Neurology Beyond Borders: Latin America

Forget the assumption that modern neurology only thrives where resources are abundant. We sit down with Dr. Daniel Ontaneda and Dr. Nelson Maldonado—two Ecuadorian neurologists driving change across Latin America—to explore how world-class care is built on clinical craft, cultural fluency, and relentless advocacy. From bedside localization when the MRI is down to expanding stroke thrombolysis from a handful of cases to hundreds, their stories reveal a system where expertise is abundant but access can lag—and how that gap is closing.

We retrace Dan’s journey from Quito to leading-edge MS research, and Nelson’s decision to return home to build services few believed possible. Together they unpack what training looks like across the region, including long-format medical school, rural service, and residencies that demand deep exam skills. We compare public and private systems in Ecuador, break down why patients often want clear directives rather than options, and examine how cultural beliefs and language shape adherence. The conversation digs into MS treatment in low- and middle-resource settings, the rise of highly effective disease-modifying therapies, and the pragmatic use of cost-effective options like rituximab.

The episode also exposes a hidden threat: substandard medications entering through price-first procurement, undermining both acute care and chronic neurologic disease. Yet the momentum is real—regional MS registries, imaging collaborations that move faster than heavily regulated systems, and conferences that bring neurocritical care and MS experts under one roof. Even subspecialists practice broadly, treating Parkinson’s disease, epilepsy, headache, and ICU cases in the same week, sharpening an exam-first mindset that delivers results.

If you care about global neurology, stroke systems of care, MS access, and the practical ethics of delivering evidence-based treatment under constraints, this conversation will challenge assumptions and spark ideas. Subscribe, share with a colleague, and leave a review telling us where neurology should invest next.

Chapters

• 0:00 Season Four Goes Global
• 1:06 Why Latin America First
• 2:14 Guest Intros And Origins
• 2:59 Dan’s Path From Quito To MS Leadership
• 5:20 Training Without MRIs And The Exam’s Power
• 9:29 Nelson’s Return To Build Systems
• 13:16 Scaling Conferences And Stroke Access
• 17:36 How Neurology Training Differs Across The Region
• 22:01 Treating With Limited Data And Cost Realities
• 25:22 Public vs Private Care Gaps In Ecuador
• 30:45 Clinical Skill, Volume, And Generalist Roles
• 34:09 Culture, Beliefs, And Communication Styles
• 39:00 Medication Quality And Procurement Pitfalls
• 44:10 Research, Trials, And Regional Registries
• 49:30 Mentorship, Networks, And Knowledge Flow
• 52:37 Rapid-Fire No-Brainers And Closing

Transcript

Season Four Goes Global

SPEAKER_00 0:16

Welcome back to the Neurophilia Podcast, a medical education podcast dedicated to dispelling neurophobia one conversation at a time. We are your hosts, Dr. Newper Goyle and Dr. Blake Baleco. In season four of the Neurophilia Podcast, we are taking neurophilia beyond borders. Neurology is often taught through a narrow lens, but the practice of neurology is deeply shaped by geography, resources, training systems, and culture. To truly understand the field, we must look globally. We are starting this journey in Latin America, a region rich in clinical expertise, innovation, and resilience. Today's episode explores what it means to practice neurology in this part of the world, how neurologists train, how they care for patients despite unique systemic challenges, and how neurologic disease presents and is managed in diverse settings. We are honored to be joined by two outstanding neurologists who will share their personal paths into neurology, their experiences, and the lessons they believe neurologists everywhere can learn from Latin America. Let's begin our season four adventure. Dr. Dan Antoneda and Dr. Nelson Maldonado, thank you so much for joining us on the Neurophilia Podcast. We are so grateful to have you here. Before we start this podcast, I'd love to hear where you both are calling in from the first one.

SPEAKER_02 1:39

So thanks so much for the invitation, Hooper and Blake. I'm calling in from the Cleveland Clinic, which I now call my home. But of course, originally I am from Quito, Ecuador, South America.

SPEAKER_03 1:51

Hiper, I Blake. Thank you so much for the invitation. Calling from Quito, Ecuador, K by From the US, and we have here a center that is called QRA. That's what I'm hearing about.

Guest Intros And Origins

SPEAKER_00 2:04

Wonderful. And we were talking before recording that Nelson's background is just beautiful and there's a bunch of nature there, and it looks a lot warmer than where the thro the three of us are recording from. Where we like to always start our conversations is understanding what inspired you to go into neurology and sort of walking us through the journey of the beginning of your interest to what landed you where you are today. And so, Dan, why don't we start with you? Can you briefly share your journey into neurology?

