International Issues: Educational programs of the World Federation of Neurology
T. Munsat, MD,
J. Aarli, MD,
M. Medina, MD,
G. Birbeck, MD and
A. Weiss, MA
From South Woodstock (T.M.), VT; University of Bergen (J.A.), Norway; Autonomous University of Honduras (M.M.); Michigan State University (G.B.), East Lansing; and American Academy of Neurology (A.W.), St. Paul, MN.
Address correspondence and reprint requests to Dr. Theodore Munsat, 3515 Fletcher Hill, South Woodstock, VT 05071 theodore.munsat{at}tufts.edu
During the past few years, several publications have documentedthe striking lack of neurologic health care givers in countrieswith limited resources.1–3 Neurologic care is particularlydeficient in those developing countries where health problemsare most severe. Even in those countries where a small numberof neurologists practice, care is often fragmented and the neurologiccommunity poorly organized. Educational programs for neurologichealth care givers and neurologic patients are typically seriouslydeficient. The problem has been defined. The challenge is reasonablyclear. A resolution is required. In North America and WesternEurope, effective organizations exist that serve the organizationaland educational needs of its neurologic community. However,no such meaningful process exists to provide these servicesfor resource-deficient countries. During the past decade, theWorld Federation of Neurology (WFN) has attempted to fill thisvoid. The WFN (www.wfneurology.org) was organized as a federationof national neurologic societies 50 years ago. Its secretariatis located in London, and it is registered as a Charity Corporationin the United Kingdom. Each country has one vote in its deliberations.A primary goal of the WFN is to assist low-resource countriesin providing meaningful education for its neurologic healthcare providers and thus improve the neurologic health of itscitizens. We hope that this brief review of the educationalactivities of the WFN will be informative for residents andfellows who are interested in working with and helping colleaguesliving in low resource environments.
The WFN’s educational programs have been operating underseveral principles.
The successful education of neurologic health care providers,and their patients, is a major strategy in achieving improvementin health care in developing countries.
In order to strengthenthe effectiveness of this educationalprocess, each countryshould develop a cohesive neurologic societywith specific individualsidentified as leading that society’seducational activities.
The WFN will provide educational assistance in response toaspecific request from a member country. It does not advocateseeking out or proactively identifying a country’s educationalneeds. These needs should be identified by the participatingsociety, not the WFN.
To counteract the destructive effectsof the emigration of trainedbasic and clinical neuroscientiststo countries with more resources("brain drain"), the WFN stronglysupports the principle oftraining neurologists in their nativecountries. Its primarystrategy is to help countries developtheir own training programs.We believe that, in most situations,this can be accomplishedwithout compromise to the educationalprocess and within a reasonableperiod of time.
The educationalmaterial used should be of the highest qualityand both problem(case) and evidence based.
Although the WFN believes thatthe best care of patients witha neurologic illness should begiven by a trained neurologist,it recognizes the need for non-neurologistcaregivers as aninterim measure. However, developing a cadreof well-trainednon-neurologist caregivers requires a core ofexperienced neurologistsresident in that country to provideadequate training.
The WFN supports the principle of establishingsmall, pilotstudies when new educational programs are beingconsidered.
Periodic follow-up evaluation and feedback ofa program’seffectiveness is essential.
The educationof an effective neurologist should be a seamlessand integratedprocess from medical school to residency trainingand then tolifelong continuing education.
CONTINUING MEDICAL EDUCATION: LIFELONG LEARNING IN NEUROLOGY
This program, now 10 years old, is a partnership between theWFN and the American Academy of Neurology (AAN). It providessix specially designed educational courses each year of theAAN’s premier continuing medical education journal Continuum:Lifelong Learning in Neurology, by hard copy or online. Forty-twodeveloping countries currently participate, including Argentina,Bangladesh, Brazil, Bulgaria, Cameroon, Chile, Columbia, Congo,Croatia, Cuba, Cypress, Czech Republic, Egypt, Ethiopia, Guatemala,Honduras, Hungary, India, Iraq, Jordan, Kenya, Lebanon, Lithuania,Macedonia, Mexico, Mongolia, Nigeria, Panama, Peru, Romania,Russia, Serbia, Slovenia, Sri Lanka, Syria, Tunisia, Uganda,Uruguay, Vietnam, Venezuela, Yemen, and Zambia. Current WFNCoordinator contact information is available at www.wfneurology.org.
Each country has a WFN Education Coordinator appointed by thatsociety’s President. The coordinator is in charge of receivingand distributing the courses and arranging for discussion groups,which are an integral part of the program. Upon completion ofa course, each participant fills out an evaluation form, andcertificates of participation are provided. Typically, theseprograms begin in the capital city of a country. In larger countries,secondary participating centers, each with a coordinator, havebeen established in smaller cities. This has occurred in Russia,Turkey, Cuba, Honduras, Argentina, and Hungary.
