Global blood and marrow transplantation training for international physicians from LMICs: 5-year experience at UIC Open Access

Blood cancers, such as leukemias, lymphomas or multiple myeloma, and life-threatening nonmalignant blood disorders such as sickle cell anemia, thalassemia, or aplastic anemia are common in low- and middle-income countries (LMICs).^1,2 Many of the patients affected by these disorders can be cured only by receiving chemotherapy followed by an autologous or allogeneic transplant of hematopoietic stem cells collected from the bone marrow or peripheral blood, thus the name blood and marrow transplantation (BMT). In high-income countries (HICs) the number of yearly BMT is >300 per 10 million people, whereas in LMICs the number ranges between 0 to 50 per 10 million people.³ Among the multiple factors that explain this gap, the most common ones include lack of adequate hospital infrastructure, insufficient number of health care providers and lack of training programs in hematology and BMT, poor health education of the population, and especially, unaffordability of high-cost therapies in countries with poor socioeconomic conditions, where health care is often paid out-of-pocket.^4,5 

In 2012, the BMT team at the University of Illinois Chicago (UIC) started a global health initiative (GlobalBMT program) to build capacity in LMIC public or private nonprofit institutions interested in establishing BMT. Over the years, collaboration agreements were officially established with partners in Nepal, India, Nigeria, Uganda, Bolivia, Cuba, and Ukraine. As a result, countries such as Nepal and Bolivia had their first BMT centers, a new BMT center was started in Bangalore, India, and a hospital in Havana, Cuba, started BMT from haploidentical donors in adult patients as the only option for patients without an HLA-matched sibling, as Cuba is banned from accessing the National Marrow Donor Program. The partnership of these sites with UIC GlobalBMT usually consists of onsite training and engagement of local stake holders, training of providers, continuous collaboration on standard procedures and protocol implementation, and collaboration in research projects.

In 2018, a 5-week GlobalBMT training course was started for international applicants mostly from LMICs. The curriculum included clinical observership, lectures, case discussions, laboratory experiences, and quality management training. The outcome of the program was assessed by questionnaires provided to all trainees before and at the end of the course, and at 6 months after the end of the training. The GlobalBMT training course has since then been repeated yearly in Chicago, except for a virtual course held in 2020 to 2021 due to the COVID-19 pandemic. Here we report on the results of the GlobalBMT training assessment of the in-person training courses held in 2018, 2019, and 2022, that included a total of 13 trainees from 8 countries, and for the online training held from October 2020 to February 2021 that was attended by 36 trainees from 10 countries. To our knowledge, this is the first global health training initiative in BMT aimed at building capacity and helping LMIC physicians to establish new programs where patients have limited or no access to BMT.

The curriculum was designed to provide training in clinical aspects of BMT by clinical and laboratory observership, participation in organizational and quality activities, and direct lectures from faculties followed by discussion. No hands-on activity was allowed because a US medical license would be required. Clinical observation was divided into outpatient and inpatient settings with mentorship of BMT faculties. In addition, trainees attended weekly planning sessions where future BMT patients were discussed with the whole team. Training then included direct observation of hematopoietic stem cell collection by leukapheresis, stem cell manipulation, as well as HLA typing. Topics addressed in 10 to 12 lectures during the training included diagnosis of hematologic malignancies and severe nonmalignant blood disorders, patient and donor selection in BMT, advances in BMT conditioning regimens, graft-versus-host disease prophylaxis and treatment, infectious complications, stem cell collection and cryopreservation, development of clinical research in BMT (data collection, analysis, and design of clinical trials), requirements for international accreditation of BMT programs, development of standard operating procedures (SOPs), and organizational structure of BMT. An example of a weekly schedule included observation in 3 to 4 clinics and alternating clinical inpatient and laboratory weekly (2.5 weeks inpatient and 2.5 weeks laboratory). When observing on the inpatient with BMT faculty, trainees would follow rounds during the day until their scheduled clinic observership. The second half of the program allowed trainees to observe on the laboratory aspect of the BMT. This included HLA, blood bank, and the stem cell laboratory, where trainees were able to follow the process from beginning to stem cell infusion of patients. In addition, participants were offered one-to-one sessions on personal and local BMT projects. An outline of the curriculum and the hours dedicated to each activity are shown in Figure 1.

