Working Globally, Thinking Locally for Improved Care


Rolvix “Robbie” Patterson has turned a passion for global health into opportunities to improve otolaryngology care around the world, thanks to opportunities through Duke Head and Neck Surgery & Communication Sciences’s NIH R25 Surgeon Scientist Track and the Global Health Residency/Fellowship Pathway at Duke.

Dr. Patterson spoke to us from Cape Town, South Africa, and updated us on his activities.

Why did you choose Duke for your residency?

I am originally from New Bern, North Carolina—not far from Duke. I was brainwashed to be a Duke fan from an early age.

I was fortunate to go to Duke for undergrad. I went to Tufts in Boston for medical school. When it came time to apply to residency programs, Duke’s Department of Head and Neck Surgery & Communication Sciences provided opportunities that no other ENT department offered—specifically with regard to research, training and global health, both through faculty mentorship and global health research options.

There's a pathway for residents to spend two years doing dedicated global health research, which really was a huge selling point. I also think the culture of the department was very appealing. I found the people truly down to earth. And there were really good relationships between the residents and the faculty.

How did your interest in global health start?

My interest started back in high school. My family and I went to Haiti every year through our church. We developed a number of close friendships with people in Port-au-Prince; those friends would come and visit us in the States and we would visit them in Haiti.

During the 2010 earthquake, our friends in Haiti really suffered due to challenges in accessing care. The infrastructure and health care system have significant barriers and limitations. A few months later, I started college at Duke and took a class my first semester in international law and global health, where we talked about ways to address these barriers and access to care from a system level, both in terms of providing health care, as well as developing policy and other necessities to get care to people who need it. My interest just continued to develop from there.

After I graduated from undergrad, I spent a year working at a hospital in Haiti, and I continued working in Haiti while getting my MD and Master of Public Health at Tufts. This has been a long-term relationship that brought me both to medicine and ENT. The commitment to improving access to health care for people who need it is what got me here.

How did you end up focusing on otolaryngology?

I spent the summer after my first year of medical school working at St. Boniface Hospital in Haiti. They had just opened a general surgery program, and I was struck by the need for surgery and interested in the challenge of providing surgical care in a place with limited resources. Before they started that program, people were dying from obstructed labor during childbirth, simple fractures or appendicitis—things that can be treated effectively with basic surgical care.

I also saw people who were suffering from cancers of the head and neck and people who had lifelong hearing loss that had never been addressed. I found those needs particularly moving, especially since there has been limited work on these issues from a public health perspective. I also fell in love with the anatomy and the breadth of the care that we're able to provide as ENTs, from ear tubes and tonsillectomies to lifesaving cancer resections to restoring hearing. All those things were pretty motivating for me.

In addition to your residency, you’re also Vice President of the Global OHNS initiative. What does the group do?

The Global OHNS Initiative is an international collaborative and nonprofit that aims to conduct baseline research on ENT conditions and care around the world. It also aims to empower ENTs in places with limited resources to be the ones to set the research agenda and lead the research.

There are large gaps in our understanding of ENT care. Until very recently, our understanding of the ENT workforce in many countries was limited. We don't have a good understanding of the barriers patients face when trying to access care in places like rural Haiti. And without that knowledge, we don't have the information we need to advocate for improved care delivery or expanded health policy to include ENT care. The Global OHNS initiative is trying to address that gap and do it in a way that's led by people who work in those health systems.

I cofounded the group in 2019 and lead it with Dr. Samuel Okerosi at Kenyatta National Hospital in Kenya and Dr. Mary Xu at University of California-San Francisco. The idea came from a broader movement to treat surgery as a public health need. In 2015, the Lancet Commission on Global Surgery published a report that framed surgery as an essential healthcare need. It found that 5 billion people lack access to safe, timely and affordable surgery. And over 80 million people every year have catastrophic expenditures when they do seek surgical care. After that publication came out, there was a big movement toward advancing research around access to surgery.

We now have over 300 members from over 40 countries around the world. The majority of our members are from low- or middle-income countries. It's been a really fun thing to be a part of, and I’m just constantly learning from all the other people in the group.

What are you working on now?

