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| REVIEW ARTICLE |
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| Year : 2012 | Volume
: 56
| Issue : 3 | Page : 227-230 |
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Challenges in neurological practice in developing countries
Sanjay Pandey
Associate Professor, Department of Neurology, GB Pant Hospital, Delhi, India
| Date of Web Publication | 3-Dec-2012 |
Correspondence Address:
Sanjay Pandey
Associate Professor, Department of Neurology, RN. 507, GB Pant Hospital, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-557X.104253
 Abstract | | |
The burden of neurological illness is much higher in developing countries. Neurological disorders in these countries are mainly due to poverty and malnutrition. Spectrums of diseases are also different in comparison with developed countries. Lack of resources, ignorance, and overpopulation make it very difficult and challenging to tackle this problem. Majority of the patients are seen by general practitioners who have little knowledge about neurological illnesses. Most of the countries have very few or no neurologist. There is a greater need of taking neurological care at primary care level where majority of the patients struggle with epilepsy, stroke and neuroinfections. Keywords: Epilepsy, Neurological care, Stroke
How to cite this article:
Pandey S. Challenges in neurological practice in developing countries. Indian J Public Health 2012;56:227-30 |
| Introduction | |  |
More than 85% population of world live in developing countries, which include [1] China, India, other Asian countries, sub-Saharan Africa, Latin America, Caribbean, and the Middle Eastern crescent as per the World Health Organisation (WHO) guidelines. [2] Due to poverty and malnutrition, many disorders are unique to these regions and rarely attract attention and priority in their cramped health budget. Unfortunately, research takes a back seat and many diseases, which are practically nonexistent in the developed nation, are still killing thousands in the developing and low-income group nations. Polio, bacterial meningitis, rabies, and leprosy are some of the examples. Major challenges are related to disease burden, inadequate neurological services, and social stigmas.
| Disease Burden | | |
World over one in nine people dies of neurological disorders. [2] But spectrum and burden of these disorders in developing countries are different in comparison with their developed counterparts. Neuroinfection and epilepsy in pediatric age group and stroke in elderly population are most common neurological diseases burden in developing countries. [1]
Viral encephalitis, leprosy, neurocysticercosis, rabies, cerebral malaria, dengue fever, and tubercular meningitis are the most common neuroinfectious disorders seen in developing and low-income countries. WHO and United Nations International Children Emergency Funds (UNICEF) started expanded program of immunization targeting measles, tuberculosis, polio, diphtheria, tetanus, and pertussis. As per the UNICEF report 34 million children are still deprived from routine immunization and most of them are from developing countries. [3] Polio and tetanus have direct neurological manifestations whereas diphtheria and tuberculosis may lead to different types of neurological complications. Polio eradication program launched in India has shown good results as number of cases of indigenous wild polio virus (WPV) has come down to 42 in 2010, and only 1 in 2011 so far. [4] However, new challenges like Japanese encephalitis have emerged, which strike every year during post-monsoon period in eastern Uttar Pradesh and other parts of India killing hundreds of patients, and most of the survivors are left with major neurological deficits. [5] Leprosy is one of the major causes of chronic neuropathy and disability in this region; 67% of all leprosy cases worldwide in the year 2008 were reported from South-East Asian region. [6] Tubercular meningitis is the most common type of chronic meningitis. In the absence of any definite guidelines for managing tuberculoma and tubercular meningitis, it becomes very difficult to treat patients. Many such patients develop complications like hydrocephalus, basal exudates, and sucortical infarcts leading to high morbidity and mortality. Infection due to human immunodeficiency virus (HIV) has made the situation worse. Diagnosis of such patients remains difficult in the absence of neuroimaging facilities at primary and secondary healthcare centers. This results in tremendous workload at tertiary care centers resulting in dilution of quality of patient care. Hemophilus influenza type B, which has been successfully eradicated by using conjugate vaccine in developed countries, still remains the most common organism causing pyogenic meningitis in young children in developing countries. Every year, there is rise in the number of cases of cerebral malaria, dengue, and chikungunya putting more challenges for the health delivery system.
Incidence of measles, tetanus, and rabies is still very high. Measles during infancy or childhood may lead to subacute sclerosing panencephalitis (SSPE), which is a fatal illness and is still prevalent in developing countries like India, Papua New Guinea, and Turkey. In Asia, Africa, and Latin America, 50,000 people died of rabies in 2007, whereas it has been eradicated from developing countries. [7]
Stroke is second most common cause of mortality in developing countries and approximately one-third occurs in younger age group. [8] Major cause of stroke in this part of world is cardioembolic due to high prevalence of rheumatic heart disease and infective endocarditis. In India and other Asian countries, spontaneous intracerebral hemorrhage and venous stroke are very common due to uncontrolled hypertension and pregnancy-related complications, respectively. [9] On the contrary, in developed countries, most important causes of stroke result from obesity and high fat intake.
