Neurology in sub-Saharan Africa

It is time to end the underappreciation of the burden of neurological disorders in global health.¹

The Chairman of the Commission of the African Union, Alpha Oumar Konaré, recently claimed that Africa now confronts the world’s most dramatic public health crisis.² Sub-Saharan Africa has become the poorest region in the world. Many countries still suffer from the legacies of colonialism and slavery. Interethnic conflicts add to the problems. With a population of about 700 million, around 45% live for less than a dollar a day. The medical infrastructure is poorly developed and has approached collapse in some areas. The AIDS situation represents an additional socioeconomic problem.

COUNTRY RESOURCES FOR NEUROLOGIC DISORDERS

There is a lack of hospital beds for neurologic disorders in sub-Saharan Africa. The median number of neurologic beds per 10,000 population in low-income countries is 0.03, compared with 0.73 in high-income countries. Neurologists are scarce and unequally distributed. In Europe, there is one specialist per 20,000 population; in Africa, one per 3 million people. Less than 50% of the sub-Saharan African countries have neurologic societies. There is a lack of nurses and subspecialized neurologic services (neurologic rehabilitation, EEG, EMG, neuroradiology, and stroke units), facilities for postgraduate training are poorly developed, more than two thirds have no disability benefits available, and basic drugs used for neurologic disorders may not be available or are too expensive. While social insurance is the most important source of financing health service in Europe, none of the responding countries in Africa use social insurance as the primary method of financing. Out-of-pocket expenditure is still the primary method of financing in 84.2% of low-income countries. This is likely to result in further inequity of neurologic services. The major conclusion is that the available resources are insufficient to meet the global burden associated with neurologic disorders.³

NEUROLOGY AND PUBLIC HEALTH

Neurologic and psychiatric disorders are a great and increasing threat to public health in all developing countries and present special challenges in sub-Saharan Africa with its poorly developed medical infrastructure. The number of people living with HIV globally has now passed 40 million. More than 3 million people worldwide died of AIDS-related illnesses in 2005. Although the situation has improved somewhat during the last year, sub-Saharan Africa is still the most affected region globally, with 64% of new infections occurring there. Neurologic complications occur in 39 to 70% of the patients. Diagnosing neurologic disease in the HIV-infected individual is important for further treatment and improved survival.⁴ Although highly active antiretroviral therapy is established, it is still not available to many patients in sub-Saharan Africa like it is in developed countries. Only 9% of people living with AIDS and in need of antiretroviral therapy are on treatment.

There are around 50 million people living with epilepsy worldwide, and near 85% of these live in developing countries. In developed countries, cost-effective therapeutic interventions are available. More than 80% of the estimated 10 million patients with epilepsy in sub-Saharan Africa receive no treatment at all. Few antiepileptic drugs are available although the average cost of phenobarbitone is around $5 USD per person per year and could be affordable in many sub-Saharan countries. Epilepsy is associated with serious psychological and social consequences caused by stigmatization. International League Against Epilepsy, the International Bureau for Epilepsy, and World Health Organization (WHO) have joined forces in the successful Global Campaign Against Epilepsy.⁵

Infectious diseases that involve the nervous system affect millions of people and represent a severe problem in sub-Saharan Africa. Malaria remains a serious public health problem with a high mortality in severe or complicated malaria.⁶ African trypanosomiasis (sleeping sickness) is fatal if left untreated, but the number of human lives lost to African trypanosomiasis is getting lower. However, 36 countries in sub-Saharan Africa still have epidemiologic risks for the disease, necessitating constant surveillance and control measures. Schistosomiasis is endemic in 74 developing countries, but has a high morbidity rate and a low mortality. More than 80% of infected people with schistosomiasis live in sub-Saharan Africa.⁷

Stroke causes about 5.54 million deaths worldwide, and two thirds of these are in less developed countries. Reliable data on the global incidence of stroke are lacking, but it is assumed that 90% of stroke-related deaths occur in developing countries. Governments and health planners in these countries may have underestimated its importance and not allocated resources for primary prevention of stroke. Sub-Saharan countries lack trained specialists and rehabilitation services with consequences for the stroke survivors. Traumatic brain injuries and neurologic consequences of malnutrition add to the picture of the burden of neurologic disorders in sub-Saharan Africa. Children are especially vulnerable, and neurologic complications of malnutrition are an important cause of preventable brain damage in young age groups.

