Head and Neck Surgery Fellowship Training in Sub-Saharan Africa

Though it was early in medical school, I vividly remember our patient’s bright smile and singsong voice as she greeted the surgeon in rural Haiti. The warmth of her face drew attention away from the ill-boding contour of her neck, where a malignancy lurked just beneath the surface.

She was full of hope. Yet, even my then-elementary understanding of cancer in rural Haiti produced an intense dread deep within my stomach. The tumor had grown rapidly, she said, to the point where her voice had changed. The mass had invaded her trachea long before she sought surgical care. We didn’t have the resources or training to treat such advanced disease, which meant that it would be only weeks before she suffocated. Nevertheless, she left our clinic smiling, clinging to a hope against all odds.

Dr. Wayne Koch has dedicated his career to fighting these odds. In 2005, there were zero head and neck surgeons in sub-Saharan Africa, meaning that approximately one billion people had no access to specialists who could treat head and neck cancer and trauma. Dr. Koch, an otolaryngologist and fellowship trained head and neck surgeon at Johns Hopkins, is changing this paradigm by training head and neck surgeons across the sub-Saharan region.

The head and neck surgery team operates at Mbingo Baptist Hospital.

Through the Pan-African Academy of Christian Surgeons (PAACS), Dr. Koch has established the Cameroon Head and Neck Fellowship - the second training program in sub-Saharan Africa. This one-year fellowship at Mbingo Baptist Hospital in northwest Cameroon trains fellows from across the continent with the intent that, upon graduation, they will return to their communities equipped to provide lifesaving care and develop new head and neck fellowships. With limited resources, the Cameroon Head and Neck Fellowship team has harnessed the train-the-trainer model to develop a fellowship that could exponentially increase access to head and neck surgical care.

International surgical efforts have oft-provided solutions that were developed in high-income settings of abundant resources. Not recognizing the need to resculpt these interventions to fit local conditions, they have frequently failed due to untenable cost, inadequate training, or the like. However, Dr. Koch and the team at Mbingo Baptist Hospital endeavor to tailor this fellowship to the health care realities in Cameroon and across the continent. They align their care with the unique challenges in their community by incorporating social workers to provide appropriate treatment for patients across the socioeconomic spectrum. Furthermore, they adapt their techniques to limitations in the supply chain while simultaneously working to grow supply chain capacity.

Dr. Koch shares the work of the Cameroon Head and Neck Fellowship with the PGSSC.

This train-the-trainer model of a head and neck surgical fellowship was first pioneered in sub-Saharan Africa by Dr. Johan Fagan at the University of Cape Town (UCT), South Africa. The UCT program has trained 14 head and neck surgeons since 2005. In a recent survey, graduates of this fellowship unanimously agreed that it is “the most appropriate way to build [head and neck] capacity in Africa.” Each trainee subsequently returned to their home country, and graduates of UCT and the Cameroon Head and Neck Fellowship have collaborated to create the continent-wide African Head and Neck Society (AfHNS).

Upon return to their home countries, Dr. Koch expects the newly-minted head and neck surgeons to drastically increase provision of head and neck surgery, offering care to patients who would otherwise go untreated and suffer the debilitating and deadly effects of advancing disease. Furthermore, their expertise in directly providing and managing care provision in low-resource settings will equip them to develop their own head and neck fellowships. 50% of Dr. Fagan’s graduates intend to start their own programs, and it is likely that the Cameroon Head and Neck Fellowship will produce similar results.

There is much work left to be done, and challenges abound. Radiotherapy for cancer is nonexistent in many sub-Saharan African countries, and jaw reconstruction for trauma requires materials that can be challenging and expensive to procure. Dr. Koch and his colleagues remain undeterred. Because of their work, momentum for head and neck surgical care continues to grow, and with it rises the hope that bright, smiling patients like mine will no longer face impossible odds.