Hello friends 👋

In this special episode of the Incubator Podcast, hosts Ben and Daphna are joined by Dr. Alex Stevenson, a neonatologist from Zimbabwe who serves as the president of the African Neonatal Association (ANA) and principal investigator for the African Neonatal Network. Dr. Stevenson shares his journey into neonatology and highlights the stark differences in neonatal care and outcomes between well-resourced private hospitals and less well-resourced public hospitals in Africa.

The discussion focuses on the objectives and accomplishments of the ANA, which aims to improve neonatal mortality, morbidity, quality of care, education, collaboration, and advocacy across the continent. Dr. Stevenson emphasizes the importance of unifying African neonatologists, nurses, and parents to advocate for better resources and care for newborns. He also touches on the ethical considerations of conducting research in low and middle-income countries, stressing the need for research to directly benefit the communities involved.

Throughout the episode, Dr. Stevenson expresses hope for the future of neonatal care in Africa, citing advancements like the African Neonatal Network and the potential for African-led innovations in care. The conversation concludes with a call for greater collaboration and support between high-income and low-income countries to address the global burden of neonatal mortality and morbidity.

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Short Bio: Alex Stevenson is a Zimbabwean neonatologist, based in Harare Zimbabwe.  He trained in Cape Town and Zimbabwe. He is President of the African Neonatal Association and also PI in the African Neonatal Network. His research interests are wide, but focus on trying to improve the care for African Neonates as quickly as possible. At present that involves setting up good data systems and improving quality of care. He still practices as a clinical neonatologist and is particularly interested in neonatal haemodynamics. He is married, with three children. He enjoys reading novels, hiking up mountains and spending time in the African bush.

Learn more about the ANA here: https://africanneonatal.org/

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The transcript of today's episode can be found below 👇

Ben Courchia MD (00:01.513)

Hello everybody. Welcome back to the incubator podcast. It is Sunday. We are doing a special interview today. Daphne, how are you this morning?

Daphna Barbeau (00:09.605)

I'm doing really well. We've really been looking forward to this interview. Our guest has been very patient with our schedule and I think people are really going to learn a lot, I think. So I'm very excited.

Ben Courchia MD (00:22.481)

Very excited as well. Today we are joined by Dr. Alex Stevenson, who most of you may already know from his activity on social media, on Twitter. He's a very active Twitter-tician, whatever we call that. But for those of you who don't know who Alex is, he's a neonatologist from Zimbabwe based in Harare, and he trained in Cape Town and in Zimbabwe. Notably, he is the president of the African Neonatal Association and also a principal investigator in the African Neonatal Network. His research interests include neonatal databases, quality improvement in low and middle income countries, and understanding why different neonatal units have different outcomes. He practices as a clinical neonatologist in Harare, as we said, both in a well-resourced private hospital and less well-resourced public hospital. Alex, thank you so much for making the time to be on with us today.

Alex Stevenson (01:19.416)

Thank you for having me. I'm also very excited to be having this conversation.

Ben Courchia MD (01:24.337)

Yeah, we've been meaning to invite you on the podcast. And then our paths crossed more than once as we were doing more work with the global Neonatal podcast, with the Newborn Toolkit. And so that was the serendipitously, it was the opportunity to finally bring you on the podcast. I wanted to ask you my first question. I've been wanting to ask you this is you did you did you grow up in Zimbabwe or did you grow up anywhere else?

Alex Stevenson (01:53.632)

Yes, well, yes and yes. So I was actually born in Eswatini, previously called Swaziland. And then when I was very young, we were in Zambia and moved to Zimbabwe when I was five years old. So grew up. Yeah.

Ben Courchia MD (02:02.44)

Mm-hmm.

Ben Courchia MD (02:12.169)

very interesting. And so we like to ask this question to people we have on the show. Where did the drive to become a physician, specifically a neonatologist, came from? And I'm curious to hear what does that look like for someone growing up in Africa and to hear if the motivations are different based on how physicians are viewed in different parts of the world.

Alex Stevenson (02:35.904)

Yeah, that's an interesting question. To be a physician was a sort of last minute change. I always thought I was going to be a vet. I went to a mission school and we had to spend some time either at a mission hospital or a mission school. I ended up at a mission hospital and I was absolutely blown away by the job of the doctor there, not so much from a sort of humanitarian.

perspective, but just from the science and the, I will never forget the case that a man came in with a croaky voice and she looked at him and she said, do you smoke? And he said, no, no. And she said, well, did you ever smoke? Yes, when did you grab up this morning? And she said, oh, you better go and have an x-ray. And as he walked out, she said, oh, he's got cancer of his throat. And I was astonished that someone could be so clever.