Neurologic disorders currently cause around 12% of all deaths globally. The burden of neurologic disorders is, however, considerably underestimated when measured only by mortality data. Many neurologic disorders, such as leprosy, cause considerable ill health and involve a high number of disability-adjusted life-years, but may have a low mortality. The Global Burden of Disease studies have analyzed not only mortality, but also disease prevalence and lost years of healthy life.⁸ In 2005, over 92 million years of healthy life were lost through neurologic disorders worldwide; more than half of this burden was caused by cerebrovascular disease. Disability due to Alzheimer disease and other dementias, communicable diseases, such as parasitic diseases, meningitis, Japanese encephalitis, and poliomyelitis in some countries, add to the picture of disabling neurologic disorders. It has been calculated that more than 103 million years of healthy life will be lost in 2030 unless trends are reversed.⁸

Many neurologic disorders are associated with stigma. Misconception and myths give a special stigma to patients with epilepsy, inhibit access to treatment, and contribute to the isolation of patients. Stigma is a universal phenomenon, but is most severe in poor countries. The stigmatization denies people some of their basic human rights.

Disease prevention is essential in public health strategies, and some neurologic disorders can be successfully prevented by public-health efforts such as vaccination programs and traffic safety measures to avoid traumatic brain injuries. There are a few examples of public health solutions that work in the African setting, such as the elimination of river blindness and to some extent also leprosy, but the HIV/AIDS problems now represent a serious obstacle to economic development in the African continent.⁹ Most neurologic disorders require extensive therapeutic strategies which again call for the coordination of public health efforts among governments, international agencies, and non-governmental organizations. The neurologic problems associated with sub-Sahara are too complex to be solved by individual organizations, but have to be faced and analyzed in a worldwide co-operational pattern. In the recent report Neurological Disorders, Public Health Challenges, WHO points out that the most promising approach for reducing the burden of neurologic disorders in developing countries is a comprehensive system of primary health care. Rehabilitation has to complement other treatment modalities. Public health professionals have an important contribution in gaining political support, and public and professional awareness of public health aspects of neurologic disorders needs to be raised by campaigns, which also may relieve stigma and discrimination against people with neurologic disorders. The global campaign against epilepsy is an excellent example of developing national capacity and international collaboration, and may be transferred to other fields of neurology.⁷

THE ROLE OF WORLD FEDERATION OF NEUROLOGY (WFN) IN THE DEVELOPMENT OF NEUROLOGY IN SUB-SAHARAN AFRICA

The new Director-General of the WHO, Dr. Margaret Chan, has declared that she wants WHO to be judged by the impact their work has for the health of people in Africa. To the WFN, the development of neurology in Africa is a leading vision for the coming 4-year period.

In 2006, WFN prepared a roadmap for neurology in Africa. This plan is based upon suggestions made by neurologists who practice in African countries. The importance of working with the African neurologists and the local health systems is critical. A Task and Advisory Force for Neurology in Africa (TAFNA) co-chaired by the WFN President, Johan A. Aarli, and Professor Amadou Gallo Diop, Senegal, is the hub for the coordinated WFN activities. TAFNA will advise, support, fundraise, evaluate, and accompany the WFN African Committee. The African Committee will be set up at the end of 2007 and will be composed of African neurologists working and residing in the continent. A first task for the committee is to prepare a directory of neurologists in Africa, similar to the directories of American Academy of Neurology (AAN) or the European Federation of Neurological Societies (EFNS). The directories are essential also for the selection of candidates for international training and for research funding.

Educational activities are central in the WFN Programme for Africa. First, there is a need for training of more neurologists. WFN hopes to assist in increasing the number of neurologists by 10 more annually. The long term goal is that all countries on the continent train their own specialists in neurology. This is still far ahead, and a short term goal is therefore to train candidates outside the countries which today do not have training possibilities. This can be done in some cities in Africa or in North America, Europe, Australia, or Japan. But international training is expensive when performed on another continent, which may not always reflect the same disease panorama as in the countries where the neurologists will have their practice. Completing locally acquired experiences with a focus on sophisticated techniques would be preferable versus full 4 years training out of the continent. In addition, new specialists may prefer to stay in the countries where they have been qualified (brain drain). The alternative is to focus upon existing training centers on the African continent, with a higher probability that the candidates, when graduated, return to their countries of origin.