Of the 50 million epilepsy patients worldwide, 75% are in developing countries and 94% of them are not seeking any treatment. [10] Major causes of treatment gap are lack of resources and cultural beliefs. [11] Central nervous system (CNS) infections like viral encephalitis, bacterial meningitis, and inflammatory granuloma are major causes of status epilepticus and refractory seizure in developing countries. Due to high incidence of home delivery and pregnancy-related complications, hypoxic injuries leading to cerebral palsies among children are very common.
| Neurological Services | | |
As per the WHO report, the number of neurologists per 100,000 population is 0.03 in Africa, 0.07 in South-East Asia, and 4.84 in Europe. [12] This imbalance is not only in terms of number of neurologists, but majority of them are based in big cities. Fellowships and subspecialty training after neurology residency are not available, leading to scarcity of trained pediatric neurologist, neuroradiologist, and neuroanesthetist. Primary care centers do not have adequate drugs and treatment of chronic disorders like Parkinson's disease and Wilson's disease is very costly, leading to treatment failure and poor compliance. Deep brain stimulation and newer advances in treatment are largely confined to a few select centers. Thrombolysis for ischemic stroke is available in much selected urban centers, and the high cost of tissue plasminogen activator and poor infrastructure are the most important barriers. [13] Treatment of multiple sclerosis mainly revolves around steroid pulses. Treatment modalities like intravenous immunoglobulin, plasmapheresis, and epilepsy surgery are rarely used due to very high cost and poor availability. In India, there are more than 500,000 epilepsy surgery candidates, but only 200 surgeries are done annually. [11] Many patients die of head injury due to lack of neurosurgical facilities. Majority of these patients are young and are in the prime of their lives.
In the absence of basic diagnostic facilities like cerebrospinal fluid examination, many patients of meningitis receive empirical treatment in rural or semiurban areas. Patients on anticoagulation rush to the cities for getting prothrombin time. Management of viral encephalitis patients become extremely difficult in the absence of neuroimaging, viral studies, and electroencephalography at primary and secondary health centers. Use of acyclovir is also limited by poor availability and very high cost. Majority of the genetic disorders remain undiagnosed. Electrophysiology labs in institutes are overburdened, as these facilities are unavailable in most of the medical colleges. Neurology journals are not subscribed in most of the medical colleges due to very high cost. Lack of internet facilities in state-level medical colleges deprives medical students and faculty members of recent advances in the field of neurology.
| Social Issues | | |
Stigma related to neurological disorders is very high leading to poor compliance, delay in seeking treatment, loss of job leading to financial loss and poverty. [14] Epilepsy patients lack knowledge related to risk of inherited epilepsy, driving restrictions, adverse effects of the drugs, and issues related to drug withdrawal. Parents conceal the information regarding epilepsy history of their daughters at the time of marriage leading to seizure recurrence postmarriage due to poor compliance. Uncontrolled seizures are major causes of drowning and burn in poor patients who take out water from open wells and cook their food with open fire. Some family members are not aware of benefits and availability of vaccinations and because of age-old misconceptions they do not administer the vaccines to their children.
| Solutions | | |
Many of the difficulties outlined above stem from limited healthcare resources in developing countries, and substantive improvements are unlikely to be quick or easy. Paucity of resources makes it almost impossible to craft meaningful long-term solutions to the care of neurological patients. Therefore, any attempt to improve neurological care must, of necessity, emphasize available cost-effective approaches. Most of the neurological disorders can be treated at primary healthcare level by ensuring availability of basic resources like drugs. This will reduce substantial cost and time. Cost may also be reduced by using drugs like phenobarbitone, which may be very helpful in fighting with epilepsy treatment gap. "Epilepsy out of the shadows", a joint initiative by WHO and international league against epilepsy is leading the global campaign against epilepsy in Africa. There is a need to start similar initiatives in other developing countries. [15] Social health insurance by government modeled on the line of China and developing countries like Brazil and Mexico may help deprived population to afford better treatment modalities. [16] Effective programs to vaccinate all the eligible population is an urgent need. Public education and awareness by involvement of government and nongovernment organization will be critical in fighting with social stigmas. Providing educational material related to common neurological conditions in local languages may be helpful in tackling social issues. Public awareness is also very helpful in encouraging people for using seat belts and helmets, which may lead to less incidence of head injury. There is a need for establishing trauma center at every state and national highways so that patients may get immediate care and many lives can be saved. To overcome the lack of manpower, effort should be made to train primary care physicians and internist for managing common neurological disorders. This may be done by short-term intensive training for 6-8 weeks by neurologists. Good neurological care at primary care level supported by efficient secondary and tertiary care facilities is the best possible option. Telemedicine may be an important tool in this direction. More research is needed to tackle specific neurological disorders pertaining to developing countries. There is an urgent need for better cooperation from developed countries that can help in developing manpower, and multicentric research which requires significant funding. This will lead to a better understanding of pathogenesis, more vaccines, and better treatment guidelines. Recent initiatives by world federation of neurology are a right step in this direction. We need to act faster before it is too late.
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