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DOI: 10.1212/01.wnl.0000257827.43171.23 2007
DOI: 10.1212/01.wnl.0000257827.43171.23 2007
DOI: 10.1212/01.wnl.0000257827.43171.23 2007
DOI: 10.1212/01.wnl.0000257827.43171.23 2007
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DOI: 10.1212/01.wnl.0000257827.43171.23 2007


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  • 1. Neurology education and global health: My rotation in Botswana Nabila Dahodwala Neurology 2007;68;E15-E16 DOI: 10.1212/01.wnl.0000257827.43171.23 This information is current as of October 18, 2010 The online version of this article, along with updated information and services, is located on the World Wide Web at: Neurology® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2007 by AAN Enterprises, Inc. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X. Downloaded from by on October 18, 2010
  • 2. RESIDENT AND FELLOW SECTION International Education Neurology education and global health My rotation in Botswana Nabila Dahodwala, MD The University of Pennsylvania’s Department of Infectious Dis- eases received an HIV education grant through the President’s Emergency Plan for AIDS Relief in 2002. Since then, they have es- tablished a permanent clinical and educational program at the main public hospital in Gaborone, Botswana. An attending faculty member resides in Gaborone year-round, and additional infec- tious disease specialists, fellows, medical residents, and students rotate through the hospital. A team of Penn doctors and stu- dents admit patients to the medi- cal ward, care for them through discharge, and often follow them up as outpatients. They have re- cently invited neurologists to as- sist in their efforts, and as a fourth-year resident, I spent 5 weeks there in the spring of 2006. To date, three Penn-affiliated and one non-Penn-affiliated neurology residents have participated in the program. Botswana is a parliamentary republic in southern Africa (fig- Figure. Map of Botswana. ure). Most of the 1.7 million resi- dents are Setswana, whereas the other ethnic groups include residents. However, Botswana 10 to 20% initially present with Basarwa (bushmen), Kalanga, has one of the highest preva- neurologic symptoms, and up to and Caucasians. Botswana repre- lences of HIV in the world at 24% 70% will have neurologic disease sents one of the few African coun- in adults.1 Recently, the govern- during the course of their illness.2 tries to have sustained high rates ment has started to cover anti- In addition, both HIV-infected of socioeconomic and infrastruc- retroviral therapy through its and noninfected patients are at ture growth over its 40 years of outpatient clinics, but it has been risk for non-HIV-related neuro- independence. It provides free slow to reach all those in need. logic disease. The Batswana (the healthcare and education to all Among HIV-infected patients, people of Botswana) have high From the Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania, Philadelphia. Supported by the University of Pennsylvania Department of Infectious Diseases (funding for travel) and Robert Wood Johnson Foundation (salary). Disclosure: The author reports no conflicts of interest. Received August 11, 2006. Accepted in final form November 27, 2006. Address correspondence and reprint requests to Dr. N. Dahodwala, Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania, 423 Guardian Dr., Blockley Hall, 13th fl., Philadelphia, PA 19104; e-mail: Copyright © 2007 by AAN Enterprises, Inc. E15 Downloaded from by on October 18, 2010
  • 3. rates of hypertension, diabetes, clinical skills was high. In addi- ond, we can add to the resources heart disease, stroke, cancer, cog- tion to seeing inpatients, my role in these countries by providing nitive dysfunction, and epilepsy. expanded to include private pa- supplies, but especially by provid- However, there are no neurolo- tients from outside clinics, outpa- ing neurologically trained health- gists in Botswana, nor are there tient follow-ups, and even the care providers. We should develop medical schools or neurology resi- chance family member of a hospi- educational programs to increase dency training programs. This tal employee. The patients were knowledge of neurologic diseases. combination has led to little re- responsible, respectful, apprecia- By establishing exchange pro- cording and no publications about tive, and eager to learn. Lan- grams with local providers and the basic epidemiology or burden guage proved to be the biggest cultivating study abroad opportu- of neurologic disease. barrier in obtaining the history nities, we will be able to provide During my rotation, I would re- and discussing results and plans. and improve neurologic care in view all the cases that were admit- Most older patients spoke only Botswana and other resource- ted from the previous day with the Setswana, though a growing poor countries. Botswana