International Education Issues: Neurology and poverty
Farrah J. Mateen, MD
Address correspondence and reprint requests to Dr. Farrah Jasmine Mateen, Mayo Clinic, Rochester, unit #1, #7-11th Ave. NW, Rochester, MN 55901
Few people in the world today are rich; the vast majority, 86%of the global population, live in the developing world, in countriesthat are classified as low or middle income.1 The most recentdata on extreme poverty suggest that nearly a billion people,spread over many continents, live on less than one dollar perday.2 It is in low and middle income (LAMI) countries wheremost cases of neurologic disease occur, including stroke, epilepsy,primary headache disorders, and Alzheimer disease,3 and in thesecountries neurologic disease is studied little if at all.
The public health challenges for neurologic disorders in LAMIcountries are multiple. Among the poor, there is special considerationof the 1) overall burden of neurologic disease, 2) lack of accessto essential medications, 3) paucity of epidemiologic researchavailable, 4) reduced ratio of practitioners in LAMI countries,5) double burden of communicable and noncommunicable disease,and 6) stigma. At every level of society, there is a need formore education, in rich countries as well as poor ones. Healthcare workers, students, governments, teachers, and members ofthe general public all have important roles to play.
Dementia and stroke are among the most common disabling diseasesworldwide,4 and in some regions of the world, stroke accountsfor more deaths than ischemic heart disease. Although oftenconsidered developed world diseases, 86% of all stroke mortality5and 85% of all cases of epilepsy3 occur in the developing world.Overall, neurologic disorders now account for a greater burdenof disease than HIV/AIDS.4
Studies from LAMI countries reveal poor access to underprescribedand often unaffordable medications. In one recent analysis6of four low and six middle income countries, just 71.5% of patientswith cerebrovascular disease were taking aspirin. In sub-SaharanAfrican nations, most medications are simply not available inpublic and private facilities, regardless of a patient’swealth. The World Health Organization (WHO) estimates that 150countries do not have adequate access to medications to treatpain.3
Moreover, 50 to 90% of people in LAMI countries must pay fortheir medications entirely by themselves.7 In Chad, a 30-daysupply of carbamazepine 200 mg twice daily costs the equivalentof 8.8 days of an unskilled government laborer’s wages,rendering treatment of a very treatable disease effectivelyunattainable.8 Thus, access to essential medications is a resultof both availability and affordability. Although costs and wagesare objectively measured, the health-care seeking behavior ofthe poor is largely unstudied.
PAUCITY OF EPIDEMIOLOGIC DATA AVAILABLE ON NEUROLOGIC DISEASE
From a public health stance, there is a lack of research inneurologic disorders. In other medical specialties, high incomecountries produce more than 90% of the world’s researchalthough they account for approximately 10% of the global population.This is the so-called 10–90 divide in medical publication.It is uncertain whether the 10–90 divide exists in theneurologic literature because it has not been formally studiedexcept in the case of dementia.9
Among the neurologic disorders, research in LAMI countries hasbeen so limited that their prevalence is difficult to estimate.Unlike census reports and sophisticated database analyses availablefrom high income countries, epidemiologic information from LAMIcountries is often obtained via tedious door-to-door surveysand reported in non-indexed, low-impact journals.10 Many studiespiggyback on cardiovascular disease research and lack an emphasison neurologic disorders. Little, in fact, is known about thecognitive effects of neuroAIDS outside of industrialized nations.11
The value of research publications in LAMI countries also differs.A publication in the developing world, even more so than inthe developed world, may have little effect on real life practice.12Thus, searches for "neurology," "headache," "dementia," andother common diseases in popular medical databases reveal noarticles on neurologic disease, at any point in time, from anumber of LAMI countries, accounting for knowledge gaps thatencompass millions of people over decades.