Dan’s Path From Quito To MS Leadership

Training Without MRIs And The Exam’s Power

SPEAKER_02 2:33

Yeah, for sure. I was always fascinated with the brain. I think from early on when I was in medical school, what attracted me the most was actually neuroanatomy. I found it fascinating. I kind of memorized all this neuroanatomy that I have to admit right now I do not use almost at all. So it was a lot of useless information that I learned for a period of my life. But I kind of realized that I was attracted to hard problems and probably not straightforward problems. And I think a lot of people who go into neurology are similar in that sense, kind of this detective sense. And I was early on exposed to neurology in Ecuador, which was extremely clinical. So I remember when I did my training in the public hospitals where I trained, there was no MRI machines. And in many of our public hospitals, there still is no M are no MRI machines. And so it was complete reliance on the neurological examination plus sometimes a CT scan. And that process of neurological localization, syndromes, etiologies, and then ultimately treatments, really was what got me hooked. And I was like, this is what I want to do, you know, for the rest of my life. And I had a family member actually in the U.S. who was affected by multiple sclerosis, and that led me to do some work at Baylor College of Medicine with a person who was, I would consider kind of my first real mentor, who was Victor Rivera, who's a true Latin Americanist. And he was from Mexico originally. But I think what he taught me early on was the importance of being connected and being very proud of being Latin America. I think one thing that happens in Ecuador is that people tend not to be super proud of our country and we try to see all the faults with it. And it was so refreshing to see somebody who was so proud to be Latin American and to have Latin American connections. And that really stuck with me. And I think that's a part of the I think, you know, mentorship that he he gave me and he introduced me to Clinical MS. And then I went on to do multiple sclerosis in in Cleveland, Ohio. You know, it's cold and snowy here, so you know, it was quite a departure from Ecuador. But I had grown up in Canada, so it was a little bit of I was already used to the snow a little bit. And I came to the Cleveland Clinic because of our multiple sclerosis center. You know, it's one of the largest multiple sclerosis centers in the world. And you know, I had seen kind of multiple sclerosis care in several different settings. I had the you know, personal family connection with it. And this, you know, that's what I wanted to do because it was a disease that you could actually intervene on, right? And I think early on when I was uh you know starting out my residency, it was one of the few neurological diseases where we have true disease-modifying medications for. And so being able to not just be an armchair neurologist, but somebody who actually changes the course of their patients' lives, I think, was super exciting. And probably as people who do stroke, yourself and and and Blake probably also feel that way. And I think, you know, then I took a path of mainly doing research. I have always done clinical care and very translational resource that is like actually touching patients. And one of the things I tried to do at all times was to remain connected with Latin America. And so I have colleagues and friends in almost every country in Latin America, people I know, and it is just a such, such a rich exchange, and it's really one of the parts of my career that I value the most.

SPEAKER_00 6:07

That was beautifully said, Dan. Thank you so much. Nelson, could you walk us through your journey as well?

Nelson’s Return To Build Systems

SPEAKER_03 6:13

Sure. I don't think it was as long as the Frontaneras one. But I was we were actually at the same university. I was a couple of years below Danielle. And what I saw in my university was that as Daniel was saying, we went to this rotation in neurology where, first of all, in Ecolore, you didn't have a neurology residency. So there were like two or three neurologists that were coming either from Europe or from other countries in Latin America, and you have all these very obscure diagnoses for us because we lack technology. So we were talking about meningitis, and we were talking about possibly a brain tumor and epilepsy and all these things in the public hospitals, but there was no MRI, there was no EGs. It was a very different thing from any other special. It was like this has no solution ever. And unfortunately, if you don't have the right technology and you don't do the right decisions, you don't have the best outcomes all the time. So it was a very, very difficult area of of specialty in Equal. So my idea of do neurology was because I always want to work in my country. So I saw neurology as a major, major deficit in Equal. And that's what why I decided to do neurology. I did my residency at Kendrick World Calls with Human Detroit Michigan. I I really enjoy my time in neurology. My work very done into pediatric pediatrics. But what we really enjoy about Detroit was either either though that it is seen as a as a low-income or more chronic disease type of state in the US. For me, nine color is exactly how color is. So um I ended up doing ICU at the Baylor College of Medicine in Houston. So I was from 2013 to 2015 in Houston doing a pretty poker, as my wife was doing pediatric ICU for the same reason. And we were back in Ecuador September 1st working in the public system, and from then on I have been in Ecuador for for a little bit more than a decade. It is wonderful because like the movie Back to the Future is like you remember all that is really logic that is happening in the States, and you go to Ecuador, especially in the public system, and you see that there's nothing happening. So when I first came to Ecuador, imagine that was 2016 or 15, 16. And TPA was not a medication that was given for strokes in the public sector. So you were giving TPA for the private sector, right? Which was about five TPAs a year in the country, but TPA was not a medication that you were able to get in the public sector, or MS medications you were not able to get. And Dr. Antaneda helped us bringing medications or making the pharmaceutical companies see in Ecuador as an option, and then we had another issue which was generic medications. The kind of issues that you have in the US is a very easy medicine comparable during the developing country. You have to you have to fight against the whole system all the time, and it has been a very cool path because we were we have been able to do a lot of big things with with Daniel from the get-go. We start a conference, so our conference is the only one that puts neurocritical care and MS at the same time, right? But we were able to be so successful that before COVID 8, the last conference we had were 70 speakers. So we had basically half of the neurocritical care directors and all the MS directors from the US coming to Ecuador, giving talks about a thousand people in the audience, even people from all Latin America and even from the US joining us. Then we threw everyone to the a lap house. We wrote a couple of papers about the gaps in neurocritical care, and we did the same with the MES in stroke, which I think is the biggest way. We're able to put in TPA in the basic medication base. And we went for giving 510 TPAs a year to giving 500 TPAs a year. So it's like our developing countries get stuck on time. There's no more information coming from because everyone who goes stays, and it makes complete sense because it's too difficult to come back to the reality that we have here. But if you come with this knowledge, you change a lot.

