- At the request of leaders in Somaliland, a country in East Africa that's impoverished following civil war, faculty at Massachusetts General Hospital helped establish a dual residency program in psychiatry and neurology there
- Along with teaching medical knowledge and skills in Ethiopia and Somaliland, the program prepared residents to lead multidisciplinary teams, teach allied clinicians and laypeople and conduct mental health research
- The residents had to be relocated twice, once because of tribal fighting and later because of the COVID-19 pandemic; the complete unreliability of internet service in Ethiopia was a more minor challenge but had no solution
- The authors are available to consult with educators who would like to offer neuropsychiatric training in additional countries where there is substantial political and civil unrest or other severe barriers to psychiatric and neurologic care
In the least developed countries, a shortage of trained physicians is one of the most important causes of the extensive burden of neuropsychiatric disease. To address a severe shortage of clinicians in Somaliland, faculty at Massachusetts General Hospital recently helped create a dual residency program in psychiatry and neurology there.
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Zeina Chemali, MD, MPH, medical director of the McCance Center for Brain Health in the Department of Neurology and a neuropsychiatrist in the Department of Psychiatry at Mass General, Gregory Fricchione, MD, associate chief of the Department of Psychiatry, and colleagues describe in The Journal of Neuropsychiatry and Clinical Neurosciences the development of the program and substantial challenges that had to be overcome.
Somaliland, a self-declared state in East Africa, is internationally considered an autonomous region of Somalia. However, it remains in the throes of post–civil war regional conflict, and 82% of its 3.5 million people live in poverty.
The educational institutions in Somaliland provide specialty services in internal medicine and obstetrics, but they have few resources to recruit or train neuropsychiatric specialists.
The impetus for the Residency Program
At the request of the Somaliland government, physicians at Mass General and Boston University (BU) School of Medicine drafted a strategic plan for a dual residency program in psychiatry and neurology. They partnered with the president of the University of Hargeisa in Somaliland, the chief of the Hargeisa Neurology Hospital, and other top local clinicians.
The Boston-based collaborators had experience in developing and administering this type of program and a history of successful healthcare collaborations in the region. They helped secure funding from a private foundation.
Elements of the Program
The Boston group and their Somaliland counterparts planned for residents to be exposed to all major topics in neurology and psychiatry over 36 months (18 months per specialty). The innovative curriculum emphasized community-based, rural-based, and problem-based education.
Along with demonstrating medical knowledge and skill, the residents were expected to learn to lead multidisciplinary teams, teach allied clinicians and laypeople, and conduct research on mental health issues. The curriculum, a culturally sensitive training module on cognitive-behavioral therapy, was selected because fast and practical delivery is possible in both community and hospital settings.
Local university hospitals offered grand rounds, specialty rounds, group supervision, and faculty-supervised tutorials. Mass General and BU sponsored regular videoconferences for presentations, grand rounds and supervision.
Dr. Chemali made quarterly in-person visits to participate in clinical rounds with the residents, supervise their presentations, provide individual and group supervision and support on-site faculty in implementing the curriculum.
The Oromo insurrection—The residents started with psychiatry training at Jimma University near Addis Ababa in Ethiopia. Unfortunately, they soon had to be evacuated by the Ethiopian government because of a flare of the longstanding conflict between the Oromo and Somali ethnic groups in Ethiopia.
The residents' training was moved to other hospitals in Addis Ababa. However, the fighting led to casualties among Somalis, and the residents remained anxious about their families in Hargeisa. Because of the civil unrest, they could not return until months later, when they began their neurology training in 2019.
Internet service—In Ethiopia, high-speed internet service was inconsistently available for videoconferences and other elements of the program, a concern with no clear solution. Internet access in Ethiopia is highly regulated, and governmental shutdowns occur frequently and unpredictably without prior notice.
The COVID-19 pandemic arrived on the African continent in mid-April 2020. The residents were excluded from their current training site, a large public hospital run by the University of Hargeisa. They were relocated to Hargeisa Neurology Hospital, where they provided psychiatric services and their time was reallocated to scholarly projects.
Success Despite Extraordinary Difficulty
Ultimately, the program graduated three well-trained, competent specialists. In the face of literal threats to their lives, these courageous, determined individuals realized their dream of becoming their country's first cohort of brain health specialists.
Efforts are underway to further develop this program and also to replicate it in other low-resource countries. Already, a similar dual-residency program is ongoing in Liberia. The authors are available to consult with other educators who would like to offer neuropsychiatric training programs elsewhere in the world.
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