Where neurologists are needed most, they are least likely tobe found. Although the WHO estimates that one neurologist isneeded for a population of 100,000 people,13 in Africa, thereare an estimated 0.3 neurologists per million.14 Many countriessee neurologic care provided, if at all, by health care workerswith no formal training in neurology. Eleven African countrieshave no neurologists.15 Physicians practicing in countries withthe greatest need of neurologic care lack resources, educationalopportunities, and health care workers. Some physicians emigrateto countries that can provide these desired resources and opportunities.An estimated 20,000 physicians leave Africa each year,16 a regionwhich exemplifies this problem. Compared to the number of physicianswho leave, the number of high-income country physicians workingin Africa is small.
LAMI countries may continue to deal with diseases that havebeen eradicated or are easily prevented in high-income nations,the so-called double burden of communicable and noncommunicabledisease. For example, the last case of locally acquired poliomyelitisoccurred in the United States in 1979. Yet needless sufferingfrom poliomyelitis among the poor of Pakistan, Afghanistan,India, and Nepal persists,17 for both medical and cultural reasons,in a world that has largely moved on.
The majority of people with epilepsy, approximately 40 million,do not receive treatment.3 It would be wrong to assume thatthis is simply a financial issue, easily corrected by free medicationsand more health care workers. Recognition of neurologic disorders,particularly neuropsychiatric manifestations, as disease islong overdue.
Adding insult to injury, neurologic disease, even in the richestnations, in the hallways of the wealthiest institutions, canbe stigmatized as incurable or barely treatable. In the developedworld, common neurologic disorders are both under-recognizedand undertreated.3 Not only a matter of science, this is a failureof education as well. The situation is probably worse in LAMIcountries. If such stigmata persist, neurologic disorders willremain distant from the priorities of public health and publicpolicy worldwide.
Conceptually, neurologic disease and poverty are connected.The idea that poverty and its consequences—most notably,malnutrition—can lead to poor cognitive ability, poorschool performance, and eventual school desertion has been exploredfor decades.18–20 More recently, data from these samecountries demonstrate that secondary prevention of neurologicdisease in adulthood, such as stroke, is positively influencedby a higher level of education.21
Thus, when a neurologic problem is addressed scientifically,it next demands collective action for sustained population-widehealth improvement. Although small in scope compared to theburden with which they are faced, a number of agencies, academicgroups, and nonprofit organizations have begun the great dealof work required. Solutions occur at multiple levels. In February2007, the World Health Organization (WHO) and World Federationof Neurology (WFN) addressed the European Parliament, launchingNeurological Disorders, Public Health Challenges,3 a comprehensivesummary of the public health knowledge of neurologic disordersto date. Widespread changes for success include the entranceof women into the health care workforce, a focus on neurologywithin existing health systems, and the need for better epidemiologicinformation on which to set future priorities. The WHO callsfor a "paradigm shift beyond the current preoccupation withprevention and simple curative interventions to encompass long-termsupport and chronic disease management."3
Others have responded similarly in magnitude. Among them, theGlobal Campaign Against Epilepsy, the 10/66 Dementia ResearchGroup, the Global Burden to Reduce the Campaign Against Headache,and the WFN have each made progress. The WFN features an onlinebook, Where there is no neurologist,22 which is meant to actas a guide to paramedical professionals in the care of neurologicdisease. Many universities actively organize, sponsor, and encouragetheir staff and students to train abroad for short periods oftime. Most journals, including this one, are available to physiciansin low income countries at a reduced rate of subscription. Headacheclinics and neurology training programs now exist where previouslythere have been none. In more than 100 countries, neurologistsand non-neurologists alike participate jointly in alleviatingthe global burden of neurologic disease.
In the current Resident & Fellow pages of Neurology®,two American physicians recount their experiences studying neurologyabroad. Dr. Chad Heatwole,23 a neurology resident at the Universityof Rochester, relates his story teaching neurology at JagiellonianUniversity in Kraków, Poland. Dr. Porter provides aneye-opening account of the neurologic care in an impoverishedKenyan town.24 Together, their stories provide the humanitarianperspective, inarguably the most important reason of all, toaggressively tackle these challenges.
farrah_mateen{at}hotmail.com
Disclosure: The authors report no conflicts of interest.
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