Neurological Care in Developing Countries

Founder of non-profit NGO Global NeuroCare®, Neurologist James C. Johnston, MD, JD has dedicated significant time and resources to improving neurological care in some of the least developed regions in the world.

Dr. James C. Johnston focuses the NGO on sub-Saharan Africa (SSA), a region plagued by the ‘triple burden’ of ongoing communicable diseases, rapidly increasing non-communicable disorders such as cancer, stroke and heart disease, and escalating problems directly attributable to globalization including increased accidents, climate related health issues, and most notably, the current SARS-CoV-2 pandemic (also known as COVID-19 or the Wuhan virus).

The most significant factor beyond the current pandemic adding to the overall disease burden in SSA is the increasing incidence of non-communicable disorders. Ethiopian neurologist Dr. Mehila Zebenigus and Dr. James C. Johnston discussed these non-communicable disorders at the United Nations High Level Political Forum and last World Association for Medical Law conference, focusing on the neurological diseases 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. The Global Burden of Disease Study underscored the fact that these neurological disorders are the main cause of disability worldwide. (Global, regional and national burden of neurological disorders during 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurology 2017.).

There must be improved access to neurological care in SSA in order to manage the increasing incidence of these diseases, which mandates addressing extraordinarily complex challenges such as a severe shortage of healthcare workers, poor infrastructure, limited transportation, and a dearth of supplies, equipment and medications, all compounded by abject poverty with food and water insecurity.

Global NeuroCare® focuses on improving healthcare access by establishing collaborative partnerships to increase the number of neurologists in SSA, and has worked with the Addis Ababa University Department of Neurology for the past fifteen years. This autonomous training program has been extraordinarily successful, having graduated over fifty board certified neurologists since inception in 2006. These neurologists not only see tens of thousands of patients but more importantly they train the general physicians to manage some of the common neurological conditions such as stroke, epilepsy and neuropathy. This teaching is an essential means of improving care in SSA, where it is unlikely there will ever be enough neurologists to meet the burden of disease.

Drs. Zebenigus and Johnston will attend the upcoming UN Forum to discuss the importance of maintaining collaborative partnerships, and caution against withdrawing, limiting or redirecting resources from ongoing programs to address the pandemic, as this would lead to increased morbidity and mortality from neurological diseases.

Advancing Neurology in Africa

A neurologist and attorney, James C. Johnston, MD, JD, is the founder of Global NeuroCare, a nongovernment organization (NGO). Global NeuroCare was established by Dr. James C. Johnston to improve neurological services in developing regions. Dr. Johnston and one of his Ethiopian colleagues Dr. Mehila Zebenigus, serve as Directors of this organization.

Holding Special Consultative Status with the United Nations ECOSOC, the highest status granted to an NGO by the UN, Global NeuroCare has engaged in a long-term collaborative partnership with Addis Abada University Department of Neurology to advance the training of physicians in Ethiopia. The Neurology Residency Training Program has been an outstanding success, substantially increasing the number of practicing neurologists in the country, leading to the treatment of more patients. These neurologists are also teaching a new generation of doctors to manage common neurological problems which represents the most effective was to improve healthcare in regions with a severe shortage of doctors and other healthcare providers.

On behalf of Global NeuroCare, Dr. Johnston and one of his Ethiopian colleagues Dr. Mehila Zebenigus have discussed the medical, ethical and legal aspects of advancing healthcare in developing regions at several meetings over the recent years including the United Nations High Level Political Forums, World Congresses for Medical Law and American Academy of Neurology conferences. They have highlighted the serious concerns of short term medical missions which fail to provide any substantive benefit to the host nation, and may cause significant harm to the local population. An additional concern is that developing nations have inherently vulnerable populations that may be intentionally or unintentionally exploited by these types of brief self-serving medical missions.

Drs. Zebenigus and Johnston presented the Ethiopian model to demonstrate that effective capacity development requires increasing the recruitment, training and retention of medical staff, which mandates stable long-term collaborative North-South partnerships focused on establishing local training programs, staffed by local physicians, to address the particular local community needs. They recently published a white paper for the UN on this topic, and will be present those recommendations at the 26th Congress Meeting of the World Association for Medical Law.

