Introduction

The socio-cultural, economic, and geographical underpinnings of Kenya influence the accessibility to timely healthcare for complex head and neck diseases. Kenya’s population is largely rural with majority of inhabitants living in villages or small communities dependent on agriculture and small-scale farming.1 In addition, many Kenyan healthcare providers reside in rural settings with  limited access to resources that support and further medical advancement. Higher-income nations recognize the need for sustainable global outreach training programs to teach didactic and clinical skills across all medical specialties. For more than 10 years, well-established head and neck surgical training camps in Kenya have provided no-cost complex head and neck surgeries in resource-challenged settings. There has been a recognized need for speech pathologists to provide sustainable training in swallowing and swallowing disorders to local healthcare providers. This article discusses the challenges and opportunities of dysphagia care in a head and neck surgical camp in Kenya. 

Etiologies of Dysphagia in Head and Neck Cancer Surgical Camps

Malignant Tumors

Head and neck cancers (HNC) in developing countries account for 67% of HNC cases and 82% of HNC-related deaths worldwide. It is estimated that the mortality from HNC in Africa will increase 2-fold between 2010 and 2030.2 In sub-Saharan Africa, lack of advanced imaging, nasopharyngoscopy, and ability to test for human papilloma virus (HPV) oncogenes result in a scarcity of staging information necessary for accurate prognosis and treatment.3 The risk factors for development of HNC in sub-Saharan Africa are different in comparison to those of high-income countries. Various environmental exposures, use of Toombak products, and kola nut consumption are known risk factors for HNC in Africa.3 Although present worldwide, the human immunodeficiency virus (HIV) epidemic has the greatest impact in sub-Saharan Africa.4  Individuals with HIV may have increased rates of HPV infection and persistence of HPV strains, increasing their risk of HNC development.3 Currently, only 5% of patients with HNC in Africa have timely access to safe and affordable surgeries due to lack of qualified healthcare providers specializing in HNC care.2 Limited accessibility to healthcare providers unfortunately results in patients presenting with more advanced tumors requiring larger surgical resection.2 Invasive surgical resections, such as removal of the tongue or larynx result in a high incidence of dysphagia, or difficulty swallowing. 

Benign Tumors

Oral and maxillofacial tumors within the skull, mandible, and facial bones are rare and can cause disfigurement of the face. Africa has the highest incidence of odontogenic masses, or tumors arising exclusively from the jaw, in comparison to any other continent worldwide.5 The most common odontogenic tumors are ameloblastomas followed by keratocystic odontogenic tumors and myxomas, respectively.5 Due to limited access to healthcare, odontogenic tumors are often not treated until the mass has caused facial disfigurement and impairments in speech and swallowing. Surgical resection and reconstruction of advanced odontogenic tumors can lead to impairments in the oral phases of swallowing, such as poor labial seal resulting in anterior bolus loss, difficulties with mastication, and diminished posterior propulsion of the bolus within the oral cavity. 

Head and Neck Trauma Arising from Economic Challenges 

While malignant and benign tumors account for majority of head and neck surgeries in Africa, trauma-related injuries, such as eldercide or the unjustifiable killing of persons over the age of 60 years, also require the need for head and neck surgery.1 Unique to the coastal regions of Kenya, eldercide plagues elderly community dwellers. Younger adults accuse elderly community dwellers of performing witchcraft, thereby, justifying violence against them typically through beheadings. The competition for limited resources in Kenya has spurred tensions between younger adults and the elderly. Jealousy over generational economic differentiation has motivated younger adults to accuse the elderly of performing witchcraft. Younger individuals conclude that witchcraft is the reasons for drought, crop failure, or livestock deaths. While masked in witchcraft accusations, such ageist attitudes and violent acts are motivated by regional economic distress, with younger adults seeking to profit from the property of slain elderly individuals.1 Beheadings are one of the most common forms of eldercide. If an attempted beheading is survived, significant trauma to the larynx and pharynx remains and results in severe and prolonged swallowing dysfunction. 

The sequelae of swallowing dysfunction arising from head and neck surgeries can result in poor health outcomes such as dehydration, malnourishment, and aspiration pneumonia.6 To further exacerbate the risk of adverse health outcomes, long-term feeding tubes are not performed in the head and neck surgical camp due to lack of necessary resources, further highlighting the need for early diagnosis of swallowing dysfunction and rehabilitation.

Need for Dysphagia Care in Resource-Constrained Settings

Currently, there are no formal training programs for swallowing sciences in East Africa. Comparatively, in the United States, there are 315 accredited Speech-Language Pathology programs that have formal didactic and clinical curricula in swallowing sciences.7 The negative impact from a lack of formal training in dysphagia is observed on many levels. Firstly, head and neck surgeons may choose to forego surgeries in candidates who would have significant swallowing dysfunction as the result of surgical resection. Secondly, patients who have undergone head and neck surgery are left with significant impairments to their swallowing function without options for proper diagnostics or therapeutic interventions for their swallowing disorders. Thirdly, the lack of a foundational training program in dysphagia care leaves a continued void in what could be a sustained lineage of qualified practitioners in swallowing and swallowing disorders in East Africa.