I mean, obviously she was standing on the shoulders of giants. And yeah, I thought, no, this, I definitely, I want to do a job like that. And then neonatology was also quite fortuitous. I, after university, my medicine, I ended up in the diaspora. I was in Australia for 11 or 12 years. And I actually ended up doing rural and remote medicine, like flying doctors. And part of...

my training for that was to do some neonatology because there's quite a lot of neonatology in retrieval medicine. I passed through the neonatal unit in Hobart where Peter Dagerville works and I just thought this was amazing but I never thought that would be my career but I really enjoyed my three months there and then came back to Zimbabwe and you see I thought that neonatology was

Ben Courchia MD (04:10.521)

Mmm.

Alex Stevenson (04:24.428)

like the last thing that developing countries need. It's like very high tech, very expensive. But actually it's not. Neonatology is probably one of the biggest priorities for developing countries. It's an area where we can make a huge amount, or my woofing dog, where we can make a huge amount of impact. So it was only after I came back to Zimbabwe, and then, yeah, I sort of...

decided this is what I was going to do. So I did pediatrics as a mature student and then I went on to do neonatology. I've only been a neonatologist for about four or five years now. So I'm still young in the field.

Ben Courchia MD (05:04.981)

So interesting. Yeah, and so it seems like your dog is barking in agreement with the premise that neonatology is a desperate need. Uh-huh.

Daphna Barbeau (05:14.253)

The right path. I actually am hoping for our listeners who may not be familiar with a setting like yours, and I know that you've traveled all over the world and you've seen a variety of neonatal units, tell us what the setting really looks like. If most of our listeners, not all, come from the US.

Okay, Canada, Australia. And so we have these really high, like you said, high tech units. And it sounds like there's a variety of types of units across say the African network. Tell us a little bit about what the settings look like.

Alex Stevenson (06:00.236)

Definitely, I mean, you've already got it, that there's a variety. And I mean, even here in Harare, I work in two very different hospitals with very different outcomes. Just like if you look at ELBW survival rates, one hospital, 90% of them survive and then the other hospital, 10% survive. So very different outcome in two hospitals that aren't even two kilometers apart. It's, I mean,

in the public hospital if you were to walk in, I mean, as I did, because I was in Australia for 12 years and I came back and actually my first job here was in neonatology, more by coincidence, and I walked into the unit with my Australian eyes on and I remember the nurse was walking over with a limp child and she put the child on a table where there were other, there were like layers of children.

And I said, what are you doing? And she said, oh no, the baby needs resuscitation. I was like, yes, that's quite clear, but why you put it? She said, that's the resuscitation table. I said, well, have you called someone? She said, no, they'll come. And it was, and now that's, you almost become used to that. And I walk people around my unit and I think about that moment because you can see dreadfully sick.

Daphna Barbeau (07:14.401)

it was and now that's you almost become used to that.

Alex Stevenson (07:29.996)

children who are breathing their last. And I walk past them because I've given them some IV fluids, I've given them some first-line antibiotics, I've given them this sort of makeshift CPAP, and that's what I have for you. And I could spend the next hour intubating you and bagging you, but there's nothing further for you. That my job there is to rather...

Daphna Barbeau (07:37.149)

I've given them some IV fluids, I've given them some first-line antibiotic, I've given them this sort of makeshift sinker, and that's what I have for you. And I could spend the next hour intubating you and begging you, but there's nothing further from that.

Alex Stevenson (07:58.728)

improve for the basic care that we've got to increase the amount of CPAP to avoid hypothermia, etc. Whereas in another hospital, which is not even two kilometers away, very different resources, very different standard of care. And it's almost schizophrenic to, it's unjust, and it weighs on you a little bit as well that you can participate in two systems that are so different. But...

they are and we offer the best that we can. So yeah, people who come into NeoCare Baby Hospital are often very surprised to see such a neonatal unit in Harare. I mean, I'm sure it's nothing compared to what you have in Florida, but we are making progress in the right direction. We have high frequency.

Daphna Barbeau (00:45.147)

Mm-hmm.

Alex Stevenson (00:58.387)

ventilation, we have TPN, we're starting to cool babies, we have developmental care packages, it's very different to where we are at the moment in public. Although things are changing in public, we're about to start an immediate kangaroo mother care unit in our public hospital, which trying to sort of...

concentrate our and coordinate our efforts into one, what we think is the lowest hanging fruit to make a big difference to our terrible outcomes. For our babies between 1,000 and 1,500, we've got a 67% mortality in public. I mean, that's just terrible. But at the same time, it's an opportunity to hopefully and potentially make a very big difference. So.

Ben Courchia MD (01:46.31)

Wow.

Alex Stevenson (01:55.199)

That's, I'll report back in a year and tell you how much of a difference we've made.

Daphna Barbeau (01:56.967)

Mm-hmm. Yeah.

Ben Courchia MD (01:58.237)

Um.

