Slightly >200 million people world-wide are estimated to be affected by peripheral arterial disease (PAD), 140 million of them in low- or middle-income countries (LMIC). The number of people with PAD in sub-Saharan Africa is believed to be at least 14 million, about the same number as in the high-income countries (HIC) of the Americas combined but with access to only a fraction of their health care resources1,2. Data on the incidence and prevalence of PAD in single countries in sub-Saharan Africa are scarce and uncertain3. Based on an ankle-brachial pressure index below 0.9, prevalence can vary between 2.8% and 29.3% among rural populations above 50 years of age in Gabon and South Africa, respectively4,5. In Ghana, a lower middle-income country, vascular disease incurred a 5-fold increase in disability-adjusted life years per 100,000 people from 1990 to 2010 due to rising prevalence of hypertension, diabetes, and smoking. However, surgical resources required to meet the increasing needs for vascular care in Ghana are virtually missing6. Although data are lacking the same is most likely true also for other sub-Saharan countries, since most of them are low-income countries. Ethiopia, one of the poorest countries in the world, is a typical sub-Saharan low-income country with immense needs for improved surgical services particularly pertaining to vascular surgery7–9.
The International Medical Program (IMP) at Linköping University Hospital, County Council of Östergötland, Sweden operates exchange programs for health care professionals between the Linköping University Hospital as well as neighboring hospitals in Health care region Southeast Sweden and partner-hospitals in LMIC. The aim of this exchange programs is to strengthen health care systems and medical proficiency of both partners by engaging in bilateral capacity building partly by using so-called reverse innovation10. An exchange program between Linköping University Hospital and Tikur Anbessa Specialized Hospital (TASH) in Addis Abeba, Ethiopia was launched in 2015 regarding cardiology and cardiothoracic surgery. The program was extended in 2017 to include vascular surgery. As there are few reports in the literature specifically dealing with methods for improving vascular surgical services in LMIC, we describe our experience with this exchange program.
There is only one formally trained consultant vascular surgeon (N.S.) in Ethiopia who is based at TASH, a tertiary referral hospital receiving patients from the entire country. Support is needed to make advanced reconstructive vascular surgery available and to provide diagnostic methods such as ultrasonography and vascular computed tomography, surgical equipment, training of fellows and residents as well as the organization of services and research7. In addition, anesthesia needs to be customized and adjusted to meet the needs of the often frail patients as demands become more complex with the introduction of more advanced procedures. Likewise, for residents and junior faculty Swedish vascular surgeons, there is a growing need for training in open access vascular surgery as many procedures in HIC including Sweden increasingly tend to be performed using endovascular techniques11. Competence in open vascular access is, however, still required when treating rare or sophisticated conditions, postoperative complications or trauma. Activities at TASH involve an abundance of open basic vascular procedures such as peripheral by-pass surgery which offers good opportunities for joint training. Furthermore, valuable insights could be gained by Swedish surgeons from LMIC-partners at TASH when it comes to working in a resource scarce context in terms of creativity, coping with lack of equipment and how to economize with resources10,12,13. All this constitutes the rationale for the mutual benefit of the exchange program. A Memorandum of Understanding (MoU) between the International Medical Program representing Linköping University Hospital and TASH was signed in 2017. The following year a similar exchange program in vascular surgery between TASH and the University of Wisconsin, Madison was started.
TASH is a tertiary referral and teaching hospital with 800 beds affiliated with Addis Ababa University. Specialized vascular surgery services have been available since 2015 as represented initially by the presence of one single consultant surgeon trained abroad. In 2017, 2 fellows in vascular surgery were added. Currently the vascular surgical unit has weekly access to 2 operating tables for elective cases, runs 3 out-patient clinics weekly and provides care for all postoperative patients. The unit also offers 24-hour service for emergency cases. Over a period of 12 months in 2016–2017, 386 patients were seen and 78 were operated on at the unit. The 2 most common diagnoses were PAD and vascular injury7. Patients are referred to TASH from all over Ethiopia, a country of 110 million people. Linköping University Hospital is a 600-bed tertiary referral and teaching hospital with a referral vascular surgery unit serving a population of 1.1 million in Health care region Southeast Sweden. Within the region there are additional units at 2 county hospitals (Jönköping, Kalmar) and 1 local hospital (Västervik) where vascular surgery is also performed. Altogether there are 17 consultants, 3 fellows and 3 residents in vascular surgery appointed at the units performing ~950 elective and emergency arterial vascular procedures yearly of which 65% are endovascular. The corresponding number of venous procedures is ~40010.
