Global Neurology Report: The WHO ‘Neurology Atlas’ Second Edition

Emergency Room in Ethiopia

The World Health Organization (WHO) published the first comprehensive report (Neurology Atlas) on the
status of neurological care and services throughout the world over a decade ago. This compilation provided a
unique and invaluable source of data on the rapidly increasing burden of neurological disorders, and the available neurological services in 109 countries. It highlighted the large disparities between neurological care in the developed and developing nations, and provided critical information for medical specialists, healthcare planners, policy makers and national training programs. This Atlas provided the first detailed picture of the global situation for neurology, and the updated second edition was released in September 2017. It may be accessed here (

This updated Atlas reviewed 132 countries comprising 94% of the world’s population and the data will continue to be helpful to policy makers, although the findings were not surprising and may be summarized as follows:

(1) Neurological disorders are a significant cause of the global disease burden, which was thoroughly addressed in the Global Burden of Disease studies.

(2) Neurological disorders are disproportionately high in developing regions, which are also plagued by resource limitations and severe shortages of healthcare workers.

(3) Neurological conditions are expected to grow exponentially in the future.

The Atlas report focused on several key areas including legislation for neurological disorders, financing of neurological services, social welfare support, workforce data, available neurological services and informational gathering systems. As expected, sub-Saharan Africa fared the worst, with the lowest proportion of healthcare workers, the most limited services and poorest geographical distribution of those services. There were 0.04 neurologists per 100,000 people in the WHO African region, compared to 4.75 per 100,000 people in high income countries.

In Ethiopia, for example, where Dr. James C. Johnston serves as an Honorary Professor of Neurology with the Addis Ababa University neurology residency training program, there is one neurologist for every 3-4,000,000 people, and most of those neurologists are in the capital city Addis Ababa. This ratio, although exceedingly poor compared to the WHO recommendation of at least one neurologist for every 25,000 – 100,000 people, represents a significant improvement since before inception of the program in 2006 when there was one full time neurologist for the one hundred million people in the country.

Dr. Johnston established the non-profit organization Global NeuroCare ( to advance neurological services in developing regions. Global NeuroCare holds Special Consultative Status with the United Nations ECOSOC and fully supports the self-sufficient, sustainable Ethiopian neurology residency program. This program has made a significant and measurable difference in the Horn of Africa, graduating 32 board certified neurologists with 21 more physicians in the three year training, improving the lives of tens of thousands of people.

On behalf of Global NeuroCare, Dr. Johnston discussed the healthcare concerns affecting developing nations at the 2016 and 2017 United Nations High Level Political Forums, the 2017 United Nations Commission for Social Development, and at the World Association for Medical Law conferences in Los Angeles (2016) and Baku (2017). One of the main concerns impeding development stems from academic medical centers with global health programs that engage in short term medical missions which are tantamount to doctor tourism, fail to provide any substantive benefit to the developing nations, and cause more harm than good. He presented guidelines to improve sustainable, ethically congruent, collaborative partnerships focused on capacity building to advance neurological services in sub-Saharan Africa, using Global NeuroCare’s focus on Ethiopia as a model plan.


Global Neurology Report: Access to healthcare in Africa

Gondar Outpatient Waiting

Gondar Outpatient Waiting

The Economist Intelligence Unit recently published a report on access to healthcare in Africa and the Middle East. ( The report recognized the complex challenges of improving access to healthcare in sub-Saharan Africa, a region plagued by the ‘double burden’ of ongoing communicable diseases and rapidly increasing non-communicable disorders. These problems are compounded by a severe shortage of healthcare workers, poor infrastructure, limited transportation, and a dearth of supplies, equipment and medications.

The Economist Intelligence Unit Index ranked the countries on both (1) accessibility for most disease categories and access to medications, and (2) the healthcare system including coverage, infrastructure, efficiency and innovation. The Index evaluated progress considering current global policy agendas, such as the UN Sustainable Development Goals. It also adopted a forward-looking approach, asking whether each country is implementing the right mechanisms today for optimal access in the future.

Ethiopia ranked at the bottom in a cluster of other sub-Saharan countries. These least developed countries struggle with additional challenges such as underdeveloped supply chains for medications, a significant urban-rural gap in access and, most importantly, a continuing shortage of healthcare workers.

The increasing incidence of non-communicable diseases including neurological disorders is exacerbating poverty and significantly adding to the disease burden. The EIU reports that financial expenses of healthcare drive 11 million Africans into poverty every year. But, as Drs. James C. Johnston and Mehila Zebenigus discussed at the July 2017 United Nations High Level Political Forum, the situation is magnified by neurological disorders which afflict tens of millions of people, typically the young, causing cognitive impairment and physical disability, leading to loss of employment, marginalization, increased vulnerability and exclusion, contributing to a profound impact on the economy.

