Learning Objectives: To understand the challenges and difficulties in developing an otology service in one of the world's poorest countries. To reflect on the help that can be provided from more developed countries.

Malawi is one of the world's poorest and least developed countries. It has a population of 16 million, with over half living below the poverty line. Life expectancy is little over 50 years with 1 in 8 children dying before the age of five. The main health burden in Malawi is HIV (10% of the population are HIV positive) along with tuberculosis and malaria, which together account for 40% of hospital deaths.

The rate of chronic ear disease is unknown due to lack of trained clinicians and difficulties in diagnosis however the population is twice as likely as those in Europe to be born with, or develop, hearing loss. Untreated ear disease is one of the causes of such loss.

The co-author is one of only two ENT surgeons in the whole country and the presenting author visited Malawi as part of a sabbatical in 2013. It was evident during this visit that whilst the infrastructure was being slowly developed there was a complete lack of expertise and equipment to carry out any complex otological surgery. With the support of various charitable organisations and associated industry the visit subsequently led to four cochlear implants being successfully implanted on 2 separate visits to Malawi.

Due to these developments the facilities are now such that future plans are in place to carry out regular weeks of otological surgery alongside developing a CI programme. These weeks will facilitate the short term aim of training Malawian (non-medical) clinical officers in the diagnosis and treatment of ear disease as well as the longer term aim to identify and train a Malawian otologist. The project has also raised awareness of deafness in Malawi and has highlighted the significant public health issues relating to the aetiology of ear disease and deafness in 3^rd world countries.

As well as addressing the practical and ethical issues relating to the project the presentation will outline future plans in developing both implant and otological surgery in Malawi and southern Africa.