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Countering Global Neurological Burden Will Take Advocacy, Training



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Neurologists involved in global health programs calls for more advocacy and training in neurologic disorders in developing countries around the world.

As mortality and disability-related years of life lost due to neurological disorders have grown significantly in the world since 2005, advocacy and training neurologists in lower-income countries are increasingly needed, experts told Neurology Today.

In many developing countries, funding for training in clinical neurology and neurological research is critical, said Ana-Claire Meyer, MD, assistant professor in the division of global neurology at Yale School of Medicine. She cited the importance of programs of the World Health Organization, the Fogarty Center training programs at the National Institutes of Health, as well as the Academy of Neurology and World Federation of Neurology.

“While training, treatment, and reporting of diseases in poorer countries have improved in the past decade, neurologists need to become more vocal advocates for care in less developed parts of the world,” she said.

Gretchen Birbeck, MD, MPH, FAAN, professor of neurology and research director for the Strong Epilepsy Center at the University of Rochester Medical Center, NY, works for part of the year in rural Africa. She said the key for reducing global neurological mortality is to enhance basic care.

“Strengthening the primary care system's capacity to provide very basic care for common conditions could go a long way toward decreasing neurologic mortality,” she said. “Screening for hypertension and providing blood pressure lowering medications and dietary counseling, especially in stroke survivors, and assuring adequate supplies of antiepileptic drugs that can be safely co-administered with antiretroviral agents would help, as would pushing for a more expansive list of neurologic medications on the WHO Essential Drugs List.”


Dr. Birbeck said neurologists in the United States need to advocate with policymakers, political leaders, ministries of health, and other stakeholders to educate the next generation of neurologists, especially in regions currently underserved by neurology.

“We need to think broadly about what cadre of health care personnel is actually in the trenches providing care, and develop appropriate medical education opportunities to allow them to provide the best possible care in the setting where they are working,” she said. “Within the US, this may mean better programs for advanced practice providers or rural primary care physicians. In low-income settings this probably means programs for nurses and clinical officers.”

Developing programs for non-US settings will require working closely with local medical professionals whose knowledge of the healthcare setting, resources, and capacity will be critical for creating and implementing feasible, relevant training programs, she noted.

Her work has been in Zambia and Malawi, both of which are low-income sub-Saharan African countries.

“In addition to my own research programs in cerebral malaria, neuro-HIV and epilepsy, I mentor and collaborate with US and African clinician scientists studying a range of conditions including TB meningitis, neuropathies, and psychiatric comorbidities in people with neurologic disorders. As clinical researchers, we also participate in clinical care and medical education activities. I am the epilepsy care team director for a large rural catchment area in Zambia's Southern Province and am able to provide hands-on care around six months a year and telemedicine support when I am in the US. I've also had the privilege of working with Zambian Institutes of Higher Learning to develop training curricula for non-physicians.”


Dr. Birbeck said one of the more exciting developments she hopes to see in the next 12 to 24 months is the launch of a neurology master of medicine program at Zambia's University Teaching Hospital, led by Omar Siddiqi, MD, who has been working in Zambia for some years.

“Training Zambian neurologists will be a real game-changer. Dr. Siddiqi and his colleagues are to be congratulated on pursuing this,” she told Neurology Today.

There is also a lot of enthusiasm among young US neurologists and neurology trainees to work abroad and contribute in any number of ways, Dr. Birbeck said, noting that several US residency programs have strong linkages with foreign hospitals and provide important clinical services as visiting consultants.

“The AAN's Global Health Section is working to solicit materials and input to develop a draft curriculum that might serve broadly as a template for the core, foundational knowledge that needs to be included in a solid training program in global neurology,” she said.

Nirali Vora, MD, clinical assistant professor of neurology and director of Global Health Neurology at Stanford University, said there are still major gaps in diagnosis, treatment, and prevention for stroke, epilepsy, and other neurological diseases in low-resource/low-income regions.

“For example, for spinal cord disorders, there is often no access to high quality imaging. This condition won't be reflected in the GBD but is common, or may get reflected under spinal cord problems although the accurate diagnosis is not made,” she told Neurology Today.

“My biggest experience is with stroke mortality in parts of sub-Saharan Africa, where mortality can be reduced by prioritizing primary vascular disease prevention and access to cheap prevention medications, as well as organizing care within the hospital to reduce mortality once a stroke has occurred. A similar approach can be taken with epilepsy and headache.”

However, this starts with building neurological capacity through education and training providers, which will have the longest reaching effects in inspiring the next generation of neurologists in lower-income regions, she noted.

“These neurologists need a seat at the policy table in order to advocate for drug and diagnostics, together with continued research to accurately measure disease prevalence. In many lower-income countries these are still lacking for neurology. It does not help to infuse more technology such as EEGs until there are adequate personnel to operate and maintain equipment, interpret results, and actually treat.”

At the Stanford Global Health Neurology program, Dr. Vora and her colleagues support trainees who spend four to six weeks at partner teaching institutions in low-income countries building neurology capacity, primarily through bedside teaching and involvement in systems change research.

“Embedding neurologists in these regions would inspire local physicians or students to become neurologists, while teleneurology education, when effectively coordinated, will also help.”

The newly-formed AAN International Task Force, on which she sits, has recommended the AAN support these types of neurology capacity building activities.

“There is an extraordinary amount of work to be done to address mortality, especially for stroke,” said Farah Mateen, MD, PhD, FAAN, assistant professor of neurology at Harvard Medical School and head of the Global Neurology Research Program at Massachusetts General Hospital.

“Most important in my view is training the next generation of physicians to know and understand neurological diseases, as neurologists or as other practitioners who will see neurological patients,” she said. “There is a pressing demand to train a truly skilled cadre of neurologists around the globe. I envision a neurological practice in lower-income countries where treatment and cure will become more normal than fatality.”


•. Yale Global Health Track in Neurology:
    •. Stanford Global Health Neurology Program:
      •. Global Neurology Research Program, Massachusetts General Hospital:
        •. Neurology: Without Borders: