Dr. Morgan Prust is an Assistant Professor of Neurology at the Yale School of Medicine in the Division of Neurocritical Care and Emergency Neurology. His interest in global neurology developed through time spent at the University Teaching Hospital in Lusaka, Zambia, and his work is focused on the care of neurologic emergencies in resource-limited settings.
Q: Tell us about your interest in global neurology.
My interest in global neurology was sparked by a visit I made during my second year of neurology residency to the University Teaching Hospital (UTH), Zambia’s largest referral hospital. Zambia is a country of roughly 18 million people, and at the time of my visit in 2017, there were only three full-time neurologists practicing in Zambia, all of whom were at UTH. Working under the mentorship of Dr. Omar Siddiqi, I spent a month caring for patients with neurologic disorders in the inpatient wards, ICU, and outpatient neurology clinic. The range, volume, and severity of disease that I encountered was utterly staggering. Infectious diseases of the central nervous system that are considered rare in high-income countries are very common in Zambia, where there is a high prevalence of HIV (and therefore of the opportunistic nervous system infections that patients with HIV are vulnerable to), tuberculosis, and malaria. Beyond infectious diseases, I also witnessed a tremendous burden of ischemic stroke, cerebral hemorrhage, and traumatic brain injury, which the existing health care infrastructure is poorly equipped to manage, given the severely constrained access to diagnostic imaging and critical care resources.
That initial experience of working in Zambia was completely life-changing for me. At that time, I was already working toward a fellowship training in neurocritical care, and through my experiences at UTH, I discovered that I wanted to devote my academic career to solving problems that improve outcomes from neurologic emergencies in resource-limited settings. Since that initial visit, I have had the opportunity to spend additional months working at UTH, where I continue to collaborate with Dr. Deanna Saylor and other colleagues on projects aimed at improving care for patients with acute stroke and other neurocritical illnesses.
As a field, global neurology has attracted some of the most incredible people working in academic neurology today, and I feel so grateful to have the opportunity to work with and learn from such dedicated, skillful, and humane colleagues. A comprehensive list would be far too long, but I am profoundly and particularly indebted to Omar Siddiqi, Deanna Saylor, Aaron Berkowitz, and Kiran Thakur for all of the mentorship and opportunities they have given me over the past several years.
Q: How do you envision building global neurology into your career?
As a neurointensivist, I am fortunate to have dedicated weeks when I am on service in the neuro ICU at my home institution, beyond which I have time and flexibility to work on my academic collaborations in global health neurology. While my family and I are based in the U.S., my schedule affords me opportunities to travel abroad for global health-related projects. This year, for example, I am planning to travel to Zambia to initiate a study on preventive care to limit the burden of aspiration pneumonia in patients with stroke admitted to UTH.
I also recognize the growing interest in global health among neurology trainees in the U.S., and that being on faculty at a large academic medical center gives me the opportunity to pay forward the incredible global health mentorship that I’ve received onto rising generations of medical students, residents, and fellows. The scale and complexity of the problems in global neurology and neurocritical care are vast, and I’m excited by any role I can play in broadening the workforce of people focused on these issues.
Q: How would you advise someone with a neuro-critical care background about what they can uniquely bring to global neurology?
On its surface, a highly resource-intensive discipline like neurocritical care might seem to have little to offer to the global health community. And I think it’s important to recognize that many of the elements of neurocritical care, as practiced in high-income countries, aren’t feasible or even valuable to implement in many resource-limited settings. One example of this is invasive neuromonitoring, which has a proven role in the management of traumatic brain injury and other acute neurologic emergencies in high-income countries, but has not been shown to be beneficial in low- and middle-income countries. This is likely due to limitations in more fundamental components of care for neurocritical illness, like readily access to a CT scanner, mechanical ventilation, antibiotics, and skilled nursing.
Thinking about how to optimize the prevention of common hospital-acquired complications and the delivery of basic life-saving interventions for patients with neurocritical illness is where I think the neurocritical care community can have the most impact in resource-limited settings. For example, at UTH, we found that nearly one third of all patients admitted with stroke developed aspiration pneumonia. Sixty percent of those patients died, compared to 8% of patients without aspiration pneumonia. If we can implement systems of care that use proven, low-cost interventions to minimize preventable causes of death, we may be able to save a tremendous number of lives.
It’s important to recognize how severe the burden of neurocritical illness is globally. Neurologic illness is the greatest driver of disability worldwide, and about half of that disease burden is due to stroke. Stroke is the number two cause of global mortality, second only to ischemic heart disease. Burgeoning access to motor vehicles has led to a massive global increase in road traffic collisions, and an aging global population has increased the incidence of trauma from falls. Both of these factors have conspired to create a global epidemic of traumatic brain injury, the overwhelming majority of which occurs in low- and middle-income countries. Rates of meningitis and encephalitis remain important drivers of neurologic mortality worldwide, and survival gains from increased access to vaccines and antibiotics have been smallest in poorer countries. Bending the curve toward more favorable outcomes from these conditions is likely to depend, in part, on the implementation of evidence-based interventions that improve quality of care in ways that are feasible, affordable, and scalable across a wide array of health care settings.
Q: What advice would you give to residents interviewing for any kind of fellowship on how to approach programs about one’s interest in global neurology?
If someone is serious about incorporating global neurology into their fellowship training and their career after training, it helps to have a well-articulated sense of the specific issues they are interested in working on and how that might fit into their training curriculum. Having the time and mentorship to pursue those goals is very important, and the more specific one can be in articulating their ambitions, the easier it will be for a prospective fellowship mentor to help think through how to make things work. I was fortunate in fellowship to have a fantastic program director who took my global neurology ambitions very seriously, and who worked tirelessly to foster the opportunities that helped me grow this aspect of my career during fellowship training.