Daphna Barbeau (02:02.623)

struck by two things. The first is that we have significant disparities even in the United States as well, especially because of the type of insurance system that we do. That one hospital has this kind of outcomes, one hospital has that kind of outcomes. Certainly not to the degree what you see. I wonder how this impacts you and your colleagues knowing that.

other types of support are theoretically possible and that you have the knowledge and the education and the skills to provide different interventions, but you aren't able to, especially in some of these low, really truly low resource settings. And I wonder how you kind of deal with that on a kind of cognitive emotional level and deal with the loss. I think loss is hard for all of us, but you see it on a totally different level.

degree, I think, than we do.

Alex Stevenson (03:00.783)

Yeah, that's a profound question to which I don't think I have the answer. And I mean, I think the simple answer is that you just, you become habituated and you don't think about it that much, which is probably has its strengths and weaknesses. I mean, I was telling you earlier, I remember that very first day when I came back to Zimbabwe after being in Australia, it was shocking. Whereas...

I now see that every day and it's not shocking. But you try to positively use that to say that, you know, we have to make systematic progress. And I think that's one of the things that I hope I have semi-learned now is that you can't just go chasing your tail.

and thinking, you know, we need this, we need nitric, we need that, we need this. It pays, I think, to step back a bit and try and think about what are our strengths, what are our weaknesses, what are our opportunities, what can we realistically do, and then concentrate on that. So actually, I think in some ways, walking past a baby who, in America or Australia, you would then spend two hours resuscitating is

it is the appropriate thing to do because those two hours are better spent in a systematic way, trying to improve outcomes with the resources that you have or mobilizing more resources.

Ben Courchia MD (04:37.058)

I have a philosophical question on this very topic. So it's interesting that Daphna just cut me off. But what's interesting is that when we're in medical school, we're being asked questions and we're asked, what is the next thing you would do or what is the right answer? And you answer this in a very idealistic manner, saying, I have everything available in a timely fashion with all the staff members that I need. But then we step into the real world and we realize that medical school never told us or taught us about.

physical constraints of like, well, you don't have that service or you don't have that specialist and you don't have as much time as you'd like. And then you have to have this, this growth where you say, okay, um, the right thing to do in the real world may not always be the right thing to do on a test. And I think that it probably is even more striking for you as you describe these different limitations, especially when you're working yourself in two different hospitals. How does your philosophy around what is the right thing to do for a patient?

evolved from you as a student to you as a physician and especially you as a physician in both types of practices.

Alex Stevenson (05:44.955)

Yes, it becomes difficult and I can even expand the question to the issues of protocols and evidence-based medicine because I often have to, people will ask me, well, what should I do? I have a baby, they might have sepsis, we couldn't do a blood culture, the baby seems a bit better after day two.

What should I do? Shall I just stop the antibiotics? To which officially my answer is yes. But that's just Alex making that up. And in fact, it was on your show of when you presented the wonderfully named International League Against Epilepsy and their guidelines on seizures. And it was the first time I'd ever heard they made a real effort in those seizure guidelines to think about...

Ben Courchia MD (06:39.758)

You

Alex Stevenson (06:42.127)

low-income countries, what to do if you don't have an EEG, what to do if you don't have this, what to do if you don't. And I thought that was magnificent because the vast majority of babies with seizures are in low-income countries where we don't have EEGs, where we don't have blood gases, where we don't have all those things. And so I was really happy and inspired that people were starting to think about

low income countries in that way. And I would encourage others to do. And as for me, I think, yeah, you just have to, you have to work within the resources that you have and advocate for more resources. And also just, you know, you can't let every single case go under your skin, otherwise you're going to go crazy. And probably you should just stop the antibiotics after two days anyway.

Ben Courchia MD (07:35.382)

Hmm

Ben Courchia MD (07:40.947)

Yeah, the episode you're referring to is episode 150. It was a journal club with Dr. Rene Chellhass, who helped write these guidelines. And it was so refreshing, finally, to hear someone in this level of authority saying, well, if you don't have this, then do that instead of, well, then get the machine, you know, just buy yourself a nicer machine, which is very, my opinion, condescending, which was so nice to have her on because they had thought this through. And and that was that was great. So if.

people listening are wondering where we referring to episode 150 journal club. Dr. Rene Schell has, she's, she's great.

Daphna Barbeau (08:16.639)

You were talking about in large sweeps what you're calling quality improvement, but the work that you guys are doing in the African Neonatal Network Association and with the Newborn Toolkit is really quite tremendous. This is rooted in all of the academic nuts and bolts of QI work.

