Physicians battle pediatric diseases of ear, nose, throat in Zimbabwe
Stanford’s Peter Koltai is participating in an effort to advance much-needed ENT care for children in Zimbabwe.
Titus Dzongodza, MD, was at the end of a long work day, throwing on his jacket to go home, when an 8-year-old girl gasping for breath walked through the doors of the new pediatric otolaryngology clinic at Harare Children’s Hospital in Zimbabwe.
“Immediately I knew we were in trouble,” Dzongodza, who was director of the clinic at the time, said in a Skype interview. “She looked obviously stressed and tearful.” Anoona (not her real name) had traveled all day with her mother by bus from their home in a rural village hundreds of miles away to reach the nearest hospital. It was springof 2018, a year after the opening of the pediatric otolaryngology clinic, which treats disorders of the ear, nose and throat. “I could hear the grating sound in her shaky voice indicating the return of the viral warts on her larynx,” Dzongodza said. “I knew we’d have to gather the whole team together in a matter of minutes.”
After two years of planning, building, fundraising, training staff and scrounging for medical equipment, the new clinic opened its doors in March 2017. Within its first year, thousands of new patients were making daylong trips by bus to get treatment for neglected conditions. It was only the second such clinic in Africa. (The first was in neighboring South Africa.)
In a country of 14 million people, there are only eight otolaryngologists, also known as ear, nose and throat doctors. Many consider the subspecialty of pediatric ENT unnecessary because of Zimbabwe’s many other unmet health care needs.
“This was a bold dream for a full-scale clinic with audiology and speech therapy services, as well as two operating rooms with a recovery room and beds for overnight care,” said Peter Koltai, MD, professor of otolaryngology and of pediatrics at the Stanford School of Medicine, who was recruited three years ago as a volunteer adviser for the project. “Now we believe that this new clinic can be used as a role model to be duplicated across all of Africa.”
The clinic was the vision of Clemence Chidziva, MD, an ENT surgeon and professor of otolaryngology at the University of Zimbabwe. Chidziva knew firsthand the effects of malnutrition, poor medical care and uncontrolled viruses on his pediatric ENT patients. He also knew these problems reached far beyond Zimbabwe into other parts of Africa and the developing world.
“I wanted to build a clinic that could provide high-quality care for children and proper training for pediatric ENT surgeons as well,” Chidziva said in a Skype interview.
Harare Central Hospital, in the country’s capital, comprises the children’s hospital and an adult hospital, maternity hospital and psychiatric hospital. Conditions are poor. Prior to the opening of the new clinic, Chidziva’s pediatric ENT patients received care at the adult hospital. (They still undergo surgeries there.) When Koltai first traveled to Zimbabwe in 2015, he stayed in the background, listening and learning about the problems he and Chidziva’s staff were going to try to fix.
“When I first arrived, I saw the fragility of this medical system,” Koltai said. “The lack of supplies, questionable water and electricity, the marginal cleanliness outside of critical areas in the hospital. There were no fiber-optic capabilities — that is, medical equipment used for internal examination of the body — and no record-keeping for patients. But I also saw the dedication of these doctors, who were working under conditions we would find almost intolerable at Stanford."
The types of ENT problems Chidziva routinely treated — and that Koltai would eventually assist with during his repeated visits to Harare over the years — were far more serious than the general population understands, Chidziva said. There’s a common misperception in Zimbabwe that ENT problems in children are trivial. Parents think that continually running noses in their children, constant snoring and painful ear infections are just a way of life.
But, in fact, the list of serious problems is long: untreated ear infections that lead to perforated eardrums and often deafness; HIV infections that cause repeated ear and throat disorders; congenital neck masses; ingested button-cell batteries lodged in airways; leeches that crawl into the ears of babies left to play in the grass, causing uncontrollable bleeding.
When I first arrived, I saw the fragility of this medical system.
“Many of these things are no longer problems in the modern world, but big problems in the developing world,” Dzongodzasaid. He is now on a fellowship in Melbourne, Australia, where he is training to become certified as a pediatric otolaryngologist. He will be the first physician with the certification in Zimbabwe when he returns to lead the clinic in July.
One of the most serious and common medical problems treated by the Zimbabwean physicians is called recurrent respiratory papillomatosis. It’s a disease caused by the human papilloma virus, or HPV, that causes growths in the upper respiratory tract. The growths can cause difficulty breathing, damage the vocal cords and become life-threatening. The conditionoften gets misdiagnosed as asthma, delaying treatment. Children first lose their voices and then struggle to breath until, as in the case of Anoona, the growths threaten to block respiration completely.
“By the time they get to us, they can’t sleep, they’re not growing, their breath is raspy and they are struggling to get in air,” Dzongodza said. “Usually they’re about 3 years old when they first show up, then they return maybe three to five times for surgery as the warts keep growing back. It’s a challenge for us, especially when much of the equipment we had been using was quite archaic.”