Surgery and anesthesia
Eleven 1-week long visits have been made to TASH from Sweden by 5 consultant vascular surgeons together with 5 residents/young faculty since the start of the program. Most of the surgeons have been accompanied by anesthesiologists and on many occasions also by scrub-nurses. Altogether 4 consultant anesthesiologists, 3 residents in anesthesiology, and 3 scrub-nurses have visited TASH. Between 2 and 5 persons have participated in each visit. All visitors have actively taken part in surgery where the Ethiopian partners had primary responsibility and have also participated in ward-rounds and outpatient consultations. Conversely, visits from TASH have been made at Linköping University Hospital and the 2 county hospitals during periods of 1–2 weeks on 3 occasions by the sole vascular consultant at TASH and twice during periods of 2–6 weeks by 1 senior fellow and twice during periods of 1–2 weeks by 3 residents. Ethiopian surgeons have been able to scrub in and participate actively in the operation procedures as assistants. Moreover, they have joined Swedish colleagues in ward-rounds, outpatient consultations and taken part in all joint discussions at the departments of radiology and clinical physiology. Finally, 1 consultant in anesthesiology from TASH has stayed at Linköping University Hospital for 6 weeks. In total, 68 vascular procedures of different complexity have been performed at TASH with the involvement of Swedish visitors (Table 1). Necessary equipment such as grafts, Fogarty-catheters and special surgical instruments has been donated to TASH as part of the program. The most important technical skills acquired or improved by both partners are presented in Table 2.
Table 1 -
Types and number of procedures performed involving Swedish vascular surgeons since the start of the program 2017.
|Peripheral arteries/veins (by-pass, posttraumatic AV-fistulas, giant hemangiomas, etc.)
|Carotid arteries (carotid body tumors)
|Aorta and iliac arteries (aneurysms)
|Trauma (all kinds)
|Thoracic arteries/veins (aneurysms, venous stenosis)
Table 2 -
Technical skills gained or improved as results from the exchange program.
|Aneurysm surgery such as minimal inlay-technique for grafts
||Routine femoropopliteal by-pass surgery
|Management of below-knee anastomoses
||Carotid body-tumor surgery
|Vascular access techniques such as close artery dissection and lymphoid tissue protective incision of the groin
||Technique for operating AV-fistulas and pseudoaneurysm of posttraumatic origin
||Giant hemagioma surgery
||Management of rare and advanced vascular pathologies
Teaching and education
Several lectures on different issues in vascular surgery and anesthesia have been held for staff and fellows at the Departments of Surgery and Anesthesia at TASH by Swedish visitors. Seminars for residents and medical students have been given as well. Fellows at TASH have been trained in diagnostics using in particular ultrasonography as part of preoperative planning, and this has been done both in Ethiopia and in Sweden under the supervision of partners. Generally, preoperative planning involving radiologists, clinical physiologists, and anesthesiologists has been emphasized during Swedish visits. Swedish residents have participated in basic open vascular surgery at TASH jointly with Ethiopian fellows. The exchange has facilitated the establishment of a formal curriculum in vascular surgery at TASH. Finally, attendance at an international congress for one Ethiopian colleague has financially been supported by IMP. Management skills acquired or improved by both partners are presented in Table 3.
Table 3 -
Management skills gained or improved as results of the exchange program.
|Patient-selection pertaining to preoperative multidisciplinary planning and the use of ultrasonography
||Innovative abilities and coping with limited resources in case of crisis
||Critical evaluation of the need for imaging studies and awareness of costs for disposable items
|Establishing and running a curriculum for fellows in vascular surgery
||Cross-cultural understanding useful in a culturally diversified Swedish society
ICU indicates intensive care unit.