SPEAKER_00 11:04

That's incredible, Nelson. Thank you so much for walking us through that. And I thought there were so many important parallels that you dropped along the way. One of the things that I found extremely interesting was your reflections of Ecuador and then where you practice residency in Detroit and how you saw a lot of similarities in terms of socioeconomic barriers, as well as the sort of the wage disparities and how access to care differed and the considerations and thought you put into bringing all the knowledge you gained from the states back to your home country and providing care in Ecuador. You know, something that both of you have talked about was sort of a little bit about the training process in in Latin America. And we we use that term broadly and we hope to define it during the course of this episode. I'm wondering if one of you could briefly mention how the training process to become a neurologist is like in Latin America.

Scaling Conferences And Stroke Access

How Neurology Training Differs Across The Region

SPEAKER_02 11:58

Maybe I can start out and then Nelson can can chime in. I mean, I think, you know, I think one of the big differences between medical training in Latin America and the United States is that in Latin America, as is in the case in a large portion of the world, typically we have six to seven to eight-year medical school programs. And that's pretty much the norm. And after that, one typically does complete a year of rural medicine, at least in Ecuador and several other countries in the region, it's the same. It's a social service. And so many countries in Latin America, medicine or studying medicine is subsidized by the state. And one of the ways that the state gets a return on their investment is actually by having young graduating physicians practice in regions that are underserved. And so it's typical rural or tropical. And then after that, then you can actually start your training in neurology. And I would say that this is where there's a lot of variability across Latin America. I would say there are countries where there are many, many established neurology residencies and also fellowships that are well structured based in universities, countries like Mexico, countries like Brazil, countries like Argentina. And then the rest of the region, it's a little bit more precarious. Countries that have one or two residencies, some countries that don't have neurology residencies. Neurology residencies are typically small. The structure is typically, you know, depending on the country, either one year of internal medicine plus three years of neurology, similar to what we do in the States. Other countries have a requirement for you to do internal medicine three years and then actually go on to get formal training in neurology. One of the differences I would say that is, you know, I think significant is that many times residencies in many countries in Latin America are not paid, right? It's not like it's a job. It's actually you have to pay to get residency training. You have to pay a university to enroll into a program. And so, you know, one, it's a financial hardship. And two, it requires people to, on top of getting, you know, you know, having their job as a neurology resident, many times they have to work in other hospitals to kind of help, you know, make ends meet. And I would say that another difference is that many countries in Latin America, neurology residency has a formal curriculum with classes in universities, which is a little bit different than how we do things here in the United States, where it's mainly basically clinical training. And then I would say that, you know, after that, there are several neurology programs that require a thesis. So it's much more kind of university-based before you can graduate. And then I think the career path after that basically is either go into practice or then you actually do some subspecialty training. In countries like Argentina, Brazil, Mexico, many times those fellowships can be done in those same countries. And for example, in neuroimmunology, there's a couple or handful of places in Latin America where you can do a fellowship. But it's not uncommon for then neurologists to go to other countries to do subspecialty training. So a fellowship, for example, many people come to the United States. Some people, I would say the majority probably go to other places in Latin America where they can do it, Mexico, Brazil, Argentina, or even Europe. And then after that, once you're done, when you come back to practice, very different than it is in the United States, and Nelson can probably talk about this, is that you know you've fully trained in neurocritical care, but you can't just do neurocritical care. That is, you're not really just going to be practicing in the scope of your of your subspecialty. And I would say that the clin the training is much more clinical. And so there's a much higher reliance on your clinical acumen in general in the entire region. And the reality is that the availability of tests is improving. But many, many times in the public sector, those tests are not available through the public system. And so, for example, if I see a patient who has episode of optic neuritis and transverse myelitis, and my suspicion is high for NMO, if I'm in the public hospital, I can try to order the NMO. Many times it won't get done. I have to actually order the test so it can be sent somewhere else, Colombia or Mexico. And in many circumstances, that will be an out-of-pocket expense for the patient, where the cost of the test represents, you know, easily, you know, what's up, you know, a whole week's worth of wages. And so many times they just don't get the tests. And so you're constantly in this environment where you're living with, you know, you only order the things that are a bare necessity, right? And so you become very judicious about how you order tests. And so one of the things that you adapt to when you come to the United States is that here we kind of order everything under the sun and at you know, at subspecialty hospitals like the Cleveland Clinic and MGH, you know, we really don't even think about the cost associated with these versus in Latin America, many times it's an individual decision that's made based on kind of the finances of the patient, which is said it shouldn't be like that. But it also makes you very judicious and it makes you rely on your clinical acumen much more. So you know, I think in general, I would say the fellows, for example, that we take from Latin America, and we have plenty of people who come rotate here at the Cleveland Clinic. I have to say that I am so impressed. Every time they come, their clinical acumen is amazing. They are amazing clinical neurologists in Latin America because they have to rely on their clinical skills to get good outcomes.

