The changing face of global health: Yale and South African doctors partner to expand care

While working in South Africa several years ago, Dr. J. Zachary Porterfield came across a young child in a clinic in rural KwaZulu-Natal. During the examination, the doctor was surprised to find that the patient had drainage from her ears and loss of hearing.
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This young patient (right) at a clinic in rural KwaZulu-Natal, South Africa has been suffering from a chronic ear infection and is being evaluated for treatment and for inclusion in a study of the dramatic impact chronic ear infections have on these communities by (from left) Dr. J. Zachary Porterfield, research assistant Pume Mhlongo, and Dr. Julia Toman. (Photo by Dr. J. Zachary Porterfield)

While working in South Africa several years ago, Dr. J. Zachary Porterfield came across a young child in a clinic in rural KwaZulu-Natal. During the examination, the doctor was surprised to find that the patient had drainage from her ears and loss of hearing.

“It had progressed to the point that she was having difficulty in school,” said Porterfield. “When I asked her mother how long this had been going on, she said three years. Her ears had been draining, and she had been losing her hearing for three years.”

Unfortunately, this is not an unusual situation in some KwaZulu-Natal communities. Indeed, many children in at-risk communities around the world are losing their hearing as a result of chronic untreated ear infections, a phenomenon largely unheard of in the United States. The socioeconomic and personal costs of acquired deafness are usually devastating.

The issue of chronic ear infections is particularly interesting in the case of South Africa because the country has skilled physicians and the medical technology necessary to treat such infections, explains Porter, now a senior research fellow in the Yale School of Medicine’s Department of Infectious Disease.

The problem, he said, is access to care: South Africa’s major cities have modern medical infrastructure, but many rural areas lack such resources, and traveling from a rural town to the city is often too expensive, time-consuming, and difficult for people in need of medical attention.

“South Africa is a remarkable country: From a healthcare delivery standpoint, it has a number of unique challenges which have resulted in the juxtaposition of extremely well-trained physicians and healthcare professionals working in state-of-the-art hospitals that are only a stone’s throw away from areas with incredibly limited access to healthcare,” he said. “You have this significant burden of disease, but right next door, you have the doctors and infrastructure to cure it.”

Education is at the heart of the UKZN-Yale Collaborative. At a microvascular surgical skills course taught by Dr. Alexandra Kejner (Yale) at the University of KwaZulu-Natal in March 2017, Dr. Julia Toman (Yale) and Dr. Tanusha Nandkishore (UKZN) worked together with other residents and senior surgeons to discuss and practice these advanced surgical techniques. (Photo by Jared Govender, Zoom Photography)

It was this situation that inspired the formation of a partnership between South Africa’s University of KwaZulu-Natal (UKZN) and Yale.

“We are working with our South African colleagues to extend the reach of medical care—helping to connect the dots, so to speak,” said Porterfield, who is honorary senior lecturer at UKZN. “This collaboration makes a powerful statement about what can be accomplished through partnership in a country with a well-developed medical system, like South Africa.”

The idea for the partnership came in 2015, when Porterfield and Dr. Julia Toman, a senior ear, nose, and throat (ENT) resident surgeon at Yale, were introduced to the head of UKZN’s ENT Department, Dr. Yougan Saman. Porterfield and Toman had already engaged in research to understand and treat the epidemic of chronic ear infections in rural Tugela Ferry, South Africa, but recognized that partnering with UKZN would maximize the project’s impact and sustainability. Saman shared the Yale clinicians’ interest in developing research and clinical care across KwaZulu-Natal, and the Yale-UKZN Collaborative was formed.

“Successful global health partnerships require a dedication to bilateral and equitable international relationships,” said Porterfield. “We’ve been very fortunate to have paired with Dr. Yougan Saman, who has become our chief collaborator in this partnership. Dr. Saman has a clear and comprehensive vision for developing research and clinical care within his department and across the KwaZulu-Natal Province.”

Since its inception, the Yale-UKZN Collaborative has expanded dramatically. Today, the collaborative focuses on addressing public health priorities in at-risk communities, while simultaneously advancing research programs and supporting the education of trainees at both Yale and UKZN. In addition to chronic ear infections, the collaborative concentrates its efforts on the interface between HIV and non-communicable diseases facing the KwaZulu-Natal province, especially the epidemic of head and neck cancer. Much of the Yale-UKZN Collaborative’s current success and ongoing development is due to its early supporters, including Dr. Elias Michaelides, the program director for the ENT residency program at Yale, and Dr. Melynda Barnes, a facial plastic surgeon from Yale. Both travelled to KwaZulu-Natal — donating their time, expertise, and the cost of their travel — to help develop and strengthen the collaborative. Michaelides, in particular, made changes to the ENT training program to increase the educational benefit of the partnership and allow for increased resident participation.

“We have developed an exchange program, founded the biannual UKZN-Yale Research and Clinical Care symposium, have numerous collaborative research initiatives, and will be rolling out educational and clinical care programs across the province,” Toman said.

This child seen in clinic with hearing loss from prior chronic ear infection now has improved performance in school using a hearing aid band. South Africa has the technology and expertise to both treat children who have lost their hearing, including advanced approaches using Cochlear implants, and also to treat and prevent the causes of hearing loss. (Photo by Dr. J. Zachary Porterfield)

Porterfield also drew particular attention to the academic aspects of the program, explaining that the collaborative offers benefits to both Yale and UKZN medical residents. For Yale residents, the exchange program with UKZN offers the opportunity to gain exposure to unusual and advanced presentations of diseases that would not typically be seen in the U.S. and to learn from South African experts about the provision of excellent care in resource-limited settings. Meanwhile, for UKZN residents, the program offers a chance to experience the delivery of healthcare in the U.S., increases access to international meetings, and helps to generate research projects. Collaborative research projects offer opportunities for first authorship on publications for South African registrars, which fulfills a South African graduation requirement that can otherwise be difficult to meet. This relieves a bottleneck of training physicians, who can then go on to have a substantial, long-term impact in the province.

In addition, Toman pointed out that the collaborative has had important implications for the field of global health.

“One of the early roadblocks for this project was convincing people that surgery has a role to play in global health,” she said. “Within the community of surgery, it’s something that’s not well understood. Ten years ago, global health was about combating HIV, tuberculosis, and malaria, especially in South Africa. But today, the definition of global health has expanded. So part of this program has been about increasing people’s understanding of the role that everyone can play in global health and the changing meaning of global health.”

For the collaborative, the next steps will include, among other things, continuing the launch of a province-wide educational campaign teaching general practice doctors, dentists, and other health care providers to identify head and neck cancer earlier; implementing electronic learning initiatives in South Africa; expanding research directions to tackle problems of public health concern; and strengthening referral pathways so that patients can get the care they need.

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Part of the In Focus Collection: Yale and Africa: Empowering through partnership

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