Thomas Friedman, in his 2005 book The World is Flat, explainedthat a combination of progress in technology, transportation,and economic forces has accelerated "globalism."1 Globalismmeans that our once-distant neighbors in the world—thosein faraway countries—are no longer that far away. Ourwealth, peace, health, and well-being are all tied together.Because of this, health problems throughout the world cannotbe so easily ignored as in the past. In some areas of the world,especially in Africa, the ability of people to get good healthcare for neurologic problems or diseases receives less attentionthan other global health problems.
Johan Aarli and his co-authors discuss neurologic care in Africain their article "Neurology in sub-Saharan Africa: A challengefor World Federation of Neurology."2 Publication of this articlereflects the increasing attention that the journal Neurology®is paying to global health issues. Sub-Saharan Africa (SSA)is the part of Africa that is south of the Sahara Desert andcontains many of the poorest or "developing" countries in theworld. Developing countries have widespread poverty, high birthrates, poor economy, and most often depend on other countriesfor financial support.
Dr. Aarli and coworkers discuss the problems in SSA, ways toimprove the situation, and plans that are already in place.
WHAT IS HAPPENING WITH NEUROLOGIC CARE IN SUB-SAHARAN AFRICA?
Dr. Aarli and his co-authors note that sub-Saharan Africa hasbecome the poorest area in the world, and those who live inthis area receive very limited neurologic care. While WesternEurope has approximately one neurologist for every 20,000 people,all of Africa has one neurologist for every 3 million people.
The problems in SSA involve all aspects of health care, includingvery few trained nurses, few services to diagnose and treatillnesses, few training programs, and poor access to drugs totreat illness. Another important problem affecting neurologicconditions is that there are no useful disability programs.These are programs that help those who have an illness to copeor receive care. Most countries in the region do not have ahealth care system where the government pays for care, and nearlyall medical costs are paid by the patient. This situation makesit even harder for most people to get care for neurologic problems.
WHAT AREAS OF NEUROLOGY NEED THE MOST ATTENTION? WHICH PROBLEMS ARE MOST EASILY SOLVED?
The authors discuss specific disorders and diseases that arenot getting enough attention. Some of these conditions are similarto those seen in wealthier countries. For example, epilepsy,a common problem throughout the world, is seen even more indeveloping countries, with about 85% of cases occurring in thosecountries.
The direct medical effects of seizures are a major source ofdisability. Also, the stigma people with epilepsy go throughis a problem throughout the world but is worse in the developingworld, adding to their loneliness and disability. There arelow-cost medications to treat epilepsy (for example, phenobarbitalcosts about $5 US/year), which shows that much could be donewith little money.
Infectious disease affecting the brain or nervous system, muchof which can be treated or prevented, affects millions in SSA.For example, 64% of new HIV infections are in SSA, and aboutone-third to two-thirds of these individuals will develop neurologicproblems.
Even though stroke is common in the developed world, the authorsstate that two-thirds of strokes and 90% of stroke deaths occurin developing countries. A large number of deaths from strokeoccur in developing countries, probably because there are fewtrained specialists, little help for rehabilitation, and poorsocial support systems. Many deaths from neurologic diseasein SSA can be prevented.
Dr. Aarli and coworkers note that simply counting the numberof deaths from neurologic disease underestimates the problem.The effect of neurologic conditions is more often felt in "lostyears of healthy life" and in loneliness because of stigma.
Dr. Aarli and coworkers identify prevention as an importantcomponent of health promotion efforts in SSA. Prevention effortscan limit the development of neurologic problems in many ways.Vaccination programs can prevent infectious disease. Other programsmight be able to rid the region of other infectious diseasessuch as malaria and river blindness. Traffic safety effortscould reduce the problems with brain injury from accidents.Many of these efforts depend on the development of completesystems of primary health care and the efforts of leaders inthe health care system. If officials from government, nongovernmentalagencies, and international organizations work together, someof the problems will be solved.
The World Federation of Neurology (WFN) is an important organizationthat deals with global neurology issues, and the efforts ofthis group are the focus of the article by Dr. Aarli and co-authors.In 2006, the WFN created a plan for the future of neurologyin Africa. They did this with help from neurologists in Africa.By the end of 2007, a WFN Africa committee made up of Africanneurologists will begin working together. Their first stepswill be to organize, including gathering a list of neurologistsin Africa. They also hope to increase the training of neurologistsin Africa by 10 per year and expand the number of training programson the continent.
If local training improves, this may help the problem of "braindrain," which occurs when African physicians who get medicaltraining in another country do not return to Africa.
Examples of specific steps to improve the problems have includeddonations of educational materials and training funds from theAmerican Academy of Neurology and the Japan Neurological Society.New programs including visits of US neurologists to Zambia,providing neurology guidebooks for nonphysician health workers,and "neuro caravans" (travel of neurologists from large citiesto other regions for giving care and training of health careworkers) are in place or planned. The WFN would like other organizationsto follow their lead.
Neurologic care in SSA needs to be better. Governmental, nongovernmental,and international groups must work together. If public healthand primary care systems are put in place and combined withefforts to improve neurologic care, there may be great successin improving these problems in SSA. The World Federation ofNeurology hopes to be at the center of these efforts.
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