SPEAKER_00 17:42

If I can ask a follow-up question, Dan, I'm I'm I'm very curious about this. And then I'll like I'll up like tick over. But you know, you're you were talking about if you're concerned about someone having an MO or MS based off if they're having optic neuritis, transverse myelitis, you know, area postrema syndrome, what have you. And let's say you can't get imaging, let's say you can't do an LP. How are you going forward in either treating with steroids or starting DMT? Like how do you make that decision with very little data?

SPEAKER_02 18:11

I mean, I think you have to really trust your clinical judgment, right? At the end of the day, you know, if you can get the test, great. If you can't get the test, you kind of make an informed decision with the patient and you tell them, listen, you know, I'm, you know, not 100% sure, but I think this is most likely what's happening. I'm going to treat it as such. You know, the advantage in your immunology is that a B cell depleter is kind of good for almost everything. So we've got that advantage going for us in terms of the difference between NMO and MS. But I think the reality is that you, you, you tend to trust your clinical judgment, you know, much more. And, you know, it does make practicing, I think, a little bit more difficult. But at the same time, you know, I think that it makes you also, you know, think a little bit more about your patients and the details and, you know, what helps differentiate one theme with another.

SPEAKER_01 19:03

You know, I'm curious about a few things that have been brought up so far. I mean, first, Nelson, hearing the story about TPA, I mean, you know, the NINS trial happened and was published in 95, and FDA approved here in the States in 96, shortly thereafter. I mean, one year turnaround. Um, and then hearing your story about it getting to Ecuador, I think for me as a stroke neurologist, I mean, that's our bread and butter, right? So I I guess just hearing that was super impactful. And then I'm curious, we've heard a couple things said about the public sector versus the private sector and what that might look like. How does care differ in these sectors? Can you talk a little bit more about this, at least in Ecuador, and and what the care models look like in those different sectors?

Treating With Limited Data And Cost Realities

SPEAKER_03 19:45

Of course. And it is the MF is completely different. Like in my private hospital, I TPA. I don't have to make the place yet. I can do in the from I have everything. I have my MRIs and I have I have almost all everything the same as the states. In the public sector, when I came back, I was leading the urology department at the Hospital Genius Pejo, which is known to be one of the most important public hospitals, the specialized hospitals in Ecuador. As Danny said, there's an MRI, but half of the time is not working because it's out of maintenance or there's something that is missing. And myasthenia gravitation, for instance, we don't have how to order the antibodies. So we do in fear diagnosis, which means, oh, it looks like it. Let's keep some mestinal, let's keep some predism, it's improving. It is in the myasthenia gravitation, right? So you become fearless. But you could you become fearless when you are coming from a place like the states that you understand the other part, right? I have this Greek professor of mine that he always tells me, you don't know what you don't know. Because I was always very impactful and I was telling him, How do I make this decision happen? And why the guys here are not as scared as I am to make a diagnosis or or to give medications, right? The only IV medication we have in the public hospital to decrease blood pressure is IV nitroprussate. Right? If you go to the guidelines for anything that has to do with ICP in the brain, is please don't use nitroprussate. Right? Now I have a patient who has high blood pressure and only nitrocruciate. And if you use it, please get rid of it as fast as possible. So a week out of IV nitroprussate, and I am scared at what point this patient is gonna have a major crisis, and I never saw a major crisis come. Now, you don't know what you don't know, but the people who train here or who works here all their life, they haven't seen the other end. So as Danny said, they become very good clinicians, but to the point of their own experience. Right? So I have seen this 10 times of 11 times I should do this. When you are when when you are training here, there's no such thing as simulation centers. Now they have startups to become uh to have simulation centers, especially the very big places around South America, right? Or you don't have the clinically oriented uh rotations in which you are only seeing the mess and you're only seeing stroke, and you are only seeing peripheral rotation, right? You have everything coming all at once. So to learn that way makes it makes it very, very difficult, right? And and your learning afterwards comes out of whatever experience you have seen. And when the experience for something like neurology comes without imaging, comes without basic blood tests like a mystenial gravity antibody, or comes without an each for a seizure, you can you you just know how to predict things, but not really are making a full diagnosis.

SPEAKER_01 23:15

You don't have to have exact numbers for me, but I guess what part of the population or percentage of the population about have access to private hospitals?