NON-COMMUNICABLE DISEASES: A GLOBAL HEALTH THREAT

World Association for Medical Law Congress in Tokyo on 6-8 August 2019.     

Non-communicable diseases (such as heart disease, stroke, cancer, diabetes) are collectively responsible for 7 out of 10 deaths in the world, 41 million people every year.  Many of these people die prematurely and the vast majority of these deaths are in the low income countries.  The World Health Organization considers non-communicable diseases to be one of the top ten global health threats.

The situation is even worse in the least developed nations that are facing a triple burden on ongoing infectious diseases, rapidly increasing non-communicable disease and the effects of globalization including accidents and injuries, compounded by a dearth of healthcare workers.

Neurologist and Attorney James C. Johnston, MD, JD and Neurologist Mehila Zebenigus, MD discussed these concerns at the 2018 United Nations (UN) High Level Political Forum in New York and provided specific recommendations for improving healthcare access in the least developed nations, particularly sub-Saharan Africa.

On behalf of Global NeuroCare® Drs. Johnston and Zebenigus published a written statement on improving healthcare as a strategy for poverty reduction at the UN 56^th Commission for Social Development with specific recommendations for Member States to improve healthcare access.  Global NeuroCare® is a non-profit organization holding Special Consultative Status with the United Nations ECOSOC.  This allows Drs. Johnston and Zebenigus, as Directors of the NGO, to provide expert analysis on issues related to global health, make written and oral recommendation statements, and serve as UN Delegates at the United Nations sessions in New York, Geneva and Vienna.

Drs. James C. Johnston and Mehila Zebenigus reviewed their recommendations for improving healthcare in developing regions with leading international experts from over 40 countries at the 24^th World Association for Medical Law Congress in Tel Aviv, Israel.  The WAML, in conjunction with the Israeli Ministry of Health and Tel Aviv University honored Dr. Johnston with the Inaugural Davies Award in Public Health.  Dr. Johnston dedicated the award to the Addis Ababa University Department of Neurology and donated the funds to Global NeuroCare.®

Drs. Johnston and Zebenigus have published another statement for the 57^th Session of the UN Commission for Social Development addressing inequalities and challenges to social inclusion through advancing healthcare strategies.

They will also present these recommendations to the 25^th  World Association for Medical Law Congress in Tokyo on 6-8 August 2019.

Medical Error: Third Leading Cause of Death in the United States

Medical Error Third Leading Cause of Death in the United States

Role of Evidence-Based Guidelines in Medical Malpractice

Medical errors rank behind heart disease and cancer as the third leading cause of death in the United States (see BMJ 2016; 353:i2139), with over 250,000 deaths a year.  700 a day.  And despite tort reform, medical malpractice litigation will never entirely disappear.  It remains important for physicians to understand the elements of a malpractice claim not only to protect themselves but more importantly to improve patient care.

The most confusing aspect of a medical malpractice claim is the standard of care element, and this is further complicated by the increasing use of evidence-based guidelines (EBG) or practice guidelines.  In some countries, EBG provide the legal standard of care, while most common law countries such as UK, Australia and New Zealand place great reliance on guidelines but allow courts discretion in accepting them on a case by case basis.

In the United States, most courts allow testimony using EBG both for and against physicians.  Whether a particular guideline applies to a specific case is simply another argument for the expert witnesses with the jury deciding who to believe.  In most cases, the actual written EBG may not be admissible as an exhibit.  It would fall into the same category as learned treatises and medical journals – the witness can talk about it and be cross-examined, but the document itself is not admissible.  Some courts have adopted a more liberal approach by admitting EBG as demonstrative aids.  Regardless of which approach, a physician on trial for malpractice must recognize that although EBG are not sacrosanct, any deviation from the guideline represents a very powerful argument to the judge or jury.

Neurologist and Attorney James C. Johnston, MD, JD and renowned medical malpractice attorney Thomas P. Sartwelle published the seminal article on expert witnesses discussing guidelines in the Journal of Child Neurology (http://journals.sagepub.com/doi/abs/10.1177/0883073813479669).

