Capacity Building in Pediatric Critical Care-Global Health Research and Education: The Blantyre Experience

ABSTRACT.

Pediatric critical care medicine (PCCM), as it is practiced in high-income countries, is focused on specialized medical care for the most vulnerable pediatric patient populations. However, best practices for provision of that care globally are lacking. Thus, PCCM research and education programming can potentially fill significant knowledge gaps by facilitating the development of evidence-based clinical guidelines that reduce child mortality on a global scale. Malaria remains a leading cause of pediatric mortality worldwide. The Blantyre Malaria Project (BMP) is a research and clinical care collaborative that has focused on reducing the public health burden of pediatric cerebral malaria in Malawi since 1986. In 2017, the requirements of a new research study led to the creation of PCCM services in Blantyre, creating the opportunity to establish a PCCM-Global Health Research Fellowship by BMP in collaboration with the University of Maryland School of Medicine. In this perspective piece, we reflect on the evolution of the PCCM-Global Health research fellowship. Although the specifics of this fellowship are out of the scope of this perspective, we discuss the context allowing for the development of this program and explore some early lessons learned to consider for future capacity-building efforts in the future of PCCM-Global Health research.

INTRODUCTION

Despite overall reductions in pediatric mortality, ∼5.2 million children under 5 years died of preventable causes in 2019.¹ Over 75% of these deaths occurred in low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia, where only half of the population of children in this age group reside.² These disproportionately higher rates of childhood mortality are attributable to income disparities, limited healthcare access, and persistently disadvantaging socioeconomic structures.^3–7

Pediatric Critical Care Medicine (PCCM) is a specialty aimed at directly reducing childhood mortality. Its practice requires complex and expensive equipment, specialized around-the-clock staffing, rapid diagnostics, and advanced therapeutics that are challenging to replicate in low-resource settings where the needs are greatest.⁸ Recent trends in global health emphasize solutions that are sustainable and focus on capacity building, relying on “transformation that is generated and sustained over time from within.”^9–15 Specifically in pediatrics, a focus on public health, education, and research is vital. It is critical to align priorities with national health goals; partner with local leadership; invest in technologies, equipment, and advanced training and personnel; and engage stakeholders and policymakers. As an example of local efforts to move toward these long-term goals, we report and reflect on efforts designed to build research and training capacity in Blantyre, Malawi.

The Blantyre Malaria Project (BMP): background and context.

The Pediatric Research Ward (PRW) at the Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, was established in 1986 when the Malawi Ministry of Health (MOH) identified severe malarial disease in children as its top research priority.¹⁶ It is the site for clinical care of critically ill children with pediatric cerebral malaria (CM) who are eligible for research investigations. Research, clinical care, education, and capacity-building activities in the PRW occur under two research affiliates: the Blantyre Malaria Project (BMP) and the Malawi/Liverpool/Wellcome Trust Clinical Research Program, both of which are integrated into the Kamuzu University of Health Sciences.¹⁶

The PRW contains six beds and houses specialized diagnostic equipment, including magnetic resonance imaging (MRI), electroencephalography, and transcranial doppler.¹⁶ Research has led to meaningful progress in CM, including the creation and standardization of the Blantyre Coma Score, a measure of level of consciousness (now used across Africa), and the recognition that diffuse brain swelling on MRI is strongly associated with mortality in CM.^17,18 Blantyre Malaria Project’s work has attracted researchers and funding worldwide, improved access to specialized clinical care for pediatric CM patients, and enhanced local healthcare provider skill sets (e.g., indirect ophthalmoscopy, detailed neurological examinations).

Blantyre Malaria Project supports the larger Malawian healthcare system by providing access to research diagnostics (e.g., MRI, electroencephalography) to all clinicians working at QECH. Beds are available in the PRW for critically ill patients without CM when the pediatric intensive care unit (PICU) or high dependency unit (HDU) is full. Within the PICU, BMP’s research efforts have provided instruments (e.g., mobile X-ray, blood gas analysis), funding for staffing two PICU beds, and training in management of neurological emergencies for Malawian nurses and physicians. Outside of QECH, BMP staff provide outreach work to regional health centers, teaching the management of children with severe malaria and facilitating referral of critically ill patients to the PRW. More than 80 Malawians are employed by BMP. A full report of BMP’s activities since its founding is outside the scope of this paper.

The PCCM–Global Health Research Fellowship.

