Establishing an orthopaedic trauma service in rural Ethiopia

Richard Power

Richard Power was a Consultant Orthopaedic Surgeon in Leicester 1995-2020 specialising in hip surgery and is winding up his career as a Medical Examiner. He has been involved in the development of orthopaedic care in Gondar, Ethiopia since 2017. Since then he has been one of the leaders of the Leicester Gondar Orthopaedic Partnership and is currently Chair of Health Action Leicester for Ethiopia. He was awarded an MBE in the New Years Honours for his work.

“Give a man a fish and he will eat for a day. Teach a man to fish and you feed him for a lifetime”.

Ancient Chinese Proverb

Much of the surgical support provided in Low and Middle Income Countries (LMICs) by developed countries involves specialised teams providing specialist care not available in the relevant country. This is surgery which can be scheduled and may not even involve local facilities, such as Mercy Ships. However, as the orthopaedic trauma workload is 24/7 and cannot wait for a team to arrive, a sustainable solution has to involve locally trained surgeons working within appropriate facilities.

The original link between Leicester and Gondar in the northwest Amhara region of Ethiopia was established more than 25 years ago. Laurence Wicks, initially as a Medical Student and subsequently as an orthopaedic trainee visited Gondar and recognised the paucity of trauma care. The only operating theatre had been built by the Italians during their brief occupation of Ethiopia in the 1930s which was virtually derelict and the single surgeon only had the skillset or equipment to provide non-operative management. This was for a population estimated at five million, approximately the size of the East Midlands.

Laurence persuaded two Leicester Orthopaedic Consultants (Alwyn Abraham and Christopher Kershaw) to travel to Gondar in 2016 and during that visit they met with senior members of the Gondar University Hospital who indicated a strong desire to establish an orthopaedic trauma service capable of operative intervention. On returning to the UK they approached myself as a colleague and the President Elect of the Rotary Club of Leicester to seek support in raising the necessary funds to provide all the equipment required for a fully functioning orthopaedic trauma theatre.

After a fact-finding visit to Gondor in early 2017, I, along with the Club, agreed to take on the project. We were successful in our application for a Rotary Foundation Global Grant amounting to a project total of $200,000 with the Club being required to raise approximately two thirds of that amount. The Rotary Club of Gondar Fasiledes were our local International partner (a requirement for a Rotary International grant is involvement of a local Rotary Club in that country). At this point the Leicester Gondor Orthopaedic Partnership was formed.

Medical Aid International, a social enterprise specialising in providing medical/surgical equipment appropriate for LMICs agreed to provide all the equipment, which came from a variety of sources including donations, closing hospitals, ex-demonstration, film sets and new purchase from India. A good example was the ‘Big Bertha’ US Army field steriliser, which simply requires a bucket of water and electricity supply in order to function.

During my presidential year of 2017 and 2018, the Rotary Club raised the necessary funds during which period Gondar Hospital commenced the structural work to the operating theatre. They also appointed Dr Ananya Kassahun, a newly graduated orthopaedic surgeon off the Black Lion Programme. Ananya proved crucial to keeping up the momentum in Gondar and she also visited Leicester to appreciate the important aspects of theatre management and infection prevention principles. Two theatre nurses were also funded to visit Leicester and spend two weeks in an orthopaedic theatre environment. During this time, my colleagues from various disciplines and I made regular visits to Gondor to maintain the momentum of the project and I was in regular communication with the University of Gondor regarding the building work and staff appointments.

By 2019, all the money had been raised and the equipment procured. It was then shipped to Ethiopia via Djibouti. As the shipping container had been purchased as part of the consignment, we decided to use it as an additional space alongside the theatre by building an external concrete plinth and cutting an access door in the side. This subsequently housed the autoclave. As the building work had not been completed, the shipping container remained sealed.

By March 2020, the main building works had been completed but as adjacent work was still ongoing with significant dust creation, live surgery wasn’t viable. Despite this, we went to Gondor in early March 2020 and were able to unload the container and assemble all the equipment and conduct some teaching. >>

Everything was then placed in the storeroom adjacent to the theatre with the plan to return in July 2020 to commence live surgery and carry out further teaching. At this point the COVID-19 international lockdown descended preventing any further visit. By July, the Hospital had appointed four surgeons from the Black Lion Programme. We agreed that there was no option other than releasing everything for their use with online support from the team here in Leicester.

To further compound the difficulties, the Tigray conflict started in August 2020. The Amhara Region is adjacent to Tigray and Gondar became one of the main casualty receiving hospitals with up to 150 casualties arriving each day on top of the day-to-day trauma. Although the Partnership had provided a 12-month supply of trauma implants, this rapidly proved inadequate and had to be augmented by implants provided by the Federal Government military.

The Partnership provided further equipment in the form of proximal femoral nail sets. The four surgeons had online access to advice from the Leicester trauma surgeons and the surgery carried out would have been a credit to any UK Trauma Unit.

The Tigray conflict lasted for two years with an estimated 600,000 lives lost due to injury, disease and starvation. By November 2022, the newly formed University of Gondar Department of Orthopaedics had carried out approximately 4,000 operative procedures.

The Leicester team were finally able to visit in November 2022 to assess progress. Although the operative surgery element had clearly flourished, many challenges remained with basic cleanliness and nursing care. A number of items of equipment had either broken or had not been used because of lack of training. We then planned further training visits. Sadly at this point, internal conflict started between the Ethiopian federal Government and FANO, (the Amhara militia), with further visits put on hold. I have continued to have regular monthly meetings online with Dr Birlew, the head of Service in Gondor, to provide encouragement and support in developing the department as a cohesive unit.

The department has now expanded to ten trained surgeons and has even commenced its own training programme in conjunction with the regional University Hospital in Bahir Dar. One surgeon was able to take up a six-month spinal fellowship in India and has subsequently been able to carry out surgical intervention without the patient needing to make the long and expensive journey for care to Addis Ababa.

As an allied project, a Rotary-funded Jaipur Limb Centre has recently opened which enables lower limb amputees to receive basic lower limb prosthetics which previously were not available.

I continue to have regular online meetings and am forever hopeful that peace will return to the Amhara region allowing further visits.

In summary, the Gondar University Hospital has gone from having no orthopaedic operative ability in 2019 to having a well-functioning department with ten trained surgeons and its own training programme carrying out 2,000 trauma procedures annually all within five years. This has happened as a result of a multi-agency collaborative approach, giving rise to a longterm sustainable service that hopefully is now ultimately independent of external support. n

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References: 1. Arthrosamid®, Instructions For Use. Release Date March 2022. 10082-003; 2. Christensen, L., et al. (2016). Histological Appearance of the Synovial Membrane after Treatment of Knee Osteoarthritis with Polyacrylamide Gel Injections: A Case Report. Journal of Arthritis. Vol 5: 217; 3. Christensen, L., et al. (2016). Synovial incorporation of polyacrylamide hydrogel after injection into normal and osteoarthritic animal joints. Osteoarthritis and Cartilage. Vol 24(11):1999-2002. DOI:10.1016/j.joca.2016.07.007; 4. Bliddal, H., et al. (2024) 3 year follow-up from a randomized controlled trial of intra-articular polyacrylamide hydrogel injection in subjects with knee osteoarthritis. Poster LB-31, OARSI 2024 World Congress on Osteoarthritis; 5. Bliddal, H., et al. (2024) A Prospective Study of Polyacrylamide Hydrogel Injection for Knee Osteoarthritis: Results From 4 Years After Treatment. Presented at EORS 2024, Aalborg and Orthopaedic Proceedings of the Bone & Joint Journal.

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