GLOBAL NEUROLOGY REPORT: WORLD ASSOCIATION FOR MEDICAL LAW CONFERENCE

World Association for Medical Law (WAML) Congress

World Association for Medical Law (WAML) Congress

The 50th Anniversary Meeting and 23rd World Association for Medical Law (WAML) Congress was held on 9-14 July 2017 in Baku, Azerbaijan.  Leading international experts from around the globe discussed topics related to GlobalHealth, Medical Law and Bioethics.

Drs. James C. Johnston, Mehila Zebenigus and Guta Zenebe presented recommendations for improving relations between developed and developing countries through guidelines that focus on ethically advancing collaborative partnerships to improve health care. This topic followed Dr. Johnston’s lecture last year at the WAML meeting in Los Angeles, USA discussing the medical, ethical and legal problems that arise when Western countries engage in short term medical missions to resource limited nations, resulting in medical paternalism, doctor tourism and actual harm to the very patients that are most desperate for help.  Specific examples of these problems were presented at both meetings, along with clear guidelines on how to avoid the harmful effects of these self-serving missions.

Drs. James C. Johnston and Mehila Zebenigus also discussed concerns related to neuroimaging for the patient presenting with headache. They recommended deleting the currently used guidelines because those guidelines are outdated, and have been a contributing factor in the continuing misdiagnosis of headache disorders.  Dr. Zebenigus discussed the management of the patient with headache in Ethiopia.

Drs. Thomas P. Sartwelle, James C. Johnston, Berna Arda and Mehila Zebenigus highlighted the concerns related to using electronic fetal monitoring in sub-Saharan Africa, how that procedure causes more harm than good, and wastes scarce resources that would be better used helping children with cerebral palsy.

In terms of disclosure, Drs. Zebenigus and Johnston are Directors of the non-profit organization Global NeuroCare® which focuses on advancing neurological services in sub-Saharan Africa and particularly Ethiopia, and is actively involved in all of these areas.

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GLOBAL NEUROLOGY REPORT: TRIANGULAR COOPERATION

Dr. James C Johnston

Triangular Cooperation | Dr. James C Johnston

Global NeuroCare is a non-profit organization dedicated to advancing neurological care in developing regions, especially sub-Saharan Africa and particularly Ethiopia.  It is one of the few non-government organizations to hold Special Consultative Status with the United Nations ECOSOC, which allows Director and Neurologist Dr. James C. Johnston to actively participate with the UN intergovernmental bodies, decision makers and related organizations.  Additionally, Global NeuroCare is accredited by the World Health Organization, and affiliated with the Office of the Special Adviser on Africa.

On behalf of Global NeuroCare, Dr. Johnston presented several statements over the past few years to the UN High Level Political Forum, the Commission for Social Development and the Integration Segment.  Four of these statements have been adopted and published, focusing on advancing collaborative partnerships between the North and South in an effort to improve healthcare in Africa.

Dr. Johnston emphasized the importance of ensuring that relationships between the North or developed countries and the South are based on sustainable, collaborative, ethically congruent partnerships that truly benefit the South, as opposed to the short term medical missions that are so harmful to developing regions.  Successful partnerships will allow sub-Saharan African nations to develop functional capacity building, thereby becoming self-sustainable, further advancing patient care, physician training and medical research.

These types of North-South partnerships can be even more effective by encouraging South-South and triangular cooperation.  South-South cooperation is the process whereby two or more developing countries pursue individual or shared objectives through exchanges of knowledge, skills and resources.  This is not a substitute for, but rather a complement to North-South partnerships.  In triangular cooperation, partnerships between two or more developing nations are supported by a developed country or even multinational organizations.

For example, Global NeuroCare focuses on advancing neurology in Ethiopia where Dr. Johnston serves as an Honorary Professor of Neurology in the Addis Ababa University Department of Neurology Residency Training Program.  This program has graduated 32 board certified neurologists over the past decade.  However, there are no local opportunities for advanced neurophysiology training, so Dr. Johnston arranges for the resident physicians to attend the University of Siena, Italy for 6 month fellowships.  This requires separate funding which has been provided through scholarships sponsored by a Canadian based neurophysiology society.  Thus Global NeuroCare coordinates Ethiopian training through Italy with financial support from Canada and, in turn, as an example of South-South cooperation, the Ethiopian physicians return to train their colleagues as well as physicians from other African nations.

Global NeuroCare plays a crucial role in coordinating this type of triangular coordination, which is the most effective means of ensuring sustainable capacity building leading to self-sufficiency that will truly advance healthcare in sub-Saharan Africa.