Public vs Private Care Gaps In Ecuador

SPEAKER_03 23:25

90% of the population goes to the public system, 10% of the population go to the private system. Now, in the public system, at least in Ecuador, and that is very different from country to country, so I wouldn't generalize in Latin, but we have something that is called the social security. So there is three three layers of medical systems. You have the social security ones, in which you tend to have more technology, but at least half of the time is not working, right? And then you have the private group, which they have everything. In the hospital where we work at we have two MRI machines, and we have five CAT scans, and we have a biplane for doing convectomies, etc., etc. Right? And then you have a third layer, which is the biggest group, which is a group of people that are not working formally. So they don't have a formal work, which means they don't have access to the social security hospitals. And they go to the Minister of Health ones. And these ones are these ones are the poorest hospitals of all, and are the ones that's in most of the people. So, in a specialty like neurology, when we were working with the MES, it's difficult. It's difficult because we couldn't do oligo coronavirus, right? And if we were doing an MRI, if the if the hospital didn't have the MRI machine working that day, they the patient has to go to an MRI outside, to a private location that has some sort of collaboration. Now, most of the private hospitals don't have collaboration because differently than in the US, that Medica and Medicaid might pay less for the dollar, but they do pay. In Ecuador, they don't pay to the private institutions, and then the private institutions get in problems because they they they get no payments for things. They don't so they tend not to have a good collaboration, right? So it becomes very, very difficult when you are a specialty that is technology-based, and you can be the best of the clinicians, but still the best of the clinicians, up to your knowledge, because you never compare, you never say, Oh, I was so good that I was able to diagnose a temporal brain lobe tumor, because I know that there was a temporal brain tumor later when I did the image. Yeah, I think that is that and it remains like that. So it's difficult. It is difficult to see how big the gap is, even in the same country between the public and private. Now, on the other end, you have you have a lot of people. So when I when I came to Ecuador, a lot of people from the states that were really happy coming and seeing this other way of doing medicine and helping us improve. Right? Imagine that we can have a brain aneurysm, we can have a superignaric hemorrhage with a diagnosis of brain aneurysm three days later when they were able to do the cut cutscene, the CTA, and the guy was laying down on the bed for 21 days with that aneurysm open because we couldn't coil it. We didn't have the stents, we didn't have the so from time to time I will get a visit of a couple of my friends with their bags and sticks full of stents and coils. Uh marathons of stenting or coiling everyone around because at any given point I can have in my list of aneurysms that need to be closed 100 people. And I thought in the beginning that, well, if we do this, maybe we can help. The problem was when the rest of the country understood that we were able to call from time to time, the list was always bigger after we were finishing to do it. It's sad because there are many things that you know that you can treat and that they will be better treated in and seeing that they are not able to get the correct treatment, it it is the bad part of the developing country, and it is the biggest amount of population.

Clinical Skill, Volume, And Generalist Roles

SPEAKER_02 27:36

Yeah. I I but I would like to kind of reflect a little bit on kind of the inverse of you know how actually, you know, I remember when I was a medical student and I came to the US, the gap in knowledge was large. It was very, very large. So that the stuff that we got taught was mainly from textbooks back then. And, you know, I I remember that neurology seemed like a completely different field when I went to Baylor to rotate as a medical student, like completely different. And what I've realized is that over the last, you know, several years, that differential in knowledge is smaller and smaller and smaller. And you know, now information exchange is immediate, right? And that's one of the things that I think, you know, to me amazes me most about kind of Latin America, which is despite having not as much resources, despite not having as much tests, Latin American neurologists are completely up to date on the latest treatments. And I have to say with confidence, you know, I you know, my area of expertise is multiple sclerosis. I visited almost all countries in Latin America. And I have to say that the neurologist expertise in terms of management is very, very good. I mean, there's not a there's not a knowledge gap anymore, especially when you're talking about subspecials, so people who dedicate themselves to multiple sclerosis treatment. And like Nelson says, the gap is a little bit more on the technology, but at the same time, there are some benefits of of working in in Latin America. And so, you know, I'll tell you a funny story. You know, I spent the past 10 years trying to develop something called the central vein sign for multiple sclerosis, which we finally got into the diagnostic criteria. And I've been trying to convince the Cleveland Clinic neuroradiologist for several years now to use the central vein sign. And you know, the reality is that here it's highly regulated, right? And if it's not an FDA-approved scan, we can't use it. And time is a major limitation. So any minute that you add to a scan is essentially, you know, will increase the time of an MRI. And so not just at Cleveland Clinic, but across all our network of North American Image and MS centers, we had a lot of difficulty getting the central vein scan imaging as part of the protocol. And I can't tell you how many times, you know, I get patients from Latin America who have beautiful central vein sign images. Why? Because it's just a conversation with a radiologist and it just happens, right? And so there are some advantages, I think, of practicing in Latin America, that there's a little bit more flexibility sometimes to get stuff done that we can't in the United States. So as, you know, I I think we painted the picture that, you know, for a lot of people, access to care is difficult. I would say that uh the way neurologists compensate for that difference is you know, they're inventive, they figure out ways around problems, and and and that's something that's really that's really humbling. And it kind of makes you reflect that, you know, wow, I'm here at Cleveland Clinic, and these people can figure out how to do stuff. There's surely a way that we should be able to as well.

SPEAKER_01 30:56

I was I was just thinking a little bit on that point, too, to shift gears just slightly. We've talked about subspecialization, but we've also talked about you you both are subspecialty trained, but practicing in Latin America and Ecuador, I would imagine that there are not as many subspecialists as there are here in the States. And even though you are subspecialty trained, we talked a little bit whenever we first started the conversation that you are not just sticking with your subspecialty training, and that's not all of what you do. So I guess can you walk me through maybe what it's like to be a subspecialist or how many people are just general neurologists in Latin America? And what does a typical patient volume or census look like either in a day or a week based off of what you're seeing in the hospitals and clinics?

