Q&A: Neurology Fellowship in Haiti, Now Led by First-Ever Graduate, Continues to Evolve

When Dr. Aaron Berkowitz read Mountains Beyond Mountains during medical school, he quickly became interested in Partners In Health (PIH). But he wasn’t quite sure how a neurologist could get involved in global public health. So he reached out to PIH leaders, including Drs. Kerling Israel and Michelle Morse.

“And they said, without missing a beat: you can teach,” says Berkowitz, PIH’s neurology advisor. “You can build systems of care around neurology in Haiti. There’s tons of stroke, Parkinson’s disease, epilepsy, migraine, and other neurological disorders and people need to learn how to treat these conditions.”

Since that eye-opening conversation, Berkowitz has helped develop the first neurology training program in Haiti, in collaboration with Zanmi Lasante, as PIH is known in the country, and the Department of Neurology at Brigham and Women’s Hospital. The program is one of many offered through Hôpital Universitaire de Mirebalais’s medical education program, which has trained 152 clinicians since 2012 in residences across family medicine, pediatrics, internal medicine, nurse anesthesia, surgery, emergency medicine, and OBGYN. There are also fellowships in plastic surgery and emergency sonography.

In Berkowitz’s new book, One by One by One: Making a Small Difference Amid a Billion Problems, he discusses his work with PIH through the story of Janel, a young man in Haiti who had a brain tumor removed through surgery in 2015 and continues to receive support from Zanmi Lasante’s mental health and social work teams, among others. The conversation below, edited for brevity and clarity, gives an inside look at the book and highlights the importance of neurology training.

What inspired you to begin the book with PIH’s mission statement?

When meeting patients like Janel with advanced, debilitating neurologic disease in rural Haiti, I asked myself, “how am I going to live up to the mission statement in the context of these patients and as a neurologist?” This book traces how I wrestle with that question in collaboration with our colleagues in Haiti. I had read the mission statement and quoted it in talks about my work with PIH, but I think there’s so much depth to the statement and every time you read it, having done this work, you go a little deeper into it. You can read about PIH, donate to PIH, work for PIH, but what PIH is really asking us to realize is the accompaniment model—and what does that really look like? And that’s what I wanted to bring out in the book. I think Mountains Beyond Mountains is in some ways a hero’s tale of larger than life figures like Paul Farmer, Jim Kim, and Ophelia Dahl. In my book, I wanted to zoom in on someone who is just a regular person like me–a neurologist who got interested in PIH and asked “how can I help?” I kept returning to that mission statement, and so after I finished writing the book, I decided to put it at the beginning because it is the guiding principle for our work.

A conversation with Dr. Kerling Israel (detailed on page 149), PIH’s senior advisor for medical education in Haiti, made you realize neurology was equally important as other needs in Haiti, such as tuberculosis and malnutrition. Shortly after, you helped start a neurology training program. How has the fellowship grown since it began nearly a decade ago?

I began working with PIH in 2012 and at the time, there was one neurologist for all of Haiti’s 11 million people. That would be similar to having one neurologist for all of Manhattan or Los Angeles County. And most medical school students in Haiti were not having any contact with a neurologist. Primary care doctors who were seeing patients with neurologic diseases didn’t have significant training in neurology because there was no neurologist to teach them. Before HUM was built, I started working at Hôpital Saint-Nicolas de Saint-Marc with PIH’s family medicine program, which was in its first year. Our goal was to try to help these front line doctors care for their patients with neurologic diseases. Then when HUM opened and started their residencies, we did the same for their internal medicine residents. Around that time, the one neurologist in Haiti died, so there was a huge gap. We realized the best way to improve neurology care in Haiti was not only to increase the neurology knowledge of primary doctors but to train a few neurologists. So at HUM we started Haiti’s first neurology training program, a two-year neurology fellowship for graduates of internal medicine or family medicine residencies in Haiti. 

Dr. Francois Roosevelt was our first graduate. He was our pioneer and he did phenomenally. During his first year, Zika came to Haiti and we started seeing a lot of cases of neurologic disease related to Zika. He presented the results of what we saw at a national conference in Boston and won an international scholarship. There’s since been two more graduates (one works in Hinche and the other in St. Marc) and the fourth trainee graduates in 2022. And for the first time, this year we have two first-year fellows. I like to say that we increased the number of neurologists in Haiti by infinitely because we went from zero to a few. 

Ultimately, our goal is to have a neurologist in all 10 regions of Haiti over the next 10 years.

You write in the book (on page 46), “HUM is a testament to the depth and breadth of PIH/ZL’s thirty-year commitment to and collaboration with the communities they serve.” With that in mind, how did it feel when HUM received international accreditation last year, affirming it meets the highest global standards as a teaching institution? 

It was an amazing moment. I remember my first visit to Mirebalais, after HUM just opened, and people had already begun working to make sure the program met international standards. While I wasn’t part of that team, many people I work with and admire, including Dr. Kerling Israel and Dr. Michelle Morse, who are both profiled in the book, contributed to the amazing accomplishment.

What impact has the COVID-19 pandemic had on neurology training in Haiti?

Despite very challenging circumstances, the program is still running under the leadership of Dr. Francois, and the neurology clinic is still seeing patients. The goal of the program was always to make it a Haitian-run, independent program. And even before the “Zoom era” with COVID-19, we started having some faculty teach and discuss patient cases remotely. There’s a lot you can do remotely, but there’s nothing like examining a patient in person and being able to discuss the patient’s case with another doctor. But the silver lining is we were actually able to grow the team and now have more people supporting neurology remotely, including sub-specialists in Parkinson’s disease, epilepsy, and stroke whereas before we just had a small group of neurologists who could spend time on the ground in Haiti. 

What do you want readers—both new to PIH and longtime supporters—to take away from your book?

The goal in writing this book was to highlight the challenges in Haiti—they may seem insurmountable, but they’re not. I also wanted to profile the extraordinary courage and faith of the patients whose stories I tell. They wanted their stories told so other patients did not lose hope that there is always a possibility if you are courageous and faithful. These are some of the patients who have the least access to health care and the least access to any resources and are some of the poorest patients in the world. What does it mean to be in “solidarity and not charity alone” and to “provide healthcare as if we were providing it to members of our own family” as the PIH mission statement inspires us to do? I tried to answer that question through this book.