This was the case for 8-year-old Anoona, who was rushed into emergency surgery when she arrived on that spring evening struggling to breathe. It would be her eighth surgery to remove the viral warts from her larynx. As a toddler, she had been misdiagnosed with asthma and appeared at the hospital for the first time when she was 3 years old, gasping for breath. This time, though, she would be initially seen at the new clinic, with staff better trained to treat children, and operated on at the adult hospital with new equipment and advanced new imaging technology designed for use with children.
“All the surgeons on the unit had met her one way or the other over the years,” Dzongodza said. “Often the senior colleagues would dig into their pockets to get her bus fare for the next journey back to the hospital.”
To make his vision a reality, Chidziva started by raising funds for construction of the clinic from the Christian Blind Mission International, a charity committed to improving conditions of those living in some of the poorest communities in the world. Next, he invited Koltai to join his team. Koltai’s prior experience in helping to set up several pediatric ENT clinics in the United States and working for 10 years as the director of the pediatric otolaryngology program at Stanford, would prove invaluable, Chidziva said.
“Clemence had a vision, and I bought into it,” Koltai said. “This project resonated with my goals of seeing the footprint of pediatric otolaryngology spread far and wide. I would supply some of the experience, and Clemence supplied the leadership.”
Koltai has spent endless hours scanning eBay in an effort to scrounge up reusable medical equipment at affordable prices. He brought two decommissioned surgical microscopes from Lucile Packard Children’s Hospital Stanford to Harare and has been instrumental in plans for the delivery of an ultrasound machine. The Jenks family of Menlo Park, who had supported Koltai’s research work in the past, helped pay for the eBay purchases and their shipping fees. Early on, he secured funding from Stanford’s Department of Otolaryngology-Head and Neck Surgery to fly the physicians from the clinic, including Dzongodzaand Chidziva, to the Bay Area, where they stayed with Koltai and observed him for a month at Stanford Medicine.
“Peter’s work, together with his Zimbabwean counterparts, helping to stock the clinic with instruments and develop a novel training program for the surgeons was a terrific example of an equity partnership,” said Michele Barry, MD, director of Stanford’s Center for Innovation in Global Health. “Having worked on and off in Zimbabwe for almost 30 years, I can tell you that this accomplishment was no small feat.”
Over the years, Koltai has returned repeatedly to Harare to teach advanced surgical techniques, hold seminars and set up the previously nonexistent record-keeping program. The record-keeping will be essential for Chidziva’s long-range plan of creating a training ground at the clinic for future pediatric ENT surgeons, along with a research program to help advance academic appointments at the University of Zimbabwe. The first research project on the docket, he said, will be a clinical trial to provide evidence of what appears to be the widespread scourge of the HPV disease.
“We feel that with scientific evidence to support us, we can get our government to vaccinate for HPV to prevent this disease,” Chidziva said.
Still, the clinic remains a work in progress. Plans are moving ahead to open two operating theaters adjacent to the clinic and dedicated to treating children with ENT problems. Fundraising efforts have been amped up to fill gaps in care caused by the tripling of the patient load following the opening of the clinic. Due to constant funding shortfalls, much of the equipment considered essential at Stanford, such as MRI or CT machines, remains out-of-reach luxuries in Harare.
“When we created this clinic, we did it to improve care for our patients,” Chidziva said. “But within the first year of opening, we saw 3,500 patients, three times the average caseload. The struggle now continues to get them all onto an operating table in time.”
In May, the team organized the first international symposium to advance pediatric otolaryngology across Africa, called PENTAfrica, held in Victoria Falls in Zimbabwe, with the goal of advancing pediatric ENT across Africa. Attended by otolaryngologists and other health care professionals from Africa, Europe and North America, the event launched the organizers’ long-range plan to use the new program as a model to provide great access to care across the continent.
“We’re hoping our new clinic will plant a seed in each and every country in Africa,” said Chidziva. By July, with the return of Dzongodza from Australia and with the opening of the clinic’s operating wings, Chidziva will be well on his way to achieving his goals.
For Dzongodza, training thousands of miles away in Melbourne, he still worries about his patients back home, including Anoona. Dzongodza remembers taking off his jacket that evening, then scrambling, like usual, to track down equipment being shared by other staff at the hospital, including the oxygen tank and the pulse oximeter, before operating on the child’s airways. But the new surgical equipment and surgical training from Koltai made a difference that night.
“Surgery went on successfully, but our nightmare remains of how to offer social support given her circumstances,” Dzongodza said. “I saw the child once more before leaving for Australia, and she was doing well. We can only hope that she continues to make the long journey back to the hospital when she needs us again.”
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