AAMC Reporter: December 2008

Brain Gain: Helping Developing Countries Grow Their Own Medical Expertise

Bill Finn (standing, right) of the University of Washington School of Medicine works with local health providers in Cameroon

Old models of solving health problems in the developing world amounted to little more than a Band-Aid on a major wound. Sweeping in and building a clinic or vaccinating a village were helpful, but had a limited impact in regions where disease and suffering ran rampant.

By contrast, however, more organizations today are working to create sustainable change that will endure long after aid workers leave the village. Several academic medical centers are lending their expertise to these efforts.

"Ours is a two-part mission: to serve and to teach," said Mark W. Kline, M.D., president of Baylor International Pediatric AIDS Initiative at Texas Children's Hospital. "That is the exit strategy."

One of the most debilitating contributions to the AIDS crisis in developing countries is the lack of trained physicians—especially pediatricians—who can provide care. Baylor's Pediatric AIDS Corps (PAC), launched in 2006, aims to expand care and treatment for HIV-affected children and families in underserved countries by increasing the number of health professionals trained to provide care. Currently, PAC has teams in Botswana, Burkina Faso, Malawi, Lesotho, and Swaziland. When PAC arrived in Lesotho in 2006, only one pediatrician served the entire country of more than 2 million.

One problem behind the shortages has been termed "brain drain," a phenomenon in which doctors and would be doctors from developing countries emigrate in large numbers to train and work in the United States and Europe. This "brain drain" is exacerbated by the impact of AIDS deaths on a generation of adults and the low productive capacity of health professions schools in these nations. PAC's mission is to send a corps of medical students, residents, and practicing physicians to work in these countries for a year or longer, teaching nurses and other community caregivers the skills needed to treat children with HIV/AIDS and provide primary care to their families.

"We don't want to be a permanent fixture or solution to the crisis—ours is an interim measure to get children into care who would die before an adequate number of providers can be trained to save them," Kline explained.

Teaching It Forward

"The medical system is never going to produce the number of physicians it needs, so others need to learn to carry out these tasks," said PAC alumnus Michael A. Tolle, M.D., assistant professor of pediatrics at Baylor. "We mentor non-physicians to do a physician's job, like diagnosing HIV and making decisions on starting meds. When these local caregivers learn to do HIV care and treatment, this will last through their careers."

PAC has built a network of children's health centers in African countries hardest hit by HIV/AIDS. There also are centers of excellence where doctors, nurses, pharmacists, and others from across the African continent can come to get additional training. Over a year and a half, the number of children receiving antiretroviral therapy in the region went from 20 to more than 100. "This is a huge breakthrough for rural Africa," Tolle said. "We were able to get it started, and it just keeps growing."

While PAC aims for a kind of "reverse brain drain" by developing home-grown health professionals in their own communities, emigration of the best and brightest continues to be a big problem globally. Medical schools and teaching hospitals are in the middle of this pushpull dynamic. Young international medical graduates (IMGs) flock to unfilled U.S. residency slots to get a top education, and the market encourages them to stay and fill the gaps in the U.S. health care system.

Health workers administer treatment to indigent populations as part of Case Western Reserve University School of Medicine's Health Frontiers Program.

"The academic medicine community is in favor of the free flow of people and ideas, but we recognize that a consequence of this is the loss of physicians from poor countries," said Edward S. Salsberg, M.P.A., director of the AAMC's Center for Workforce Studies. Each year, about 5,000 IMGs who are not U.S. citizens enter residency training in the United States. According to Salsberg, about 350 come from Africa. "That doesn't sound like a lot to us in America, but it is a significant number for African medical schools to lose."

U.S. academic medical centers are in a unique position to stem the flow of medical graduates from developing nations by partnering with schools in those countries to expand training capacity and reduce "brain drain." Case Western Reserve University School of Medicine, through its nonprofit Health Frontiers Program, in partnership with the Faculty of Medical Sciences of the National University of Laos, is running a postgraduate training program for Laotian physicians. Participants do clinical rotations through three hospitals and a clinic in the capital city of Vientiane under the guidance of American faculty modeling an evidence-based approach to care.

In May 2007, the George Washington University Medical Center (GWU) began working with the government of Eritrea to create the first graduate medical education program at the Orotta School of Medicine in Asmara. According to the World Health Organization, Eritrea has only five physicians per 100,000 people, with three pediatricians serving 4 million people. "By providing residency programs on the ground in their own country, we hope to lessen, or even eliminate, the flow of trained doctors to the United States. and other developed countries," says Huda Ayas, M.D., GWU's executive director of international medicine programs. "We think this is a model we can replicate throughout Africa."

Phoning It In

Telemedicine is another approach to expanding the reach and expertise of health professionals in underserved regions. According to new data from the American Telemedicine Association, more than 100 U.S. hospitals and medical centers are using some form of telemedicine to provide care overseas through interactive video, medical imaging, and other telecommunications.

Dale Alverson, M.D., professor of pediatrics and medical director of the Center for Telehealth and Cybermedicine Research at the University of New Mexico (UNM), said that "things are happening fairly quickly as technology is cheaper and easier to use, and connectivity is biquitous. Now in the developing world, many more people have cell phones than land lines. We are seeing a paradigm shift of bringing care to the patient rather than the patient going to the care."

Telemedicine has made it possible for UNM to link its students and doctors in Albuquerque to floating mobile clinics in South America's Amazon region, providing expertise and training to promotores de salud, or community health workers. But rather than simply transmitting Western medicine over the wires, this program aims to work in country-specific contexts, according to Alverson. "Our model is always looking at mutually beneficial ways to partner," he said. "It starts with identifying the health care needs of the population and determining the best way to integrate the tools of telehealth to address them."

For example, "On my last visit, we visited a promotore who had a microscope and was taking distance learning classes to learn to diagnose varieties of malaria so he could provide the right medications. We asked him if he would like to have his diagnoses verified, so we supplied him with a digital camera that fit over his microscope. Now, he can share images with tropical disease experts in Quito."

Benefits Flow Both Ways

Importantly, academic medical centers' overseas outreach delivers a balance of benefits right back to its own campus. Students who spend time immersed in the health care of developing countries "begin to realize the full scope of the problem in the world, and how different and desperate health care needs are in lowresource settings," Tolle said. "It's a big eye-opener to be faced with things like high death rates in children. But they also gain an awareness that something can be done, and where they can fit in as individuals. It's hard not to take this back with you." Tolle added that many of these students go on to practice in underserved areas.

On a practical level, students acquire experience-based skills they won't find in a typical medical setting in the United States. They see a large number of sick patients in unique conditions, do a high volume of procedures, and gain teaching skills. They also receive a valuable perspective on the interdisciplinary nature of medicine.

Increasingly, students are seeking out these opportunities when they consider their medical school or residency choices. "Everywhere I go, I hear exactly the same thing: more students and residents are interested in global health," said Kline. "Schools need to have an outlet for them to pursue this commitment. There is a pool of talent willing to work in the developing world, and they are at every U.S. medical school." To compete for top students, he asserts, medical schools need to be able to offer service opportunities that also teach.

"We are producing the desired results in the developing world," he said. "We have transformed care, but we have also transformed our own doctors."

—By Marsha J. Frase, special to the Reporter