Robbie Patterson with children

I'm in the research track at Duke. Instead of five years, my residency is seven years, and I have two dedicated research years which are added to the traditional curriculum. I'm working on research full-time right now during the second of those two research years. The principal investigator and primary mentor is Dr. Susan Emmett, who was previously a faculty member in the Department and is now at the University of Arkansas. 

I am spending the year in South Africa testing a new type of tympanometer, a hearing screening device that detects middle ear disease—ear infections and other conditions of the middle ear. Tympanometers are used in audiology clinics around the world.

The difference between this device and the ones already found in audiology clinics is that this one doesn't require an audiologist to operate it. Because many countries don’t have even one audiologist, this overcomes a big workforce barrier. It’s also cellphone-based and low-cost; traditional tympanometers are pretty bulky and expensive and are not designed for field use.

If we can prove this device is as effective as a traditional tympanometer, then teachers, community health workers, and other lay health screeners can use this device to detect ear infections in school-aged children. This will help children receive simple treatments like antibiotics before they develop long-term hearing loss.

We're working with a company called hearX and its affiliated nonprofit organization called hearX Foundation. This hearing screening device company is on the cutting edge of implementing hearing care in resource-constrained settings. We're working in communities within Paarl, a town outside of Cape Town. This area is lower income and has relatively limited access to health care. With their network of community health workers, we’re testing this device in a setting that would be representative of where it can be scaled up around the world.

I'm training community health workers and teachers to use the device, and they screen preschool children. An audiologist comes with us and they screen the children with the traditional tympanometer so we can compare how accurate this new device is. If effective, the goal is to then scale this up within school hearing screening protocols around the world.

What did you do in your first research year?

During my first year, I spent some time in Alaska. Similarly, this was for an access to hearing care study. We were looking at reasons why Alaskan Native children have high rates of ear infections and infection-related hearing loss.

I spent a couple of months in Nome, which is pretty far north in Alaska and remote. It's a town of about 4,000 people and has 15 villages in its catchment area. The villages are only accessible by boat and plane. We did hearing assessments with children in the communities and collected information about risk factors that could be contributing to hearing loss. We looked at things like access to running water in the household and exposure to wood-burning smoke in the home and correlated that with rates of ear infections and infection-related hearing loss.

Another component is a genetic trait called CPT 1A that is common among Arctic populations and can predispose them to increased respiratory infections and a number of other health issues. We're also looking to see if there's any correlation between that trait and ear infections or hearing loss.

Who in the department has helped you in your efforts to make an impact globally?

Dr. Howard Francis, our chair, and Dr. Bradley Goldstein, Vice Chair of Research and lead for the R25 NIH grant that funds our Surgeon Scientist Track, have been extremely supportive. In many ways, they made this type of training program and career possible. They created the structure and supported me in doing this.

I think global health and public health have not been well represented within funded ENT research in the past. Dr. Francis really has a forward-thinking approach to making this a priority and sees the importance of improving access to ENT care.

What's next for you?

We'll finish the South Africa study in the coming year, and then I'll return to clinical medicine next summer. I have three more years of residency, and I plan to train to be an ear surgeon, or otologist. My goal is to lead large-scale implementation studies of ear and hearing care to improve access.

I think I'll always have a foot in the door working internationally. There's a lot to be done in places like South Africa and Haiti. But there's also a huge need for access to care in our own state.

I'm from eastern North Carolina, a more rural area, where people can have pretty significant barriers to care. I could see myself working in other places like rural Appalachia. I think there are a lot of ideas that translate between rural North Carolina and Haiti and vice versa.

It's not that we always need to develop a new technology or a new cutting-edge treatment to improve lives. We need to help them get to clinic or help them afford their medications—just enable them to access care that already exists. I'm excited to see all the work that's going on in the department to do this.

Are there any big themes that you've learned during your experience?

The people are the most important. I just left Paarl, the community we're working in, about an hour ago. And I left feeling really excited about the research we're doing, because of the people that I get to work with. And because of the people that we get to take care of and support.

Seeing how thankful the teachers were that we were screening their students for hearing loss—that's really encouraging. It can be easy to lose sight of that given the demands of residency and clinical practice. But the more that I'm able to keep in mind that it's really about the people we're serving and the people we're working with, that keeps me pretty motivated and grounded.