And actually what I was, I think, most intrigued by is that some of the things on your wheel here are things that we are all working on globally, regardless of the setting in which we work. I'll just mention a few of the things on the toolkit, and then I will let you talk more about the toolkit.

right in the middle of the wheels, family-centered care, and then around that infection prevention equipment, infrastructure, referrals, leadership and governance, human resources, financing, post-discharge follow-up, and the linkage to maternal care. And when I thought about that, I was like, it's the same, you know, I'm trying to do the same things in my hospital using the same techniques of quality improvement. And so

Tell us one, what you're working on in the newborn toolkit. And two, I actually think hospitals worldwide could benefit from the work that you guys have structured even on your website.

Alex Stevenson (09:51.659)

I definitely I couldn't agree more. And like most neonatologists and health care providers who are listening to this podcast, we spend a lot of time listening to you. And actually what our similarities are far, far more than our differences. And I often hear you or your guests talking about issues in high income countries. And they're exactly the same.

And it's the same office politics, it's the same hierarchies, it's the same inertia, it's the same obstacles, it's the same, no different. And that's also true of babies. Babies are babies. They have the same physiology, they get the same diseases and they need the same treatments, whether they're born in the back of Mali or they're born in Paris. And QI...

Daphna Barbeau (10:22.604)

Mm-hmm.

Alex Stevenson (10:48.363)

Now I'm relatively new to QI, but what happened was the African Neonatal Association partnered with VON, the Vermont Oxford Network, to set up the African Neonatal Network. And that has been such a wonderful partnership. We're about 18 months into it. We've got 20 hospitals. We're getting our first lots of data in, and we're starting with our first QI project, which you're asking about, which is around...

a new concept that we've invented called maximal KMC, which is as much KMC as you can do as soon as possible. Yay. Yeah. And because obviously the push is towards.

Ben Courchia MD (11:29.914)

For those of you who don't see the podcast, obviously they're both raising their arms and cheering and because Daphna is such a proponent of those response to KMC. So yeah, hitting the nail on the head right there.

Daphna Barbeau (11:33.467)

We're cheering, we're cheering.

Alex Stevenson (11:37.523)

The push.

Daphna Barbeau (11:43.53)

That's right.

Alex Stevenson (11:43.911)

Yep, yep, absolutely. And the push is towards immediate kangaroo mother care. And in my hospital, we're fortunate that we're about to open an IKMC unit, but it takes a lot of investment and a lot of preparatory work that not every unit can do. Whereas maximal KMC, you just need to improve what you're doing for, you know, is there a rule that says you can only start at 1,500 grams? That's very common in Africa.

I mean, throw that rule out the window. And is there a rule that babies can't do it when they're on oxygen or on CPAP or getting IV drugs? All of these minor, well, not minor, minor obstacles, major, major obstacles. But these are things where incremental gains can be made. And so that's what most of our hospitals are working on at the moment is improving KMC.

Ben Courchia MD (12:43.846)

Alex, I wanted to ask you about the African Neonatal Association and the driving force behind that initiative. And it's interesting because we've talked to other providers in Africa and I remember one of them, Misha Mfuana, who mentioned how she mentioned, I mean, I'm quoting her and she said, you have to find African solution for African problems and saying that it's not always the solution to just...

import whatever other people are doing, we have to find local solutions. Can you tell us a little bit in that context, what was the driving force behind the ANA and what are the objectives you're trying to achieve with it?

Alex Stevenson (13:27.263)

Sure, sure I can. So that ANA started out of the University of Cape Town, which has this amazing program called the African Pediatric Fellowship Program, which is training subspecialists in various pediatric subspecialties at the University of Cape Town. And so I was fortunate to.

be one of those chosen from Zimbabwe to go. And Kunda, who you recently interviewed, she came from, yeah, there's a whole bunch of us. And we realized, Kunda was, yeah, we realized that when we went home, we would be very isolated.

Ben Courchia MD (13:54.214)

Mm-hmm.

Alex Stevenson (14:07.243)

and that we wouldn't have all those sort of academic accoutrements that you're used to or someone to run a chest x-ray by, etc. So actually the ANA started out of that sort of physician level need for a physician support group and was very effective at that as a WhatsApp group. But...

it slowly emerged and evolved that actually the problem here wasn't the isolated doctors, it was the absolutely shocking and overwhelming and like unimaginable burden of neonatal disease.

And so actually as the organization matured, our objective, once we became a formal organization, our objectives are fundamentally around and absolutely around improving neonatal mortality, morbidity, quality of care, education, collaboration, cooperation and advocacy. And...

Ben Courchia MD (14:49.837)

Mm.

Alex Stevenson (15:15.735)

there is such, it was like we were sucked into existence and then inflated like a big bang because there were, it was never my intention at all to run the African Neonatal Association. I just sort of seemed to be in the wrong place at the wrong time. The WhatsApp group got a life of its own and before you knew it, and here we are.

