Dr Fiona Kabagenyi recalls the following experience:

For 1 billion people, sub-Saharan Africa (SSA) has only one paediatric otolaryngology fellowship program and nine fellowship-trained paediatric Otolaryngology Head and Neck Surgery (OHNS) specialists covering seven countries. In an informal survey, seven of these specialists estimated an average of 40+ patients per month are in need of critical surgical airway management in their respective countries. Additionally, they estimated that roughly 2–25 deaths per year occur in their country from lack of access to foreign body (FB) removal equipment.

‘It’s like flying blind’, Dr. Samuel Okerosi at Machakos Level five Hospital in Kenya explains about navigating paediatric airway emergencies without proper endoscopic equipment. Some paediatric otolaryngologists in SSA have reported their airway endoscopic equipment to be up to 20 years old. Some centres only have access to one or two functional sets of equipment for airway FB removal, with limited ability to repair broken equipment. Three specialists reported having no access to flexible bronchoscopes. In addition to the lack of functional equipment, limited staffing and inefficient referral networks, respondents also reported limited availability to paediatric intensive care units (ICUs) and multidisciplinary subspecialities, such as cardiothoracic surgery, for open surgical removal of FBs refractory to endoscopic removal. Improved access to resources and basic equipment for diagnosis and retrieval of FBs is critical to reducing mortality and morbidity of the affected paediatric population in SSA.

Studies estimate the global mortality for paediatric inhaled FB emergencies to be 4% – 7%.¹ Mechanical obstruction from FB is the primary source of fatal accidents in children under age 1 and a major cause of death in children aged 1–4 years.² The burden of care for paediatric airway emergencies was highlighted in a Delphi methods study, which found paediatric FBs to have the second highest consensus agreement as a priority OHNS condition.³ A partner study determined that 5 of the 11 highest priority procedures in paediatric otolaryngology were related to airway obstruction.⁴ The Disease Control Priorities Third Edition emphasised the economic and a moral imperative that global partners invest in paediatric surgery as a vital component of reducing the burden of disease and improving the public health and economic fortunes of LMICs.⁵

While challenges in strengthening health systems appear insurmountable, investing in basic essential equipment for diagnostic airway assessment is a tangible step (Figure 1).

Having an ‘endoscopy tower’ (Figure 2) with a monitor, connecting camera-head and light source in tertiary institutions is ‘nice-to-have’, as it addresses needs across various subspecialties such as urology, general surgery and sinus and/or endoscopic ear surgery. Therefore, local concerting efforts can be made in procurement with investments utilised by multiple departments.

For interventional purposes, a rigid bronchoscopy set with optical forceps (Figure 3), a diagnostic laryngoscopy set up and a shared endoscopic tower can be effectively used to retrieve the vast majority of airway FBs.

Collaborative approaches in procurement and maintenance of high-quality equipment that are simple to set-up and cost-effective are crucially desirable factors in both LMICs and higher-income countries.

We call upon multiple stakeholders including surgical equipment companies, SSA health organisations, surgical societies, and non-profit and individual donors to engage in collaborative, context-appropriate and innovative solutions to alleviate these disparities. As healthcare practitioners, conscious about global surgical equity, we must (1) increase awareness of the urgent need to improve access to paediatric airway care, (2) promote essential airway equipment infrastructure, (3) invest in policies including global resource sharing and (4) collaborate with industry to develop distribution models in resource-limited health systems such as in SSA.

The passion and desire to improve outcomes in paediatric airway disease in SSA must be matched with the surgical infrastructure. As a region of the world with the largest paediatric populations, SSA has a need that is critical and pressing. We urge multi-stakeholder engagement and collaboration to forge lasting change.