Global Neurology Report: Neurological Disorders are the Largest Cause of Disability

The Lancet: Life Expectancy

The Lancet: Life Expectancy

Neurological diseases are the main cause of disability worldwide according to a recent analysis of the Global Burden of Disease (GBD) Study. (Global, regional and national burden of neurological disorders during 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurology 2017).

The significant increase in the burden from 1990-2015 occurred despite remarkable advances in the prevention and treatment of neurological disorders, and is partially attributable to population growth and aging. Additionally, the World Health Organization recently re-classified stroke as a neurological disease instead of a cardiovascular disorder which provided a more realistic view of the true neurological burden.

Cerebrovascular disease accounts for the largest proportion of disability adjusted life years, and in fact was the leading cause of disability in 18 of the 21 Global Burden of Disease regions including sub-Saharan Africa (SSA). And the study may underestimate the extent of stroke related disease and disability due to the paucity of data in many developing regions. More research is necessary to define the true extent of stroke and formulate effective prevention and treatment protocols that comport with the available resources in specific areas.

The most serious concern is in SSA which harbours the highest burden of disease, with the least resources, and has a population of one billion people that is expected to double in the next generation.

There are serious impediments to neurological care including stroke management in SSA – a dearth of specialists, limited imaging facilities, lack of medications, adherence to traditional beliefs and seemingly insurmountable infrastructural challenges, all superimposed on abject poverty with food and water insecurity. In addition to the high morbidity of stroke related complications, there are limited if any secondary stroke interventions, and an absence of neurorehabilitation. It is not surprising that the rates of stroke mortality and disability are ten-fold higher in SSA than in developed regions.

As a Director of Global NeuroCare, a non-profit organization dedicated to advancing neurological care in SSA and particularly Ethiopia, Dr. Johnston strongly recommends capacity building through sustainable, comprehensive, multimodality programs to address stroke prevention, treatment and rehabilitation, focusing on realistic goals that are commensurate to local resources. But, stroke prevention is of upmost importance, and funding should be allocated accordingly.

The most effective means of advancing neurological care is to form 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 physician training, patient care and medical research, provide triangular cooperation and encourage South-South cooperation.

This is the approach Global NeuroCare has adopted with the Addis Ababa University Department of Neurology, which has an expanding, autonomous neurology residency program that has graduated 30 neurologists over the past decade. The program is now training physicians from other African nations and developing South-South ties that will serve to more effectively combat the neurological burden of disease.

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Global Neurology Report: Medical Training in Ethiopia

Addis Ababa University

Africa suffers one-quarter of the global burden of disease, yet has only 3% of the world’s healthcare workers. It consumes less than 1% of the world’s healthcare expenditure. And the continent’s population of one billion people is set to double in the next generation.

The situation is even more disconcerting in the least developed nations such as Ethiopia, which is perhaps the most medically underserved country in the world. A recent World Bank Study reported there were just over 2,000 doctors for the country of 100 million people. This is a dismal situation that warrants increased international support.

There is some recent improvement with an increasing number of medical schools – in 2006 there were four medical schools, and now there are over 30 training centers that will begin graduating 2,000 physicians annually. Additionally, Ethiopia trained 38,000 healthcare extension workers to provide basic health education and services in the rural areas where 85% of the population resides.

However, there remain very serious impediments to advancing healthcare in Ethiopia and the other least developed countries – poor infrastructure, inadequate transportation, lack of equipment and medications, limited geographical distribution of services, and a continuing dearth of specialists.

External support is critical to further advance healthcare and specialist services in these regions, but it must be the right type of help. Unfortunately, many United States academic medical centers have focused on self-serving short term medical missions which can and do cause harm to the very regions that so desperately need help. These types of missions are lucrative and beneficial to the sending institution, but do not provide any substantive benefit to the developing country.

Neurologist Dr. James C. Johnston discussed these concerns at the United Nations High Level Political Forums in 2016 and 2017, and at the World Association for Medical Law Congress Meetings in Los Angeles (2016) and Baku, Azerbaijan (2017). He recommended focusing on a sustainable, comprehensive, ethically congruent approach to partnerships with a focus on advancing patient care, physician training and medical research to benefit the South.

Global NeuroCare is a 501(c)(3) non-profit organization founded by Dr. Johnston to advance neurological services in developing nations, particularly Ethiopia, and strictly adheres to these principles of sustainable partnerships dedicated to capacity building. Dr. Johnston is an Honorary Professor of Neurology at Addis Ababa University in Ethiopia, where the Department of Neurology has graduated 32 board-certified neurologists over the past decade, with 21 more physicians in the expanding three year training program. These neurologists have improved the lives of countless thousands of Ethiopians, and are now training physicians from other African countries.

Continued support of neurological training is crucial, especially since the World Health Organization reported that neurological diseases are one of the greatest threats to global public health. Please go to www.GlobalNeuroCare.org to contribute your support which will have an immediate impact on the lives of many of the world’s most vulnerable people. This registered tax-exempt non-profit organization does not use any of the funds for administrative expenses or salaries – every penny goes to the people in need.

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 (http://apps.who.int/iris/bitstream/10665/258947/1/9789241565509-eng.pdf).

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 (www.GlobalNeuroCare.org) 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.