But it's a very important organization and it's doing a lot of important work and it's networking people across the continent. And what I'm very proud to say is that we are now expanding or encouraging sister affiliate organizations. So the African Neonatal Nurse Group got

roared into action last week with the support of COIN. They just had, I still haven't caught up with exactly what's going on, but I know they had a meeting in Lusaka last weekend. And suddenly that organization has roared even more into life than the ANA, where supporting parents groups to coalesce and organize. Yeah, so that it's a multidisciplinary phalanx in this fight.

Ben Courchia MD (16:38.751)

The ANA has over 250 members at this point. It was officially established in 2021. To date, what is the thing you're the most proud of that was accomplished by the ANA?

Alex Stevenson (16:55.484)

Um.

I think our African Neonatal Network is very impressive, that we now have, I think, 19 hospitals that are entering high quality, real-time data on every baby that's passing through the unit and that we have collaborative quality improvement teams. I think that, you know, you were talking about African solutions to African problems, and

that's going to be a catalyst for exactly that, that we are getting high quality data about African babies and we have high quality teams who are going to collaborate in a South-South way to address some of these problems. So I think that's...

That's probably the thing I'm most proud about. But I mean, just that the ANA exists, that the conversations that go on, the people who are representing us, the as I when I talk about how it gets sucked into existence and I see these little embers get lit. And then before, you know, they're roaring flames. The sepsis working group.

doing amazing work. The next working group that's roaring into action is actually on post discharge care and neurodevelopmental and anthropometric follow up. And that's also that's, yeah, that's just all of it. It just makes me proud to see people doing their thing.

Ben Courchia MD (18:39.618)

What do you think is the strength and the power of just having a unifying entity? Sometimes, I mean, sometimes you just having a name, almost like having a flag, is just enough to rally people behind that symbol and say, and then you do a very objective appraisal of the situation and you're like, we don't really have much. There's no, sometimes even for us at the incubator, you're like, well, there's no facility, there's no this, there's no that, and yet we're able to create this movement.

I think what do you say about that, especially when problems, as you mentioned earlier in this episode, can be quite overwhelming, quite stressful, and yet it's something so simple as just saying, let's all unify behind a name, behind a mission, and everybody starts getting into active motion and starts doing work. Can you tell us a little bit about that from your experience?

Alex Stevenson (19:30.363)

Yeah, I mean, as I mentioned, it sort of happened to me passively that I think the need was there and the people were there. And actually what was needed was, as with any organization, sort of clear delineation of what our objectives were, an organizational model that...

that we have a sort of X and Y axis. So we have three committees, one for education, one for research, and one for collaboration and advocacy. And then we have working groups on CPAP, et cetera, et cetera. So that's a sort of interesting matrix of an organization. And then just, it also kind of helps that these are neonatal people

And whether it's the clinical nurse, the neonatologist, the clerk, like I think it's well known to all of us that people who are, most people who are working in neonatal care are truly driven to improve the outcomes of their babies. And so, yeah, you've got that sort of mindset and that sort of group of people.

who are suddenly in communication with each other. I mean, it's also, we came into life at the time of COVID-19 and suddenly there were Zoom meetings. Had it been two or three years ago, we would have waited for a grant and then 10 of us could have met in Addis Ababa and suddenly there was nothing like that. It was just like, guys, get on the Zoom meeting. We're having a talk about this and here's this person. And yeah.

Ben Courchia MD (21:24.294)

I'm out.

Alex Stevenson (21:29.207)

We had been an organization for two years. It was only last year that the executive committee met each other for the first time in Cape Town. Like these were people that I was working with day in and day out. And I knew them well, and they knew my woofing dog the whole story, but we'd never actually seen each other. And then suddenly I was like, oh my God, Olofunke, it's you. Yeah, it was wonderful.

Daphna Barbeau (21:40.144)

Wow.

Ben Courchia MD (21:58.582)

Can I ask, I know Daphna is going to ask you about advocacy because I think that just resonated with us, but I wanted also to ask you about, you said, parents group. I'm curious about what has been the response of the parents to having an entity like the ANA and what do parents now feel are the possibilities in the African context? And I mean by that, what you mentioned earlier in this episode with quite staggering rates of morbidity and mortality.

Do they feel now more empowered and what has been their response to seeing this forward momentum?

Alex Stevenson (22:34.879)

Probably the best person to answer that would be one of the parents themselves or the parents' representatives. I really wouldn't know. And I think the parents who are coming through the neonatal unit, it's all so new and shocking. Like they had many of them didn't really have an idea that they were preterm babies or that preterm babies could survive.

And I certainly don't think they knew about parents groups, but at our well-resourced hospital, one of our parents advocates is actually is training as a counselor, and she is visiting our parents twice a week. And I'm told that is very...

very popular and very needed. And she's also involved in various quality improvement projects for preparing for discharge and assisting after discharge. I hear through the grapevine that they are very well received, but I'm probably not the best judge of that. But I now I'm about to jump on one of my hobby horses because I mean, when you ask what, what...

needs to be done. What are we going to do about these 2.2 million neonatal deaths a year? And as a Zimbabwean, when I started medicine, we were in the midst of the HIV epidemic and it was absolutely awful. I remember doing my pediatrics and every single child on the pediatric ward had AIDS and they were all going to die in the near future in some ghastly way.

