Cut off by COVID and conflict, Canadian medical mission to Yemen goes virtual

It's nothowDr. William Cherniak pictured it would go.

The emergency room doctor at Markham Stouffville Hospital north of Torontois co-founder of agroup called Bridge to Health, a Canadian non-governmental organization that delivers medical and dental aid to countries around the world.

He hadjust receivedapproval for a pilot project to train doctors in Yemen to use portableultrasound machines. Then came COVID-19.

"Initially, we were supposed to actually fly in and bring the devices with us for an initial one-week training period, but then, the pandemic kicked in just as we got approval for the grant," he said.

He's led missions to Uganda and Kenya using the same technology,which relies on a hand-held scannerthat connects toa smartphone or tablet,but says it's the first time people in Yemen are being trained to use the scanners.

"We had to figure out how to get these into a country without us going how to getthem to the hospitals we are working with and how do we train people virtually,"Cherniak said.

Majority of Yemenis relyon humanitarian assistance

The impact of COVID-19 has been disproportionately harder on poorer countries, and in Yemen, the situation hasbeen made worse bya civil war that haslasted since 2014, when Houthi rebels ousted PresidentAbdrabbuhMansurHadiand seized control ofnorthern Yemen.

Saudi Arabia entered the war in 2015, heading a coalition that backedthe country's Sunni faction against the Houthis, who areZaidi, a minority Shiasect,and haveIran's support.

According to the United Nations, more than 233,000 people have been killed in the conflict and more than four million people have been forced to flee theirhomes.

The UN considers Yemen one of the poorest countries in the Arab world, and food insecurity, lack of access to clean water and a fragilehealth care system mean an estimated24.1million people, or about80per centof the population, are in need of some form of humanitarian assistance.

Canada has pledged $70 million in aid for Yemen but has been criticizedby the UN and others for continuing to sell military equipment to Saudi Arabia. According to Global Affairs Canada in 2020, Canadian weapons exports to that country totalled $1.3 billion.

The ongoing conflict and pandemic travel restrictions have also stopped fly-in medical missions from Canada and the United States.

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Real-time feedback

Cherniaksaid 12 ultrasound scanners and10 iPadswere delivered toIbn SinaHospital and the Hadhramout University Hospitalin the port city of Al Mukalla in southern Yemen.

The delivery was funded in part by $250,000from Grand Challenges Canada, a not-for-profit organization that invests intechnologicalinnovations and is supported by the federal government.

On the ground, liaison personnel with MedGlobal,a U.S.NGO that works with Bridge to Health,have helped set uponline training for agroup of 15 medical staff.

"It's the first time to my knowledge ever where we are trying to do 100 per cent of the training 100 per cent remotely," said Cherniak.

It meant getting the hospitals access to satellite internet. That allowed them to remain connected after much of the country lost internet access after deadlyair strikes in northern Yemen that killed 82 and damaged the infrastructure of TeleYemen, the state-owned monopoly that controls internet access in the country.

Half a world away in his home office in a downtown Toronto condo Cherniak can review the scans done by trainees in Yemen and give them feedback on how to improve technique and guidance on making a diagnosis.

Hope to improve health outcomes

According to Bridge to Health, except for the local trainer in Yemen,all the doctors involved are volunteers.

Dr. Nahreen Ahmed is an assistant professor of clinical medicine at the University of Pennsylvania in Philadelphia. She is the head of ultrasound training for Bridge to Health. Along with instructing the trainees by video link,she reviews the scans they upload to the cloud.

"If I place a comment on an image, they can see it almost immediately in Yemen. And so that's pretty incredible to give that kind of real-time feedback," she said.

Ahmed says while the project is unique, having ultrasound or radiological scans viewed by another physician in a different country is common.

"You have to have an expert review your images, and most of the time, your images are being reviewed remotely," she said.

From detecting pediatric pneumonia to pregnancy complications and internal trauma from injuries sustained inthe ongoing conflict, access to diagnostic medical imaging can savelives.Ahmedsays Bridge to Health will be tracking how effective the training and tools are and expand the projectto other hospitals across the country if it's successful.

"We can really improve these kinds of health care outcomes across a country that's been debilitated by warfare and famine," he said.

Sharing knowledge

Dr. Abdulla Bagahizel is Bridge to Health's local trainer. He divides his time betweenhis medical studies in Cairo, Egypt, andtraining in Al Mukalla. He says the 15 trainees all have medical backgroundsand come from three departments in the hospital pediatrics, maternity and trauma with about halfmen and half women.

"It's not just the device but how these trainees share all their knowledge," Bagahizel said. "We are looking at the sustainability of this project, and that will be how the trainees will be trainers in the future."

"I saw [the trainees]...asking for details and giving feedback on videos. They provide us with great feedback," said Bagahizel.

According toBagahizel,Ibn SinaHospital andHadhramout University Hospital,serve about threemillion people in theregionand are experiencinga shortage of all kinds of medical equipment, includingspecialized IV pumps,ventilators,ECGmonitorsand defibrillators. Patients in need of X-ray imaging have to be transported50 kmaway.

Sincelocal power stations are experiencing a chronic shortage of fuel, there is currentlyno electricity in Al Mukalla, and the hospitals are beingpowered by gas generators, Bagahizel said.

Dr. Abu Baker Wajeeh Bin-Noob,a pediatricresident atHadhramout University Hospital, says having ultrasound scanners right at thepatient's bedside is "aquantumleap" improvement in care.

"This saved us a lot of time, which we need,since time here, in the medical field generally, is very important for saving lives," he said.

"And this has reflected onto the patients themselves in their happiness and admiration with this new technology, which hasn't been known to us ...for a very long time."

Could impact future missions

Cherniak from Bridge to Health says it's the '"train the trainer" model that differentiates thismedicalmission from the typical one where doctors parachutein, sets up temporary clinics totreat as many patients as possible, then flyback home.

"We still come in as external folks, but the aim is to help those local physicians to becomeexperts themselves."

Still,Cherniak says there is no substitute for having physicians experienceother health care settings in person.

"It's different when you see things with your own eyes it bursts that bubble of what care lookslike in a wealthy country, which is different than whathealth careis like for most people around the world."

Cherniak saysthe changes made during the pandemic have shownhow medical missions could be done in the future.

"I would like to see medical missions continue, but in a more thoughtful way," hesaid. "Maybe you don't always send a team or maybe not as large a team. We can find ways to complement what we've learned."

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