WFN has already evaluated the Service de Neurologie, University of Rabat, the University of Abidjan (Ivory Coast), and the University of Dakar (Senegal) as potential Regional Training Centers for clinical neurology in French-speaking Africa. These cities receive trainees originating from African countries. Recently Rwanda received its very first neurologist after 4 years of training in Senegal with 3 months complementary neurophysiology in Belgium. This is a success story of South–South and North–South cooperation which needs to be accompanied by material support of international neurology organizations for setting up a service of neurology and a league against epilepsy in a country coming out of a war situation. Many neurologists have been trained in Dakar and Abidjan universities and have joined their countries. The other countries which have benefited from such Francophone interuniversity cooperation are Mauritania, Burkina Faso, Benin, Togo, Mali, Guinea, Congo-Brazzaville, Chad, and Morocco.

There is also a need for similar training activities in English-speaking African countries. Some neurologists from other African countries are already in training positions in South Africa. At present there are four in training at various centers: one in Durban (from Libya), one in Stellenbosch, one in Cape Town (from Mozambique), and one in Johannesburg. South Africa has generously offered to accommodate three further registrars for training in neurology, which will be an important step forwards. WFN also looks forward to the establishment of new Neurology Centers of Excellence in other African countries. WFN, TAFNA, and the African Committee plan to establish a system of Department-to-Department cooperation with support from various sources for obtaining equipment, neurologic examination materials, and EEG and EMG equipment for African neurology services.

In 2008, neuro-courses will start in Africa with support from WFN, EFNS, IBRO, and local African training staff. For those who are already qualified neurologists, a Continuous Medical Education (CME) program is of great importance. In 2006, the AAN generously offered the WFN the opportunity to access Continuum on-line for members of the CME program.¹⁰

WFN has already established short-time Junior Traveling Fellowships. The Japanese Neurological Society has generously offered a Japanese scholarship for training of one African neurologist at a Japanese neurologic center.

In many areas of sub-Saharan Africa, the lack of neurologists is part of a general lack of physicians and health personnel. In a program established in 2001 by the WFN and the University of Zambia, neurologists from the United States pay regular teaching visits, and Dr. Gretchen Birbeck has developed popular neurology manuals for non-physician health workers working in Zambia and in Malawi.

Other initiatives such as “Neuro-Caravans” are progressively developing in West Africa, with the support of the pharmaceutical industry, to bring teams of neurologists from capital cities (Dakar, Abidjan, Ouagadougou) to the regions for 2 days training of health personnel in care of patients with epilepsy and other neurologic conditions. After initial strong support from WHO and other international organizations, this initiative may need financial and material sources to become sustainable. Initiatives such as “Where there are no neurologists” and Neuro-Caravans are important to support, develop, and expand to other African countries because some may not yet have a neurologic unit, or, when existing, the whole staff is concentrated in the capital city.

WFN has now regionalized its structure, and the new Regional Directors will have an important function. The Regional Directors will serve as links between the central administration of the WFN and the regional neurologic association they are representing. They are to be responsible for liaising with their WHO Regional Office in order to collaborate with the regional levels of WHO, to assist in the identification of areas where there exists a need for campaigns aimed at the prevention of neurologic disease, and provide information on neurologic disorders in the region.

In 2001, World Neurology Foundation was established to provide a fund-raising arm of WFN within North America, and this organization is already meeting with challenges in providing basic neurologic and neurophysiologic equipment.

The Pan-African Association of Neurological Sciences (PAANS) brings together African neurosurgeons and neurologists. WFN wants the PAANS to become stronger in order to have the international voice it deserves in neurology. In the future, the PAANS congresses should be the venue for African neurology; for example, PAUNS and EFNS are in their respective regions. Clearly, in a region where neurology is underdeveloped, an umbrella organization covering Africa will have much stronger input on the health authorities than the few individual neurologists will have in their respective countries.

Neither PAANS, nor WFN, nor WHO has the necessary resources to develop the neurosciences in sub-Saharan Africa. One important motivation for the Africa initiative is to put Africa on the agenda, systematize the efforts done and the resources available, and to establish a roadmap for our further work.