Global neurology: It ' s time to take notice

For many of us, the desire to do something “good” for humanity was a strong motivation for entering the field of medicine. Indeed, we likely trumpeted that specific goal in our application essays and to our medical school interviewers. Over time, that simple, lofty ambition often becomes subsumed by other urgent necessities. We become lost in the immediate concerns of medical school, obtaining a good residency, a fellowship, and, finally, landing that first faculty position as an academic neurologist. And a faculty position only represents a new beginning with new struggles and new needs: becoming a truly outstanding physician, an effective teacher, and creative researcher while simultaneously obtaining funding, building collaborations, and running internal programs. Many of us do much good in these roles. For dedicated clinicians and educators, this could mean helping care for many patients and training future generations of neurologists. For clinical researchers, it can mean helping advance new therapies for challenging neurological diseases, and, for basic researchers, perhaps disentangling complex disease mechanisms or developing new understanding of brain connectivity. On reflection, in all this work, we may have a less than global impact. We certainly might help Americans and others living in our country, and also some in high-income, well-resourced countries in Europe, Asia, and the Pacific. Unsurprisingly, however, much of the Global North and South, with low- or middle-incomes, is overlooked and not directly impacted by our efforts. But there are a few committed American neurologists who are forging a very different path. These are people who have seen a need for processes that extend beyond providing the newest designer pharmaceuticals and procedures to only those living in the wealthiest countries. These are people who understand that to create improved neurological care and achieve full implementation of our tripartite mission of academic neurology—patient care, education, and research—and for our entire global community to benefit, it requires “boots on the ground” far from the United States. These are people who recognize that establishing such outposts, while staying connected to academic neurology at home, offers the possibility of doing good at global scale. In January of 2023, a small group of senior American neurologists along with leaders from the National Institutes of Health and its Fogarty International Center were invited to witness first-hand one of those outposts: the University Teaching Hospital in Lusaka, Zambia (Fig. 1). They had been invited by the University Teaching Hospital's administration where a small but committed group of American neurologists, including David Bearden, Gretchen Birbeck, and Michelle Kvalsund (University of Rochester), Archana Patel (Boston Children's Hospital), Deanna Saylor (Johns Hopkins), and Omar Siddiqi (Beth Israel Deaconess Medical Center), have, for the past decade, chosen the unusual career path of pursuing an academic neurological career nearly 8,000 miles away from their homeland. It is safe to say that none of the visiting contingent were fully prepared for what greeted them. The meeting commenced with a full day of research presentations (see supplementary material for full listing), revealing the breadth and depth of the research being pursued in Zambia, including the following areas: understanding and preventing long-term complications of cerebral malaria in children (e.g., by aggressive fever prophylaxis), improving stroke outcomes by more aggressive fluid management, understanding the mechanisms of tuberculous meningitis by novel minimally invasive post-mortem sample approaches, and surveying the distribution of nutritional polyneuropathies. The scope of research being undertaken by this group of neurologists, each having come to Zambia with a commitment to make a difference, was truly remarkable, and even more so because the work included, and was often led, by past or present Zambian neurology trainees. Critically, much of this work was being supported by American taxpayers through competitive NIH grants. So while many of us academic researchers think of NIH as supporting mostly American health, the NIH, and NINDS in particular, has actually been thinking at a grander scale, and supporting these intrepid individuals, while helping advance the care of the residents of this sub-Saharan country. The National Institute of Neurological Diseases and Stroke is, in fact, international in its purview and impact. But the research was only one part of the story. A major effort of these American neurologists has been to create the infrastructure for a self-supporting, freestanding neurological training program in Zambia, “capacity-building” in NIH parlance. Prior to the establishment of this training program, there were only 4 neurologists for a country of 20 million people. None had been trained in Zambia. This infrastructure is now in its fifth year and has trained the first generation of Zambian neurologists, including the first seven adult neurologists—Drs. Melody Asukile, Lorraine Chishimba, Mashina Chomba, Moses Mataa, Frighton Mutete, Naluca Mwendaweli, and Stanley Zimba—and first two child neurologists—Drs. Nfwama Kawatu and Lisa Nkole, all of whom are now helping to train their country's own future neurologists going forward (Fig. 2). The program now has a regional presence, establishing Zambia as a hub for neurological training and research, and we witnessed some of the remarkable capabilities of people who had already come through the program—superb neurologists, both adult and pediatric, dedicated to teaching bright and excited residents the intricacies of the clinical examination and pursuing their own research and educational efforts. Where none existed just a few years ago, there is now an established neurology training program with several adult and pediatric neurology residents each year. Impressively, the program also attracts other faculty and trainees from more than 15 US institutions in which they spend time in Lusaka teaching and collaborating in research. We also had the opportunity to observe the final piece of our tripartite mission: patient care. Here, we saw patients with a vast array of maladies, including a 23-year-old woman with Guillain-Barre Syndrome related to recent HIV conversion, despondent that she could not be with her children in a rural