participate in these camps.
This is a collaboration between fellowship-trained surgeons, local surgeons, charitable institutions, and local workers. The outcome has been uniformly positive for the patients and for the surgeons. For the visiting professor, there is the satisfaction of knowing competent, hard-working individuals are getting a chance to access some of their potential.