Sharing information for professionals and patients
Author: Professor Tony Magana
Professor Tony Magana is Head of the Department of Neurosurgery, School of Medicine, College of Health Sciences at Mekelle University in Mekelle, Ethiopia. He directs a neurosurgery residency and training program as well as neuroscience research.
At Ayder Comprehensive Specialized Hospital, the university medical center for Mekelle University in Ethiopia, our experience with finely controlled hypotension during brain surgery for both adults and children has reduced the need for blood transfusion by half.
In many underdeveloped African countries the surgical treatment of brain tumors is often very late in the course of the disease due to delay in the patient seeking treatment, having a diagnostic study to find the tumor, and being scheduled for surgery as many university centers have long waiting lists. Such is the situation we are in Ethiopia. These large brain tumors, often 10 centimeters or more in diameter, can require massive transfusion during the surgery to remove or reduce them.
The Department of Neurosurgery in the School of Medicine at Mekelle University in a close partnership with our Department of Anesthesia has been working on creating sustainable safe controlled hypotension techniques to reduce our blood loss during brain tumor surgery in adults and children at Ayder Comprehensive Specialized Hospital. Thanks to the donation of a high quality intravenous perfuser by a diaspora American anesthesiologist and the cooperation of the university to gain stocks of Isoflurane inhalation agent and Propofol intravenous agent as well as in house training together we have significantly reduced blood loss leading to much less transfusion during brain surgery. End tidal CO2 is kept at 4.5 to 5% and mean arterial blood pressure maintained at 65-70 mm/Hg.
A joint study by the Departments of Neurosurgery and Nutrition (School of Public Health) of Mekelle University and the Department of Epidemiology of Emory University has concluded that thousands of newborn deaths and lifelong disability from neural tube defects could be prevented by fortifying food and possibly salt with folic acid to significantly reduce the epidemic currently occurring in Ethiopia.
Ethiopia is now at a point where non-communicable disease is overtaking the classic major infectious and malnutrition disorders which dominated the major morbidity and mortality for the country. Now more than ever with scant resources and unique cultural situations there is a need for effective clinically related medical research at the top universities in Ethiopia. Effective clinically related medical research in Ethiopia requires that academic medical centers begin to train physician-scientists.
Unfortunately the model of how to do medical research and by whom it should be directed and/or overseen is outdated. Because medical schools lagged behind the development of fields like Public Health and Nursing these entities dominated the university structure. At the beginning there were no specialists and very physicians who were so overworked they really had no time for training in methods of research let alone doing it.
Today over 50% of the needs of Ethiopian doctors require specialist training. Additionally the experiments such as occurred in British National Health Service of relying on mostly non-physician scientists to direct and oversee medical research backfired. In the current system almost no funds are directed to physician directed medical research yet Ethiopia desperately needs physician-scientists to lead the way into dealing the health care needs of a growing population of over 100 million people.
We are currently advocating changing this system at Mekelle University. Similar changes are already occurring at St. Pauls Millenium and Addis Ababa University in Addis Ababa, Ethiopia.
The Alliance for Academic Internal Medicine has published these recommendations for training physician-scientists which I think should be strongly considered for adoption wholly or least substantially in Ethiopian university training centers.
Summary of Best Practice Recommendations for Physician-Scientist (The American Journal of Medicine, Vol 131, No 5, May 2018) Physician-Scientist Training Programs (PSTPs) Curriculum and Infrastructure
A. Providing combined residency and subspecialty fellowship training is an attractive feature.
B. PSTPs should include training in study design, biostatistics, team science, ethics, scientific regulatory requirements,
institutional review board application, grant writing, time management, leadership, work/life balance, and mentor/mentee
C. Directors of PSTPs would benefit from organizing a formal alliance and meeting regularly. Recruitment and Selection of Trainees
A. Candidates for PSTPs most likely to translate their training into successful careers as well-established physician-scientists
are those who have significant research experience and can demonstrate a balanced commitment to both science and
B. PSTPs should make increasing diversity among its trainees a stated goal, with active efforts to recruit qualified women and
members of underrepresented minority populations.