Dr. James C. Johnston is one of the very few neurologists in the world that is also qualified in law, and licensed to practice both professions.  He wrote the comprehensive chapter on advancing a neurology malpractice claim in Preparing and Winning Medical Negligence Cases, Third Edition (http://www.jurispub.com/Neurology-Chapter-11-Preparing-And-Winning-Medical-Negligence-Cases-Third-Edition.html).

He has published a number of journal articles and book chapters on how neurologists can improve patient care and protect themselves from malpractice claims.  These publications include book chapters in multiple editions of the American College of Legal Medicine textbook Legal Medicine and Medical Ethics, the Medical Malpractice Survival Handbook, and the landmark three volume treatise Legal and Forensic Medicine.  Dr. Johnston has published peer-reviewed articles in Neurology Clinics, Journal of Child Neurology, Headache, Medical Law International, Journal of Legal Medicine, Medicine and Law, and a number of other journals.

In a recent Neurologic Clinics, Dr. Johnston published a case studies article highlighting specific neurology claims related to malpractice (https://www.neurologic.theclinics.com/article/S0733-8619(16)30011-1/abstract).  This was co-authored with Thomas P. Sartwelle and leading neurosurgeon Professor Dr. Knut Wester, with the purpose of providing recommendations to improve patient care and safety.

GLOBAL NEUROLOGY REPORT: WORLD ASSOCIATION FOR MEDICAL LAW MEETING 2018

Topic:  Electronic Fetal Monitoring in Developing Nations – A Public Health Threat

The 24th World Association for Medical Law (WAML) Congress was held in Tel Aviv, Israel on 2-6 September 2018.  Leading international experts discussed topics related to Global Health, Medical Law and Bioethics, with a focus on Public Health concerns.

James C. Johnston, MD, JD, reviewed the use of electronic fetal monitoring (EFM) in Africa, and presented a paper co-authored with pre-eminent medical malpractice attorney Thomas P. Sartwelle, renowned medical ethicist Professor Dr. Berna Arda, and leading neurologist Dr. Mehila Zebenigus from Ethiopia.

Dr. James C. Johnston raised the concern that EFM has no proven efficacy in childbirth yet it is being increasingly employed in sub-Saharan Africa in a misguided approach to reduce perinatal morbidity and mortality.  In fact, EFM has a 99.8% false positive rate, and does not prevent or predict cerebral palsy or any other neonatal neurological disorder.  It does cause significant harm by dramatically increasing the cesarean section rate with all of the attendant risks and complications of that procedure, as well as increasing the risk that babies born in this manner may have a higher incidence of developing chronic diseases such as juvenile arthritis, asthma, inflammatory bowel disease, and neurodevelopmental problems.

After reviewing the overwhelming evidence against EFM, Dr. Johnston discussed the recent trend of developed countries to stop this procedure through specific guidelines published by birth-related professional organizations in the United States, United Kingdom, Canada, Australia and New Zealand.  For example, the United Kingdom National Institute for Health and Care Excellence states “Do not offer electronic fetal monitoring to women at low risk.”

The 24th World Association for Medical Law (WAML) Congress was held in Tel Aviv, Israel on 2-6 September 2018. Leading international experts discussed topics related to Global Health, Medical Law and Bioethics, with a focus on Public Health concerns.

And yet, EFM is rapidly increasing throughout sub-Saharan Africa due to a combination of intense marketing from the EFM manufacturing companies, and the failure of the medical community to understand that the procedure causes more harm than good to mothers and babies.  Dr. James C. Johnston provided specific examples of the marketing, including the Allied Market Research ‘Global Fetal Monitoring Report’ which concluded that the fetal monitoring market is expected “to reach USD 3.6 Billion by 2022,” that the market in “developing countries is lucrative,” and there is a “perpetual need” for these EFM machines.

Dr. Johnston and his colleagues concluded that the WHO should establish guidelines stating that EFM is an experimental procedure that is not scientifically reliable, the standard of care does not warrant EFM in low risk pregnancies, and it should not be performed.  This will allow local health boards in each country to adopt the guidelines, and ensure the medical community stops harming mothers and babies through this procedure.  Then, the resources wasted on EFM can be properly allocated to provide additional training of midwives and healthcare workers, and provide care for children with cerebral palsy and related conditions.