Neurological Care in Developing Countries

Founder of non-profit NGO Global NeuroCare®, Neurologist James C. Johnston, MD, JD has dedicated significant time and resources to improving neurological care in some of the least developed regions in the world.

Dr. James C. Johnston focuses the NGO on sub-Saharan Africa (SSA), a region plagued by the ‘triple burden’ of ongoing communicable diseases, rapidly increasing non-communicable disorders such as cancer, stroke and heart disease, and escalating problems directly attributable to globalization including increased accidents, climate related health issues, and most notably, the current SARS-CoV-2 pandemic (also known as COVID-19 or the Wuhan virus).

The most significant factor beyond the current pandemic adding to the overall disease burden in SSA is the increasing incidence of non-communicable disorders. Ethiopian neurologist Dr. Mehila Zebenigus and Dr. James C. Johnston discussed these non-communicable disorders at the United Nations High Level Political Forum and last World Association for Medical Law conference, focusing on the neurological diseases 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. The Global Burden of Disease Study underscored the fact that these neurological disorders are the main cause of disability worldwide. (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.).

There must be improved access to neurological care in SSA in order to manage the increasing incidence of these diseases, which mandates addressing extraordinarily complex challenges such as a severe shortage of healthcare workers, poor infrastructure, limited transportation, and a dearth of supplies, equipment and medications, all compounded by abject poverty with food and water insecurity.

Global NeuroCare® focuses on improving healthcare access by establishing collaborative partnerships to increase the number of neurologists in SSA, and has worked with the Addis Ababa University Department of Neurology for the past fifteen years. This autonomous training program has been extraordinarily successful, having graduated over fifty board certified neurologists since inception in 2006. These neurologists not only see tens of thousands of patients but more importantly they train the general physicians to manage some of the common neurological conditions such as stroke, epilepsy and neuropathy. This teaching is an essential means of improving care in SSA, where it is unlikely there will ever be enough neurologists to meet the burden of disease.

Drs. Zebenigus and Johnston will attend the upcoming UN Forum to discuss the importance of maintaining collaborative partnerships, and caution against withdrawing, limiting or redirecting resources from ongoing programs to address the pandemic, as this would lead to increased morbidity and mortality from neurological diseases.

GLOBAL NEUROLOGY REPORT: A CRITIQUE OF ELECTRONIC FETAL MONITORING

 

The Surgery Journal recently published a peer reviewed critique of electronic fetal monitoring (EFM) by neurologist James C. Johnston, MD, JD and leading healthcare attorney Thomas P. Sartwelle.

These authors, Thomas P. Sartwelle and Dr. James C. Johnston, along with pre-eminent medical ethicist Professor Dr. Berna Arda, have repeatedly advised that continuous EFM should not be performed in routine labour due to a 99.8% false positive rate, and the fact it does not predict or prevent cerebral palsy or any other neonatal neurological injury.

EFM does increase the caesarean section rate, with an increase in maternal and newborn deaths and birth complications as well as devastating long term complications. In fact, these very concerns have led Australia, New Zealand and the UK to advise returning to intermittent auscultation (IA) instead of EFM, and in 2017 the American College of Obstetrics and Gynecology finally provided a long overdue recommendation that women be given an informed choice between IA and EFM.

Unfortunately, there are EFM apologists continuing to defend the procedure, and journal editors suppressing scientific debate on the topic. This most recent Surgery Journal article exposes one example of these harmful practices, and should raise serious questions about those EFM proponents recommending a procedure that causes more harm than good to mothers and babies alike. But perhaps the more disturbing aspect is a medical journal editor determined to stifle scholarly debate.

This open access article is available through the following link:

https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0038-1632404

The authors have also published their concerns in the Journal of Child Neurology, Maternal Fetal and Neonatal Medicine, British Medical Journal, Neurologic Clinics, Journal of Pediatric Care, Maternal Health Neonatology and Perinatology, Medical Law International, Surgery Journal and several other journals and books. These articles are available at James C. Johnston’s ResearchGate.net site:

https://www.researchgate.net/profile/James_Johnston6/contributions

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

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.

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.

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

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.