Global Neurology Report: Medical Training in Ethiopia

Addis Ababa University

Africa suffers one-quarter of the global burden of disease, yet has only 3% of the world’s healthcare workers. It consumes less than 1% of the world’s healthcare expenditure. And the continent’s population of one billion people is set to double in the next generation.

The situation is even more disconcerting in the least developed nations such as Ethiopia, which is perhaps the most medically underserved country in the world. A recent World Bank Study reported there were just over 2,000 doctors for the country of 100 million people. This is a dismal situation that warrants increased international support.

There is some recent improvement with an increasing number of medical schools – in 2006 there were four medical schools, and now there are over 30 training centers that will begin graduating 2,000 physicians annually. Additionally, Ethiopia trained 38,000 healthcare extension workers to provide basic health education and services in the rural areas where 85% of the population resides.

However, there remain very serious impediments to advancing healthcare in Ethiopia and the other least developed countries – poor infrastructure, inadequate transportation, lack of equipment and medications, limited geographical distribution of services, and a continuing dearth of specialists.

External support is critical to further advance healthcare and specialist services in these regions, but it must be the right type of help. Unfortunately, many United States academic medical centers have focused on self-serving short term medical missions which can and do cause harm to the very regions that so desperately need help. These types of missions are lucrative and beneficial to the sending institution, but do not provide any substantive benefit to the developing country.

Neurologist Dr. James C. Johnston discussed these concerns at the United Nations High Level Political Forums in 2016 and 2017, and at the World Association for Medical Law Congress Meetings in Los Angeles (2016) and Baku, Azerbaijan (2017). He recommended focusing on a sustainable, comprehensive, ethically congruent approach to partnerships with a focus on advancing patient care, physician training and medical research to benefit the South.

Global NeuroCare is a 501(c)(3) non-profit organization founded by Dr. Johnston to advance neurological services in developing nations, particularly Ethiopia, and strictly adheres to these principles of sustainable partnerships dedicated to capacity building. Dr. Johnston is an Honorary Professor of Neurology at Addis Ababa University in Ethiopia, where the Department of Neurology has graduated 32 board-certified neurologists over the past decade, with 21 more physicians in the expanding three year training program. These neurologists have improved the lives of countless thousands of Ethiopians, and are now training physicians from other African countries.

Continued support of neurological training is crucial, especially since the World Health Organization reported that neurological diseases are one of the greatest threats to global public health. Please go to www.GlobalNeuroCare.org to contribute your support which will have an immediate impact on the lives of many of the world’s most vulnerable people. This registered tax-exempt non-profit organization does not use any of the funds for administrative expenses or salaries – every penny goes to the people in need.

Global Neurology Report: The WHO ‘Neurology Atlas’ Second Edition

Emergency Room in Ethiopia

The World Health Organization (WHO) published the first comprehensive report (Neurology Atlas) on the
status of neurological care and services throughout the world over a decade ago. This compilation provided a
unique and invaluable source of data on the rapidly increasing burden of neurological disorders, and the available neurological services in 109 countries. It highlighted the large disparities between neurological care in the developed and developing nations, and provided critical information for medical specialists, healthcare planners, policy makers and national training programs. This Atlas provided the first detailed picture of the global situation for neurology, and the updated second edition was released in September 2017. It may be accessed here (http://apps.who.int/iris/bitstream/10665/258947/1/9789241565509-eng.pdf).

This updated Atlas reviewed 132 countries comprising 94% of the world’s population and the data will continue to be helpful to policy makers, although the findings were not surprising and may be summarized as follows:

(1) Neurological disorders are a significant cause of the global disease burden, which was thoroughly addressed in the Global Burden of Disease studies.

(2) Neurological disorders are disproportionately high in developing regions, which are also plagued by resource limitations and severe shortages of healthcare workers.

(3) Neurological conditions are expected to grow exponentially in the future.

The Atlas report focused on several key areas including legislation for neurological disorders, financing of neurological services, social welfare support, workforce data, available neurological services and informational gathering systems. As expected, sub-Saharan Africa fared the worst, with the lowest proportion of healthcare workers, the most limited services and poorest geographical distribution of those services. There were 0.04 neurologists per 100,000 people in the WHO African region, compared to 4.75 per 100,000 people in high income countries.

