Into Africa: The Epic Adventures Following Gut Feelings

Dr. Louis Liu, Head of Gastroenterology, University Health Network and Sinai Health System, University of Toronto

May 12, 2017

Imagine, you have finally settled into a secure academic position at a prestigious university, doing what you love to do in medicine and teaching, at the peak of your career in one of the greatest metropolitan cities in the world. You invested more than a decade of post-secondary education, survived gruelling call nights, passed certification and licensure examinations, won praise from mentors, and now contribute meaningfully to provide health care and medical education in your local community. What would it take for you to leave it all behind for a month, and travel to a place unknown, all because someone said other people need your help?

Inspired by “Into Africa: The Epic Adventures of Stanley and Livingstone”, Dr. Louis Liu took us on his journey to Ethiopia, where he rediscovered passion and humility. Where he believes he learned more from the people he went to help, than they may have learned from him.

Through the Toronto Addis Ababa Academic Collaboration (TAAAC) between the University of Toronto and its affiliated Academic Hospitals, and the Addis Ababa University, many of our specialists travel to Ethiopia to teach and co-build their medical graduate education programs. And so began Dr. Liu’s epic adventure.

When he first arrived in 2009, Ethiopia had a population of approximately 85 Million, with a median age survival of 46 years. It was supported by only 2 gastroenterologists, 1 of whom was about to retire. A quick survey of the land was reassuring – Addis Ababa is situated at high altitude, has no malaria, and is safe. But where to begin?  Could he take the easy way out and bring the residents to Toronto to teach them? It was quickly apparent that would backfire. The epidemiology of disease is vastly different. We don’t see the same diseases. While there is a lot of liver disease, it is disproportionately represented by schistosomiasis and hydatid cysts, considered rare back on our continent.  Not to mention, it is never sustainable to train people outside their own environment without building the local infrastructure to support the skills acquired.

Instead, he stayed there and focused on curriculum design, tailored to the local needs.  He asked: What are the needs, the challenges? The medical trainees were strong in book knowledge. This was apparent as he sat through their didactic general medicine case discussions. He was humbled to become a learner again, reaching back to first principles to remember the core medicine, yet he observed that they lacked skills to move beyond the classroom to the bedside. Formal assessment practice was underdeveloped. This is where he found he could contribute and leave an impact. Each year, Dr. Liu returns to Addis Ababa with excitement and determination to continue building on the strong collaboration between our Universities. The successes could not be achieved alone. The GI Training Program is co-lead by Dr. Jordan Feld. Since 2009, he has gone to Addis Ababa with two GI residents, one GI fellow and seven GI faculty. Here is part of his legacy:

• He taught trainees how to translate book knowledge to the bedside
• He implemented evaluation tools based on the Royal College of Physicians and Surgeons of Canada, adapted to their local needs.
• They introduced their first OSCE for resident promotion.
• They graduated three classes including 11 graduates into seven new full time University faculty members, two affiliated faculty members, and two community practitioners.
• He employed diplomacy and politics:
• When he first arrived, they could not treat Hepatitis B or Hepatitis C. With the increase in knowledge and working with the local authority, the Ministry of Health is now providing the resources to treat both Hepatitis B and C.
• Malnutrition was a significant problem - they were able to advocate successfully for increased population level nutrition funding for admitted patients.
• The only treatment for inflammatory bowel disease was steroids – he has started working with the local authorities to develop local treatment guidelines for steroid-sparing agents when the agents become available
• Resources were lacking – he helped raise $1 Million-in-kind to purchase high definition endoscopy equipment, and established the first endoscopy training program in Ethiopia.
• He helped them build an administrative structure to support the division and training programs.
• He forged collaborations with a Norwegian group to set up abdominal ultrasound and plans to develop therapeutic options to liver cancer

The most poignant surprise? The beautiful people and culture – the resilient, smiling and proud, though poor and ill people are grateful for the care the group provides when they arrive. The trainees and new faculty feel a sense of belonging to the greater academic and medical international community in contrast to isolation.

Dr. Liu accomplished great things in a short time since he first travelled to Addis Ababa. It was not alone. Many of his colleagues from his division with diverse expertise now travel with him. The Gastroenterology program offers invaluable educational electives for their fellows to travel with the group. Improvements to the structure and delivery of GI training and health care services was successful because of the respectful collaborations with the local stakeholders to co-create a model, not to unilaterally transplant one based on our existing model back home.

The future for the TAAAC GI is moving quickly. They are hoping to begin a live journal club, but are looking for solutions to the limited internet. They are building the local GI society, which now has around 30 members. Lastly, there are opportunities for their new Faculty members to attend conferences opening doors to international contact and collaboration.

Aiming to discover the source of the mighty Nile river, Stanley’s chronicling of Livingstone’s nine year epic adventures was embarked on with "alarming foolishness, intense courage, and raw human achievement.” While Dr. Liu’s 21^st Century travels are no comparison to that intensity and danger, they are out of his usual comfort zone, from which the greatest rewards are found. Dr. Liu sums up his personal reflections with familiar lesson, reminiscent of those from Dr. Robert Fowler’s #CEEPAoM talk, “Art of Medicine, Unplugged” (October 25, 2016):

• Value opportunities - Accept uncertainty and take a chance
• Have a passion and act on it – But, be an active listener
• Ask for help - Identify allies within your local community
• Do not accept the status quo -  Overcome barriers with solutions
• Make a difference - Give back 

BIO - Louis Liu, MD, PhD, FRCP(C)

Dr. Louis Liu is Director of the Division of Gasteroenterology at UHN/SHS and the Director of the Clinical Motility Unit at UHN. In 2009, he established the Neuro-gastroenterology and Motility Fellowship Training Program at the University of Toronto, where he holds an appointment as Assistant Professor in the Department of Medicine. He is also lead for the GI Residency Training Program at Addis Ababa University in Ethiopia. Dr. Liu is the Chair of the Admissions Committee for the Canadian Association of Gastroenterology.