The effectiveness of these programs depends in great part onthe skills, dedication, and active involvement of the WFN EducationCoordinator in that country. This program is now being usedincreasingly for certification purposes, grand round presentations,educational retreats, and the education of non-neurologists.The WFN and AAN are currently gradually moving from hard copyto online distribution, which will significantly reduce shippingcosts and delays. Future plans include an online chat groupwherein participants can communicate with the authors of thecourses.
The WFN provides assistance in establishing neurology trainingprograms where there are none, and helping further develop existingprograms. We have worked with programs in Ethiopia, Honduras,two in Guatemala, Nicaragua, and Mexico. The request for suchassistance must come from the national neurologic society andchairman of the neurology department and have the support ofthe neurologic society members. After a request is received,the WFN carries out a preliminary site visit to answer the followingquestions: 1) Is the need for help shared by most members ofthe neurologic community and are they prepared to make a long-termcommitment? 2) Are there adequate resources, both human andinfrastructural, to establish a program? 3) Are university andhospital administrators, the national minister of health, andthe chiefs of related departments, such as medicine and neurosurgery,supportive? 4) Above all, is the chief of the proposed departmentadequately committed and capable of assuming this most importantleadership position? Following this visit, a report is presentedto the requesting society and the WFN Trustees with specificrecommendations. Follow-up visits are arranged according toneed.
An early experience in Honduras has been very informative.4,5A collaboration between the WFN and the Neurologic Society ofHonduras began in 1997 when the WFN was asked to help the societyestablish a training program for neurologists. The Director,Prof. Marco T. Medina, is a dynamic, capable leader dedicatedto improving the neurologic health of the citizens of his country.Prior to the WFN’s site visit, he had collected soundepidemiologic data showing that the health of citizens livingin Honduras was being adversely affected by the lack of goodneurologic care.6 In addition, it was demonstrated that an improvementin neurologic care would result in significant economic benefitsto the country. Armed with these data, a meeting was held withthe Minister of Health, who agreed to fund four resident positionsat each level of a 3-year training program. The WFN continuedto monitor the progress of the first several resident trainingclasses.
This training program is now about to celebrate its 10-yearanniversary. The results have been dramatic. The Neurology Departmenthas become recognized as one of the best departments in themedical center and in Central America. A neuroscience PhD programis being developed. Importantly, every graduate of the neurologytraining program has stayed in Honduras. The program is attractingthe better medical school graduates. Cities of secondary sizeare getting well-trained neurologists for the first time. Outcomeassessment has shown, for example, a dramatic reduction of deathsfrom status epilepticus. A vigorous stroke prevention programhas been initiated. Preventive programs for neurocysticercosis,a scourge of the country, are beginning to show results. Importantly,neighboring countries have begun to ask for similar help fromthe WFN.
The WFN has recently provided a program certification processfor programs that wish to have an external review. This hasbeen carried out in Honduras, Guatemala, Mexico, and Ethiopia.If a program meets certain predetermined criteria for an effectivetraining program, it receives a certificate. This process isvery effective not only in confirming that the program is functioningeffectively, but also in notifying other members of the hospitaland university communities that the program meets internationalcriteria of performance.
Several countries have requested that the WFN provide a processof external evaluation of their residents at time of graduation.A logical extension of that process may lead to a more formalcertification and recertification process. The WFN has respondedto requests for resident evaluations and has begun discussionsof a certification and recertification process. In carryingout these regulatory functions, the WFN is providing a servicethat is available internally in most, if not all, developedcountries but not in countries with limited resources and fewerneurologists.
What, then, are adequate criteria for a training program ina developing country—for example, in a country of 20 millionpeople with no CT scans, MRIs, or adequate electrophysiologiccapabilities and 10 or fewer well-trained neurologists? Thereis general agreement that the goals of a training program shouldbe goals that are appropriate for the needs of that country,4as determined in great part by individuals practicing in thator a similar environment. How are those goals defined in thecontext of what constitutes adequate modern neurologic care?Can there be criteria that are internationally appropriate?