community many hours' drive away. A 38-year-old Rwandan refugee without any past medical information except that he was becoming progressively demented. A group of manganese miners all with early onset Parkinsonism. A little girl with a past bout of NMDA-R-antibody-associated encephalitis now with a recurrence, and the occasional more “straightforward” headache, stroke, and refractory epilepsy cases. Local resource limitations mean slow workups, unavailable or unreliable laboratory studies, even as “routine” as CSF WBCs, and all-too-frequently non-working CT scanners, making it impossible to confirm something as critical as whether a stroke is hemorrhagic or ischemic in nature. Despite donations from private foundations, resource limitations also mean a limited and often changing list of medications. These were all people clearly in need, and this group of courageous and thoughtful doctors were trying to help, working around the minefield of resource limitations, to do outstanding neurology. They were also not seeking to take credit for their successes, but rather simply serving as good stewards to help advance care. They were doing this alongside their recently minted Zambian neurological colleagues who have exhibited outstanding dedication of their own by developing practices in the public sector to care for the most vulnerable patients rather than pursuing greater financial gain and shorter working hours in the private sector. There was nothing more heartening to see than the American neurologists working side-by-side their Zambian comrades, staffing clinics and the inpatient wards with the residents. This work extends far outside the University Teaching Hospital to remote areas of Zambia where this team staffs clinics as well, via a telemedicine program (highlighted by BBC World Service TV https://www.bbc.co.uk/programmes/p0dt91rs). The teaching opportunities are also having an impact in nearby countries where some physicians have been coming to Zambia to learn their neurology first-hand. It also extends to areas that are not directly medical—such as Dr. Siddiqi's successful effort to have the broken, unevenly tiled floor in the neurology clinic replaced with a concrete industrial one, ensuring the safety of the many disabled individuals traversing it, and acquiring necessary technologies, such as EMG and bedside ultrasound systems. As leaders in academic neurology, it should be our responsibility to ensure that global neurology receives the attention it deserves. At the departmental level, this means making trainees aware that global neurology is a viable career option available to all who want to commit to this rewarding but difficult work. Specifically, adult and pediatric neurology training programs could offer global neurology electives. Departments could also direct some of their internal philanthropic fundraising efforts directly toward global neurology causes. By highlighting that donors can do good at a global level while still helping an individual department or researcher could provide a compelling incentive for giving. Funds from such efforts could be used to help support resident rotations, dedicated fellowships, and to allow early career investigators to pursue global neurology as an area of work. They could also be used to help support fellows from those countries so that they can work alongside our teams, pursuing research or other health-related work. Showcasing the successes currently being achieved abroad, by inviting grand rounds speakers (either virtually or in person) to talk about their initiatives and work, could provide another valuable opportunity. Through such presentations, we will be able to demonstrate the remarkable need and the endless possibility. Finally, departmental leadership can seek to recruit physicians specifically interested in this area, perhaps ultimately creating divisions of global neurology within their departments. There are also important efforts that should also be pursued beyond the departmental level. For example, at the medical school level, it could mean adding courses and programs on global medicine, perhaps even with lectures specifically focusing on global neurological issues. It might also include advocating for or facilitating interinstitutional agreements between medical schools to promote global equity in medical education, foster cross-cultural exchange and cultural humility, and engage in the symbiotic building of local expertise through cultural immersion and educational innovation. At the national level, this could mean asking our professional societies to support these goals, providing courses, training, advocacy, and sustenance. The ANA and other societies have recognized global neurology as a major focus and have other nascent programs in place. However, more will be needed to achieve a durable impact. Fortunately, NINDS and the Fogarty program have already recognized the importance of this work and are supporting clinical research in Zambia through K career development awards and R awards, beginning 20 years ago with Dr. Birbeck, who paved the way for the entire group of US-based academic neurologists in Zambia. Further expanding programs with specific funding opportunities would be truly valuable. A celebratory dinner was organized at the end of the Zambia visit. As we all stood outside in the warm tropical air under an extended canopy while the season's rains descended, we heard the kind words of appreciation and support from Professor Elliot Kafumukache, Dean for the University of Zambia School of Medicine, Professor Charles Mutemba, Senior Medical Superintendent for the University Teaching Hospital, Elwyn Chomba, the first female physician trained in Zambia who brought neonatal medicine to the country, and the newly minted US Ambassador to Zambia, Michael Gonzales. They all applauded the importance of this mission, the successes already achieved, the strong collaborations and true partnerships built, and the work that still needs to be done. It was an occasion none of us will forget, and the message was clear: The burden of neurological disease is not a “first world problem.” Neurological disease is global and growing. As concerned leaders of American neurology, if we really want to “do good” and have meaningful impact, we must take notice of, participate in, and strongly support and encourage that global effort. No relevant conflicts. Supplementary Material Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.