The Mercy James Center for Pediatric Surgery and Intensive Care (MJC) was founded in 2017 and is the site of Malawi’s first PICU. Support for MJC came from Raising Malawi, a non-governmental organization, and the MOH. The opening of this PICU allowed BMP to leverage funding from a phase III clinical trial, “Treating Brain Swelling in Pediatric Cerebral Malaria” (TBS, U01 AI126610, NCT03300648), to fund two research beds in the MJC PICU and a yearlong PCCM research fellowship.¹⁹ Blantyre Malaria Project worked with PCCM collaborators at the University of Maryland and Washington University in St. Louis to design this unique training program. A pending publication following the end of phase 1 of this program will highlight the details of the specific development of the educational program. The basics of the program are summarized below.

The fellowship seeks to expand access to mentored global health research opportunities for pediatric intensivists. Participants are required to have completed formal training in PCCM and to be actively practicing physicians in their home countries. Applicants are sought worldwide, with advertisements placed within international pediatric critical care societies, including the World Federation of Pediatric Intensive and Critical Care Societies and Pediatric Acute Lung Injury and Sepsis Investigators Global Health Group. The fellowship enrolled its first two fellows in 2017 with the intention to matriculate two fellows per year for the duration of the TBS clinical trial. Participants have come from diverse clinical backgrounds (e.g., cardiac critical care, mixed units, mid-career versus newly graduated) and countries of origin (including Nicaragua, Mexico, Canada, United States, United Kingdom).

Briefly, the first half of the fellowship is spent completing global health–focused didactics and designing an independent research project related to the active clinical studies occurring in Blantyre through the BMP. Example fellow projects include describing the incidence of multi-organ failure in CM and the concept of brain death in LMICs.^20,21 Fellows have presented their work at international meetings and have published in peer-reviewed journals, and many have joined teaching divisions in PCCM in their home countries. Half of the graduates continue to collaborate with BMP. The second block of the curriculum takes place on site in Blantyre, Malawi, during peak malaria transmission season (January–June). During this time, fellows provide all clinical care for CM research patients in the PICU. They also work with Malawian pediatrics residents and medical students in the care of non-malaria critically ill patients in the PICU and HDU.

Challenges.

Despite wide advertisement through international pediatric critical care professional societies, including Africa-specific groups like the Critical Care Society of Southern Africa, no African pediatric intensivists have completed the program. We suspect this may be due to the relative scarcity of pediatric intensivists in Africa, the limited protected time for research, and the high clinical demands at home institutions. Further, compensation for research careers in LMICs is generally significantly less than clinical careers when compared with high income countries (HICs), making it a difficult choice to pursue research full time. At the time of publication of this paper, there are only two training programs in PCCM in sub-Saharan Africa (South Africa and Kenya), compared with over 75 in the United States alone, explaining the limited supply of African intensivists. As more PICUs are established, we expect the number of African PCCM fellowships to increase, amplifying the growth of PCCM on the continent. Specific to Malawi, the PICU at MJC is new, and at the time of the fellowship’s creation, there were no pediatric intensivists in Blantyre.

The research agenda of the BMP was derived from MOH goals, which align with the goals of their HIC-based funding agencies; however, this may not always be the case in other global health research settings, highlighting a major limitation of this model of work. Funding for this clinical trial and, subsequently, the research fellowship comes from the National Institutes of Health in the United States, which may lead to a power imbalance to direct the focus of research questions, indirectly altering capacity building priorities. Blantyre Malaria Project’s research activities have minor financial support from the MOH, but unfortunately, local financial resources cannot independently support the entire scope of BMP’s activities, limiting sustainability. Additionally, it has been challenging to balance the need for academic visibility to support grant applications while maintaining an active dialogue and engagement with the local medical community when making decisions about authorship and where to publish data obtained through BMP’s research work.

To address these limitations, recruitment efforts have continued to explore all avenues to continue to have a diverse workforce within BMP. Engagement of the local medical community, particularly in pediatrics, has been key and is an area that continues to be developed. Interaction with the local medical societies and journals has been prioritized, and all grant applications contain a separate budget for open access publication fees. Efforts are made to advance trainees by way of educational grants and travel grants to networking meetings. Open dialogue is maintained with MOH contacts to ensure continued governmental engagement in this research area.

As BMP surpasses 35 years of work, the mission remains the same: to decrease the burden of malaria. Future project goals include fostering the careers of Malawian investigators via training grants, assisting with local grant submissions, and providing on-the-job and formal training, including possible educational exchanges.

CONCLUSION

Effective pediatric critical care is integral to achieving the goals set forth by the international community toward reducing pediatric mortality. Due to significant disparity in resources between LMICs and HICs, successfully providing high-quality, evidence-based care is dependent on context-specific research development. This educational and research endeavor was developed to provide basic research tools to motivated pediatric intensivists who would then go forth and develop their own research programs, making up a small contribution toward reducing the inequities of research opportunities in PCCM, focusing on locally prioritized research agendas, an inclusive publication model, and the development and maintenance of bidirectional collegial exchange.