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After completing fellowship training in Parkinson’s disease (PD) and movement disorders abroad, I (SH) returned to clinical practice in Pakistan, a country of over 255 million people1 but with only a handful of fellowship-trained specialists in this field. I expected challenges, but the systemic, cultural and clinical realities I encountered over the first 18 months were more complex than anticipated. Similar issues would be prevalent in other low- and middle-income countries (LMICs) that are not expected when caring for people with Parkinson’s disease (PwP) in the West. This viewpoint offers on-the-ground insight into the barriers to PD care in Pakistan and potential strategies to address them.