and Penn house staff. number of the younger patients Residents and fellows who Routinely through this morning in- could understand, and often, study abroad will be providing es- take, there were 5 to 10 neurologic speak English. Although less sential services to an underserved cases presented: acute-onset weak- than an ideal solution, nurses population and education for local ness, progressive weakness, un- were called upon to act as trans- providers. At the same time, they steady gait, seizures, headache, lators. Throughout my 5 weeks, I will add to their training by im- and confusion. I maintained a pa- discovered that patient and fam- proving clinical and teaching tient log of the new cases I encoun- ily education was one of the more skills and increasing exposure to tered during my time at the valuable services I had to offer. the neurologic complications of hospital. Of the 98 cases that I re- Because there was also a high HIV. Bergen and Silberberg com- corded, 29 (30%) presented with demand for education of the ment in their editorial “Nervous seizure, 21 (21%) with ischemic house staff, teaching became an- system disorders: a global epi- stroke, 12 (12%) with neuropathy, other integral part of my job. The demic” that “in many regions, 9 (9%) with intracranial hemor- medical house staff had all com- centers of . . . neurologic excel- rhage, 6 (6%) with intracranial pleted medical school and had lence and expertise are needed, mass, and 6 (6%) with myelopathy. varying degrees of clinical experi- not only to help plan research and I also saw two cases of snake bites, ence. Most expressed discomfort prevention strategies appropriate one case of organophosphate poi- with performing the neurologic for local needs, but also to edu- soning, and two cases of immune- exam, interpreting head CT cate the primary health care pro- reconstitution syndrome. About scans, and diagnosing and man- viders who care for most 75% of these patients were HIV- aging common neurologic dis- disorders of the nervous system.”3 positive. Diagnoses were based on eases. I started with a series of Both the AAN and individual history and exam, and rarely was formal lectures focused on basic training programs should support quick and reliable blood or CSF topics (e.g., a review of the neuro- these efforts. This support should testing available. Head CT scans logic exam and acute stroke man- include travel funding and allow could take up to 1 week to obtain, agement). As my time there for time away from clinical re- and there was no EEG, electromyo- progressed, and as I saw more sponsibilities at one’s home insti- graphy/nerve conduction studies, cases, I gave talks on seizure tution. The AAN might even or MRI equipment. management in HIV-positive pa- consider establishing interna- tional neurology grants for clini- Within the constraints of lim- tients and HIV myelopathy. cal rotations, education, and ited testing, I relied heavily on On my return to the United research abroad. Improving the history and exam to guide di- States, I flew directly to San Di- global health and providing eq- agnosis and management. My ego, CA, for the 2006 AAN meet- uity in care is a daunting task, clinical exam skills sharpened, ing. Surrounded by more than but we can help meet the and the scope of my differential 11,000 neurologists, I was challenge. diagnoses widened to include tu- amazed by the cutting-edge re- berculosis, parasitic (i.e., malaria) search and wealth of resources. Acknowledgment and fungal infections, nutritional We have the extraordinary oppor- The author thanks Dr. Craig Pollack for deficiencies, complications from tunity to leverage this wealth to his invaluable editing assistance. traditional medicines, and HIV- change how people with neuro- related complications. Unfortu- logic diseases are cared for glo- References nately, therapeutic options bally. First, we can expand our 1. 2006 report on the global AIDS epidemic. remained limited; supplies often research on the neurologic com- Accessed June 15, 2006. 2. Berger JR, Levy RM. The neurological com- ran out and neurosurgical ser- plications of HIV to include plications of human immunodeficiency virus vices were nonexistent in cheaper diagnostic tests and infection. Med Clin North Am 1993;77:1–23. 3. Bergen DC, Silberberg D. Nervous system Gaborone. treatments that would be sustain- disorders: a global epidemic. Arch Neurol The demand for neurologic able in the developing world. Sec- 2002;59:1194–1196. E16 NEUROLOGY 68 March 27, 2007 Downloaded from by on October 18, 2010
  • 4. Neurology education and global health: My rotation in Botswana Nabila Dahodwala Neurology 2007;68;E15-E16 DOI: 10.1212/01.wnl.0000257827.43171.23 This information is current as of October 18, 2010 Updated Information including high-resolution figures, can be found at: & Services Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on October 18, 2010