Trainees were selected among applicants from centers already in partnership with UIC, or from other LMIC institutions that learned about our training through former participants. Required application materials to qualify for the training program included a resume showing background in hematology, a personal statement, and a letter of support from their LMIC institution expressing its commitment to BMT. When selected, we provided the trainee with information and a letter of recommendation to obtain a B1-visa at the local US Embassy. They also were required to enter the United States with documentation of health insurance for the time of training. Funding from an internal grant and philanthropy covered the travel expenses, lodging in an on-campus facility with a small kitchen, and some food supplies. At the end of the training, every participant received a certificate for attendance.

Trainers were UIC faculty members involved in different areas of BMT, such as clinical practice in BMT, stem cell processing laboratory, radiation oncology, infectious diseases, hematopoietic progenitor cell apheresis, HLA tissue typing laboratory, molecular pathology (posttransplant chimerism), and clinical pharmacy (BMT). They served as mentors of the trainees during clinical rotations, laboratory activities, case discussions, quality management/improvement meetings, and/or formal lectures as described above.

The GlobalBMT virtual training program was held from October 2020 until March 2021. The schedule included 11 live lectures from UIC mentors, followed by question and answer sessions and 2 patient case discussions with trainees presenting cases from their institutions. Every session was held via Zoom technology at 9 AM CST to allow the participation of attendees in multiple time zones.

Trainees of the GlobalBMT program were asked to complete a questionnaire before the training, at the end of the training, and 6 months after training.

The pretraining survey focused on needs assessment and demographics of trainees, it consisted of 13 questions regarding type of hospital where they practiced, such as urban/rural location, bed capacity, availability of a blood bank, or flow cytometry and molecular biology diagnostic laboratories, postgraduate training/fellowship degree, and the number of years working in hematology.

The end-of-training survey included questions that could be rated on a 1 (strongly agree) to 5 (strongly disagree) scale in addition to 3 open-ended questions. The trainees were asked to rate how the training program met the following: “clear objectives,” “encouraged to participate,” “relevant topics,” “clearly organized content and materials,” “preparedness of academic trainers,” “sufficient time for training,” and “adequate training rooms.” Open-ended questions included “what did you like most about the training,” “what could be improved,” and “how do you hope to change your practice due to this training.”

The 6-month posttraining survey included 9 open-ended questions that asked the trainees to describe the changes to their practice based on the GlobalBMT training, current challenges, and if networking connections continued after training. The same surveys were used for the 2018, 2019, and 2022 training.

Trainees in the GlobalBMT virtual training seminar series (2020) were also asked to complete a posttraining survey with 9 questions that could be answered in a “yes” or “no” format. The survey questions included delivery of training objectives, encouraged participation, relevant topics, clearly organized lectures and presentations, and the strengths and weaknesses of the virtual training.

Quantitative analysis involved summarizing responses to closed-ended questions using frequencies and percentages to provide a descriptive analysis of the trainees’ responses. The qualitative analysis involved using thematic analysis, focusing on open-ended responses to assess strengths and weaknesses for both the in-person and virtual training format.^6,7 Transcripts of open-ended responses from trainees were organized for thematic analysis and responses were summarized into similar groups that referenced common values and themes such as strengths and weaknesses of the training, changes in practice, and ongoing challenges. Relevant themes were identified to provide an understanding of trainees' experiences and perceptions.

A total of 13 trainees from 7 LMICs and 1 European country participated in the GlobalBMT training in Chicago. The first training in 2018 had 5 physicians from Bolivia, Nepal, Nigeria, Ukraine, and Uganda. In 2019, there were 4 trainees from Greece, Nigeria, and Ukraine, and in 2022 there were 4 trainees from Argentina, Bolivia, Tanzania, and Ukraine.

For the 2020 virtual series, a total of 36 trainees participated from 10 different countries including, Argentina, Bolivia, Cuba, Dominic Republic, Ethiopia, Greece, India, Nepal, Nigeria, and Ukraine.

The results of the pretraining survey conducted in 2018, 2019, and 2022 from all the 13 trainees are shown in Table 1. Regarding work settings, 85% of respondents reported working in urban settings, whereas 15% worked in both urban and rural environments, offering unique insights into hematology practice across different contexts. Their hospitals had a median capacity of 600 beds (interquartile range, 175-880), 85% had a blood bank, 77% a molecular biology laboratory, and 77% a flow cytometry laboratory. The trainees reported about 10 years since obtaining their medical degree (median, 10 years; interquartile range, 4.75-10.5). It was found that 85% of the trainees had completed a fellowship program in hematology or oncology, and 69% had some exposure to BMT. All trainees reported having received training in clinical research and 54% of them indicated direct involvement in clinical trials at their institution.