Because of the special and relatively unaddressed neurologichealth issues in sub-Saharan Africa, the WFN has mounted a specialeffort. A special task force has been established and severalmeetings held in an effort to define the best way to approachthe immense needs in that region. Currently, six sub-Saharancountries are participating in the WFN Continuing Educationprogram: Cameroon, Uganda, Zambia, Nigeria, Ethiopia, and Kenya.The WFN has recently formed a partnership with the People toPeople Foundation, which has made major contributions to neurologiccare in Ethiopia. Under this arrangement, a site visit of theneurology training program at Addis Ababa University was recentlycarried out by a team from the WFN. A recent conference fornon-neurologists was held under the auspices of People to People,the Mayo Clinic, and the Ethiopian government in Addis Ababa.The European Federation of Neurologic Societies (EFNS), oneof our component regional societies, has a long experience inorganizing training courses in neurology in developing countries.EFNS will soon arrange a teaching course in neurology in Dakar,Senegal. Most participants will come from French-speaking countriesand the course will follow standards given at teaching coursesat EFNS congresses. EFNS also has a long experience with department-to-departmentexchange programs, which will be utilized in the future. TheWFN is in the process of designating a small number of AfricanCenters of Neurologic Excellence for regional training. Thereis need for training activities in both English-speaking andFrench-speaking African countries. Some neurologists from otherAfrican countries are already in training positions in SouthAfrica. South Africa has offered to accommodate others for trainingin neurology.
In our discussions with health ministers, deans, and other seniormedical officials, it is often pointed out that in a countrywith threadbare health services, especially in rural areas,major problems, such as HIV/AIDS, malnutrition, and parasiticinfestation, must take precedence over neurologic diseases,which are still considered esoteric and untreatable. They oftenexpress the view that it is much more reasonable to train clinicalassistants, nurses, and primary care physicians.7 However, itis often overlooked that in order to train non-neurologistsproperly, appropriate training materials and a core group ofclinically experienced academic neurologists are necessary.Thus, in addition to focusing on training neurologists, theWFN has developed training materials for nonphysician healthcareproviders8 and established a program for nonphysician/neurologistclinical officers in Zambia. Under the direction of GretchenBirbeck, MD, this increasingly effective training program forclinical officers in Zambia now involves Malawi as well.9 InEthiopia, the WFN plans to train an existing cadre of psychiatricnurses to diagnose and manage neurologic problems. Such trainingis particularly urgent in resource-poor regions, where nonphysicianhealthcare workers provide clinical services without recourseto physician-level referral.10
However, the two educational tracks—neurologist and non-neurologist—neednot and should not be mutually exclusive. Both approaches areneeded and clearly reinforce each other.
Because of the lack of educational material specifically designedand directed to neurology health care givers practicing in low-resourceenvironments, the WFN has initiated a series of books producedby neurologists with experience in these issues. This series,published by Demos, Inc., is edited by Jerome Engel, MD, andis available in hard copy or online. Other related and moretraditional programs offered by the WFN, when resources permit,include a book sharing program by which over 8,000 books andjournals have been provided by individual donors and publishingcompanies. Approximately 150 visiting professorships have beensponsored or cosponsored. Ten traveling fellowships have beensupported and several small equipment grants have been made.
Preliminary experience with providing assistance to our neurologiccolleagues in developing countries has led the WFN to concludethat effective help in improving neurologic care can be providedwith modest resource investment in a relatively short periodof time. The effective elements of the WFN’s programsinclude a detailed needs assessment by the recipient country,local dedicated and committed leadership, the production ofrelevant evidence-based educational material, periodic feedback,and periodic reevaluation of goals and strategies.
World Health Organization, World Federation of Neurology. Atlas: Country Resources for Neurological Disorders
World Health Organization. Neurological Disorders: Public Health Challenges. Geneva, Switzerland: WHO Press;
Aarli JA, Diop AG, Lochmüller H. Neurology in sub-Saharan Africa: a challenge for World Federation of Neurology. Neurology 2007;69:1715–1718.[Free Full Text]
Medina MT, Munsat T, Portera-Sanchez A, et al Developing a neurology training program in Honduras: a joint project of neurologists in Honduras and the World Federation of Neurology. J Neurol Sci 2007;253:7–17.[Medline]
Medina MT, Munsat T. Continuing medical education in developing countries. J Neurol Sci 2001;190:1–2.[Medline]
Medina MT, Durón RM, Martínez L, et al Prevalence, incidence, and etiology of epilepsies in rural Honduras: the Salamá study. Epilepsia 2005;46:124–131.[Medline]
Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet 2008;370:2158–2163.
Birbeck G. Where there is no neurologist: 2002. Available at: www.wfneurology.org.
Chomba EN, Haworth A, Atadzhanove M, et al Zambian health care workers’ knowledge, attitudes, beliefs, and practices regarding epilepsy. Epilepsy Behav 2007;10:111–119.[Medline]
Birbeck GL, Kalichi EM. Primary healthcare workers’ perceptions about barriers to health services in Zambia. Trop Doct 2004;34:84–86.[Medline]
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