SPEAKER_03 31:43

So here in Ecuador, for instance, all of the neurologists are general neurologists. We have a couple of guys that came from Spain that are FPHC, but the majority are general neurologists. In the sense of it all depends, like you're seeing patients in the public or the private sector. If you are seeing patients in the public sector, any day you do you do clinics every day, plus you round people in your in your department. So our department at Hospital Esteco had 30 beds, and those 30 beds were full all the time, plus whoever was waiting in the yard to be able to come out, right? And then you have 40 more beds from the researcher that were full as well, and you were taking care of them from time to time. In the private sector, it depends on how much the private patients look for, right? So if you are someone that people believe is well cleaned and well established, you are the ones who decide what your chances are. So for instance, I don't put more than 10 patients a day in my clinic because I like to stay and talk to them, and then I get my actual specialty neuroSU. And I'm doing general neurologic every single day. And I see some Parkinson patients, and I see some headaches, and I see a lot of anxiety in the youngsters now that they are confused with neurological problems, and I saw and I see a lot of MS. So I don't dare to diagnose a MS. Every time I have an MS patient, that patient gets teleconsulted with Dr. Dontaneda, for instance, right? And and if Dr. Dontonela, if the Nelson is MS, then we start everything the whole path. So it all depends. In other countries like Brazil, you do have energy training, then you are gonna have a lot of stroke doctors and epilepsy doctors, and so it depends a little bit on on where are you trained. But usually neurology as such is not a specialty that is seen completely broken into subspecialties or fellowships, and it's more a whole.

Culture, Beliefs, And Communication Styles

SPEAKER_00 34:03

And so it's it's interesting to hear, even as an intensivist, that you're treating Parkinson's disease daily. You know, something that we've talked a lot about during this conversation is resource scarcity and barriers to care, depending on if you're in the public versus private sector. Something that we haven't really talked about is cultural influences. And I'm wondering because both of you have done so much work in improving access to neurologic care in Ecuador, I think it was mentioned, Dan, that you've helped expand DMT treatment for MS in Ecuador. And Nelson, you've been involved with so many initiatives, including increasing access to TPA, helping develop brain death guidelines for patients in Ecuador. And I'm just wondering, as you as you take care of patients in Ecuador or try to bring, you know, new neurologic treatments and diagnostic modalities, what are sort of cultural limitations or things that people in the States should be aware of when it comes to Latin America? Understanding it's very diverse depending on where exactly you are.

Medication Quality And Procurement Pitfalls

SPEAKER_02 35:07

Yeah, I mean, I would say that, you know, there's this, you know, I think there's two issues. One, one is the kind of the cultural appreciation of the diseases that might affect the population, and the other one is kind of, you know, cultural differences in kind of how you talk to patients about conditions and their knowledge of them. And so I think Ecuador is a nice example, right? We know there's a latitudinal effect with multiple sclerosis, you know, higher latitudes we know are associated with uh higher rates of multiple sclerosis, even within the United States. And historically, Ecuador, you know, being on the equator was considered a place, at least I was taught when I was in medical school, that multiple sclerosis doesn't exist in Ecuador. It just plain does not exist. And then I actually took uh a neurologist who actually trained in Mexico and then did a fellowship, I believe, at UCLA with Wally Tortola and did some MS work while he was there. He actually came back to Ecuador in the 90s and started diagnosing all these MS cases. And you know, from there, it was like, well, MS exists, but MS is not a treatable condition, right? And so then, you know, DMTs were you know developed and you know, it was a culture shift and you know, to associate the fact that yes, MS indeed can be treated. And for many years, you know, individuals just use interferons or or or glutarium or acetate as kind of their main treatment. And then we have a paradigm shift in MS that occurred, you know, in the 2010s or so, where we started having highly effective disease-modifying medications. And that was a final shift in the culture where people were like, oh, we have to treat this medication with highly effective therapies. And now, you know, if you go to Ecuador, and it's uh I think something similar happened across all of Latin America. And it's very interesting when you ask, you know, when you ask neurologists in a room to say, you know, who here would use highly effective medication in a treatment naive patient? And I would say that 70 to 80 percent of neurologists in Latin America raise their hand and say they would use highly effective treatment in those patients. And then you ask them, how many are you actually able to use highly effective treatments? And then it drops down to like 20 percent of people or 30 percent of people, depending on the country. And so I think the neurologists have the knowledge, and then there's this little bit of lag between the neurologist changing the culture of the system within which it exists, you know, to actually impact the change. And I think that's where it's you know, it's helpful to have a couple of people who really believe strongly in a disease process and have the knowledge and can actually advocate and to health regulatory agencies. So I've spoken to health regulatory agencies in several countries in Latin America about expanding the use of highly effective medication as a first-line treatment. And to be honest, it it's ever growing. And so, you know, it's more and more now that you can see that. And that's modern treatment. And there's countries where you know people use Rituximab, which is a cost-effective medication, highly effective medication, and they use it basically as first line, and almost everybody gets it. So, you know, it's having a will, you know, it's kind of working a little bit against the system as Nelson was describing, but I think you can get through it. And then I think the last thing is that uh I think a lot of Latin America, and this kind of comes back to how is Latin America different? And you know, I I know we kind of recognize that countries like Canada and the United States are certainly melting pots because we received immigrants from a lot of places. But you know, I think the difference with Latin America is that we have really age-long cultural differences. So you have civilizations and cultures like the Aztec, like the Inca, who have been in the Americas for many, many years and had civilizations here. And so in several countries, there's this kind of mix of a European type belief system and a more, you know, you know, native or indigenous first people belief system. And especially when it comes to the belief of health practices, um, they are very different. And so I think one of the things Nelson probably remembers these classes when we were in university, we got these amazing classes on kind of, you know, it was called, you know, it was called alternative medicine, which is interesting, but it was the medicine of people in Ecuador that you know didn't use kind of traditional oxygen, you know, Western medicine. It was based on, you know, a lot of herbal products, a lot of you know, organic products that are used to actually. actually serve as you know treatments. And we were always taught that, you know, if you want to give your patient their, you know, cinnamon, right? And you give them their cinnamon with, you know, and Parkinson's can be probably a cold disease or a warm disease, you have to give it with the appropriate type of water with them, right? So that you ensure that they take the medication. And if you give them with the wrong type of herbal water, they can completely lose trust in you. And so I think that's, you know, we learn a different way of communicating with patients due to that. And you know, I think this varies, of course, across countries, but you know, I've been in places in in Mexico, for example, where there's they're purely indigenous communities. I've been places in Peru, for example, where you know many of the patients have very limited Spanish. They only speak quichua. So these are all kind of hurdles that you kind of have to overcome. There's no translator or anything. It's kind of you can use your your best ability. So you know those cultural differences are all the way from systemic things, government institutions, regulatory to belief systems of individual people. So it's it's a it's a beautiful and challenging region.

