FROM THE FRONT LINES OF ETHIOPIA: A PLEA FOR THE GLOBAL HEALTH SECTION TO RECONSIDER PRIORITIES
Regarding the June 5 article about the AAN Global Health Section (Inside the AAN Sections: “Global Health Section: A Mission to Spread Neurology Expertise Where Scarce Resources, Training Exist,” http://bit.ly/AANSection), the AAN Global Health Section strategic plan generally espouses laudable educational and advocacy goals for improving neurological care in the developing world. However, it is disconcerting that a “high priority” is “to facilitate opportunities for US neurology residents and fellows to do clinical rotations in resource limited countries.”
This “high priority” mandate is a striking example of international medical paternalism — improperly assuming that short-term visits by American neurology residents are helpful to the host country. Nothing could be further from the truth. There may be potential indirect benefits in select circumstances, such as increased exposure leading to advocacy that may generate future aid. In general, however, visitors do not recognize the local needs, are unfamiliar with cultural differences, and are ill-suited to providing any meaningful care.
These barriers are not mitigated by pre-trip preparatory lectures. One-off visits for grand rounds, lectures, or clinic attendance are tantamount to international doctor tourism — an educational holiday for the visitor, but extraordinarily disruptive to the host program. For example, the already overburdened local physicians are pulled from their regular duties to orient visitors with respect to clinical activities, resource limitations, and personal matters (accommodation, food, transportation) while managing cultural and language issues.
There are a number of other contributing factors beyond the scope of this letter that make the visits counterproductive, and increase the likelihood of compromising patient safety. Additionally, these visits raise serious legal and ethical issues.
In our experience over the past decade in Ethiopia and other sub-Saharan regions, many American visitors are seemingly unaware of these concerns. Perhaps this is partially attributable to the fact that some cultures consider it inappropriate to refuse a request to host a foreign visitor, or to indicate that the visitor's presence was unhelpful. Thus, the visitor misconstrues the host's acquiescence to a visit, and returns home with the misconception that he or she helped. Host institutions are fearful that negative feedback will disrupt a relationship harboring the potential to provide other benefits such as scholarship grants or equipment donations. We have also encountered sending institutions that exploit the situation by dangling a carrot to induce the host into accepting visitors, and then the promised benefits never materialize.
It is important to recognize that one-off visits secure one-sided benefits for the sending institution — these visits do not provide any substantive benefit to the host nation. The only way to ensure sustainable growth of neurological care in developing nations is to promote capacity building through stable, long-term partnerships offering regularly scheduled teaching visits, reciprocity of training, and appropriate educational donations in a coordinated fashion. The needs should be determined in conjunction with the host, rather than outsiders imposing their views.
Therefore, we strongly urge the Global Health Section and the wider neurological community to reconsider what constitutes a “high priority,” and focus on facilitating long-term partnerships rather than “clinical rotations.”
The burgeoning interest in global health will continue to escalate. After all, American universities reap multiple diverse benefits from international rotations in resource-limited countries, including financial gains through grants and philanthropic donations. However, the scramble for these benefits should never override the ethical obligation to ensure that any visit truly improves care, services or education in the host nation.
Abenet Tafessa, MD
Chairman, Department of Neurology
Addis Ababa University, Ethiopia
James C. Johnston, MD, JD
THE GLOBAL HEALTH SECTION RESPONDS:
Both the Neurology Today story about the AAN Global Health Section and this letter provide important perspectives on the new and emerging field deemed “global health.” As the current chair of the AAN Global Health Section, I find the discussion reflective of some of the many ongoing conversations on how neurologists and neurologists-in-training can best participate in neurological care beyond traditional boundaries. Moreover, the conversation expands to include the larger arena of how institutions and professional societies can meaningfully and responsibly participate in international endeavors.
Drs. Tafessa and Johnston use one pull quote to make their point on international endeavors and what the AAN Global Health Section should prioritize. In my experience, neither “missions” nor “frontlines” fully convey the relationships and partnerships that are occurring among neurologists around the globe.
I would highlight the following main points for future consideration by the AAN Global Health Section and relevant stakeholders in countries of all income levels:
- Only some institutions and individuals want and need international partnerships. The distinction of what type of international relationship is intended and needed is a very important one. The separation into clinical care, research, education, and policy discussions is valuable since particular guidelines and programs may be well-equipped to address one need but less able to address the range of intentions and needs of a visiting and/or host group.
- Currently, there is a range of interactions between institutions, individuals, and groups. This includes formal and informal partnerships.
- Establishing what basic criteria are required for an international collaboration is essential. Other institutions have done so and these include, but are not limited to, mutual benefit, transparency, and accountability. I would consider this an especially important criteria for long-term relationships between organizations and groups.
- No one location or country's experiences can be fully extrapolated to another's. The diverse experiences of individuals and institutions should be carefully recognized. Even in the same country, two institutions may have very different needs and goals. In the same institution, separate departments may have a range of priorities.
- The practice of neurology is less amenable to the experiences sometimes called “parachute” experiences, to which the authors of the letter refer. By nature of our specialty, the need to understand context, culture, environment, and longitudinal care is especially important. Programs that are very short, that may also receive a lot of attention, as occurs in some surgical specialties for example, are not an appropriate model for neurological care.
- As in many aspects of public health, the establishment and affirmation of minimum standards is needed. Although we can promote particular ideals through a document, our actions must be collectively and responsibly adherent to core principles. I would argue those same principles that drive our medical practice and professional standards at home, wherever that may be, must be exercised and even heightened when we venture away from home. These principles should follow the core ethical principles of beneficience, non-malificence, and respect for persons. As in all of our work, we should “first do no harm.”
The Global Health Section currently includes representation of more than 300 members from more than 30 countries. This includes many countries that would be considered “low- and middle-income” by the World Bank and fit the oft-used descriptor “developing.”
I am continually impressed by the Section's members whose positions range from professor emeritus to student. The Global Health Section is among the fastest growing sections in the entire Academy and is an important forum for discussion of these and other related issues. I am confident the Section will navigate these intricate and emerging topics with the sensitivity, courage, and experience that it will take to strengthen the international relationships among neurologists and their relevant organizations.
Finally, my personal experience is that no country has finessed its neurological care without foreign influence and international partnerships. The practice of neurology and neuroscience is by nature international. I am reminded of the African proverb: “If you want to go fast, go alone. If you want to go far, go together.”
Farrah J. Mateen, MD, PhD
Department of Neurology
Massachusetts General Hospital