In 2003, Ethiopia – a landlocked country of 72.5 million people – had only a handful of psychiatrists, all located in the capital city. Psychiatry was in its infancy, and most people sought treatment for mental disorders at religious Holy Water sites.
Fourteen years later, a U of T-Addis Ababa University partnership has propelled the number of psychiatrists from 11 to 70. There are now seven psychiatry departments around the country, and mental health is being integrated into the Ethiopian government’s primary health-care strategy.
The collaboration, called Toronto Addis Ababa Academic Collaboration (TAAAC), has expanded beyond psychiatry: U of T faculty helped to develop emergency medicine from scratch, training ER doctors in a country that didn’t have any. A group of U of T physicians, including Dr. Jane Philpott, now minister of Indigenous services, helped start family medicine in Ethiopia in 2013. And earlier this year, a Toronto-based thoracic surgeon and his Ethiopian counterparts conducted sub-Saharan Africa's first video-assisted pneumonectomy.
The program has inspired other academic fields to come on board – U of T faculty have helped train Ethiopian pharmacists, radiologists, dentists, anesthesiologists, engineers, hematologists, rehab specialists and librarians.
On average, 80 faculty from across U of T travel to Ethiopia every year as volunteers to provide academic training, teaching, support, research collaboration, clinical supervision and mentorship in 21 different programs. The program as a whole is making a difference in the east African nation, but Dr. Dawit Wondimagegn, chief executive director of the College of Health Sciences at Addis Ababa University, points to family medicine in particular.
“Having family medicine is changing the face of primary care in Ethiopia,” Wondimagegn said.
U of T’s efforts in Ethiopia – supporting the development of graduate programs at Addis Ababa University – will be on full display as President Meric Gertler visits the country this week. This is believed to be the first official trip by a U of T president to the African continent.
President Gertler also travelled to Rwanda during this trip as part of a Mastercard Foundation (MCF) Scholars event, but the bulk of his time in Ethiopia is being spent seeing first-hand how this under-the-radar initiative with Addis Ababa University is helping to transform a nation.
The TAAAC program has not only helped Ethiopia slow down the brain drain – keeping newly graduated medical and academic experts in the country – but it has also become the model for collaboration in global health.
“TAAAC has established itself as a sustainable model of educational partnership between two universities: one situated in a low-income country and the other in a high-income country,” said Dr. Brian Hodges, professor of psychiatry at U of T who is executive vice-president, education of the University Health Network and chair of TAAAC's governance committee.
“In partnership with our colleagues in Addis Ababa, U of T and its partner hospitals have supported the establishment of a number of programs for health professionals where there was none, strengthened fledgling ones and helped to create a new generation of specialists who are taking up leadership roles in health care and education across the country.”
Minister of Indigenous Services Jane Philpott (fourth from right) was one of several U of T faculty instrumental in helping Addis Ababa University's school of medicine train family physicians (courtesy of TAAAC)
Ethiopian partners reach out to Canadian partners to identify needs, and then U of T faculty and affiliated hospitals volunteer to train on-site specialists, develop graduate-level and professional programs and supervise doctoral researchers in Ethiopia. The idea is once those new specialists graduate, they can go on to build up capacity in their field.
The Partners in Health program at Harvard University, started by global health guru Dr. Paul Farmer, has spent time getting to know TAAAC, hoping to base seven new programs on the model, said TAAAC co-director Dr. Clare Pain.
“The program works because of decent people on both sides who care about health equity and education,” Pain said. “Ethiopians are amazing people. We all fall in love with the country, the people, the students, the patients – they are gracious, generous people. What little we can do is multiplied many times by our Ethiopian colleagues, which feels inspiring and very rewarding.”
In 2002, Addis Ababa University’s three psychiatry professors, Dr. Atalay Alem, Dr. Mesfin Araya and Dr. Abdul Rashid Bakali, began reaching out to western universities, requesting assistance to open the university’s first psychiatry residency program to quell the exodus of psychiatrists leaving to study abroad and not returning. U of T Faculty of Medicine’s psychiatry department took them up on their offer.
In 2014, U of T's Faculty of Dentistry began collaborating with Addis Ababa University. With only 11 postgraduate specialists and roughly 250 dentists in the country, the training by U of T faculty has been in periodontology, oral and maxillofacial radiology, preventive and restorative dentistry (courtesy of TAAAC)
Pain had been visiting Ethiopia for several years at this point – initially living there and working as a physiotherapist, and later after she had finished training as a psychiatrist.
“I think Dr. Atalay wrote to everyone he knew in the West to assist, but thanks to Dr. Donald Wasylenki, the then chair of the department of psychiatry at U of T, we were able to explore the possibility and follow through,” Pain recalled.
The Ethiopian psychiatrists transformed the asylum in Addis Ababa into a modern psychiatric hospital. The U of T faculty began going to Addis Ababa – two at a time with a resident – three times a year to teach, observe and clinically supervise trainees for a month. Some of the Ethiopians also travelled to Toronto for fellowships. With a critical mass increasing, the Ethiopian psychiatrists have successfully lobbied for the integration of mental health services into all levels of health care, meaning that all health-care workers now need to be trained in mental health and illness.
Wondimagegn, now head of Addis Ababa University's College of Health Sciences, was one of the program’s first graduates. He has been working with priests to help integrate psychiatric care into cultural norms. Partnerships with Holy Water priests are growing, which allow patients to receive both modern and traditional care for their disorders.
