We need to do better to create awareness on the type of quality health care services being provided in the country so people do not go through unnecessary trouble to go abroad for the same type of services. Agents who send patients abroad should do so in an ethical manner for those services only that are not provided in Ethiopia.
 
By Zekarias Woldemariam

After receiving his Doctor of Medicine degree from Addis Ababa University Dr. Samuel Hailu chose to specialize in the field of General Surgery. Unexpectedly, he faced a car accident from which he sustained multiple bone fractures. This led him to realize some problems in Ethiopian Orthopedic care. As a result, he decided to specialize in Orthopedic Surgery at the Addis Ababa University. Subsequently, he traveled to Canada for further study to specialize in hip and knee joint replacement, along with the treatment of complex Orthopedic trauma. This specialized training was completed at the University of Toronto. He completed his training abroad and returned home 5 years ago.

At that time, he was the only hip and knee joint sub-specialist in the country. Hundreds of Ethiopians traveled abroad, paying large sums in foreign currency for joint replacement surgery. After he started delivering the service here, he was able to retain 10 to 20 percent of those who would have otherwise traveled abroad for joint replacement.

He is currently training more Ethiopians to perform these services, as well as training foreigners from various African countries. During his recent interview with The Ethiopian Herald, he has explained more about the treatment which is called “Surgery of the Century”.

Could you elaborate on the situation of the problem in Ethiopia?

One of the health problems that hinder the day-to-day life of the people and hold them back from economic activity is a joint problem that needs to be replaced. There appears to be a general unawareness in Ethiopia of local options, as many people go abroad for such treatment. We do not know how many people need joint replacement in Ethiopia, but according to statistics from Indian Embassy in Ethiopia, the Embassy issued a visa for 800 Ethiopians that needed joint replacement in a year’s time. No less number travel to Thailand, South Africa, and Europe. When we try to project the statistics from other countries to the population of Ethiopia it is quite clear that thousands of patients need the surgery every year.

What are the main reasons people need a joint replacement?

There are many reasons why people come seeking hip and knee joint replacements. By far, in my experience, the demand for a hip replacement outweighs that of the knee in Ethiopia by more than 5-folds. Some of the most common reasons people need a total hip replacement in our country are related to accidents, avascular necrosis (AVN) of the femoral head (death of hip ball bone tissue due to interruption of blood supply), osteoarthritis, and other types of arthritis. AVN occurs due to various reasons, but in our country, the main causes are steroids, alcohol, smoking, HIV, and as a sequel to accidents. In my observation, the most common reason for AVN in our setting is related to misuse (overzealous use) of steroid drugs. Steroids may have been ordered once by a physician, but many people tend to continue using it by getting a refill from a pharmacy without prescriptions.

What are the main accidents that cause it?

Simple falls and car accidents are the two most common injuries we see that result in fractures requiring joint replacements.

Hip fractures in relatively older patients occur as a result of simple falls while walking. Fractures occur as their bones tend to weaken due to osteoporosis; this age group is also prone to falling. Some hip fractures can be fixed and healed. However, some will not heal properly and hence hip replacement is the primary mode of treatment.

In the younger age group, car accidents are the main causes of fractures. When not treated timely and appropriately, they result in sequelae that need to be treated with joint replacement. Worksite injuries, assault, and gun-shot injuries are other causes of accidents we see in our country.

How is the delivery of the treatment and know-how in Ethiopia currently?

I am the first fellowship-trained sub-specialist joint replacement surgeon in Ethiopia. Before my return from Canada 5 years ago, foreigners used to perform the traditional joint replacement technique either as a campaign or in missionary centers. However, at a subspecialty level, I am pleased to pioneer the service using the most modern technique called “minimal invasive, muscle-sparing anterior total hip replacement”. In the past 5 years, we have been building our national capacity and providing an all-Ethiopian team for hip and knee joint replacement.

In my private practice, mainly at the Samaritan Surgical Center, I provide both hip and knee joint replacement surgeries. In the same center, we are working to serve those who would have otherwise traveled abroad to get these procedures done. We are able to apply the most modern techniques of hip replacement called anterior total hip replacement. It is minimally invasive, efficient, minimizes the risk of complications from the procedure, and enables me to do bilateral total hip joints replacements at the same time when needed. The rehabilitation process is facilitated as no muscle is cut, the pain is less and the power of their hip muscle is largely preserved. This is important for everyone undergoing hip replacement, but especially, the elderly following hip (femoral neck) fractures as this enable them to achieve the main goal of treatment in this age group- to get them up and going as soon as possible after fractures.