Research, Trials, And Regional Registries

SPEAKER_03 41:12

And and I think that one of the biggest biggest things at least for me that that I found here as a general reason because Danny was talking about indigenous people that is a small sector is a sector there that they believe in all these now technology medicine is medicine here is very important language. If I tell my patient you know what this is option A, option B, option C, what are you gonna choose? He's gonna tell me doctor I pay for a visit so you tell me what to do right don't give me options. Why don't you give me options you are the one who knows what is better for me. Right? So if you approach the American way or the way that we were teached that you have to give options to the patient you have to the patients get they don't like it right they are not all super genius of the diseases because they have read everything from Google or they have been already reading in in social media because whenever it comes to health people believe a lot in their doctors right and they have these things especially the elder they are like well first God then my doctor and then everything else so it it is a very different approach and it is approaching which whenever they ask me what will you do it is the normal answer to us if it was my case I'm doing this. Right? If you tell them well it's not my case you have to choose between these they will stand up and leave and go to the next doctor that will tell them what to do that's what they are expecting as patients. Another big I don't I don't know if if we can place it in the cultural place but one of the big big issues that we have especially in neurology is superstandard medications. Right? And the WHO has a full department of superstandard medications and in the developing countries more than 50% of medications that arrive at any given time are superstandard. And that is a huge problem and actually with the meal we have fought for for MS for the biological medications all the way up to the governmental agencies because in a small country and as being a developing poor country to say it in a in a way for for pharmaceuticals the main medication comes with a pharmaceutical no one is purchasing it because it's too expensive. The governments have a way to buy medications that is called a reverse auction right in which five medications come into place I'm gonna buy the cheapest there's no other there is no quality assessment there's nothing like that. So the cheapest medication gets bought medication done in some other developing country or maybe India Iran China non-FDA approved and then they come to the country and as soon as the other medication the real agent leaves the country because no one is purchasing these guys increase the price right so we have a lot of these here in Ecuador for instance they are called brand generics just imagine you have generics and you have brand generics so the brand generics are not they don't have uh FDA never review them EMA never review them we don't have our own agencies that review them they just wrote we do exactly the same as the other medication and if you get a side effect that is not the one that is placed on the real medication it's not us right because we are the same as the other medication and it is crazy that when I was in the public hospital there were times that we were giving heparin and heparin was the the the the the the the PTT was never coming up the PT was not coming up so you can see that on the acute medications right we were giving with Asalam at lethal doses and the patient was white away because it was not doing nothing. In the acute setting you can see that but in the chronic setting as MS you can have a patient that just keeps on worsening and they are blaming to something else. I remember I got into huge trouble once because I was leaving the the the the public hospital and there was this biological generic coming in and I I couldn't find a way to make them stop. I'm like no either we buy the real thing or let's just not treat the patient because it's worse for them. They're gonna have side effects. So I end up calling Daniel and Daniel make a whole consortium of their experts file and they wrote a note of why we shouldn't be given this medication. And then I was the political problems because they were saying that I want to I was power uh I was favorizing that the the the pharmaceutical company against this other one that is cheapest but that part for our diseases that are chronic it is a huge huge problem.

SPEAKER_01 46:02

It's a huge problem worldwide but it hits us much more than anybody else because as the developing countries our control and our regulatory agencies are close to non-existent and in and I think that is one of the biggest issues when you are treating diseases chronic diseases especially we talked about a lot of flexibility but we've talked about some inavailability of a lot of medications what is it like with regards to clinical trials and research collaboration amongst a lot of different countries in Latin America do you find that it's easier? Do you find that it's harder? What is your experience like with research collaboration?

