Aeromedical Services in Sub-Saharan Africa
Authors: Dr.Seblework Temesgen, Dr.Ola Orekunrin,Dr.Ryan Wubben,Dr.Minh LeCong,Dr.Nazanin Meshkat
Aeromedical service, in conjunction with pre-hospital emergency services, allows for rapid rescue and transport of acutely ill or injured patients. The concept of moving patients to definitive care by air, dates back to more or less the same time as fixed wing flight did. Aeromedical service has a long history of trial and error, success and failure and ultimate achievement. Shortly after the Wright Brothers successfully flew their first Airplane,two United States army(USA) medical officers,Captain George H.R.Gosman and Lieutenant A.l.Rhodes,designed an airplane built to transport patients.Using their own money,they built and flew the world’s first Air Ambulance at Fort Barrancas,Fla,in 1910.During the First World War,French medical officer Eugene Chasseing first adapted French military planes for use as air ambulance. Modified Dorand II Air crafts’ were used at Flanders in April 1918.By the end of the War, the US government recognized the growing need to transport the wounded by air.In 1918,Major Nelson E.Driver and Captain William C. Ocker converted a Curtiss JN-4” Jenny” biplane into an airplane Ambulance by modifying the rear cockpit to accommodate a standard Army stretcher.(1) Following the early success, military aeromedical services have been operationalized by the civilian sector. Today, civilian aeromedical services are provided in most developed countries.
There are challenges to civilian aeromedical evacuation when compared to military transport due to the inherent differences between military wartime transport and civilian peacetime transport.In time of War,the echelons of care are well defined, the mode of transport is usually known,and the receiving facility is certain.In peace time air medical transport these criteria are not well-defined, and have to be carefully delineated by local agencies or the government.(1) Despite these challenges, use of aeromedical service for the purpose of pre-hospital emergency response or inter-facility transfer, has been recognized as a vital component in the continuum of patient care.
In this editorial we provide an overview of the current state of civilian aeromedical services in South Africa, Nigeria, Kenya, and Ethiopia as an example of the services at different stages of implementation in Africa. We describe the need for the service and the challenges encountered in their implementation, and we provide possible solutions to moving the service forward in African countries.
There are multiple considerations in the development of aeromedical services in Sub-Saharan Africa. The needs are great. In most African countries people live in geographically remote areas where access to healthcare is logistically difficult. Simultaneously, the burden of disease is high.Though some patients can walk hours to nearby clinics, the critically ill patients cannot.(4) Further, the delay in seeking care compounds the morbidity and mortality experienced by patients.
According to a study done in Lesotho, in many regions of Africa plagued by high burden of disease,there is also difficulty in accessing basic medical care.This is often due to logistics constraints and lack of infrastructure. In the short term, medical aviation can play a major role in addressing some of these crucial issues as it allows for the rapid transport of patients, and provision of personnel and medication to remote and sometimes otherwise inaccessible areas.(4)
Foreign and local investment in African countries has led to the growth of business ventures, such as mining projects, hydropower plant construction, mechanized farming, often in remote areas. It is not unusual to find various medical and traumatic emergencies requiring urgent response.It is undeniable that aeromedical service is the best way of response in such circumstances.
It is also identified that traumatic emergencies have a better outcome in setups where there is developed aeromedical service. A study published in the journal of American Medical Association reported that patients with traumatic injuries may have a better chance of survival, if they are flown to dedicated trauma unit instead of transported by ground ambulance. In this study helicopter transport was associated with greater chances of being discharged alive from a level 1 or level2 Trauma Center.(3) Though this study was conducted in the setting of developed countries, the care of trauma patients at trauma centers have been shown to improve mortality.
The history of African aeromedical service started since 1957 with the establishment of the Flying Doctors in East Africa in Kenya, now known as the African Medical and Research Foundation Flying Doctors. Aeromedical service inSouth Africa started in 1976. Since then multiple nonprofit and private organizations have developed. Coming to West Africa, Nigeria Flying Doctors’ establishment dates back to mid 2000’s. The service is in its infancy in many other countries, including Ethiopia.
Currently, in Sub-Saharan Africa the state of aeromedical service level varies from country to country in terms of facility, skilled manpower and models of the service. South Africa’smodel is a case which can be taken as example of a highly developedaeromedical servicein Africa.There are many aeromedical service providers in different provinces in South Africa.One of well organized regional aeromedical models is located in Western Cape Town. It is anextensive aeromedical program complementing the groundambulance emergency medical services. This service is given bySouth African Red Cross Air Mercy Service(AMS)in conjunction with government Emergency Medical Services (EMS) program.AMS is a non-profit organization operating as an independent trust that has been providing aeromedical services in SouthAfrica since 1966.
AMS air transport of patients encompasses a range of mission from long distance, fixed wing aeromedical evacuation movements to short distance, rotary wing. These air craft’s are used to pickup patients from scene to heath facility and also provide inter facility transfer. AMS also gives outreach program and flying doctor service to remote areas where there is no specialist in agreement with the regional health department.