C. Initiatives to recruit qualified international medical graduates as trainees should be increased and additional sources of
funding for international medical graduates trainees should be pursued. Mentorship Practices
A. Mentoring teams are essential for PSTP trainees and should be carefully crafted.
B. Mentors need to be formally trained in mentoring, and they need to be recognized for their contributions.
4. Funding of PSTPs and Their Trainees
A. The success of PSTPs and their trainees is highly dependent on strong institutional support.
B. The success of PSTPs and their trainees is also highly dependent on adequate levels of external funding including the
successful receipt of individual career development awards. Tracking Success of PSTPs and Their Graduates
A. Success factors of PSTPs and their graduates should be tracked.
B. Tracked data should be coordinated with other PSTPs and shared in a national data base.
6. Sustaining PSTPs and Employing Continuous Improvement Practices
A. Sustainability is contingent on institutional support and an adequate census of qualified applicants.
B. Sustainability is also impacted by the percentage of trainees who successfully complete their training.
Neurosurgery began to function as a unit in September 2015 with addition of a full time senior neurosurgeon. The Department of Neurosurgery officially separated from being a unit in the Department of Surgery in January of 2018 to become its own department in the School of Medicine. The Department will perform more than 1000 operations per year, train neurosurgical residents, teach medical students, carry out research and community service for Tigray and Ethiopia.
Academic Activities The Neurosurgery Training Program
The neurosurgery training program which began in January 2018 consists of either a five year residency program for general practitioners or a three year fellowship for general surgeons was initiated. The training program is recognized by the Ethiopian Ministry of Health and participates in the Ethiopian National Matching Program for general practitioners to join post graduate medical training programs. Ayder Comprehensive Specialized Hospital and the Neurosurgery training program are certified to give training programs by the College of Surgery East, Central, and South Africa and their member countries. The program is now beginning its second year. Currently there are a total of 2 fellows and 13 residents in the program.
Besides teaching neurosurgery residents the Department provides rotations and didactic session for General Surgery, Ear Nose and Throat, Oral Maxillofacial, and Orthopedic residency trainees. The Neurosurgery department participates in the teaching of C1, C2, and interns under the General Surgery course offered by the School of Medicine.
Current and Future Enrollment Plans for the Neurosurgery Department Training Program Estimates of Ethiopia’s future need for neurosurgeons based upon World Health Organization estimates for specialists assume there is a need for one neurosurgeon for every 250,000 population. Ethiopia will need in excess of 400 practicing neurosurgeons for its rapidly growing population reaching over 100 million. Currently there are less than twenty practicing neurosurgeons most of whom are in Addis Ababa. Currently there are three programs ( Addis Ababa University, St. Paul Millenium, and Mekelle University) which are taking in about 21 new trainees per year. Recently about 40% of graduates have left the country to practice in other countries such as Malawi, Uganda, and Somali-land. No new training programs are expected in the new future.
The Neurosurgery Department has agreed to take four PGY1 trainees in the Fall of 2019 to be assigned by the Ministry of Health to be trained at Ayder CSH. We will continue to take four PGY1 each following year.
The Neurosurgery Department plans to expand its clinical services, training, and teaching as the new cancer center, Quiha Trauma Center, and Pediatric Neurosurgery Center of Excellence are established in the future. When these development occur we will increase our resident intake to potentially 6 to 8 per year instead of the 4 per year currently. (This development is further discussed in staffing report below)
Staff The Neurosurgical Department has three total active staff and five recruited staff in training.
Current and Future Staffing Plans
Our perceived need for training requirements, teaching, research, and clinical care at Ayder Comprehensive Specialized Hospital is 8 full time faculty. At the current time the 300 bed cancer center is under construction with planned opening sometime in the next two years.
Additionally we are having discussions with the Tigray Regional Health Bureau about
1. Providing neurosurgical services and extending the training program to the H.E.W.O. Hospital in Quiha which would would function as a Pediatric Neurosurgery Center of Excellence. Mekelle University, Tigray Regional Health Bureau, and the Reach Another Foundation (USA and Netherlands NGO) have signed a Memorandum of Understanding to develop such a center.
2. Providing neurosurgical services and extending the training program at the Quiha Hospital in Quiha. Currently there is a 100 bed trauma building under construction there which will possibly be finished in the Fall of 2019.
Once the cancer center construction is completed and assuming neurosurgical services and training are extended to the cancer center, Quiha Hospital, and the H.E.W.O hospital then our full staffing requirements for senior staff would increase to 12 (twelve). The Tigray Regional Health Bureau has one employee in training (Dr. Assefa) which is assigned to Mekelle upon his finishing in two years. We have discussed sharing this individual jointly with the Tigray Regional Health Bureau.
Professor Tony has consulted with the Department of Anatomy in developing a Ph.D. Program in Neuroanatomy with experience in Neuroscience which has been approved by the University but is awaiting final approval by the Ministry of Science and Higher Education. He will be co-appointed in the Basic Sciences and serve as a graduate sponsor and advisor for the Ph.D. Program.
