The ANA Q&A: Neurology Research in Sub-Saharan Africa

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"One hears a lot about malaria deaths, but the sad reality is that a third of survivors sustain a brain injury with associated neurological sequelae. More than 200,000 African children each year end up with neurodisabilities from malaria. This is low-hanging fruit for decreasing the global burden of neurological disease and increasing the human capacity in this region of the world."

~Gretchen Birbeck, M.D., M.P.H., Professor of Neurology, ANA International Outreach Committee Chair 

To celebrate International Women’s Day (March 8), we’re highlighting ANA members who are doing impressive work both domestically and abroad. Keep reading for our interview with Gretchen Birbeck, M.D., M.P.H. Dr. Birbeck is a neurologist who divides her time between the U.S. and Africa. Her U.S. academic home is the University of Rochester, where she is the Rykenboer Professor of Neurology. She also serves as chair of the ANA’s International Outreach Committee.

We spoke with her to learn more about her research, her work with the International Outreach Committee, and what the theme of this year’s International Women’s Day, “Each for Equal,” means to her.

Can you give an overview of the initiatives you've been working on in Zambia?

My work in Zambia really mirrors what an academic neurologist does anywhere—I teach, provide clinical care and conduct research.  And for me the split is about 70/30 with the largest proportion of my time being spent on research activities.

On the research front, I am the Principal Investigator for three NIH-funded R01s. The ChASE study is a Cohort Study of HIV-Associated Seizures and Epilepsy. One of the clinical challenges in providing neurological care in sub-Saharan Africa is knowing what to do for someone who is HIV infected presenting with new onset seizure. Epidemiological data that otherwise informs if and when to start a chronic antiseizure medication may not apply to persons with HIV especially if an HIV-associated drug reaction or opportunistic infection has precipitated the seizure. And unfortunately, the choice of seizure medications may be limited to enzyme-inducing agents that interact with antiretroviral medications. ChASE is providing some insights on what causes seizures in this population, who is at risk of long-term seizure disorders and what happens when the seizure medications available in HIV endemic regions are combined with the HIV medications used locally. This is an especially dynamic study as it involves adults and children in rural and urban populations. I spent the first two decades of my time in Zambia based in a rural area and I still have excellent research teams and colleagues there so it is wonderful to remain working and engaged with them even though I am now based primarily in Lusaka.

I am also working on the Malaria Fever study which is a randomized controlled trial (RCT) of aggressive antipyretic therapy using maximal dose ibuprofen and acetaminophen for fever control in pediatric malaria. My K23 project was a prospective cohort study of neurological outcomes in pediatric cerebral malaria survivors. Since completing my K23, I’ve been working down the list of potentially modifiable risk factors for brain injury in this population hoping to eventually conduct a multi-country RCT of a neuroprotective “package” of care to improve outcomes in child survivors of cerebral malaria. One hears a lot about malaria deaths, but the sad reality is that a third of survivors sustain a brain injury with associated neurological sequelae. More than 200,000 African children each year end up with neurodisabilities from malaria. This is low-hanging fruit for decreasing the global burden of neurological disease and increasing the human capacity in this region of the world. I also think what we learn about epileptogenesis from the cerebral malaria model may help us understand the process in general and this has implications for advances in neurological care everywhere.

Finally, the MRI Ancillary Grant is an imaging study of children enrolled in the Malaria Fever study. This is evaluating structural evidence of brain injury to potentially identify neuroprotective effects and/or side effects from the antipyretics that won’t necessarily be mediated by fever control. This is really an important additional outcome for the RCT since it is quite possible that the anti-inflammatory benefits of the antipyretics might be neuroprotective yet not significantly reduce fever. But the addition of imaging may also help us better identify adverse effects from the antipyretics. One of the neurological phenomena that occurs in pediatric cerebral malaria is the development of brain microhemorrhages. These feature prominently among autopsy findings and, more recently, our research team identified microhemorrhages in children who survived cerebral malaria. So, one major concern is that children who receive ibuprofen (which is not standard of care for malaria fevers) may have an increased risk of microhemorrhages or frank bleeding. The MRI Ancillary Grant will allow us to see if this is occurring.

