In Context

www.thelancet.com/neurology Vol 10 November 2011 953

For the WHO Global Burden of Disease analysis see http://www.who.int/healthinfo/global_burden_disease/en/

Neurology in resource-poor countries: fi ghting for fundingThere is a grave lack of resources to tackle the huge burden of neurological disorders in low-income and middle-income countries. Simple, cheap measures could help to improve the lives of many patients, but neurology needs to compete for its share of limited funds. Dara Mohammadi reports.

Although neurological disorders are often regarded as complex conditions that require sophisticated treatments, simple measures can make a big diff erence to the lives of patients and their families. And in resource-poor countries, where the burden of neurological disorders is huge, simple, cheap, and easily implementable approaches to care are exactly what is needed. But misconceptions about the burden of neurological disorders in developing regions and the resources needed to treat them have meant that neurology has not received its share of available funding.

The WHO Global Burden of Disease analysis estimates that, together, neurological and psychiatric disorders now account for more than 13% of global disease burden, with much of this burden borne by the developing world. The Atlas of Country Resources for Neurological Disorders—a collaborative eff ort between WHO and the World Federation of Neurology (WFN) that set out to map national and sub-national resources for the treatment and management of neurological disorders—drew attention to the dearth of resources available to tackle these disorders in low-income and middle-income countries, where the treatment gap is often extremely wide.

Various initiatives have been launched, both globally and in de vel-op ing regions, to prevent neurological dis orders and improve treatment and rehabilita tion for individuals with neuro logical disease, but these eff orts have yet to yield substantial benefi ts for many patients. The most recent initiative to be established—the Grand Challenges in Global Mental Health study—aims to thrust neurological and psychiatric disorders to the forefront of global scientifi c and public health

eff orts, but concerns have been raised by some neurologists about the omission of neurological disorders such as stroke and cerebral malaria, which exact a huge burden in low-income and middle-income countries.

“The fi gures that are commonly cited for what proportion of the global burden of disease brain disorders represent is seriously understated,” Donald Silberberg (University of Pennsylvania, USA) told The Lancet Neurology. “There are several reasons for that. One of them is that the way in which WHO categorises disorders is antique.”

Along with the categorisation of stroke as a cardiovascular rather than a neurological disorder, Silberberg cites the pigeon-holing of neurodevelopmental disorders, head and spinal trauma, and infections of the nervous system under various other disease classifi cations as weak-nesses of recent attempts to quantify the true size of the global burden of neurological disorders. He says that when pulled together, brain disorders account for as much as 25% of global death and disability.

“Such underestimation,” explains Silberberg, “impairs the ability of people interested in these disorders to compete within health-care systems where funding is very short and where there is huge competition to get funding for various programmes.”

Other factors also play a part in this neglect of neurological disorders.

“In neurology, you have the problem that there are dozens and dozens of diff erent discrete disorders, which make the fi eld look very complex and it ends up looking daunting to ministers of health or people in funding foundations,” he adds, emphasising that simple, inexpensive measures could be introduced quite easily in developing countries for many neurological conditions.

“The low-hanging fruit, if you like, that can be addressed immediately are recognition and treatment of epilepsy,” says Silberberg. “About 60–70% of epileptics can be treated for $2–3 a month. And stroke prevention—what does it cost to provide an aspirin a day to adults over 50?”

Indeed, initiatives such as the Global Campaign Against Epilepsy have had some success in promoting the use of inexpensive drugs for the treatment of people with epilepsy. But still, according to WHO, no antiepileptic drugs are available in a quarter of low-income countries.

Many neurological disorders, how-ever, are complex in terms of both diagnosis and treatment, requiring ex pen sive diagnostic equipment and long-term care—resources that, as Johan Aarli, former president of WFN, explains, are simply not available for most people in resource-poor countries.

“The biggest problem when trying to tackle the global burden of neurological disorders is the disproportion between the global burden and the resources available to meet this burden,” he told The Lancet Neurology. “Developing countries need these resources. They need medical schools that are central. It’s a long programme that will take many years.”

Aarli points to the lack of neurologists and neurological nurses in developing

“The biggest problem when trying to tackle…neurological disorders is the disproportion between the global burden and the resources available to meet this burden”

For The Atlas of Country Resources for Neurological Disorders see http://www.who.int/mental_health/neurology/epidemiology/en/index.html

For the Grand Challenges in Global Mental Health study see http://grandchallengesgmh.nimh.nih.gov/about.shtml

For the Global Campaign Against Epilepsy see http://www.who.int/mental_health/management/globalepilepsycampaign/en/index.html

In Context

954 www.thelancet.com/neurology Vol 10 November 2011

For Alzheimer’s Disease International see http://www.

alz.co.uk/

countries as a glaring example of the disparity in global resources. According to The Atlas of Country Resources for Neurological Disorders, there are, on average, a staggeringly low 0·03 neurologists per 100 000 population in low-income countries, and some countries in sub-Saharan Africa still have no neurologists.