We are also working to make the service accessible to those who cannot afford private care; these surgeries can be provided free of charge at the Tikur Anbessa (Black Lion) Specialized Hospital. The hip joint prostheses are obtained through donations. Our goal is to provide up to 50 such surgeries annually but is limited to the number of hip prostheses provided by our donor. The donations are made by the Zimmer-Biomet company, based in the USA.

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This collaboration has been greatly aided by our good friend Dr. Alexis Falicov. He is the champion who has been at the forefront of this effort, a good-hearted Orthopedic surgeon based in Seattle, USA. He has been coming to Ethiopia for 11 years and recognized the huge demand for hip joint replacement. In 2017, we jointly conducted a hip replacement campaign which enabled us to conduct 20 successful total hip joint replacements free-of-charge. Subsequently, Alexis has convinced the company to keep donating the hip implants for use at the Black Lion Hospital every year, and hence we are providing this service free of charge. We do not yet have knee joint replacement services in the Black Lion Hospital system.

The know-how in Ethiopia is still lacking and as a pioneer in the field, we have created social media platforms on YouTube (https://www.youtube.com/DrSamuelHailu); Facebook, Instagram &Twitter @DrSamiOrtho to create awareness in my fields of subspeciality. I am also on LinkedIn (@DrSamuelHailu), this is where you noted about my services and contacted me for this interview.

How did you choose to study this discipline?

After graduation from medical school, I was the victim of a car accident. I sustained multiple fractures and had to wait 16 days with a potentially deadly fracture before receiving my first surgery. It was then that I recognized the many problems and unmet needs for proper care. It became obvious that if I, as a doctor, had this much problem getting appropriate care, one can only imagine how much our farmers must suffer. This convinced me that I must serve my people.

So, I decided to study Orthopedics. As a trainee in the field, I had the opportunity to travel to the USA and to explore various subspecialties in Orthopedics and I realized how much I could help my people if I did two sub-specialties. I decided on trauma and joint replacement sub-specialties. These sub-specialties have enabled me to properly treat acutely broken bones, including complex pelvic and acetabulum fractures. When patients present late with sequelae of complex injuries, I can provide a reconstruction of their damaged joints with hip and knee joint replacement.

 How do you see people’s awareness of the problems?

For the most part, awareness should be created at the community level. Many people, both in urban and rural areas, still initially visit traditional bone setters, for both joint problems as well as following fractures. These traditional practitioners what we call them locally Wegesha provide the service without having had any formal training. Before modern care, Bone setters were the main provider of this type of treatment. However, the problem lies when people visit these Wegeshas first and wait for too long to seek medical care until the injuries have badly damaged the cartilage and are too late for salvage of the joints. I saw a glimpse of the extent of the problem in Ethiopia when the campaign was first conducted here about 9 years ago. When people heard about the campaign by a visiting doctor from the USA at the Black Lion Hospital, more than 200 registered in less than a week.

The demand is very high, but many people do not know where they can get the service and continue to travel abroad, seeking what they perceive as advanced care.

At the moment the waitlist for hip replacement at Black Lion Hospital is around 1,000 and still, patients wait years before they get the care because of a shortage of material supplies.

Even though we provide quality care in a private setting, at Samaritan Surgical Center, many people are lured by agents and brokers, in the name of medical tourism, mainly to India, Thailand, Turkey, and elsewhere, adding to unnecessary expense and suffering.

We have to work more in creating awareness of the importance of getting these procedures done here locally. We provide minimally invasive surgery and this offers short hospital stay, quick recovery time, reduces complications, and overall cost of care. We also provide post-surgery care as postoperative care is as important as the surgery itself. The type of care each patient requires depends on the type of surgery as well as the patient’s health history and that requires a close follow-up with the patient.

What about economic factors?

Hip replacement surgery is one of the most cost-effective surgeries the world has seen in the century. The benefits and cost-effectiveness of hip replacement surgery can be compared to cataract surgery. When someone undergoes cataract surgery, one will be able to regain eye vision immediately and can be back to work in a short period of time. The same is true with hip replacement. Someone who was crippled, dysfunctional, and dependent on others for their activities of daily living, often wheelchair-bound due to a hip joint problem, will start to walk again and get back to work and become economically active. It is a very successful and life-transforming surgery, and that is why it is sometimes called the “surgery of the century”.

