Global Health and Neurology

The Department of Neurology has a Division of Global Health that is led by Jaydeep Bhatt, MD. The division aims to develop and support training and education for neurology practice in low and middle income countries and to improve awareness of global health issues in neurology. In this discipline of Neurology, Dr. Bhatt has significant experience with healthcare delivery in resource limited settings. We are pleased that this program has strong collaborations with NYU’s College of Global Public Health. NYU School of Medicine Department of Population Health and Dr. Jerome Chin, Adjunct Professor in NYU Department of Neurology and president of The Alliance for Stroke Awareness and Prevention Project (ASAPP). Dr. Bhatt’s endeavors complement a larger academic network of domestic and international neurology faculty who are members of the Global Health Section of the American Academy of Neurology. Drs. Bhatt & Chin travel to Kampala, Uganda to participate in a clinical global neurology elective to examine the diagnosis and treatment of neurologic disorders in a resource limited setting with 1-2 neurology residents per year.

 

Perspectives of an NYU Neurology Resident

At first glance, it would be difficult to overstate the breadth of differences in healthcare systems that comes from leaving NYU Kimmel Pavilion at 5:00 pm on Thursday afternoon, and arriving at Kirruddu Hospital, in Kampala, Uganda at 8:30 am on Monday morning. Despite the attempts of Drs. Chin and Bhatt, as well as my co-resident predecessors, to prepare me, words simply do not do the experience justice. And initially, it is jarring- each floor of the hospital composed of large, single room wards, more reminiscent of a 19th century Victorian hospital than any hospital floor I’ve ever encountered. Interspersed between the rows of hospital beds are the patients’ “attendants”, their family members or friends or neighbors, who remain stalwart, curled up on thinly woven mats on the floor at the patients’ bedside, 24 hours a day. They bear the weight of the majority of the patients’ care while in the hospital- acting typically as nurse, aide, translator, advocate, and fundraiser.

As soon as we enter the ward, the eyes of the patients’ and their attendants follow us as we make our rounds- three foreigner “Muzungus” would stand out and be a cause for attention throughout much of Uganda, but that is particularly the case here, as each patient waits patiently and respectfully for their turn, and they remain ever optimistic that they will be a given an answer for what ails them. And those ailments vary- but perhaps the most unifying theme among their neurologic afflictions is less about their diagnoses and more about the timing of their presentation- which is invariably late. Almost without fail, patients present to the hospital when it is impossible to continue managing their symptoms at home. For example, when their tuberculous meningitis has left them encephalopathic to the point of immobility, or when their undiagnosed neuromyelitis optica has rendered them quadriplegic, and unable to eat, speak or communicate except through hand squeezes in response to yes or no questions. The delay in diagnosis is almost always related to the family’s poverty, though in some cases, there is a permeating lack of faith in western medicine’s ability to make a difference, a sense that we cannot always dispel, despite our best efforts.

Patients who arrive at Kirruddu, which is the government-sponsored hospital, typically do so because the cost of a private pay hospital is prohibitive. While at Kirruddu, patients are still expected to pay up front and on the spot for much of their care, including nearly every lab, medication and diagnostic image, however, the cost of the hospital stay itself and access to the physicians is covered, unlike at a private hospital. A hushed bedside discussion about cost follows every recommendation made by the physicians, and is usually followed by hours to days of fundraising efforts at home by family, before the study can be undertaken, even if it is considered emergent. For that reason, every recommendation we make is informed by a solemn weighing of the cost to the patient versus its potential benefit. Decisions about a repeat lab test to check a sodium level, or imaging of a patient’s cerebral blood vessels following a stroke, actions that would be quite literally automated in New York, require careful discussion here, and expose both the severe limitations that poverty places on our ability to provide a simulacrum of comparable care, as well as the absurd excesses of the American healthcare system.

There is a level of uncertainty and discomfort that comes from making medical decisions that hinge upon your best educated guess, and it is hard to get accustomed to, especially with the frustrating knowledge that even basic studies that would give you an answer aren’t an option due to cost. For example, imagine a 24 year old, with severe pulmonary tuberculosis and tuberculous meningitis, who suddenly goes into respiratory distress. The potential causes run through your head as the clock ticks and the oxygen saturation stubbornly hangs in the low 80s. First things first, you rearrange the layout of the room, enlisting the help of the attendants and shuffling patients’ beds to align your patient’s bed with the closest wall oxygen, hoping that the nasal cannula tubing reaches comfortably, and more importantly, that the hospital has not yet run out of oxygen that day. Then, you engage your trusty stethoscope, and the decreased breath sounds over the right lung field further complicate the picture. Pleural effusions, mucous plugging, pneumothorax, and pulmonary embolism are all on the table, and knowing what step to take next without the luxury of a CT scan or an arterial blood gas or a simple chest x-ray to start eliminating possibilities can be paralyzing.

The setting of such severe illness and mortality, combined with the mental weight of grappling with every minor recommendation and how it will financially and medically affect the patient, requires a certain level of emotional fortitude, and makes each day feel a bit like preparing for battle. At times, it feels like we are practicing medicine with a blindfold on and one hand tied behind our back. It’s also a forcible reminder of how much we’ve come to rely on imaging and diagnostics in our practice of medicine.

And so, while over a three week period, one never quite acclimates to the constrictions of such a resource limited setting, one starts to appreciate the purity of a “back to basics” approach to medicine, refocusing on the foundations of healing, which is rooted in the patient, and in the clues scattered throughout their history and physical that lights the path to their diagnosis. Again, here, Uganda provides a unique experience, and a poignant reminder of the joy and privilege that inspired all of us to pursue medicine: the opportunity to help heal someone.

Just as hearing the accounts of the experiences of my preceding co-residents could not wholly prepare me, neither could these words do Uganda justice, which is why the ongoing commitment of NYU Neurology to fund and expand their global neurology program and continue to send residents to experience the humanizing, educational power firsthand is so worthwhile. It was a singular, life-altering opportunity, with lessons that I will continue to carry forward.

 

Nicole Morgan, MD - Neurology Resident PGY-3


 

Jacob Pellinen's Experience

Soon after arriving in Entebbe, we drove from airport, through the bustling city center of Kampala, to Makerere University. Our driver humored my questions, explaining everything we saw along the way, and set the pace for a trip where I would learn more in three weeks than any other rotation during residency.

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Scott Grossman's Experience

Our time at Kirrudu Hospital required, above all things, humility. In my years as a resident at NYU many amazing mentors have taught me both the science of clinical neurology and the best approach to clinical practice for that cultural context. Practicing and teaching on the neurology ward in Kampala required a radical reorganization of the approach to patient care.

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Bonnie Wong's Experience

It was the quietness of our wards that struck me the most.; Each held at least 10 hospital beds with patients, with usually more in the corridor between beds. Because bedside care was provided by family, they stayed during the day and night on colorful woven mats on the floor, with food and belongings tucked into bags and baskets nearby.There was a toddler who wandered in an out, her soft giggles audible. Sometimes, entire families stayed during the day and yet you could hear your thoughts. We leaned in close to hear rounds, review scans, and make plans at just above a whisper.

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Alexandra Lloyd-Smith's Experience

The opportunity to practice neurology at Mulago Hospital in Kampala, Uganda was life changing and will have an everlasting positive effect on my career as a neurologist. Mulago is Uganda’s national referral hospital. Patients from each corner of the country travel by various means of transportation for neurological evaluation. Together with their families and friends, they carry basic personal belongings including bed sheets and utensils in preparation for their admission. Everyone was unique and had beautiful life stories to share.

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