Rachael Collins is an ENT Surgical Registrar and East of England Global Health Fellow. As part of her fellowship she travelled to Malawi with a multidisciplinary team of healthcare staff to deliver ear and hearing care to remote and rural communities. Here she reflects on the impact of the visit and the value of the experience to her NHS practice.
“Looking back I think global health is one of the reasons I became interested in becoming a doctor in the first place. I remember going on a school trip to Gambia where we visited a school for blind children. A year previously, a group of doctors had performed procedures that restored vision for many. The local community were still talking about it and I remember thinking how amazing that was!
Since then I have travelled and volunteered fairly extensively around the world, and had a growing sense of social justice and a feeling of wanting to contribute to something on a bigger scale. Every time I have taken part in such work, last year in Tanzania and this year in Malawi, I have felt that this is the space I would like my career to develop.
Why the project is needed
The World Health Organization (WHO) estimates around 40 million people in Africa have hearing loss, a prevalence of 3.6%, which is projected to increase to 97 million by 2050. In Malawi, the prevalence of disabling hearing loss is thought to be even higher at 11.5%. The impact of poor hearing is well understood with significant individual and societal aspects. WHO estimates the cost of hearing loss to be $27.billion dollars to African economies and argues hearing health must be a global priority. [1]
Innovation, research and delivery
The Malawi Hearing Project is a global health partnership involving ENT and paediatric clinicians from the UK, healthcare professionals from Queen Elizabeth Central Hospital in Blantyre, and Anzathu, a Malawian charity for those with hearing loss.
There are several aspects to the partnership. Firstly, the introduction of a novel bone conduction hearing aid with solar charging has enabled access to hearing technology in remote regions. Secondly, through ‘ear camps’ communities have benefitted from ear assessment, basic treatment and triage. Thirdly, as the partnership develops, the partners are considering how to change policy, strengthen collaboration and raise awareness of hearing loss.
There is also an important research aspect to the partnership, which is gathering data about the most efficient hearing test method and suitability of in-ear devices, through to the experiences of healthcare professionals assessing people in rural areas and the opinions of those who would potentially benefit from the use of hearing aid devices.
One of the things that struck me about this partnership was the sense of equality and strong relationships. It felt to me that partners in Malawi were able to say what they wanted and take the lead in developing the project. I think for global health initiatives to be successful partnerships like these need to be nurtured and partners need to be empowered to lead the change they want.
The visit
The week-long visit consisted of four ‘ear camps’ as well as meetings with local partners and the signing of a ‘memorandum of understanding’ (MoU).
Our multidisciplinary UK group joined with 14 local individuals from both Queen Elizabeth Central Hospital and Anzathu, including sign language interpreters, special needs teachers, audiologists and healthcare workers.
As a team we quickly bonded and were able to reflect and adjust our approach as necessary. Before we started, I was concerned that we might not have enough people turning up. However, Anzathu had done a brilliant job at spreading the world and we ended up with the opposite problem! I was taken aback by how much chronic ear disease there was – in one week in Malawi I easily saw more cholesteatoma/chronic ear disease that I would see in a year in the UK.
Over the course of the ear camps we saw 801 people, and provided antibiotic ear drops, wax removal and audiograms as needed. A total of 30 bone conduction headsets with solar chargers were given to those with suitable conductive loss.
Making a difference
The first ear camp was based at a primary school where we saw over 100 children and identified a few as potentially benefitting from the bone conduction hearing aid/headset. This is a special type of hearing aid, developed by Cambridgeshire paediatrician Dr Tamsin Holland-Brown, that conducts sound via bone conduction thus bypassing the middle ear. The device is suitable for those with conductive hearing loss, which is caused by middle ear conditions like glue ear.
During this camp I examined a seven-year-old boy with a significant conductive hearing loss due to previously undiagnosed middle ear pathology. He gave a history of poor hearing and chronic ear discharge and told us about his experience of being bullied by his peers because of his hearing loss and the associated isolation.
When he first tried the bone conduction hearing aid, he was suddenly able to follow instructions with ease. The look of surprise on his face has stayed with me. This boy had attended the ear camp of his own accord, alone, but we had agreed that any child receiving a hearing aid required a responsible adult who could consent for them and be trained on the technology. We explained this and he quickly disappeared. A couple of hours later there was a tap on my shoulder – he had returned with his grandma.
He went on to receive the headset, demonstrated again in front of grandma, who clapped with joy at his response. It was very moving to see this boy’s determination to overcome his personal adversity. We took his details and referred him to hospital where I hope he will go on to receive the treatment he needs.
There are many more memories that will stay with me from this week; the special needs teacher who cycled a group of students three hours each way across rural terrain to come and see us; the 75 year old volunteer who spends her time going around rural communities educating about ear care, and the hundreds of deaf children who despite their adverse circumstances welcomed us with smiles and joy.
I feel honoured to have worked with an amazing group of people who share a vision of improving hearing and ear care in these remote regions. I have learnt many lessons both in terms of a renewed appreciation for my own personal privilege but also in relation to the process of assessing ears in rural settings. There are many things we can learn from places like Malawi in relation to our own healthcare system.
Impact
I think we saw an impressive number of people in one week! I hope many infections were treated, hearing improved by wax removal and by distribution of the bone conduction headsets. Many people were told they needed to go to the hospital and I hope that this educational aspect has helped to raise awareness of ear care.
The experience has made me very aware of the factors that influence our long waiting lists in the NHS. During a clinic, the process of writing each patients’ notes and dictating and requesting scans is slow and labour intensive. It’s made me wonder if there would be a way to replicate what we did in Malawi where we have a ‘one stop’ approach to ear assessment.
It was amazing to see the process of ear assessment all in one space, with clear communication between all the professionals. This makes ear assessment more streamlined. I think we have lost the ability to easily talk to our colleagues in the NHS, perhaps relying too much on letters or emails, which is less efficient and misses out on building relationships with our colleagues. I’m going to start knocking on more doors in clinic and finding those audiologists in their booths!
Looking ahead
I love meeting new people, developing new skills and thinking about ‘problems’ in new and innovative ways. The NHS is a notoriously tricky place to work for so many reasons and global health puts me back in touch with why I become a doctor in the first place. It puts perspective on my privilege and yet constantly leaves me feeling guilty because, however much I try to ‘give’ I end up feeling like I receive so much more.
I would like global health to form an integral part of my future career. Ideally I would like to undertake a PhD in Global health and ENT.”
[1] Status report on ear and hearing care in the WHO African Region | WHO | Regional Office for Africa
Find out more about the Malawi Hearing Project, the East of England Global Health Fellowship scheme or contact us at info@cghp.org.uk
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