The exchange program has mainly been financed by annual funds from the County Council of Östergötland meant for education and training of health care personnel. Financing has also come from the County Councils of Jönköping and Kalmar. The costs for the program have annually been US$79,000 which includes salaries/peer-diem, travel costs, accommodation and equipment.
A retrospective study on the treatment-results of carotid body tumors has been implemented jointly and the report has been submitted for evaluation.
Access to vascular services is scant in sub-Saharan Africa3,6. We here report our early experience of an exchange program between the largest teaching hospital in Ethiopia and a university hospital as well as 2 county hospitals and 1 local hospital, respectively, in Sweden aiming at improving vascular surgery capacity in both countries. The program has been running for almost 3 years during which period consultants in vascular surgery and anesthesiology as well as fellows, residents, and scrub-nurses have been involved in a total of 16 reciprocal visits.
There are many reports on the value of bilateral surgical exchange programs particularly involving residents. Already in 2008 Ozgediz and colleagues reported on the benefits of an exchange between the University of California, San Francisco and Makerere University, Kampala, Uganda. American residents and young faculty were exposed to novel pathologies, shared clinical experiences with colleagues working in a low-income setting and learned cross-cultural communication whereas Ugandan residents got training opportunities from visiting American senior faculty and also support for research projects14. Other residency rotation programs between academic and teaching institutions in the United States and low-income countries in sub-Saharan Africa report similar findings and importantly have also noticed an increased awareness of costs in daily practice among participants when back in their regular setting15–17.
As part of our program Swedish residents and senior vascular faculty have been exposed to a panorama of advanced vascular conditions rarely seen in a high-income context during their stay at TASH. They have thus gained experience in diagnosing and treating conditions such as carotid body tumors, posttraumatic arteriovenous fistulas or giant hemangiomas not commonly encountered in a Swedish setting. Furthermore, as an example of reverse innovation, they have learnt to adjust to a resource-scarce environment not offering the diagnostic and therapeutic options normally available which might be preparative for a possible future situation of crisis. This is also true for accompanying anesthesiologists. The program has also made it possible for residents and young faculty to get training in open vascular surgery, which is becoming increasingly less common in Sweden10.
Since the program started, with contributions from an initiative from Wisconsin, vascular surgery activities at TASH have been developed and improved. Most importantly the number of patients operated on has increased due to improved opportunities to recruit fellows and residents following the establishment of a formal curriculum for training in vascular surgery. Surgery for aneurysmal disease was previously not possible mainly due to lack of equipment and to some extent surgical and anesthetic experience but is now performed regularly. Preoperative evaluation of patients and mapping of available veins for grafting has been improved as a result of more frequent use of ultrasonongraphy. A multidisciplinary approach to vascular patients has been adopted involving radiologists and anesthesiologists to a greater extent than before. Finally, cooperation on research has started.
As an increase in prevalence of vascular disorders is expected to occur in LMIC with almost 29% compared with 13% in HIC the upscaling of vascular services in all LMIC including Ethiopia is essential1. Our program fills an educational gap for vascular care in Ethiopia but also a gap in training of open vascular surgery in Sweden by its reciprocal nature which results in sustainability. A similar program for neurosurgical services has been running for almost 20 years between Haukeland University Hospital, Bergen, Norway and TASH and has been very successful, currently making TASH a center for training in neurosurgery for several sub-Saharan countries18. The American Surgical Association Working Group for Global Surgery strongly advocates that bilateral exchange programs should be established between LMIC and HIC to address missing and growing surgical needs19. It is our aim and hope that this program will expand into more hospitals and contribute to improved vascular services in Ethiopia as well as in Sweden.
Ethical approval was not considered necessary according to the routine nature of the data reported.
Sources of funding
None except for what is already mentioned in the manuscript.
This study was conceived by F.L. and P.A. who made the first draft of the manuscript. All authors were involved in further drafting, critical revision and approval of the final version of the manuscript.
Conflict of interest disclosures
P.A. and R.H.-B. are employees of the International Medical Program. The remaining authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
The authors thank Åke Björn for laying the ground for the exchange by launching the International Medical Program.
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