Yes, it is a demanding surgery economically in terms of infrastructure and equipment needed, as one should follow international standards. It demands a well-trained, skilled, and high-volume surgeon for the best possible outcome. Many studies have shown that the outcome is not the same when done by a sub-specialist as compared to a general orthopedic surgeon – comparing an orthopedist who does replacements once in a while vs. someone who does these surgeries regularly. The operating room is another critical factor as it should follow international standards, staying clean, and be continually maintained. It is also a demanding supply chain management, keeping the stock of prosthesis needed. This is complicated by a shortage of hard currency in our country.

What are the replacement materials made of?

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Replacement prostheses (parts) are made of different types of materials. The basic total hip replacement has four parts (acetabular shell, liner, femoral stem, and head) while the basic total knee has three components (femoral and tibial component with a special plastic articular surface in between). The metal parts are made of special high-strength alloys, titanium alloys, and stainless steel. The articulating parts are made to be durable and friction-resistant. Depending on the activity level and age of the patient, we use either metal on plastic, or ceramic on plastic, or ceramic on ceramic articulating parts. The plastic we use is a special type of plastic that is made to last a long time and is a highly cross-linked ultra-high molecular weight polyethylene material. While the ceramic is primarily made of aluminum and it can be zirconia toughened alumina. The damaged ball of the thigh bone (femoral head) is removed along with the preparation of the socket of the hip joint (acetabulum reaming), then both are replaced.

Can we produce them locally?

The short answer is-not at the moment. Producing them locally is not straightforward and is quite demanding, but as things progress and our technology grow there is no reason why we should not be able to produce these in Ethiopia. Even countries like India are known for making various orthopedic implants and materials, however, the quality of these does not meet the standard of the prostheses we use. The quality standards of the parts we used for joint replacement are very specific and quite critical for the longevity of the implant. The American or European brands we use here lasts 25 years and more while the Indian brands might not last more than 5 years. This suggests the Indian parts will be more than fourfold expensive in the long run, mainly because of the articulating parts, which require a meticulous process and fine work. Repeat surgery for a failed joint replacement is much more expensive and the outcome is not as rewarding as a well-done initial replacement with good material.

So, locally, the first materials we need to start manufacturing should be materials for the fixation of broken bones, as these materials are only needed while the fracture is healing. Once a fracture is healed, we no longer rely on the implant.

How satisfied are those who attend the surgery here?

Joint replacement is not just surgery; it needs good rapport between the surgeon and the patient both in the selection process of the surgery as well as during recovery and the follow-up period. Post-operative care is as important as the surgery itself and requires very close interaction with the surgeon and the patient. Patients have been missing this when they get their surgery done by traveling abroad or by visiting missionary doctors.

We need to closely follow our patients and the follow-up should be lifelong. This is an artificial joint and hence we need to see the patients continually, looking for specific things and recognize a possible issue early. This is an advantage for our patients who can have easy access to their surgeons, but which are unavailable to those who have traveled abroad or had their surgery performed by a visiting foreign doctor. This is a lifelong commitment for the surgeon as well as the patients.

Ethiopians now have that. They can be followed closely, receiving quality surgery with standard materials, and, yes, most are highly satisfied with quick recovery, while getting explanations and the surgery speaking their mother tongue, in addition to receiving the care of the relatives and close friends. One thing to note here is, each patient is peculiar in their way and each surgery, rehabilitation, and outcome is also dependent on a lot of factors and peculiar. Hence, the importance of individualized care, patient-specific physiotherapy, and close follow up is quite important and instrumental for the best outcome.

What if many patients come looking for the service can you cater to the demand?

Over the last five years, we have developed the means to expand capacity locally, both in human power as well as supply chain. For instance, we can do this minimally invasive hip replacement with special devices that allow this to be done efficiently; it is also very effective and can be done in less than an hour. This way we can do as many as 10 surgeries per day by purchasing more materials. However, there are many constraints, especially affordability for the average Ethiopian.

Unlike other countries where the insurance system is well established, most of our patients are expected to pay out-of-pocket. Had there been a well-established insurance system in Ethiopia, this could have been an accessible procedure to the many who are disabled with a curable problem. They could be contributing to the economic growth of the nation instead of staying dependent on others.

How many people have you retained from traveling abroad?