Research Professor Tony Magana is the founding member of the multidisciplinary neural tube defects research team consisting also of members from the Departments of Anatomy (Embryology, Teratology), Microbiology Pediatrics, Surgery, Obstetrics/Gynecology, and School of Public Health ( Department of Nutrition). Four peer reviewed publications have been accepted in major internationally recognized journals. Professor Tony and other members of the team served as advisors to the Ethiopian Public Health Institute and the Ministries of Health and Maternal/Child Welfare for recommendations in developing a national policy to deal with neural tube defects. This recommendation was formalized in June 2019.
1. Berihu BA, Welderufael AL, Berhe Y, Magana T, Mulugeta A, Asfaw S. High burden of neural tube defects in Tigray, Northern Ethiopia: Hospital-based study. PloS one. 2018 Nov 14;13(11):e0206212.
2. Berihu BA, Welderufael AL, Berhe Y, Magana T, Mulugeta A, Asfaw S, Gebreselassie K. Maternal risk factors associated with neural tube defects in Tigray regional state of Ethiopia. Brain and Development. 2019 Jan 1;41(1):11-8.
3. Welderufael AL, Berihu BA, Berhe Y, Magana T, Asfaw S, Gebreselassie K, Belay E, Kebede H, Mulugeta A. Nutritional status among women whose pregnancy outcome was afflicted with neural tube defects in Tigray region of Ethiopia. Brain and Development. 2019 May 1;41(5):406-12
4. Dixon M, Kancherla V, Magana T, Mulugeta A, Oakley GP. High Potential for Reducing Folic Acid-Preventable Spina Bifida and Anencephaly, and Related Stillbirth and Child Mortality, in Ethiopia. Ethiopia (May 3, 2019). 2019 May 3.
Clinical Activities The Department provides care including consultation and surgery for adult and pediatric patients with disorders of the brain, spine, and peripheral nerves at Ayder Comprehensive Specialized Hospital.
Outpatient at Ayder CSH
The source of patients coming to Ayder CSH includes not only Tigray but also in increasing numbers Eritrea, Afar, and the Amhara regions. Ayder CSH is most advanced hospital outside of Addis Ababa in Ethiopia. Several times a month we even receive referral from Addis Ababa for some unique surgical services we offer including:
1. endoscopic pituitary tumor surgery
2. microsurgical nerve transplant
3. surgery for cranial-facial disorders
4. surgery for cerebrovascular disorders (aneurysm)
5. complicated pediatric brain tumors
Outpatients are seen in a once a who week referral clinic (Thursday) and in the emergency area twenty fours a day seven days a week. Approximately 7 (weekdays) to 10 (weekends) patients are evaluated in the emergency area every 24 hours. The number of outpatients seen in the referral clinic has grown from about 50 in 2016 to 90 per clinic day currently. Many patients wait several months for available appointments. The old clinic facility had most of the clinic day only two available stations as it was shared with general surgery clinic the same day. A new clinic facility is being set up which will be shared with Orthopedics on alternating days wherein the Thursday referral clinic will have four stations with computers instead of only two stations and an additional half day morning clinic will be added on Tuesdays. A small daily clinic attended by a junior resident is being considered when increased manpower in the neurosurgery department comes into being.
Outpatient Clinic and Emergency Room Average Daily or Weekly New Consults
Weekly Neurosurgery Referral Clinic
100 per week/400 per month/4800 per year
Emergency Room Adult
6 per day/42 per week/168 per month/2016 per year
Emergency Room Pediatrics
3 per day/21 per week/84 per month/1008 per year
Inpatient Care at Ayder CSH Average Daily Neurosurgical Census Data for Neurosurgery at Ayder CSH
Total inpatients visited daily/monthly/yearly
28 to 34 daily/960monthly /11,520 yearly
Three operating room days during the working week are alloted to neurosurgery for elective surgery. Emergency care is given 24 hours a day dependent on the availability of beds in the hospital, availabile operating room, anesthestists, and nursing staff.
Neurosurgical Operations at Ayder CSH
9 per week /36 per month/432 per year
2.5 per day/17.5 per week/70 per month/840 per year
Collaboration and Donation Emory University, Atlanta, Georgia USA
Child Help-International (Belgium) and the International Federation for Hydrocephalus and Spina Bifida (Belgium)
Reach Another Foundation (USA and Netherlands)
Hearts Helping Hands(USA)
Yves Meyers, Aesculap Corporation, and Dallas Memorial Hospital(USA)Quest Medical Supply(USA)
Quiha Hospital (Tigray Regional Health Bureau)
Over the past year in response to the Mekelle University Multidisciplinary Research team publications on neural tube defects in Tigray we have been interacting with the Ministry of Health, Maternal and Child, and the Ethiopian Public Health Institute. Two months ago Dr. Afework Mulugeta and myself as well as invited international experts gave a scientific advisory of this problem to the EPHI.