And it seemed utterly hopeless. And yet, 20, 30 years on, it's not hopeless. What the HIV army has done is incredible. It is absolutely phenomenal. And I mean, we know that from Southern Africa. Obviously, it was also an amazing. I mean, it was everywhere in the world. But here in Zimbabwe, it was just awful.

Alex Stevenson (24:58.159)

And so I've spent quite a lot of time trying to work out how they achieved their successes. And the answer that keeps coming back to me is it's when actually the HIV patients themselves and their families started getting involved, advocating for themselves and being part, like initially it was quite adversarial. I think it remains partly adversarial.

but they forced their way into the conversation rightly so and started to demand better things. And unpleasant as it may be for me as a provider, I think that also needs to happen that our families need to get a whole lot more militant and I want to support them to be at the table saying, it's just absolutely unacceptable.

And if, you know, the babies can't come to the table. So the parents, the community, we need more people advocating for our babies because at the moment they are just dying in their millions in silence. And it's just carrying on, just that's the way it is.

Daphna Barbeau (26:20.087)

Yeah, I think sometimes when we talk about the studies that come out or some of our major conferences, let's say here in the US in a high resource setting, it seems like we're working really, really hard, spending a lot of money refining interventions where we're hoping still to improve outcomes, but the mortality is vastly improved in a number of our populations.

And I just have this, just this sense, this heartache. Like you said, the bulk of neonatal deaths are occurring, not the bulk, like the vast bulk of neonatal deaths, yeah, are occurring in low and middle income countries. So what is our responsibility as say, neonatologists, healthcare professionals, advocates here in our country, but in other high resource settings?

Alex Stevenson (27:01.021)

98%.

Daphna Barbeau (27:18.447)

to buoy the work that you all are doing to minimize some of these disparities.

Alex Stevenson (27:27.551)

I think before I launch into that, my son is playing the piano. Is it disturbing? He can always play later.

Daphna Barbeau (27:36.291)

Nope, nope, we're good.

Ben Courchia MD (27:36.53)

Nah, we're good.

Alex Stevenson (27:36.879)

No, okay, yeah, I can hear him playing his scales. I think what I would say then, the first thing is the same with the ANA is communication and knowledge. And I think actually what you're doing with the incubator and what we have done with the ANA and what the...

Newborn Toolkit is doing, all of these amazing groups and fora and tools are spreading the word and also communicating between people and teams. So I think that's the first step. And secondly is just to get the scale and the importance of neonatal mortality.

out there that it is a huge problem. 10 times as many children die of neonatal conditions in Africa than HIV. There are more babies die of neonatal conditions globally than HIV and malaria put together. And yet there are huge amount more resources into other areas than neonatal care. So I...

I think, you know, if we were to get one message out there is that the resources allocated for newborn care need to match the burden of the disease. And the burden of the disease is, I think people also think it's inevitable that babies under 1.5 or under 1 kg should die. And that's absolutely, I mean, you don't need me to tell you that, but it's...

Daphna Barbeau (29:12.824)

Hmm.

Daphna Barbeau (29:22.063)

Hmm.

Alex Stevenson (29:30.415)

Absolutely not the case. And even in low income settings, I think that certainly above 1,000 grants, we should be saving the vast majority of them with relatively little resources. So I think that that's one of the responsibilities of advocacy and working together. And I can hear the wonderful Joy Lorne in my ear now saying that we need to work together. And that's.

That's very true that I, it's, we all must be careful not to start our own little silo projects when a little bit of Googling and you'll find that actually there's another 10 people doing a similar project. It's much better to join and support a well-run project than starting another, you know, another isolated intervention. Then,

It's not just you incubator folk, it's also Twitter, it's also social media, it's also the modern world. We are so much better integrated with each other that I am friends with neonatologists all over the world, which would have been unimaginable 10 years ago. And if I do have a problem.

There are people that I can talk to and ask. And I think that's wonderful. The amount of support that we get from first world units and teams is very much appreciated. And as we go forward with the ANA and we're setting up these incubator partnerships, we definitely want to have partnerships of people who are active.

in the first world with an interest in global health and also people on the ground.

Daphna Barbeau (31:29.979)

I mean, I love that message of unification and collaboration. And I think that's something that everybody can learn from, especially on the scale in which you are doing it. I did want to mention, like you said, the third arm, which is research. And on your website, you've listed a number of publications done by the African Neonatal Association. But my question is a little bit a different one. It's really about, maybe you can speak to the ethics

of including low middle income countries in research. And I'm going to ask you both sides of the coin, one in the problem in neglecting those populations. And I think we've spoken to that a little bit since there's such a burden of mortality, but also when working with other countries, pulling data from other countries, you guys are doing the work there on the ground.