The Dark Side of Doing Good

While humanitarian outreach is typically rooted in altruistic intention, the ethics and merits of medical volunteerism in developing countries have been scrutinized. Concerns regarding ‘medical tourism’ for self-interest and lack of shared decision-making are well-cited in global outreach literature.8 

The term, “medical tourism” describes the deliverance of medical care by high-income countries  to resource-challenged nations resulting in a self-serving net gain without sufficient regard for the host-country’s needs. Medical tourism can result in high-income nations performing medical care customary to their own institutions’ capabilities, but are not sustainable in the host-country. To serve a high volume of patients in a short duration of time, visiting healthcare providers may assume the role as primary clinician to perform as many procedures as possible. However, this practice marginalizes local healthcare providers and limits their clinical skill development. To avoid medical tourism, local trainees should be the primary providers of medical care while expert volunteers provide supervision.9

The concept of shared decision-making is largely adopted in industrialized nations. Shared decision-making supports a patient’s engagement in their own plan of care. It can be challenging to have shared decision-making in countries where healthcare providers are seen as the ultimate authority rather than a partner in healthcare planning. In conjunction with local care providers and language interpreters, healthcare providers should provide a thorough explanation of the benefits and risks of any medical procedure or intervention. To ensure informed consent, two interpreters should be used. One interpreter is used to translate between the patient, caregivers, and healthcare providers, while the second interpreter serves as a scribe to document the details of the discussion and plan of care.

How I Do It: Practices to Develop Sustainable Dysphagia Care in Kenya

Prior to each humanitarian outreach trip, a needs assessment with the local hospital and local healthcare providers is conducted. Current barriers, initiatives, and goals are discussed with the host institutions. With this knowledge, the visiting SLP can support the local healthcare providers’ endeavors and help build capacity for an increased volume of patients to be evaluated and treated. Sustainable healthcare is at the forefront of each humanitarian outreach trip. Trainees from Kenya are the primary clinicians, to the extent possible, while assistance and supervision is provided by the visiting speech pathologist.

In addition, swallowing diagnostics and interventions are provided within the contexts of existing resources with utilization of supplies that are accessible within limited resource settings. Instrumental swallowing evaluations are not accessible in Kenya, therefore, teaching thorough clinical assessment techniques in the context of known limitations is key. Goals of therapeutic intervention are constructed and discussed with the patient and caregiver, local trainees, and the supervising speech pathologist. Collaborative planning ensures that the recommendations and treatment plan are feasible within the community’s capabilities and aligned with cultural norms. The overarching goal of sustainable global outreach is to leave skills behind that promote a self-sufficient and locally run community. Through teaching didactic and clinical skills, local healthcare providers will be empowered to provide independent and ongoing dysphagia care. 

Bidirectional Exchange of Knowledge

With each humanitarian global outreach trip, a bidirectional exchange of knowledge occurs between visiting healthcare providers and local trainees. While the intended goal is to teach sustainable dysphagia care, humanitarian outreach teaches us about the resiliency, tenacity, and ingenuity of our local peers who practice in resource-challenged environments. Effective dysphagia care can be provided with less equipment and resources than we are accustomed to. These experiences challenge our status quo and cultivate creativity and innovation in dysphagia care. 

References

  1. Owusu, E. S. (2023). Exploring the magnitude, characteristics and socio-economic contexts of witchcraft-related eldercides in Kenya. International Annals of Criminology61(3-4), 328-354.
  1. Fagan, J. J. (2021). Africa: A window on challenges and opportunities for head and neck cancer. Laryngoscope Investigative Otolaryngology6(3), 414-419.
  1. Faggons, C. E., Mabedi, C., Shores, C. G., & Gopal, S. (2015). Head and neck squamous cell carcinoma in sub-Saharan Africa. Malawi Medical Journal27(3), 79-87.
  1. Moyo, E., Moyo, P., Murewanhema, G., Mhango, M., Chitungo, I., & Dzinamarira, T. (2023). Key populations and Sub-Saharan Africa’s HIV response. Frontiers in Public Health11, 1079990.
  1. Butt, F. M., Ogeng’o, J. A., Bahra, J., Chindia, M. L., Dimba, E. A., & Wagaiyu, E. (2012). 19-year Audit of BenignJaw Tumours and Tumour-like Lesions in a Teaching Hospital in Nairobi, Kenya.
  1. Tagliaferri, S., Lauretani, F., Pelá, G., Meschi, T., & Maggio, M. (2019). The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clinical Nutrition, 38(6), 2684-2689. 
  1. ASHA. Council on Academic Accreditation in Audiology and Speech-Language Pathology. 1 December 2023. https://caa.asha.org/programs/ 
  1. Bovid, K., Brooks, J., & Heffernan, M. (2021). First do no harm: ethical considerations of pediatric orthopaedic global outreach. Journal of the Pediatric Orthopaedic Society of North America3(4).
  1. Luginbuhl, A., Kahue, C. N., Stewart, M., Curry, J. M., Weed, D., Zender, C., … & Zafereo, M. (2021). Head and neck surgery global outreach: Ethics, planning, and impact. Head & neck43(6), 1780-1787.
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Dr. Lisa Evangelista is an Associate Professor and Director of Speech Pathology at the University of California, Davis Medical Center, Department of Otolaryngology-Head and Neck Surgery. She is a board-certified specialist in swallowing and swallowing disorders and serves as the Head and Neck Cancer Topic Chair for the 2024 American Speech-Language and Hearing Association's Annual Convention and on the Executive Board of Directors for the American Board of Swallowing and Swallowing Disorders. She provides comprehensive diagnostics and contemporary management of swallowing dysfunction following surgical interventions and radiation therapy for head and neck cancers. Her academic interests include swallowing physiology following radiation therapy, alaryngeal voice rehabilitation after total laryngectomy surgery, and quality of life outcomes following surgical and medical interventions in head and neck oncology.