Thursday, April 25, 2013

Aaron Berkowitz
PGY-3, Neurology
Travel Grant: Neurology Education in Malawi

After two weeks on the wards of Queen Elizabeth Central Hospital in Blantyre, described in my blog entry below, the last two weeks have taken me to two very different contexts in Malawi.

I spent one week in the capital city of Lilongwe at Malawi’s only medical school. It was the week of the preclinical students’ neurology block.  As the lone neurologist in the country, I was asked to participate by giving lectures on stroke, epilepsy, neuropathy, meningitis/encephalitis, HIV-related neurologic disorders, coma, headache, and interpretation of head CT (which is available in Lilongwe). I also assisted in the evaluation of students’ clinical skills in an examination in which they performed neurologic examinations on patients and presented their findings.

Teaching at the medical school in Lilongwe

In teaching neurology here, I have realized that beyond participating in training non-neurologist physicians who will see a large burden of neurologic disease, a true achievement would be to inspire one (or several) students to train in neurology. I therefore emphasized in my lectures that 80% of the world’s 50 million epilepsy patients and nearly 90% of the world’s stroke deaths are in developing countries, and invited/challenged students to consider becoming the country’s first neurologist(s). The need is enormous- during this brief visit to the capital, I saw 10 patients with primary neurologic disease on the wards of Kamuzu Central Hospital, bringing my total number of consultations to over 40 in just a few short weeks.

The main entrance (left) and one ward (right) at Kamuzu Central Hospital in Lilongwe.

This past week, I traveled to the district hospital of rural Neno, a stark contrast to the cities and the cities’ large tertiary referral hospitals. It is here that Partners in Health/Abwenzi Pa Za Umoyo works with the Malawi Ministry of Health to support the district’s main hospital (about 80 beds) and a number of health centers in the region. One sharp turn off of one of the country’s main highways took us onto unpaved dirt roads shared with ox-drawn carriages.

The road to/through Neno (left) and one of the many villages in the district (right)

One focus of the Partners in Health/Abwenzi Pa Za Umoyo outpatient chronic disease programs is epilepsy. As mentioned above, 80% percent of the world’s epilepsy burden is in the developing world, likely due to increased incidence of CNS infections, head trauma, and perinatal complications. It has been estimated that as many as 90% of patients may be untreated in some regions of the developing world, leading not only to unfortunate morbidity and mortality due to uncontrolled seizures but devastating stigma. Neno is fortunate to have a brilliant clinical officer, Grant Gonani, with training in mental health, who sees both psychiatric and neurologic patients. I spent one morning with him in his mental health clinic learning how he cares for his epilepsy patients and how epilepsy is managed here with the three available medications whose supplies may fluctuate. While in Neno, I also had the chance to give a presentation on seizures/epilepsy care to the clinical officers and nurses, and lead a practical session with the clinical officers on refining their neurologic examination skills.

The district hospital in Neno (left) and the outpatient clinic patient waiting area (right)

My time in Malawi has gone by all too fast, and I am very grateful to have had the chance to learn from diverse settings: the two largest hospitals in the two largest cities, the medical school, and a district health center in a more rural region. The need for neurology here is enormous, and I hope that I can continue to return to learn and teach. In the interim, I hope to continue collaborations and consultations by way of the internet.

I am very grateful to the administrators, medical students, clinical officers, residents, and attendings in Blantyre, Lilongwe, and Neno for so warmly welcoming me to Malawi and for allowing me to participate in the care of their patients and in their educational activities. I look forward to returning soon. I was also fortunate to work with an extraordinary mentor here, Dr. Gretchen Birbeck, one of the pioneers in global neurology. I also again want to thank the Partners Global Health Travel Grant and Partners Neurology Residency staff - Vanya Sagar and Silviya Eaton - and program leadership - Dr. Tracey Milligan, Dr. Tracey Cho, and Dr. Martin Samuels- for supporting this work.

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