Clinically, I have an epilepsy clinic in rural Zambia that I staff weekly, I pinch hit for attending on child neurology consults when needed on the inpatient service and I read EEGs Zambia at the University Teaching Hospitals (UTH) Children’s Hospital and Malawi for Queen Elizabeth Central Hospital’s Pediatric service.

On the teaching front, there is a new postgraduate training program in neurology now at UTH and it is doing an amazing job of transforming care and education here. I can’t take any credit for the program, which is led by Dr. Deanna Saylor (Johns Hopkins) and was co-founded by Dr. Omar Siddiqi (Beth Israel at Harvard), but I will proclaim myself to be the program’s biggest cheerleader. And in this vibrant environment, I’m able to spend my medical education endeavors primarily as a mentor for young researchers, both American and African. My mentees study stigma, nutritional neuropathies, cognition in adolescents with HIV, TB meningitis, the impact of health system structure on neurological care delivery, CNS IRIS, and comorbid HIV and NCDs.

So, things are busy and chaotic, but never boring!

What advice do you have for academic neurologists considering working abroad? 

I think the most important first step anyone should take when contemplating working abroad is to carefully examine one’s motives.

Academic neurologists can make many meaningful contributions across a range of settings, but the strengths and goals of the individual neurologist should be well-matched to the local needs and capacity. For neurology trainees, this can be difficult to navigate. Drs. Kiran Thakur (Columbia) and Felicia Chow (UCSF) from the ANA International Outreach Committee are working to develop some consensus guidelines that will be helpful to both trainees and their residency directors on this front.

I actively avoid facilitating global engagement with (1) individuals who think they are coming to save Africa, (2) researchers who want to parachute in to collect data without any meaningful local collaboration, and (3) bored people looking for a holiday thinly disguised as work.

How did you get involved with the International Outreach Committee? 

For my entire career, the ANA has actively supported global endeavors. I trained at Hopkins under Richard T. Johnson who was the ANA president in 1987. RTJ was essentially the father of Neurovirology and much of his early worked involved international activities. So, the development of the IOC seemed a natural evolution. I was delighted when invited to serve on the Committee.

What does your work with the Committee entail? 

We’ve got a great group of people working on the Committee, which makes a lot possible. I’ve already alluded to the consensus statement the IOC is developing to offer guidance to neurology trainees interested in working in global health. We’re also working with the ANA leadership to expand international membership by revising eligibility criteria, reducing membership fees, and getting the word out to potential new international ANA members. The IOC is also responsible for soliciting applications to the International Outreach Fellowship and selecting fellows. This year we are revamping the review procedures so we can provide detailed written feedback to the applicants. This new process will take advantage of reviewers with content-specific expertise who may not be on the Committee and will implement a review analogous to the NIH process since this is familiar to most potential reviewers and will also have value to junior researchers, many of whom will eventually be submitting NIH grant applications.

How has the ANA supported your career? 

I came to neurology already committed to a career in global research, education, and care but in the 1990s, this just wasn’t a common path and feeling professionally isolated and marginalized was a real threat. As a trainee, attending the annual meeting provided me with a sense of comradery, community, and mission that was very congruent with my own individual priorities and values. Then, as a junior faculty member, just as I was starting to worry about hitting my head on the glass ceiling, Eva Feldman became the ANA President soon to be followed by Barbara Vickrey. I could not admire and respect any two people more. With women leaders like that taking the helm, I decided not to look up for that glass ceiling and instead just go for it.

I am a member of many, many medical societies and organizations, but the ANA has always been my primary academic home.

The theme for this year's International Women's Day is "Each for Equal." What does this mean to you and how does this concept apply to your career? 

Everyone has something to contribute and everyone’s best contributions are desperately needed, perhaps more today than ever before. A level playing field has to be there for people to reach their full capacity. Without it, we are wasting our most precious resource, the human one.

In my role as a researcher, clinician, and teacher, I try to make my own best effort to contribute but I also strive to help others be their own best selves—whether that is by offering guidance to a young researcher or looking for ways to prevent brain injury in children with malaria.