What do we owe the hospitals and the communities that we work with when we're engaging in research in your communities?

Alex Stevenson (32:36.623)

Yeah, no, that is a deep and important question. I mean, I think the answer is that what we owe the patients, their families and their communities is the same as research anywhere else in that it must advance the care that we can give to that population.

And obviously we need to be very careful and wary of sort of academic tourism or coming in and sort of parachuting in, getting important data and parachuting out. However, also on the other side of that coin, like there is so much important data that happens in

my neonatal unit that doesn't, that shouldn't just be flushed down the toilet and said, you know, it's, you know, what, what does happen, just to describe what is happening in our neonatal units, we may be able to give some insights that, that others may not. Let me give a personal example.

low income setting where there was a protocol in place that babies under 650 grams did not get resuscitated. There weren't the resources, etc. And so I, but you were allowed to stimulate the babies. These babies got stimulated. But what I saw with my eyes was that these tiny little preterm babies

Ben Courchia MD (34:21.39)

Thanks for watching!

Daphna Barbeau (34:22.225)

Hmm.

Mmm.

Alex Stevenson (34:31.679)

would get breathing and their heart rate would get going by themselves. And so in that situation where you only have the ability to do delayed cord clamping, early skin to skin care, provide warmth and stimulation, you can say, hey, that's very interesting. That you would never do that in...

Daphna Barbeau (34:37.584)

Hmm.

Alex Stevenson (34:59.299)

a first world country because that's not your resuscitation guidelines. And I'm not saying, I'm not, I mean, on very thin ice here advocating research around here. I'm just giving an example where in a low income setting, you might see things that you don't necessarily see in a high income setting, but the ethics of it are absolutely fraught and complicated. And I don't think that I could, I mean, I would, I couldn't write those observations up. And I think

I would want to be very clever, very cleverly guided and properly guided in doing that's doing research in a resource limited setting. For instance, I'm quite interested in POCUS. I hear a lot of POCUS talk going on and I've gotten myself a fancy scanner, but you know, we don't have.

nor a general and we don't have milrinone, we don't have Sildenafil and yeah you think well there's potentially you know could you write an article about what the natural history is? Maybe you could. Is it ethical? I don't know. I really don't know. Would it be fundamentally I think the question is it will it be useful to this community?

So if you're doing your research and then you say, yes, we need Milrinone and you bring it in and you help babies, great. If you just do your research and then you take it off and you publish it in America and you never do anything about babies with PPH in Zimbabwe, then it's probably not ethical either. It's complicated. I don't know the answer to it. What do you think?

Ben Courchia MD (36:41.432)

Hmph.

Ben Courchia MD (36:47.383)

I kind of agree with you. I think the academic pursuit should not supersede the practical aspect of delivering good care at the bedside. So I am very much in agreement with what you're saying.

Daphna Barbeau (36:50.043)

Mm-hmm.

Daphna Barbeau (36:54.711)

Mm-hmm.

Daphna Barbeau (37:03.563)

Yeah, I couldn't have said it better. I think we need to leave the work with the communities in which we're doing the work. And you mentioned something else, you know, in terms of collaboration is, and I've heard this from many people, I think it's so fundamental is that we have to include those communities from the beginning of the research design, right? What is the research question that is a problem for those communities? Not solving a problem.

in our community is solving a problem that is part of the global community to make the biggest impact.

Ben Courchia MD (37:39.938)

And that's something that we've talked on the podcast before, where many people are saying, well, there's certain topics that we're still hammer on, where the resuscitation of 22-weekers. And then we fail to realize this represents an infinitesimal percentage of the neonatal population. At what point do we say, listen, we don't have anything earth-shattering coming through the pipeline. Let's move on to something that's actually going to be more meaningful and have more impact for a broader population. So yeah, no, I could not agree with you more, and I appreciate you sharing your thoughts on that.

As we get close to the end of this episode, we wanted to do something a little special today and we are joined today with one of our newest members to the incubator team, Dr. Rana Hussein. Rana, welcome to the podcast.

Ra'ana (38:28.438)

Thank you, Ben. Thank you, Daphna. Hi, Alex. Super happy to be here.

Alex Stevenson (38:30.991)

Hello, Rana.

Ben Courchia MD (38:31.99)

Rana, yeah, we're very happy to have you on and we actually are happy that you're joining us because for those of you who are not familiar with who you are, you're a neonatologist and you practice also in Africa, in Kenya specifically, in Nairobi. And we thought it would be great to bring you on and let you ask one or two questions, obviously, as we close out the show to Alex, based on your perspective on the ground also in Africa of...

working there. So if you'd like, take it away.

