Neurology goes global

I read with interest the article by Fleisher and Mateen1 on the globalization of neurology and the methods and means by which neurologists from high-income countries (HIC) can contribute to as well as benefit from interaction with their colleagues in low- and middle-income countries (LMIC).

Let us not forget that the globalization of neurology should be 2-way traffic. For neurology to truly go global, it should be practiced without borders in which there is free exchange of ideas, technology, and health care professionals between HIC and LMIC. Sponsoring residents and faculty from LMIC for short (2 months) to long (6 months to a year) neurology electives in HIC is one such neglected need. As things stand at present, the flow is unidirectional, with some neurologists from HIC traveling to LMIC, at times, for medical tourism. In addition, there is a brain drain, with physicians from LMIC moving to HIC for residency and fellowship training. Once their residency is over, they frequently do not return to their country of origin for fear that once they leave there is no way back. With the ongoing US global war on terrorism, the State Department has made it increasingly difficult for professionals from LMIC to travel to the United States for observerships for fear that they may not return or may indulge in antistate acts. These fears to a large extent are unfounded. If the restrictions to their travel are relaxed, physicians and neurologists from LMIC are likely to come to HIC, stay for a short time, gain skills, and return to their home countries, where they can adapt them to meet current unmet needs.

Disclosures

N. Sethi serves as Associate Editor for The Eastern Journal of Medicine.

Mamta Bhushan Singh, MD, DM: The interesting article by Fleisher and Mateen1 supplies insight and suggestions as to how a physician can approach neurology in LMICs and make a significant contribution in the often bleak situation existing in LMICs. I agree with most of their conclusions and, if handled well, both sides win. However, there has to be a departure from approaching global health only from the perspective that the West is the giver while the LMICs are the takers. For this movement to thrive, we have to find a more balanced relationship between the two; we need to explore and enunciate not only the benefits that the LMICs derive but also any advantage or opportunity that is provided to the neurologist who comes from a high-income setting. LMICs, as recognized by the authors, are heterogeneous, and their needs and what they offer to visiting neurologists vary from country to country. Most LMICs provide visiting neurologists an abundance of clinical exposure and learning opportunities for honing their clinical skills, exceeding what they may have in their own countries. For example, a scarcity of investigations and a reluctance to perform expensive tests means that greater reliance is attached to history-taking and clinical examination in India. Several neurology colleagues who have visited All India Institute of Medical Sciences, New Delhi, have been amazed at the variety and numbers of patients who present to this hospital. Overseas trainees have told me that a particular case was the first that they got to see after years of having only read about it. Some of these diseases are not found in the West, and there are others that are rare in the West but fairly common in our population because we are a populous country. Another learning point for visiting neurologists might be the innovative modification of techniques, tools, and therapies in LMICs, which makes providing care more cost-effective while maintaining acceptable standards of care. Global health has a long journey ahead and readjustment in perspective may make it a more rewarding experience for all of us.

All India Institute of Medical Sciences, New Delhi, India.

Disclosures

The author reports no disclosures.

Authors Respond:

Jori E. Fleisher, MD, Farrah J. Mateen, MD, PhD: We thank Drs. Sethi and Singh for their comments on our article1 and agree with their points. Given the space limitations of the article, we narrowed our focus to the unidirectional opportunities for neurologists from HICs traveling to LMICs, as Dr. Sethi points out. However, for patients worldwide to benefit from all that neurologists have to offer—and for neurologists in all settings to learn from such patients and each other—it is critical that bidirectional partnerships be nurtured and “duffle bag medicine”2 be avoided. The American Academy of Neurology offers scholarships for neurologists in LMICs to attend the annual meeting; however, we must look beyond such brief visits to creating sustainable programs for clinical experiences. Such partnerships would not only benefit both the visiting and hosting neurologists, but might help stem the brain drain3 by building long-term relationships and providing a forum for remote consultation and networking once the visitor returns home. While there are numerous contributing factors to brain drain, empowerment of neurologists in LMICs with training in clinical, public health, and health services research while visiting HICs might further establish their value within their communities, reducing the drain.

Dr. Singh notes the many overlooked benefits to visiting neurologists traveling from HICs to LMICs in terms of broadened clinical exposure to rare conditions and innovative techniques and therapies. Such experiences carry over to the provision of care once the visiting neurologists return to their home countries, expanding differential diagnoses and often fostering more cost-effective, patient-centered care without unnecessary overtesting. We second the issues raised by Drs. Singh and Sethi and encourage our colleagues to think broadly about the opportunities for give and take in global neurology.

University of Pennsylvania School of Medicine (JEF), Philadelphia; NYU Langone School of Medicine (JEF), New York, NY; and Massachusetts General Hospital (FJM), Boston.

Disclosures

J. Fleisher has received an unrestricted educational grant from Medtronic and training grant T32-NS-061779 from the NIH. F. Mateen has received funding from the Canadian Institute of Health Research.