Yesterday a brief was given by the EPHI which was mostly based upon our research and recommendation as well as their review of available evidence.
Officially now the Ethiopian government recognizes “that there is an alarmingly high rate of neural tube defects and folate acid deficiency in Ethiopia”. The following recommendations were made to the higher ministry officials for approval
1. Periconceptional oral folate supplementation for all women of reproductive age as an immediate solution. Low cost imported folic acid is available for the public to purchase.
2. Making the first visit for pregnancy earlier instead of the current 16 weeks
3. Promoting the consumption of folic-rich foods.
4.Implementing mandatory wheat-flour food fortification.
5.Considering salt fortification with folic acid after doing a pilot study in Tigray
6.Establishing a surveillance system for NTDs throughout Ethiopia
7. Awareness creation for all recommended interventions strategies for the prevention of NTDs
Further studies will be done on community basis and on salt
Monitoring of food fortification measures to evaluate effectiveness
The Mekelle University Multidisciplinary Research Group for Neural Tube Defects has just published its first research paper in Brain & Development Journal July 2018, “Maternal Risk Factors Associated with Neural Tube Defects in the Tigray Region of Ethiopia”. This being the first major prospective study done on neural tube defects in Ethiopia confirmed our worst fears of a very high incidence, significantly higher than the 75 per 10,000 births seen in most of Sub-Saharan Africa. There a many challenges in how this problem can be addressed involving cultural beliefs and practices, poverty, diet diversity, supplementation, and fortification. Unfortunately, applying a Western style solution for Ethiopia will not be so easy or likely to succeed as well.
For the past decade the development of neurosurgery in Ethiopia has witnessed the high incidence of neural tube defects including myelomeningocoel and anencephaly coming to their clinics first in Addis Ababa but now also in Mekelle, Gondar, Bahir Dar, and Oromia. Previous published reports noted incidences first of greater than 160 per 10,000 births in Addis with a more recent report of 191 per 10,000 births in Addis Ababa. The reports of up 300 per 10,000 in some areas of Tigray are higher than those reported in any other developing countries.
Research replicated in nine countries in the 1960s and 1970s showed that neural tube defects were somewhat but no totally related to lack of folic acid in the diet and that adding folic acid would significantly reduce the incidence of neural tube defects. At first attempts were made with prescribing supplementation for women of childbearing age but this did not have the desired result. The incidence really came down in Europe and the United States when the government mandated the fortification of folic acid in food staples like bread and cereals
One of the factors we identified was that a lack of diet diversity increased the risk for NTDS while increased diversity reduced it. About 65% of the diet of most Ethiopians is enjera bread made at home from teff and boiled chick peas called shiro. Although a serving of raw chick peas has about 1000 micrograms of folic acid its likely that boiling them reduces the folic acid to basically nothing. A similar situation exists for spinach which is often boiled and eaten during the rainy season.
Traditionally, Ethiopians avoid eating fresh vegetables and fruits as documented in our study and many previous others. In fact a study of the one hundred most elite Ethiopian runners showed that 20% had a significant folic acid deficiency which correlated with lack of dietary diversity (avoiding greens and fruit). In the countryside where the women may spend many hours a day just to get 5 gallons of water, there is not much water to spare for cleaning produce. The population fears getting diarrheal illness from such produce.
Our study showed that of more than 13,000 women interviewed who were pregnant essentially none of them had any knowledge of preconceptional nutritional needs or about neural tube defects.
Convincing Ethiopians to take medication for invisible illness such as hypertension has proved difficult. Research in many parts of Ethiopia has shown for example that as few as 50% of those prescribed medication for hypertension actually take it. There exists underlying fears of addiction to “un-natural” substances. Will Ethiopian women be convinced to take supplementation?
Ethiopians especially the 88% who live in country side rarely buy food staples like bread but instead make their own enjera from stored teff. Currently there is only one factory in the country capable of making fortified bread but it is not functioning.
