Prevention Is An Easy Way_A Story from a Hospital In Addis Ababa, ET

There is an alarmingly high rate of Neural Tube Defects (NTDs) and folate deficiency in Ethiopia. Hospital studies show prevalence rates of ~13 cases of NTDs per 1,000 births in Ethiopia (global average is ~2 per 1,000 births) (26-times higher!). Blood folate concentrations show high prevalence of RBC folate deficiency in all provinces of Ethiopia, and that contributes to a high risk for NTDs. Recent studies shows that 10% of all deaths are due to NTDs, 20% of stillbirths are due to NTDs, Prevalence in Ethiopia CHAMPS: 7.5 per 1,000 births (90% CI: 4.8, 11.3)?(VERY HIGH compared to other CHAMPS sites)

A story from St. Peter Hospital, Addis Ababa, Ethiopia

“In 2016 I was a newly assigned young CEO at St. Peter Hospital. Big vision with passion on one side and fear with resource scarcity on the other side. One day the matron called me to the small, confined and very warm NICU to show me how they keep 5 or 6 babies in a single incubator. That day in one room 4 incubators 22 babies. I left the unit with nightmares. I decided to talk to the only pediatrician of the Hospital for his suggestion to improve the situation. He has made many recommendations. After rigorous chart review lately we learnt that a significant number of NTD babies occupy beds at NICU. The only center where we can refer these babies is Zewuditu hospital. Already they have hundreds of cases on the waiting list.

I have decided to start the surgery at St. Peter. After a couples of month I managed to hire a senior Neurosurgeon and a senior Anesthesiologist already about to take their sabbatical leave from AAU for one year with the help the then health minister. Getting the OR, the ward, the diagnostic facilities ready was among the toughest jobs of my entire hospital leadership time. We start to operate four days, almost 16-20 surgeries/week. Established a 20 bedded ward with PACU unit. Unfortunately the situation worsened after we had started the service. We ended up with a waiting list of 228 babies within a month. The hospital became overwhelmed to handle referral from all over the country. In one year these two physicians managed to operate more than 500 babies with a very low mortality rate. Later this small neurosurgery unit now recognized as one among the seven neurosurgery centers of excellence for babies with SBH supported by Reach Another foundation adding prevention, after care and community ownership programs.”

From the story we can learn folic acid deficiency neural tube defects are competing for care with other babies who has treatable cases. Establishing a Pediatric neurosurgery center is expensive, time taking and complicated process especially in LMIC. The demand for surgery increases because the prevalence of NTDs are high in most of LMIC. This is the hardest way to address the problem.

Prevention is the easiest way to tackle this problem. Adding folic acid into the staple foods in every LMIC can significantly reduce SBH cases. Can contribute for the reduction of still birth, child mortality and neonatal mortality. So far only 59 countries managed to add folic acid into some kind of food items after 30 years of scientific evidence. Neurosurgeons are needed very much to deal with many health problems in LMIC. Better to spare them where we need them most. Let us prevent these preventable public health problem in easy, cheap and safe way.

Worldwide, more than 325,000 babies are born annually with neural tube birth defects – and 85 percent of these births defects could have been prevented with folic acid. We need a global action now: Babies are suffering/dying. Neurosurgeons are asking. Collaborative Action with Leadership (CAL) is needed. Let us choose the easy way –PREVENTION – adding folic acid into wheats/Salt or any staple food specific to every LMIC. Mandatory folic acid fortification/advocacy for folic acid fortification of iodized salt in Ethiopia can help to reduce child mortality and elimination of SBH.?Advocate for WHA resolution – Mandating folic acid fortification in LMIC. Funding – Small scale but implementation studies (Feeding studies, organoleptic studies, Regulation studies, Supply chain, Surveillance). Comprehensive care and support like integration of Training program + Surgery + After Care + Prevention of high risk cases and Community engagement = we call it Neurosurgery Center of Excellence

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