U of T's Dr. Clare Pain with Dr. Yonas Baheretibeb, chair of Addis Ababa's department of psychiatry, at a Holy Water site, the traditional way Ethiopians have sought treatment for physical and mental health issues. The Ethiopian program is involving local healers (courtesy of TAAAC)
Next up was pharmacy.
Heather Boon, dean of the Faculty of Pharmacy at U of T, was in Addis Ababa with her husband, a psychiatrist who was volunteering on one of the program’s trips, when she decided to knock on doors at Addis Ababa University’s pharmacy school.
“I said, ‘How can I help?’ and that began a pharmacy partnership,” she said.
Addis Ababa University requested U of T help it start a PhD program in social pharmacy, and Boon and her colleagues focused on setting up a graduate program in 2011, training pharmacist PhDs who could be the next generation of faculty members for the new universities and schools of pharmacy being established across the country. Altogether, six faculty from U of T pharmacy, a PhD student and a post-doctoral researcher took on most of the leg work, often travelling there for two weeks at a time to teach graduate classes. The program had its first two graduates this past June.
Boon herself, has travelled to Ethiopia a dozen times in 10 years, including in May to hear her students’ PhD dissertations.
What takes her back? “Ultimately the people,” Boon said. “I’m absolutely amazed at what they’ve been able to accomplish with so little resources. It actually puts a whole new spin and perspective on my life here and academic research here.
“It’s very much a true partnership. We learn just as much from them as they learn from us. That’s the key. We don’t go over there assuming we have all the knowledge, and we’re going to tell them what to do. I think when we go there, we find it’s very instructive to see how pharmacy is practised in a completely different part of the world, and it makes you reflect on why we do things the way we do things here. It gives us new insight about our own systems and our own cultural biases.”
U of T's dean of pharmacy, Heather Boon (second from right) with colleagues at Addis Ababa University (photo courtesy of Boon)
When TAAAC decided to take on training emergency physicians and family doctors, neither of those fields existed in Ethiopia. For emergency medicine, there were no well-resourced emergency rooms to train physicians.
“The ER at the Black Lion Hospital in Ethiopia initially had only two rooms and a back hall. That’s it, the place that gathers people too sick for anywhere else,” wrote Dr. James Maskalyk, an emergency room physician at St. Michael’s Hospital who helped TAAAC start the emergency medicine program in Addis Ababa and described the experience in his new book, Life on the Ground Floor. The book was nominated for the Toronto Book Awards.
“At home in Canada, emergency medicine is one of the most competitive specialties for medical students, and most who apply won’t get in,” he continues in the book. “Here, no one knows why you would do it, because it appears that for the sickest, little can be done.”
The program, which began in 2010, has graduated more than 15 doctors.
Dr. James Maskalyk (at front) wrote about his experiences helping Ethiopia build an ER from scratch with the TAAAC partnership (courtesy of TAAAC)
Similarly, when Dr. Michael Ko, an assistant professor of surgery at U of T and surgeon at St. Joseph’s hospital, was contacted by TAAAC about training Ethiopian surgeons on minimally invasive thoracic surgery, that came about after Ethiopian partners expressed an urgent need.
“The average life expectancy for Ethiopians is 53, compared with 81 for Canadians,” Ko said. “The majority are dying of preventable things such as tuberculosis, lung infections, HIV and diarrheal diseases. Due to the prevalence of complex lung infections, there is a great need for thoracic surgery in Ethiopia. With traditional open surgery, there is a higher incidence of pneumonia, infections and respiratory failure as a result of a large, painful incision. However, with minimally invasive surgery, the average length of the incision is two to three centimetres, as opposed to 15 to 20 centimetres. Patients are able to go home faster, and there’s a lower incidence of complications.”
Ko brought over two Ethiopian surgeons to Canada to learn specialized, minimally invasive techniques on standarized training equipment and a minimally invasive surgical simulator. He then returned to Ethiopia with two nurses in order to help the surgeons set up their own equipment. The equipment had been donated by well-meaning people over the years but never opened, he said.
Together, the two teams performed procedures like the first video-assisted pneumonectomy, or complete removal of the lung, done thoracoscopically.
“Most of the time, when surgeons get involved with this type of project, it’s usually a one-time thing,” Ko said. “They go there, do as many operations as they can and then leave. When the surgeon is not there, nothing happens. That’s not what we call capacity building. This doesn’t help them in the long run: We’re not teaching the surgeons to become self-sufficient. What we’re doing here is unique – we’re teaching their own surgeons to become self-sufficient, using their own equipment.”
Ko is now raising funds to bring two of the surgeons back to Toronto for further training. He’s also sent down 10 units of battery-powered portable suction units – donated by Medela Canada – to help patients recover faster from thoracic surgery.
As the program keeps growing, the success of the latest TAAAC initiative in thoracic surgery has potential to spur further surgical partnerships between Toronto and Addis Ababa.
“The project has huge impact and spin offs to other programs like in general surgery, gynecology and other surgical specialties,” Ko said.
Dr. Michael Ko (third from left) with the surgical team from Ethiopia, including Dr. Ephraim Teffera (4th from left) and Dr. Ayalew Tizazu (5th from left), in Addis Ababa (courtesy of Michael Ko)