The exit survey was completed by all 13 trainees who participated in the GlobalBMT training program between 2018 and 2022. All respondents provided valuable insights into their training experiences, highlighting the program’s overall success in meeting its learning objectives. Trainees unanimously agreed that the training objectives were clearly defined, the topics were relevant and sufficient, the presentations were well-organized and easy to follow, and that the training would be useful in their areas of work. Furthermore, 100% of the trainees felt participation and interaction were encouraged, and trainers were well-prepared (Table 2).

The open-ended questions in the survey focused on the quality of the training, and responses were analyzed and coded into quantitative data (Table 3). For question “a,” the most appreciated aspects of the program were “physician interaction, knowledge base, and networking” (69%) and “clinical experience and training schedule” (23%), with 1 respondent valuing both equally. For question “b,” trainees commonly suggested improvements such as “more hands-on trainee involvement” (62%) and “more lectures, rounds, and access to educational materials” (38%). For question “c,” trainees outlined how they intended to apply the training to their practice. Responses commonly included “better serve patients with BMT program development” (46%), “development of SOPs and publication materials” (15%), and a combination of both goals (38%).

Although the program received overwhelmingly positive feedback, 25% of the respondents felt that the duration of the training could be extended, indicating that additional time might better accommodate their learning needs. Overall, the feedback from the exit survey highlighted the effectiveness of the GlobalBMT training program in meeting the trainees’ learning objectives.

The data included in the 6-month follow-up survey came from a total of 9 respondents out of the 13 who participated in the program for training year 1, training year 2, and training year 3. The survey was sent out once the trainees had returned to their original institution. Results indicated that these trainees felt that the GlobalBMT training provided them with the ability to take leadership in a BMT development plan and with awareness of the need for BMT training at their institution (Table 4). Initial changes reported by multiple trainees were the establishment of new facilities or services (n = 4) and enhancement of operational procedures (n = 3). Useful feedback was the request to spend more time on how to develop SOPs and write articles (n = 6).

A final observation was the shared desire to maintain some level of collaboration, from regular meetings to formal agreements or even site visits. This finding is consistent with our experience of the importance of continuous support to build capacity and the time that is necessary.

All the 13 trainees returned to their countries after the training and only 1 from Nigeria is now in the United States with a research fellowship that he obtained 3 years after the GlobalBMT training. Follow-up interactions between “alumni” and the UIC team often continued over the years to ask for advice on treatment options for some complicated cases or to review protocols to implement in their hospital. Trainees from Nigeria, Uganda, and Bolivia, requested their institution to sign an official memorandum of agreement with UIC to support further steps in building capacity to establish BMT in their hospital, university, or ministry of health. As a result, in Bolivia there are now 2 clinical BMT programs connected to our GlobalBMT program, performing autologous transplants, and 1 of them also performing allogeneic transplant. The National Cancer Institute in Kyiv, Ukraine, that already had experience in autologous transplant, succeeded in starting allogeneic transplantation in 2024, thanks to daily and then weekly remote meetings with our program. More recent plans with a public hospital in Guatemala and the ministry of health of Rwanda were started following the training of 2 physicians who attended the 2024 GlobalBMT training (not included in this analysis).

