By Dr. Deanna Saylor
Zambia has the world’s sixth-highest prevalence of HIV. And HIV/AIDS — often associated with neurological effects — continues to be the No. 1 cause of death in this southern African nation. Many of Zambia’s other top causes of death — malaria (No. 2), stroke (No. 5), meningitis (No. 7) and syphilis (No. 9) — are either primary neurological conditions or commonly associated with neurological complications.
Like many low-income countries, Zambia’s health system is overburdened and understaffed. There are 800 doctors in the entire country, less than half of the estimated number of physicians required to care for its population of 17 million. Furthermore, there are only four practicing neurologists in Zambia — none are native Zambian, and all are located in the capital city of Lusaka. As a result, Zambians with neurological disorders have comparatively high rates of morbidity and mortality.
Additionally, until very recently, the nation had no system of inpatient neurological care, and no one had primary responsibility for improving neurological education at the undergraduate or post-graduate level.
Thankfully, this is changing. As a neuroinfectious diseases fellow at Johns Hopkins, I met Dr. Omar Siddiqi of the Harvard Beth Israel Deaconess Medical Center at the American Academy of Neurology’s 2014 annual meeting. He shared his vision for developing a neurology post-graduate training program in Zambia, and I enthusiastically joined the project.
Over the next two years, I wrote the curriculum for a residency training program, and then I received a Fulbright Scholar Award from the U.S. Department of State to spend two years in Zambia launching the program.
My family and I arrived in Zambia in January 2018, and I immediately set to work in the University of Zambia School of Medicine’s teaching hospital. Before my arrival, inpatients with neurological disorders received care in internal medicine wards without specialized neurology input.
By May, we had begun the first neurologist-led inpatient neurology service in Zambia at the University Teaching Hospital, with the help of internal medicine post-graduate trainees. And by October, three adult neurology and two pediatric neurology post-graduate trainees officially joined our ranks.
While a lot still lies ahead, I already have learned so much.
First and foremost, I consistently feel honored to train a new generation of neurologists. Our five trainees will be building systems of care, bringing innovative neurological treatment modalities to Zambia, and then leading and sustaining our training program.
Second, developing a neurology training program and inpatient service in this setting has been challenging largely due to personnel shortages. In many sub-Saharan African countries, foreign-trained local neurologists provide the driving force to sustain fledgling neurology training programs. In Zambia, we rely on expatriate neurologists to volunteer their time and expertise to educate our trainees and care for patients.
Third, designing this program from the ground up provided an important opportunity to challenge the status quo in residency medical education in both Zambia and the United States. Traditional Zambian post-graduate training emphasizes a didactic educational curriculum, while U.S. curriculums focus on integrating bedside teaching.
As a U.S.-trained neurologist designing a program for Zambian trainees, I combined elements from both systems to create a hybrid program that builds upon the strengths of each. We have implemented a creative, blended curriculum based on the most current theories in graduate medical education, which I believe can serve as a model for training programs in both the United States and low-resourced settings.
High Need … and Enthusiasm
Along the way there have also been unexpected challenges and rewards. The greatest challenge, which reinforces the importance of our work, is the sheer number of patients who need our services. On average, we have 40-60 adult patients on our inpatient neurology service at any given time, with 5-6 new admissions each day.
This poses a challenge because we have only one attending neurologist (me) and three residents to care for these patients. It is difficult to strike the balance between providing all patients with access to a high level of neurology care and ensuring the residents are learning while they work — not just seeing an endless of stream of patients.
Finally, I have been pleasantly surprised about the “spillover” of enthusiasm for learning neurology from our own trainees to other post-graduate trainees in the Department of Medicine. We have opened our curriculum and seminars to all medical students and post-graduate trainees.
As a result of their high participation, I have already seen a marked improvement in the initial assessment and triage of patients with neurological disorders presenting to the emergency room. Clinicians there are anticipating complications of stroke and managing neurological emergencies more effectively. These improvements are happening among not only our neurology trainees but all trainees. Raising the general knowledge and ability to manage common neurological conditions among internal medicine physicians may be one of the most important benefits of this program.
It will take many years of training new neurologists before Zambia can meet the local population’s needs. In the interim, non-neurologist health workers will continue to provide the bulk of neurological care. As such, improving their neurology training will be just as important as training neurologists.
As I reflect on my first year in Zambia, I’m honored to have worked with wonderful colleagues, especially the five neurology trainees. Mostly, I am filled with overwhelming pride in what we have accomplished — while still being aware of the substantial work that remains.
Recently I watched one of our trainees deftly assess an unconscious patient and detect subtle signs of non-convulsive epileptic seizure. As we walked away from the patient’s bedside, the trainee looked at me and said, “Wow, I feel like I’m actually becoming a neurologist.” I responded, “You definitely are, and, because of you, the future of neurology in Zambia is brighter today.”
Dr. Deanna Saylor is co-director of Johns Hopkins Global Neurology Program and a neuro-infectious diseases and neuroimmunology specialist with special interest in the neurological complications of HIV infection. Her clinical interests include infectious and inflammatory diseases of the brain and spinal cord, including multiple sclerosis and encephalitis. Dr. Saylor’s research interests include better understanding the neurologic disease burden in resource-limited settings, improving neurological education of both neurologists and non-neurologists in resource-limited settings, and improving the care of patients with neurological disorders worldwide. She has ongoing research collaborations in Uganda and Zambia and previously lived and worked in Kenya.