Many people do not yet know the availability of the surgery here. Many patients tell me they had sought care in various hospitals and clinics before someone eventually directed them to our center. For instance, in the Southern part of Ethiopia, there is a missionary hospital where an American surgeon has been doing this surgery. Patients from Addis Ababa would go there not knowing that the service is available here, and would subsequently be referred back to us in Addis. We are working on creating awareness of this problem and how to get appropriate care.

I also remember a patient who went to South Africa and was told by the South African surgeon there “Why do you come here when there is Dr. Sami in Ethiopia.” They came back to me for surgery, had their hip taken care of, and are happy. There are others also who were first treated in India and Thailand that came for corrective repeat surgery required because of some complications.

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I had patients who underwent one side of the surgery abroad and the other here, and they see the difference and tell me their stories, such as how much they suffered, the long recovery, using crutches for more than 3 months after one side hip replacement in India, but after minimally invasive hip replacement done here, they were able to go without support in a few days to weeks.

So far, we are able to retain about 10-20 percent of those who would have otherwise traveled abroad. We can expand the capacity following the demand, but still many people go abroad, not knowing the surgery can be provided here.

Can we serve those who come from abroad?

Yes, I have patients that come to me from Somalia, Djibouti, South Sudan. I have also operated Ethiopian patients that live abroad who come here to get joint replacements done at home with their family support. It looks like a paradox when many people travel abroad for care, but others travel from abroad to be operated here at home. Our goal is to make Ethiopia a center of excellence for joint replacement of East Africa.

What should we do to further improve the delivery of the service in Ethiopia?

We should improve the system to import medical materials and equipment. Foreign exchange should be given priority to import the materials needed for such services. We can save foreign currency when making such services readily available rather than having patients go abroad.

We should create a way to have a better health coverage system nationwide. Our insurance system should better accommodate coverage for the majority of our nation. At this time, only a limited number of company employees have insurance. Even as a physician, if I get sick, no insurance will provide care. We have seen this happen to our colleagues.

We should revisit our referral system of sending patients abroad when such services are rendered locally with quality. Referrals for specific surgeries abroad should only be offered by a sub-specialist in the field. We should not allow the foreign currency to be wasted.

 In government hospitals, we cannot depend on donations for such services. We need to establish a system where services. can be provided, by covering all costs within Ethiopia. Many things can be done to keep our nation from disability and support the economy again. These services can be rendered in public hospitals in a self-sufficient manner at a very affordable cost to patients. We need the system to accommodate the change to make this a reality.

What about developing human resources?

We provide the basic teaching for our specializing doctors, and we are also providing subspecialty fellowship training for orthopedic surgeons for care of complex orthopedic trauma at the Black Lion Specialized Hospital, Addis Ababa University. To start joint replacement as a sub-specialty, we must not rely on a donation-based provision of joint replacement components; we need a sustained supply of materials before we start sub-specialty training. We are not yet able to provide knee replacement in any of the government hospitals, and can only provide a basic primary hip replacement at Black Lion Hospital, based on donations arranged by Dr. Alexis Falicov from the USA, mentioned above. This will not be adequate for joint replacement sub-specialty training.

What do you feel when you see the surgery being delivered in Ethiopia capably?

I am proud that we are able to provide the services by all-Ethiopian teams over the last 5 years. It is quite rewarding to see someone who was housebound and disabled return to independence. We are providing training to both Ethiopians and other African surgeons on complex orthopedic surgeries.

We have so far trained Orthopedic surgeons on complex pelvic and Acetabulum fracture fixation from South Sudan and Nigeria. We have others coming from Malawi, Tanzania, Kenya, and other parts of Africa. I have also traveled to various parts of Africa, the Middle East, India, Europe, and, yearly to the USA to share my experience on these complex surgeries.

We need to do better to create awareness on the type of quality health care services being provided in the country so people do not go through unnecessary trouble to go abroad for the same type of services. Agents who send patients abroad should do so in an ethical manner for those services only that are not provided in Ethiopia.

Joint replacement surgery is not a simple one-time event; we have seen patients that come to us after undergoing surgery abroad with undesirable outcomes, both from the index surgery as well as a lack of postoperative care. The surgery needs close monitoring and in-person follow-up by the primary surgeon. It is the surgeon that knows what he has done and it should be the surgeon that follows the patients.

Thank you for the opportunity given to me to share my experience in the field of joint replacement in Ethiopia!

The Ethiopian Herald September 5/2020


 

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