Mentorship, Networks, And Knowledge Flow

SPEAKER_02 46:47

Yes and I think that's a fascinating question. And you know I don't think there's a simple answer to that. I would say in general one of the main problems is that there you know in in in Latin America in general there's very little resources to do research. And so biomedical institutions or institutions such as hospitals are devoting 110% of their effort to make sure that people get the care they need. And even with that it's not enough right just because hospitals typically are underfunded and the reality is that research you know with the exception of a couple places in Latin America Mexico, Brazil, Argentina, Chile, basically research has been done for free in your spare time. So you know this is neurologists that are spending their weekends and their nights instead of spending time with their family, they're spending time doing research. I would say that over the last 10 years or so there has been growth in the clinical trial space. And so as you know running placebo control trials, for example, has become more difficult as medications have gotten approved and I'll put the example of a mess, pharmaceutical industry initially started going to Eastern Europe because they said well, there there's people who don't have access to the medication so it's you know it's more likely that a patient will sign up to a placebo control trial. But even there, in those regions that has disappeared. And so there has been a lot of movement not only in neuronology but across other diseases in having clinical trials actually come in. And that works well. And I would say that generally it's you know it's done at the local hospital level and it's still done sites are then paid of course by pharmaceutical industry to recruit patients. And so it's not really research that's generated locally, right? So it ends up being that you're like a site for a trial, which is going to answer the question of a big pharmaceutical company that is probably headquartered somewhere in Europe or or in North America but might not be answering a pressing question for your need. But on the other side I think Latin American neurologists have the advantage that doing research is much cheaper. And so for example, you know in the United States while an MRI might cost$2,000 or$3,000 you know in Latin America and many countries it costs the equivalent of about$50 to get an MRI. And so it's much easier to do research. And a lot of places who have schools of research you know especially through the universities actually do compete for small grant awards typically to foundations and there are foundations that are focusing on doing research in in in in developing countries. And so there definitely are some resources and when you do get a little bit of resources it actually goes a really long way. So if the the example of Latin America is is phenomenal because we you know there's a consortium of Latin American neurologists who have created a registry for example for MS patients and it's a registry that has now thousands of patients. They're collecting clinical data on the individuals they are in the process of setting up an imaging collaborative so that they can collect imaging from patients. The regulatory process and tape red tape through this is much easier than it is for example in North America or in Europe. So there are some advantages to being able to do research. And you you start seeing kind of research productions from the region which are really remarkable. And I'll give the example of central vein and so there's plenty of central vein work for example that has occurred in Mexico that has occurred in Argentina that has occurred in Brazil that has occurred in Peru that has occurred in Panama and it's basically just patients donating their time, neurologists donating their time and I I think generating kind of questions that are important for the local population. And that's the one thing that I think we have to differentiate. Clinical trials are great but they don't answer necessarily the questions that locally neurologists need answer. They they typically answer those themselves. And so you know I I I think that it's a a huge area of growth and you know I think one of the things that is really nice about working with Latin America and really any country and and that's that we would consider developing is that they do need a lot of any assistance that can be given in terms of not just kind of resources, but just kind of know-how and recommendations is a really nice way of remaining connected. And so you know I'm part of something called the Actram's Young Scientist Summit and Actram's Resident Summit, where we bring residents from all over the country to learn about MS. And one of the exercises I do, I do a global panel and I ask people to raise their hand if they've done any training in you know another country. And it's always like 60 or 70% of the room raises their hand. And I tell them like it's your job to connect back to neurologists in your country so that you can be you know a resource for them part of the solution and try working on things. And it's it's really really I think that's a super rewarding experience. So I would recommend for anybody who's listening if if you're not connected with you know perhaps the people who trained you back home, send an email, connect, try to visit and try to help with some research or even just with clinical stuff.

Rapid-Fire No-Brainers And Closing

SPEAKER_00 52:34

I I just wanted to say that this has been such an incredible conversation and what a beautiful start to season four. Thank you both for taking the time to talk with us about your experiences and providing us with so much knowledge but also insight into how neurology is practiced in different parts of Latin America. The last thing that we were going to do is go over your no-brainers and these are going to be five rapid fire questions that you can answer with one word or one sentence maximum. Okay. And so Dan I'm gonna ask you first and then Nelson I'll give you a few seconds to provide your answer and we'll move on to the next question. Okay. We'll go through all five all at once any questions understood. Okay sounds good the first question is what was your favorite part of this conversation?

SPEAKER_02 53:24

Talking about Latin America I think sharing defense system how the Libran system works what neurologic condition has taught you the most about being a physician always an everyday multiple sclerosis where I'm an average if you could leave listeners with one message about neurology in Latin America what would it be the resilience of Latin American neurologists I agree with the resilience and the need the need of of more neural more neurologists and more fellowship trained neurologists to to come to South America and make a living in this Roman population that is in big need of knowledge what do you hope changes in the future of neurology care within Latin America I hope that the technological and clinical advances that are made that we are living day to day and that many times we're helping produce in North America become integrated into Latin American neurology and that research becomes truly global.

SPEAKER_03 54:39

I'll say three things neurology knowledge in the mean of fellowship trained neurologist technology for correct diagnosis and good quality medications.

SPEAKER_02 54:51

And the last question that I have what are you most proud of I think I'm most proud of uh being from uh Ecuador um which is a country that you know has given me you know my upbringing and my way of thinking and has kind of made me who I am which is uh hardworking resilient and up for a challenge I believe that it's have taken the decision of coming back and a huge thank you to our guests Dr.

SPEAKER_00 55:33

Daniel Antoneda and Dr. Nelson Maldonado for helping us discuss neurology in Latin America. We have many more exciting episodes planned for season four see you in the next one