The complexity of BMT, in addition to the elevated costs associated with it, still make this procedure limited in both HICs and LMICs.⁸ In many of these countries a small fraction of patients can afford to travel abroad for BMT, whereas the majority cannot and succumb to their diseases. The improved outcome of BMT observed in many hematologic disorders in the last decade, and especially the expansion of the pool of donors to haploidentical related donors for the last 15 years, have contributed to raising the interest of LMIC institutions.^9,10 The UIC GlobalBMT initiative started in 2012 initially to support the training of providers and establishment of transplant programs in Nepal,¹¹ India,¹² and the start of haploidentical transplant for adult patients in Cuba. The program has then expanded its partnerships to other countries, such as Ukraine and Bolivia. Among the activities of GlobalBMT, in 2018 an annual 5 to 6-week training course in Chicago was started, where international providers follow a comprehensive curriculum including every aspect of BMT. Here we analyzed the experience of 13 physicians from Nepal, Uganda, Nigeria, Tanzania, Ukraine, Argentina, Bolivia, and Greece who attended the training between 2018 and 2023. The study was based on quantitative and qualitative data provided by the trainees prior to the start of training, the end of training, and 6 months after the training. All 13 trainees found the training valuable and effective in meeting their learning objectives. Multiple lessons were learned through this experience. First, it is important to note that the trainees' institutions were heterogeneous and faced different levels of challenges and resource deficiencies, such as limited availability of blood products, or lack of flow cytometry and molecular diagnostic tests. Therefore, the time spent by the trainees discussing clinical cases during inpatient and outpatient observership was very important in understanding not only the basics of transplant but also diagnostic and prognostic criteria for patients that may or may not be candidate for BMT. We also rapidly added one-on-one meetings with trainees to the curriculum to address specific organizational questions and learn about different health care political and management structures in different countries of Asia, Africa, or Latin America. This was instrumental to some long-term results of the training, such as establishing official agreements with hospital or university, or ministry of health leaders in multiple countries. These are ongoing projects that brought more trainees to our institution for specific learning goals, such as stem cell manipulation or HLA typing. Moreover, it allowed us to develop ongoing partnerships that impacted the clinical service in Bolivia starting BMT in the country, or a government hospital in Ukraine to start allogeneic stem cell transplant. However, we also learned that in some cases, local multilevel financial/political barriers can prevent the implementation of initial plans.

Another result of the training was the creation of a defined process within our institutional International Office and College of Medicine to receive international trainees as observers. This program helped another department in our institution to replicate a surgical training program for LMIC physicians and could be adopted in other institutions as well.

The answers from the trainees at the end of the training showed their commitment to developing and expanding BMT programs in LMICs. They also indicated that an extended training duration with hands-on involvement, as well as additional lectures, would be useful in future training. Although the formal 1-year BMT fellowship currently available in the US cannot be offered without Educational Commission for Foreign Medical Graduates certification, we appreciate that the GlobalBMT training increased the interest and enthusiasm of all participants.

The primary goal of the GlobalBMT training is to build capacity while encouraging leadership development of trainees. These future leaders, in fact, will prioritize an equitable and effective collaboration to grow their program. This aligns with an important responsibility of HICs to global health education.¹³ Over 5 years, the GlobalBMT training established a robust network with most of its alumni and gained increasing interest from people that globally connected with UIC by “word of mouth,” social media, or shared experiences in LMICs. This has resulted in receiving applications from multiple countries where BMT is still not available, particularly in Africa. Our program seems to be the first of this type and it is very important to assess strengths, opportunities, and continuous evaluation of the curriculum. We currently prioritize the in-person training based on our findings despite the limitation of only 3 to 5 trainees per year. In fact, although the virtual lecture-series program developed during the COVID-19 pandemic allowed larger participation, it could not create and maintain networking relationships. This was also previously reported in different settings.^14,15 

Our GlobalBMT training is an asset to the mission of building capacity in BMT globally. The experiences of multiple institutions previously demonstrated that BMT can be performed in LMICs even with low resources, often through partnership or training in HICs.^11,12,16-21 Newly established centers require education initiatives that can engage young providers, in addition to an increasing number of publications that outline the basic requirements necessary to establish BMT.^22-24 We hope that programs like ours or the scholarship sponsored by the American Society for Transplantation and Cellular Therapy in the last 3 years, can be established in many HICs and envision a future BMT global training network. It is important to note that this type of international training does not have clear funding mechanisms outside of internal funding and philanthropy. In our case, the commitment of UIC to support an academic activity aligned with its mission and recognizing an objective global impact was key to starting and continuing the GlobalBMT training.

The GlobalBMT training program is supported by University of Illinois Chicago Institutional Funds to D.R. Partial support to D.R. was provided by the Ukrainian Medical Association of North America.

Contribution: A.R. and D.R. designed the study, actively participated in the training curriculum, analyzed the data, and wrote the manuscript; and N.M., K.S., S.G., A.M.A-R., M.S., E.U., M.K., C.G., E.Z., S.C.L., S.B., and S.W. actively participated in the training curriculum and reviewed the manuscript.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Damiano Rondelli, Division of Hematology and Oncology, University of Illinois Chicago – UI Health, 840 S Wood St 820-E-CSB, Chicago, IL 60612; email: drond@uic.edu.