The cost of a months supply of folic acid 4 milligrams per day is about 80 birr or about $2.40 US for a single woman. Given the fact that the average family makes about 250 birr per month to support a family of six, there is little room to allow payment of this expense. There are no current domestic producers of folic acid so considerable hard foreign currency would need to be mobilized to import stock. For the government to provide this for every women of child bearing age would cost tens of millions of dollars to be added to the budget of a country which currently spends the equivalent of about $13 per capita for the 100 million population.
Ultimately addressing the issue of the high incidence of neural tube defects in Ethiopia will be requiring taking into account cultural norms and practices in such a way that changes are seen as consistent with Ethiopian culture. Widespread public education and a major investment in folic acid purchases by the government will be necessary. This begins with the clear realization that there is a problem.
The head injury problem especially that due to interpersonal violence in Tigray is a growing and significant problem which requires a public health approach.
Research published by Fasika et al showed that 24.8% of head injury admissions came from interpersonal violence from 2011 to 2014 which was before neurosurgery was permanently established at Ayder Comprehensive Specialized Hospital. Currently we are seeing about 10 patients a day and operating on 2 to 3 every day. Most of the surgeries we do are for depressed fractures caused by stone injury received in interpersonal violence. The age range of these injuries ranges from preschool to the eighth decade of life. We know there is a cultural proclivity to this type of injury but it is not well studied.
The hospital burden of head injury includes about 19% of adult ICU admissions and bedspace and 25% of pediatric ICU admissions and bed space. Our average daily census on the adult ward is 5 for head injury and on the pediatric ward also 5. The length of stay can vary from 24 hours to months with most of the surgical patients requiring a least a 5 days stay in the hospital.This burden acts to limit the care those suffering from other maladies can receive.
At the current time there is no public health or government plan to try to prevent these injuries.The World Health Organization has created a Violence Prevention Alliance which sees interpersonal violence as requiring a public health approach.
This public health approach to violence prevention seeks to improve the health and safety of all individuals by addressing underlying risk factors that increase the likelihood that an individual will become a victim or a perpetrator of violence.
The approach consists of four steps:
1 To define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of violence.
2 To establish why violence occurs using research to determine the causes and correlates of violence, the factors that increase or decrease the risk for violence, and the factors that could be modified through interventions.
3 To find out what works to prevent violence by designing, implementing and evaluating interventions.
4 To implement effective and promising interventions in a wide range of settings. The effects of these interventions on risk factors and the target outcome should be monitored, and their impact and cost-effectiveness should be evaluated.
By definition, public health aims to provide the maximum benefit for the largest number of people. Programs for the primary prevention of violence based on the public health approach are designed to expose a broad segment of a population to prevention measures and to reduce and prevent violence at a population-level.
I propose that Mekelle University put together a multidisciplinary team consisting of not only physicians but also social scientists, public health professionals, police and prosecutors ( this was previously discussed with the head of the Tigray police who was interested), and government stakeholders. This type of investigation and policy development is exactly the type of activity which the University with all its resources and knowledge base should be tackling.
Recent research we have done at Mekelle University soon to be published has confirmed that there is a high rate of neural tube defects affecting the brain and spinal cord in Tigray. Experience suggests this is also the case in other parts of Ethiopia as well. At least 131 out of every 10,000 births is affected with some areas having almost twice that number. Defects result in death at birth for about 77% of the pregnancies affected, usually with anencephaly, while the 23% born alive usually have severe paralysis of the lower extremities and often need a operations to close the open spine, closure of myelomeningocoel, and to control pressure in the brain, ventricular peritoneal shunt, for lumbar and thoracic myelomeningocoel associated with an Arnold Chiari II malformation causing hydrocephalus. Lesser numbers of encephalocoel often requiring closure were encountered as well.
The most likely significant cause is lack of diversity in the diet and especially failing to consume foods with the vitamin folic acid. This is usually found in green and leafy vegetables as well as fresh fruits. Cooking foods such as chick peas which may contain folic acid will destroy much of it.
Around the world these birth defects have been reduced about 75% by encouraging women to plan their pregnancy and take 4 milligrams of folic acid daily starting before conception. We are working with our research group at Mekelle University to help the Tigray Regional Health Bureau and the Ethiopian Ministry of Health come up with programs to reduce these defects but this will take time.
In the meantime we encourage all women in Ethiopia to plan their pregnancy, starting folic acid supplementation before they conceive, and practice dietary diversity. They should try to wait one year between pregnancies, and understand that breast feeding increases their need for folic acid. Very young and older women are more susceptible to having children with these defects. Other factors may be involved besides folic acid deficiency but the good news is that folic acid supplementation will likely still reduce these defects.