For this month’s ANA Q&A, we spoke with Deanna Saylor, MD, MHS, Assistant Professor of Neurology at Johns Hopkins University School of Medicine who spends most of the year as a Visiting Consultant at the University Teaching Hospital (UTH) in Lusaka, Zambia. A Fulbright Fellow and the recipient of a K01 award from the National Institutes of Health (NIH) Fogarty International Center, Dr. Saylor discusses her work creating a neurology training program, inpatient service, and clinic; adapting clinical and research techniques to the resources available in low- and middle-income countries; and more.
What work did you undertake to establish a neurology training program in Zambia that would equip your graduates to participate in research?
When I arrived in Zambia in 2018, there were no Zambian neurologists, and the entirety of neurologic care was provided by expatriate neurologists. I was very cognizant that we were essentially developing a new field of medicine in Zambia — there had never been an inpatient neurology service in the country. I wanted to equip our trainees and graduates with the knowledge and skills to do local research for questions that mattered locally and generate locally relevant data that could then be used to improve local care. To ensure they would have consistent exposure to research and would have foundational knowledge of how to do at least clinical research, which can often be done with a smaller budget compared to basic science research, I included a weekly research methods seminar in the curriculum of the training program, where we reviewed the basics of designing clinical research studies and observational studies. We also hold a weekly journal club, where we talk about how to critically appraise literature and identify questions that still remain after each study we review, as well as discuss how the study’s findings translate to our setting if it was done in a higher-resource setting. This approach demonstrates to our trainees that there are a lot of important unanswered questions that would have a big impact on patients and patient care that we can answer just by systematically collecting data in our routine clinical practice. Research doesn’t have to be really advanced and have a big budget to be applicable to our patients. It can be collected within the means of what we have available to us.
Why was it important to you to establish a neurology training program in Zambia, and what is your long-term goal for the program?
The concept of setting up training within a low- or middle-income country differs significantly from sending people from low- and middle-income countries to a higher-income setting to train with hopes they return to their home country. Training someone in-country means that they’re going to train with the resources that are actually available and learn how to adapt practice to the resource constraints they’re going to face. It also means they’re going to train on the diseases they’re most likely to see, which are obviously quite different than what they would see in a higher-resource setting. Another benefit is that it makes it more likely that they will remain in their home country to practice.
My long-term goal is sustainability. I’m constantly telling my trainees and our graduates that my job is to make myself obsolete so that eventually this is a self-sustaining program that doesn’t require external support. That aspect has to be very intentional from the from the outset, because if a program is completely reliant on external funding or external faculty time and then that is suddenly withdrawn and you don’t have a transition plan in place, then you’ve really not accomplished all that you could have
What work and research are you undertaking to further develop neurological care in low- and middle-income countries?
We have launched a tele-neurology clinic, which has allowed us to expand access to our services to patients who live in remote locations. We ensure that there’s always a local provider in the room with the patient, so as we treat the patient, that provider learns how to address the patient’s needs as well. We’re also in the process of expanding our tele-EEG program. Just giving access to this important diagnostic tool to more patients will be important, but ultimately, it needs to be paired with more capacity building and training. And finally, the project that I’m most excited about right now is the development of stroke centers. Our initial research work showed that about 45% of admissions to our inpatient neurology service are for stroke, and about 20% of those patients die in the hospital. Work from the US and other high-income settings has shown that a really basic set of what are essentially nursing care protocols can substantially improve outcomes for patients with stroke. And these nursing care protocols — things like temperature control, blood glucose control, hypertension control, and ensuring patients are turned every two hours — evolved in the US around the implementation of high-cost TPA and endovascular interventions. Because those interventions are generally not available in sub-Saharan Africa, these protocols have also not been widely implemented to support them. We’re trying to adapt the protocols from high-resource settings to our setting; work to train our nursing and hospital staff on how to implement them; and then evaluate whether this actually improves outcomes for our patients with stroke, which I’m really hopeful will be the case. Two additional hospitals will also use the protocols, with the goal of showing that we can have an impact, regardless of the presence or absence of neurologists. We hope this will allow us to develop national stroke care guidelines that can be implemented throughout Zambia and potentially be scalable to other regions and countries that have similar resources.
We’re also working with regional bodies to gain certification so that we can train physicians from surrounding countries to be neurologists, with the hopes that they will eventually start their own training programs locally. In the long term, after I complete my in-person time in Zambia, I hope to leverage the experience here to partner with other countries, other universities, or other government organizations to help them to develop and implement their own curricula for neurology residency training as well.
How can neurologists contribute to the development of training programs and clinics around the world?
The most rewarding professional endeavor that I’ve ever undertaken is developing the training program here in Zambia and being able to work with these incredibly bright and accomplished physicians, enabling them to train in a subspecialty that they were interested in but didn’t think they would have access to. Watching them grow into not just excellent clinicians but also academic researchers, leaders, and mentors has been truly amazing, and it has been the greatest privilege of my career. Picking up and moving full-time to a foreign country is obviously not possible for everyone. But there are definitely ways to get involved in our program or similar programs and support these types of work, whether virtually, with Zoom now being so pervasive everywhere in the world, or in-person, by coming for short visits to support training and give trainees a different perspective and a different view on how to approach neurological care.
How has the ANA supported your career and/or work in this area?
Fifteen years ago, Dr. Gretchen Birbeck was being recognized at an ANA meeting and gave a plenary talk about her work in Zambia and Malawi and epilepsy research that she was doing. Global neurology was something that I had developed an interest in, but I didn’t realize until that meeting that it was a viable career pathway. I was able to connect with Gretchen after the meeting, and she’s remained a career and research mentor for me to date. From that perspective, the ANA has certainly played a role. But in addition, the ANA’s increasing focus on diversity and equity certainly aligns with improving equity in global neurological care. They’ve also created the International Outreach Committee, which focuses on outreach to neurologists in lower-resource settings and tries to improve training and opportunities for ANA involvement for them. I’ve been lucky to be a part of that committee and part of those efforts as well. And then of course the network of senior academic neurologists who can serve as mentors, sounding boards, and resources is unparalleled. As a junior faculty member, I have had access through the ANA to a lot of opportunities for formal and informal guidance and mentoring throughout my career. And I think that these intangible aspects of ANA membership can’t be valued enough.
Want to learn about more of the groundbreaking research being conducted by ANA members? Read past editions of The ANA Q&A.