This EIU Report raises several suggestions for improvement including national health insurance, mobile technology applications, artificial intelligence platforms and focusing on specific disease threats. However, while these proposals may be beneficial if enacted, they do not address the key problem – a shortage of healthcare workers.

Drs. James C. Johnston and Mehila Zebenigus discussed these concerns at the 2017 World Association for Medical Law (WAML) conference and, while recognizing the many overwhelming challenges, recommended focusing on the root of the problem – the shortage of physicians and other healthcare workers. Africa has one-quarter of the global burden of disease but less than 3% of the world’s healthcare workers. The only way to ensure sustainable improvement if to ethically advance collaborative partnerships between developed countries and the least developed regions, with clearly defined goals, focusing on the needs of the South to establish self-sustaining programs that incorporate training, patient care and research, and provide triangular cooperation to improve South-South relations.

This focus on collaborative partnerships is the approach Global NeuroCare has adopted in working with the Addis Ababa University Department of Neurology, and that autonomous program has been extraordinarily successful, soon entering the 12 th year, having graduated 32 board certified neurologists, with 21 more physicians in the three-year training program.

Drs. Zebenigus and Johnston serve as Directors of the non-profit organization and will discuss guidelines for developing sustainable collaborative partnerships at future meetings with the UN, WAML and other organizations.

United Nations ECOSOC High Level Political Forum 2017 – Global Neurocare Presentation

United Nations High Level Political Forum

United Nations High Level Political Forum

44 nations convened at the United Nations High Level Political Forum (HLPF) in July 2017 to discuss progress towards meeting the Sustainable Development Goals (SDG). The HLPF is the main UN body that provides political leadership, guidance and recommendations for sustainable development, and addresses follow up and review of progress on the implementation of commitments. Member States agreed that the HLPF would be the central body to monitor and review all progress towards achieving the 2030 Agenda for Sustainable Development.

Multiple stakeholders including UN Agencies, Ministers, Cabinet Secretaries, academic experts and high profile non-governmental organizations such as Global NeuroCare attended the HLPF to advise the delegates on the most effective means of advancing the Agenda.

Non-governmental organizations must have valid UN ECOSOC accreditation to attend. Global NeuroCare holds Special Consultative Status with the UN ECOSOC, is accredited by the World Health Organization and affiliated with the Office of the Special Adviser on Africa.

Drs. James C. Johnston and Mehila Zebenigus presented recommendations on behalf of Global NeuroCare, focusing on the relationship between non-communicable diseases such as neurological conditions and poverty, and how improving access to neurological care will result in poverty reduction, thereby increasing economic, social and political stability in developing nations.

They highlighted the importance of increasing the recruitment, training and retention of local medical staff in the developing countries as the most practical means of capacity building to combat the non-communicable diseases. This requires establishing self-sufficient local training programs, an approach Global NeuroCare supports in Ethiopia through the Addis Ababa University Department of Neurology. These types of training centers require collaboration with the North, and Drs. Zebenigus and Johnston focused on the significance of formulating guidelines to ethically advance North-South partnerships and protect the inherently vulnerable populations of the least developed nations. (E/2017/NGO/16).

This second HLPF presentation followed statements by Dr. James C. Johnston to the Commission for Social Development (E/CN.5/2017/NGO/19) and the Integration Segment (Statement 11603), demonstrating that the neurological disorders are a cross-cutting issue requiring attention and integration with non-health sectors. This is a crucial point since Member States must recognize that addressing neurological diseases will not only improve healthcare (SDG 3) but also stimulate economic growth (SDG 8), promote poverty eradication (SDG 1), eliminate harmful practices (SDG 5.3) and encourage scientific research (SDG 9.5). This new integrated approach is essential to attain the 2030 Agenda goal of reducing premature mortality due to non-communicable diseases (SDG Target 3.4), and funding should be allocated accordingly with particular attention to the priority of addressing neurological conditions.

Drs. Johnston and Zebenigus will be discussing the potential for co-benefit solutions addressing neurological disorders and other developmental priorities such as access to safe water and food security at the 2018 HLPF which has a thematic approach of transformation towards sustainable societies.