In Ethiopia, for example, where Dr. James C. Johnston serves as an Honorary Professor of Neurology with the Addis Ababa University neurology residency training program, there is one neurologist for every 3-4,000,000 people, and most of those neurologists are in the capital city Addis Ababa. This ratio, although exceedingly poor compared to the WHO recommendation of at least one neurologist for every 25,000 – 100,000 people, represents a significant improvement since before inception of the program in 2006 when there was one full time neurologist for the one hundred million people in the country.

Dr. Johnston established the non-profit organization Global NeuroCare (www.GlobalNeuroCare.org) to advance neurological services in developing regions. Global NeuroCare holds Special Consultative Status with the United Nations ECOSOC and fully supports the self-sufficient, sustainable Ethiopian neurology residency program. This program has made a significant and measurable difference in the Horn of Africa, graduating 32 board certified neurologists with 21 more physicians in the three year training, improving the lives of tens of thousands of people.

On behalf of Global NeuroCare, Dr. Johnston discussed the healthcare concerns affecting developing nations at the 2016 and 2017 United Nations High Level Political Forums, the 2017 United Nations Commission for Social Development, and at the World Association for Medical Law conferences in Los Angeles (2016) and Baku (2017). One of the main concerns impeding development stems from academic medical centers with global health programs that engage in short term medical missions which are tantamount to doctor tourism, fail to provide any substantive benefit to the developing nations, and cause more harm than good. He presented guidelines to improve sustainable, ethically congruent, collaborative partnerships focused on capacity building to advance neurological services in sub-Saharan Africa, using Global NeuroCare’s focus on Ethiopia as a model plan.

Global Neurology Report: Access to healthcare in Africa

Gondar Outpatient Waiting

Gondar Outpatient Waiting

The Economist Intelligence Unit recently published a report on access to healthcare in Africa and the Middle East. (www.accesstohealthcare.eiu.com). The report recognized the complex challenges of improving access to healthcare in sub-Saharan Africa, a region plagued by the ‘double burden’ of ongoing communicable diseases and rapidly increasing non-communicable disorders. These problems are compounded by a severe shortage of healthcare workers, poor infrastructure, limited transportation, and a dearth of supplies, equipment and medications.

The Economist Intelligence Unit Index ranked the countries on both (1) accessibility for most disease categories and access to medications, and (2) the healthcare system including coverage, infrastructure, efficiency and innovation. The Index evaluated progress considering current global policy agendas, such as the UN Sustainable Development Goals. It also adopted a forward-looking approach, asking whether each country is implementing the right mechanisms today for optimal access in the future.

Ethiopia ranked at the bottom in a cluster of other sub-Saharan countries. These least developed countries struggle with additional challenges such as underdeveloped supply chains for medications, a significant urban-rural gap in access and, most importantly, a continuing shortage of healthcare workers.

The increasing incidence of non-communicable diseases including neurological disorders is exacerbating poverty and significantly adding to the disease burden. The EIU reports that financial expenses of healthcare drive 11 million Africans into poverty every year. But, as Drs. James C. Johnston and Mehila Zebenigus discussed at the July 2017 United Nations High Level Political Forum, the situation is magnified by neurological disorders which afflict tens of millions of people, typically the young, causing cognitive impairment and physical disability, leading to loss of employment, marginalization, increased vulnerability and exclusion, contributing to a profound impact on the economy.

This EIU Report raises several suggestions for improvement including national health insurance, mobile technology applications, artificial intelligence platforms and focusing on specific disease threats. However, while these proposals may be beneficial if enacted, they do not address the key problem – a shortage of healthcare workers.

Drs. James C. Johnston and Mehila Zebenigus discussed these concerns at the 2017 World Association for Medical Law (WAML) conference and, while recognizing the many overwhelming challenges, recommended focusing on the root of the problem – the shortage of physicians and other healthcare workers. Africa has one-quarter of the global burden of disease but less than 3% of the world’s healthcare workers. The only way to ensure sustainable improvement if to ethically advance collaborative partnerships between developed countries and the least developed regions, with clearly defined goals, focusing on the needs of the South to establish self-sustaining programs that incorporate training, patient care and research, and provide triangular cooperation to improve South-South relations.

This focus on collaborative partnerships is the approach Global NeuroCare has adopted in working with the Addis Ababa University Department of Neurology, and that autonomous program has been extraordinarily successful, soon entering the 12 th year, having graduated 32 board certified neurologists, with 21 more physicians in the three-year training program.

Drs. Zebenigus and Johnston serve as Directors of the non-profit organization GlobalNeuroCare.org and will discuss guidelines for developing sustainable collaborative partnerships at future meetings with the UN, WAML and other organizations.