Aarli’s time heading up the WFN saw the establishment of the Africa Initiative in 2006, which, in partnership with organisations such as the International Brain Research Organization, set out to improve neurological services in Africa, helping to set up training centres for neurologists. Encouraging steps were taken in the development of relationships with neurological org-anisations in Tunisia, Egypt, Morocco, and Algeria—countries with the capacity to train neurologists from other African countries. However, the recent civil unrest in north Africa has put these plans on ice, but Aarli hopes that negotiations will be rekindled this month at the 20th World Congress of Neurology in Marrakesh, Morocco.

Although in Asia and South America the neurologist-to-patient ratio in resource-poor countries is not quite as dire as it is in sub-Saharan Africa, Guy Thwaites (Kings College London, UK) says that health-care systems there are still woefully ill-equipped to deal with the burden of neurological disease.

He describes what he calls a double hit, whereby richer populations in these

countries are experiencing a higher prevalence of stroke and dementia as a result of increasing life expectancy and the unhealthy behaviours that accompany rapid urbanisation, while poorer populations are still suff ering from many neurological infections. “It is going to place an enormous burden on health services in these countries,” he states.

“Certainly up until now, for whatever reason, probably economic, governments have left it to the family to care for people with neurological disabilities, and I think there is a little bit of a myth about how good the extended family is at caring for people with long-term illness,” he explains, stressing the need for initiatives that are aimed at educating and engaging families, and making it clear to them that much can be done for people with neurological disorders.

Thwaites refers to the work of organisations such as Alzheimer’s Disease International and the 10/66 Dementia Research Group, which are very active in defi ning the problem and thereby increasing awareness and reducing any stigma associated with these disorders. Although, at fi rst glance, initiatives to raise public awareness of neurological disorders might seem less crucial than their capacity-boosting counter parts, such work is enormously important in low-income and middle-income countries.

“It’s only recently in developed countries that we equate stroke as a brain attack equivalent to heart attack, and that we get people into hospital quickly so that things can be done that will improve their outcome,” explains Thwaites. “That whole culture isn’t there in developing countries. Families and carers will recognise a stroke, for example, as an odd event but will carry on looking after them. They don’t even engage in medical services.”

Although neurological disorders cannot always be treated successfully, the burden to a patient and their family can sometimes be alleviated with neurorehabilitation. Javier Carod-Artal

(Virgen de la Luz Hospital, Cuenca, Spain) worked for 12 years as a director of neurorehabilitation at the Sarah Network of Rehabilitation Hospitals in Brasilia, Brazil, and his exasperated reaction to the possibility of enhancing such rehabilitation in developing countries tells a huge story. “Cognitive rehabilitation in these countries is a utopia, a dream—they are no use at the moment,” he says. “Early diagnosis is virtually absent. Most of the patients with dementia or Alzheimer’s that we worked with had 5 to 8 years of disease progression before we saw them, which really limits any chance of tackling cognitive impairment.”

Limited access to care, along with prohibitively expensive drugs, precludes successful treatment in many resource-poor countries, but even if these major obstacles are removed, Carod-Artal highlights a further complication that lies in wake. “Another problem is how to test cognitive impairment in a population where many people are illiterate,” he explains. “The mini-mental state examination or the Wechsler memory scale are available, but for doctors to perform the diagnosis patients need to be able to read and write.”

With hands tied by fi nancial constraints and a quagmire of com-plexity in terms of the number and variety of countries and disorders involved, the problem of how to tackle the burden of neurological disorders in resource-poor countries is certainly not for the faint-hearted. Silberberg, however, is clear about the approach that needs to be taken. “Probably the most important step is to bring these disorders and their frequency to the attention of both the health ministries in these developing countries and to funding agencies in wealthy countries that can help address these problems,” he affi rms. “Once there is more under-standing of what the issues are, then local solutions and international approaches will begin to materialise.”

Dara Mohammadi

Limited access to neurological care precludes treatment in resource-poor regions

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For the 10/66 Dementia Research Group see http://www.

alz.co.uk/1066/

For more on the 20th World Congress of Neurology see

Editorial page 947