Ra'ana (39:06.39)

Thank you. So I'm actually a really proud member of ANA as well and part of the education committee. And what I've noticed is Africa is often considered as a country rather than what it really is, which is a continent full of different diverse communities who speak different languages. So my question, Alex, is how do you ensure that the ANA remains inclusive and representative of all these

Daphna Barbeau (39:23.159)

Mm-hmm.

Ra'ana (39:34.902)

diverse nations and their communities.

Alex Stevenson (39:41.003)

I think that's an aspiration and I can tell you right now that we don't succeed at it, but it's a very important point. So a significant part of Africa is Francophone and there's also a large Lucifone community. So...

Daphna Barbeau (39:46.34)

Hmm.

Alex Stevenson (40:04.195)

The ANA tries to be originally bilingual and I'm now pushing for trilingual, but we don't really succeed at that. We do try and we have dedicated, you know, on the executive committee, we have a Portuguese speaking representative, French speaking representative. We do try and get translation, but...

that language fault goes right through our organization and it is a big problem and it is to the detriment of the non-English speakers. And we are, you know, we're trying to get our documents bilingual, we're trying to get translators for our meetings but...

Yeah, we need to try harder and we're not succeeding. And that's just language. I mean, there are many other areas of inequity, urban, rural, and even within the hierarchies of medicine that we also need to address. So yeah, the answer is we need to try harder, but we are trying a bit.

Ra'ana (41:20.726)

Thank you. What I've noticed is that every single communication that you send out is definitely translated in more than one language. And I thought that was a wonderful way to bring people in and closer together with the same unifying message. So I really did appreciate that. And that you have members from North, South, East, and West. I don't know, are there any African countries that are missing from the ANA? It seems like we have most of them.

Alex Stevenson (41:45.731)

Yes, we don't have a member from Eritrea. But otherwise, and there's been a bit of Somalia, Somaliland aji-baji going on. I better put on my presidential hat and say that our membership from Somalia remains somewhat contested.

Ra'ana (41:50.895)

So this is a call for Traian to join us.

Ben Courchia MD (42:01.744)

I'm sorry.

Ben Courchia MD (42:10.016)

Hmph.

Ah, yeah, go ahead, Rana.

Ra'ana (42:14.863)

Okay. No, sorry, Ben, sorry. Go ahead.

Ra'ana (42:19.339)

My last question, Alex, was as the amazing president that you are, how do you see the future of new nasal care evolving in Africa? And what is the role of the ANA in this development?

Alex Stevenson (42:34.187)

That's a wonderful question. And let me think about that. Sometimes when I'm feeling silly and slightly manic, I threaten that I want to take our hospital to be the best neonatal unit in the world. Like it started off, we wanted to be the best in Zimbabwe, we're already there. Then we wanted to be the best in Africa and we've got a way to go.

but it's actually not as silly as it sounds because the future of neonatology is in Africa. There are more babies born in Nigeria than the whole of Europe put together. And yes, we've got some problems, but we are addressing them. And come 20 to 30 to 40 years, I think just because we're going to have the babies, we're going to see neonatology advance a lot in Africa.

And I would hope it advances in the way that it's already advancing the world over, that we can improve the participation of the family and community, that we can have better family-centered and respectful maternal care, and that we can have babies who thrive to the very best of their ability. I'm...

Yeah, that's, and we can throw in our own African learnings along the way. This thing with immediate kangaroo mother care, I'll just blast Zimbabwe's tune. The first report I've seen of it was from the 80s from a mission hospital in Zimbabwe, Manana Mission. Yes, it was Nils Bergman, but he was in Zimbabwe then. And

we consider him a Zimbabwean doctor. So, you know, things like kangaroo mother care that came from Columbia or immediate kangaroo mother care that came from Zimbabwe, I'm hoping there will be more and more advances that we can give the world.

Ben Courchia MD (44:40.398)

Thank you, Alex. Thank you for making the time to be with us today. I will say that we at the incubator are very much aligned with the mission and the work of the ANA and we think that making evidence and access to neonatal evidence available in other languages is paramount. So for people who are listening in Africa, who want to connect in other languages, just know that the incubator podcast is also available in French and Portuguese and in other languages and that we are always looking for opportunities to

expand the reach of the evidence that is published in Neonatology to whoever needs to access it. We will put all the links of all the things that we mentioned in this episode in the show notes and we will leave ways to contact you Alex for people who are interested in working with the ANA. Thanks again for making the time and for being so cordial and sharing your thoughts. It was a lovely conversation. Thank you.

Alex Stevenson (45:32.863)

Thank you. Thank you, Daphna. Thank you, Ben. Thank you, Rana.

Daphna Barbeau (45:37.851)

Pleasure with ours.