Another model of aeromedical service which operates actively in East Africa is AMREF Flying Doctors. It is located in Kenya, provides aeromedical service across many East African countries including Uganda, Kenya, Tanzania and, when clearance can be obtained, most neighboring countries.In Addition to emergency evacuations, AMREF Flying Doctors provides a medial outreach program, taking essential health care to some of the most impoverished and remote areas of Africa countries.Though there are exceptional cases where transports are on a charity basis, this organization uses a payable business model. Affordability and accessibility of the service is a challenge. Further, due to a lag in the development of ground emergency services, fragmentation of care is an issue.
In West Africa the Nigeria Flying Doctors, offers medical evacuation services across West and Central Africa with both fixed and rotary wing capacity. The services are provided both to government and private entities. Primary and secondary retrievals are carried out. Majority of evacuations take place within the West and Central African sub-region or within Nigeria. However, they also carry out several international repatriations a year. The rotary wing service is essential for transport within Nigeria, as many states do not have landing strips or airports; roadside rescues are carried out using the helicopter. Similar to their Kenyan counterpart, Nigerianground pre-hospital levels are also under-developed, with sparse land ambulance coverage. Security is often a concern when evacuations take place in Northern Nigeria and extra care must be taken in liaison with the armed forces and police to ensure risk to medical/aviation crew is kept to a minimum.
Another East African country where aeromedical services are in early development is in Ethiopia.Ethiopian Air Lines transports stretcher patients in a commercial aircraft’s from the periphery of Ethiopia to Addis Ababa and repatriation service is also provided from Addis to Europe, Asia and many other countries. According to Ethiopian Air Lines medical unit documentation in 2014, a total of 473 patients were involved in medical flights with Ethiopian Air Lines within a six month period: 33.6% were transported within the country and the rest 66.4% internationally. This suggests a high demand for this service in the country.In addition to Ethiopian Air Lines, a number of private companies have started aeromedical services using fixed wing aircraft.A lot of initiatives have been made to give services like medical evacuation, critical care transport,and inter facility transfer using a business model.
The Government of Ethiopia has been undergoing different initiatives to develop EMS in the country. The government is giving due attention to pre-hospital emergency medical service by developing training programs and ground ambulance service. This is a great opportunity for the development of aeromedical service in the country as trained manpower is an important weapon. Nevertheless there is still a lot of work to be done in developing the emergency medical service and integration of ground emergency care with aeromedical service.
The examples of the different aeromedical service models we have provided here, highlight the challenges of affordability, accessibility, geographic limitations on the type of aircraft used, and also lack of integration with ground ambulance.
Aeromedical service is an expensive transport technology. In low and middle-income countries, there are competing development priorities, and aeromedical services my not be amongst the government’s developing priorities. In addition to the cost, the service shortage oftrained medical crew who can understand aviation medicine and work in a safety conscious aviation environment is also a challenge.There is weak organizational capacity in managing overall command to link both ground EMS and air ambulance service. In summary, the delivery of this medical service in most African countries is constrained by economic factors, technical capacity and management.
However, aeromedicine is no longer a rare event in Africa. There is high demand for improved and standard aeromedical service from foreign investors. It is alsonecessary for the local population because of the long town-to-town distances and mountainous topographyin most African countries. In order to improve the current state of aeromedical service in Africa, and to ensure benefit to the local population, participation of the public sector to facilitate coordination is important. The coordination of the training of paramedic crews, standardizations of transport protocols, hospital intakes, and regulatory mechanisms is fundamental. The parallel development and integration with ground services is also paramount.
Correct selection of aircraft is one of the vital things to ensure operational and cost effectiveness, keeping in mind that many of the rural areas in most African countries may require an aircraft with short runway capability. The costs of aeromedical services can be circumvented by judicious use of business models, in conjunction with charitable services and donations. The disadvantage of sticking to business model is that,low- income communities may not afford to use the service and, this in turn affects the expected improvement in health care.On the other hand, since the operational and service costs are high,cost recovery will be a challenge for an organization to succeed unless they are supported with donations.For these reasons mixed type of model will be ideal in most settings on African countries.
As it is briefly discussed above, some countries provided quite developed service and others are at infantile stage. The ground and air ambulance services are complimentary and should work with strong integration to leverage a good emergency response and patient survival.Therefore aeromedical service is vital for fast emergency response andbacking up development projects taking place in most countries.Both public and private sector has worked together to find out a better way in resourcing this service to provide standard emergency response to meet the demands.Participation of the public sector will enhance coordination and financial mechanisms in order to make the service to the community at large.
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3. Galvagnos et.al: ”Association between helicopter versus ground Emergency Medical service and survival for Adults with Major trauma “JAMA 2012; 307: 1602-1610.
4. Furin J,s: Aviation and delivery of medical care in remote areas: Feb 2008; Vol79 No.2: 136-8.