James Johnston – Telling the other side of Tenet Hospitals

Neurologist and Attorney Dr. James C. Johnston is not surprised that Tenet Hospital was indicted again in 2017 for insurance fraud in an ongoing investigation by the FBI Healthcare Fraud Unit, Department of Justice and Office of the Inspector General. Just a few months ago Tenet plead guilty to insurance fraud, sham contracts, bribes and kickbacks, paying the Department of Justice over $516 million to settle criminal and civil charges. For the past two decades Tenet has repeatedly entered settlements with the government over insurance fraud, illegal kickbacks and related crimes, paying several billion in fines, earning the label as “one of the most despicable healthcare companies in the United States.” A simple google search of ‘Tenet fraud’ leads to thousands of articles on this company’s appalling misbehavior and abuse of patients.

In fact, 26 years ago, in 1991, Dr. Johnston was practicing in Texas at one of the Tenet Hospitals, at that time a chain of 116 hospitals that engaged in insurance fraud, bribes, kickbacks and performed unnecessary surgeries and procedures. Dr. Johnston refused to participate in the fraudulent schemes, referred his patients to other hospitals, and contacted the Department of Justice with a whistle-blower complaint against Tenet hospitals.

A hospital-based group of four physicians, one already repaying the government for Medicare insurance fraud, retaliated with an extortion attempt, bribing several workers’ compensation patients to make false allegations against him. The physician involved in Medicare fraud was married to the district attorney, who filed specious charges against Dr. Johnston that culminated in a lengthy court battle. At the time, terrible things were said about Dr. Johnston. The New York Times printed a biased story before the conclusion of this ordeal.

In the end, Dr. Johnston prevailed – Judge Barbara Marquardt heard all the evidence at trial and dismissed the false allegations against him as “pure fiction,” declaring him innocent of any wrongdoing. The Texas Medical Board also reviewed all the evidence and cleared Dr. Johnston of any misconduct or illegal act, found him innocent, and concluded that he maintained the highest professional standards, exceeding the standard of care. So did every other medical board where Dr. Johnston held a license. The New York Times refused to print a follow up story on Judge Marquardt’s findings or the final medical board decision, leaving their misleading story languishing on the internet for the past quarter of a century.

Dr. Johnston’s complaints, along with those of several other physicians at various Tenet Hospitals between 1991-1994 led the Department of Justice, FBI and Office of the Inspector General to investigate, eventually forcing Tenet to sell off a number of hospitals and pay a $900 million fine for billing fraud and related illegal activities. Several of the doctors making false accusations against Dr. Johnston lost their medical licenses, had to repay the government for fraud, and one ended up in prison. The district attorney and his assistant were investigated by the FBI and resigned from office.

The medical community members that know the whole story hold the highest respect for Dr. Johnston – he made a huge personal sacrifice to do the right thing, and stand up for his patients.  James C. Johnston, MD, JD has practiced neurology for 30 years and his reputation as a physician, attorney and member of the community is absolutely spotless.

World Association for Medical Law


World Association for Medical Law pic

World Association for Medical Law

Consultant Neurologist Dr. James C. Johnston is a Barrister of the High Court of New Zealand, a Fellow of both the Australasian and American Colleges of Legal Medicine, and an active member of many other professional organizations including the World Association for Medical Law (WAML).

Organized in Ghent, Belgium, in 1967, the purpose of the World Association for Medical Law is to encourage the study and discussion of health law, legal medicine and ethics, for the benefit of society and advancement of human rights. The aim is to promote the study of jurisprudence, legislation and ethics of developments in medicine, health care and related sciences; to address any matters that involve issues of medical and health law; and to encourage research and development in medical law.

The official publication of the WAML is the journal ‘Medicine and Law,’ which has been published for almost 40 years with authors from over 100 countries. The Kennedy Institute of Ethics labeled this journal as a “priority journal.”

The 50th Anniversary Meeting and 23rd WAML Congress was held on 9-14 July 2017 in Baku, Azerbaijan with major sub-themes including medical law and bioethics. Drs. Mehila Zebenigus, Guta Zenebe and James C. Johnston presented a discussion on improving relations between developed and developing countries through guidelines that focus on advancing collaborative partnerships to improve health care. This topic followed their lecture last year at the Los Angeles, USA meeting discussing the medical, ethical and legal problems that arise when Western countries engage in short term medical missions to resource limited nations.

Drs. Mehila Zebenigus and James C. Johnston also discussed concerns related to neuroimaging for the patient presenting with headache. They recommended deleting the currently used guidelines because those guidelines are outdated, and have been a contributing factor in the misdiagnosis of headache disorders.

Drs. Thomas P. Sartwelle, James C. Johnston, Berna Arda and Mehila Zebenigus presented a poster highlighting the concerns related to using electronic fetal monitoring in sub-Saharan Africa, how that procedure causes more harm than good, and wastes scarce resources that would be better used helping children with cerebral palsy.