To understand why the AAN has a Global Health Section, it might help to start with some numbers: 900 million — the estimated population of Sub-Saharan Africa; 48 — the number of countries in Sub-Saharan Africa; 300 — the approximate number of neurologists practicing in these 48 countries; and 7 — the number of countries in Sub-Saharan Africa with neurology training programs.
These figures are specific to Sub-Saharan Africa, but the situation is similar in many other resource-limited regions of the world, said Jerome Chin, MD, PhD, MPH, one of the founders of the AAN's Global Health Section, which was launched first as a Special Interest Group (SIG) in 2010 and achieved full Section status in 2011. It now has more than 300 members.
“Many low- and middle-income countries have a severe shortage of neurologists to serve their people,” said Dr. Chin, who closed his neurology practice in 2009 after nearly two decades to devote himself to public health and global neurology. He is now a lecturer in global health at the University of California, Berkeley School of Public Health and a visiting faculty member at the Makerere University School of Medicine in Kampala, Uganda.
While on an independent visit to Uganda and Kenya in 2010, Dr. Chin served as attending neurologist at Mulago Hospital, the national referral hospital in Kampala, Uganda. There, he saw firsthand the massive burden of neurological diseases and disorders such as stroke, meningitis, epilepsy, and traumatic brain injury in countries like Uganda, and the challenges for local doctors with limited neurological training and scare resources to manage these patients.
“I was the only residency-trained neurologist treating patients at the hospital,” he said. “There are four faculty members in charge of neurology, but they are internal medicine physicians who just picked up neurology on their own. They taught themselves.”
Self-taught neurologists? It's true in many developing countries, said Dr. Chin. “If you're interested in neurology, you just pick it up on your own. Most doctors don't have the opportunity or funding to get formal specialty training.”
While on that first visit to East Africa — he now returns twice yearly — Dr. Chin chanced to meet up with a fellow alumna from the graduate public health program at the University of California, Berkley, Amy Lee, MD, MPH. Dr. Lee, a neurologist at the Palo Alto Medical Foundation, was working in Rwanda with the well-known international health organization Partners in Health.
“We saw that there was such a great need for neurology education, research, and clinical care in resource-limited countries, and we thought we should try to form a Global Health Section within the Academy,” said Dr. Chin.
The two teamed up with Gretchen Birbeck, MD, MPH, FAAN, a professor of neurology at the University of Rochester, who has a degree in tropical medicine and hygiene; Ana-Claire Meyer, MD, an assistant professor of neurology at Yale University School of Medicine; and James Bower, MD, an associate professor of neurology at the Mayo Clinic. Together, they made their case to the Academy.
Global Health became the AAN's first SIG; after an impassioned plea from Dr. Chin before the Committee on Sections in the fall of 2011, it became a Section. Over the last two years, global health has “come out of the shadows,” Dr. Chin said. This year, at the AAN Annual Meeting, he directed an annual course, “Global Health Challenges: Neurology in Developing Countries.” He noted there was also an Integrated Neuroscience Session at the meeting, “The Global Burden of Neurological Diseases,” co-sponsored by the International Subcommittee, which features presenters from all over the world. Last year's Annual Meeting was the first to feature a global health abstract category.
Among the goals of the Section is the creation of an online neurology curriculum to provide to medical schools and hospitals in developing countries — a curriculum that would train the general practitioner in basic neurology skills. “General physicians are the ones taking care of neurology patients in many of these countries, not neurologists,” says Dr. Chin. “That's the model, and it's unlikely to change soon.”
One of the fastest-growing segments of the Section's membership is current neurology residents and fellows, many of whom have expressed interest in doing international neurology work. But while leading institutions like Yale, Stanford, and the University of Pennsylvania have global health programs for medicine, pediatrics, and surgery residents, which are well funded and well organized, neurology has lagged behind, Dr. Chin said.
A survey of US and Canadian neurology residency directors, conducted by a team of authors led by Jennifer Lyons, MD, director of the Division of Neuro-Infectious Disease at Brigham and Women's Hospital, found that although most residency directors are interested in international training opportunities for their residents, only about half of all US programs offer such opportunities, compared with the majority of Canadian neurology residencies.
“Another high priority for the Section, then, is to facilitate opportunities for US neurology residents and fellows to do clinical rotations in resource-limited countries,” said Dr. Chin. “We want to develop a document for residency directors that will provide guidelines for developing, supporting, and ensuring oversight of international neurology electives for US trainees.”
As it grows, the Section will also focus on enhancing the ability of clinical scientists in developing countries to do quality research in neurology, and get it published. “The overwhelming majority of biomedical research published around the world is authored by investigators in the US and the EU,” said Dr. Chin. “Research done in developing countries is often published in lesser-known journals or not published at all. We call this, ‘the invisible science of the South.’ There is a real need to support researchers in developing countries.”
Dr. Chin will be heading to Uganda again. “Every time I leave Uganda, I think about when I can go back next,” he said. “Any neurologist who spends a few weeks in a hospital in one of the poorest countries in the world will immediately recognize the massive unmet need for neurologists and neurological expertise in these countries. That's what keeps many of us returning. There's so much work to be done.”
AAN ON THE INTERNATIONAL FRONT
In a variety of ways, the AAN works with international organizations and members to enhance training opportunities in developing countries and provide support where needed. For example:
- Approximately 15 percent of AAN members reside outside the United States.
- Since 2001, the AAN, in partnership with publisher Lippincott Williams & Wilkins, has donated copies of Continuum® to the World Federation of Neurology (WFN) to use in its continuing medical education program, which consists of user groups in developing countries. Currently, WFN receives 400 print copies for distribution, and these user groups have access to the publication online.
- The Donald M. Palatucci Advocacy Leadership Forum has trained international members as well as those in the US to become effective advocates for their patients. Graduates include AAN members from Australia, Austria, Belgium, Canada, China, Ethiopia, Germany, Georgia, India, Ireland, Jamaica, Japan, Nigeria, Pakistan, Philippines, Slovenia, and Sri Lanka.
- AAN offers a scholarship program for neurologists from developing countries to enable them to attend the AAN Annual Meeting.
- The AAN offers discounted membership to neurologists in any of the 90 low/lower-middle income countries designated by the World Bank.
- Foreign-language translations of select AAN evidence-based guidelines are available in Chinese, Hungarian, Italian, Japanese, Korean, Polish, Spanish, and Turkish at www.neurology.org.
- The AAN currently is collaborating with the European Federation of Neurological Sciences on a guideline on sudden unexpected death in epilepsy.
- The AAN journal Neurology's “Global Perspectives” section features specific neurologic practice concerns within a country and important information about international educational or scientific collaborative efforts.