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Neurology Today:
doi: 10.1097/01.NT.0000363218.26720.bb
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Dispatches from Ethiopia: The Unique Challenges in Neurologic Care

STUMP, ELIZABETH

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The second in a series of reports from a Neurology Today reporter's visits to clinics, schools, and hospitals in Addis Ababa, Ethiopia. Look for more regular coverage of international issues in neurology with the launch of a new column, Global Neurology in the next issue.

ADDIS ABABA, ETHIOPIA—Ethiopia lags sorely behind developed nations in terms of medical resources and health care — at a time when both infectious and non-infectious neurologic diseases are on the rise.

The most frequent neurologic problems in Ethiopia's young population are epilepsy; neuroinfectious diseases arising from HIV/AIDS, tuberculosis, and leprosy; and complications from malaria, according to Ethiopian neurologists interviewed by Neurology Today.

In addition, common neurological disorders include neuropathies, movement disorders, brain tumors, mental retardation, and myelopathies. Stroke also poses a huge burden; this is due to an increased incidence of hypertension and diabetes mellitus and lifestyle changes like diet and cigarette smoking, according to local neurologists and a paper published last April in the Sudanese Journal of Public Health.

Diagnostic certainty regarding neurological cases in Ethiopian hospitals is poor, said James H. Bower, MD, associate professor of neurology at Mayo Clinic in Rochester, MN, who has been traveling to Ethiopia to teach since 2001. Lack of a clear diagnosis hinders appropriate neurologic treatment, said Dr. Bower, citing a 2007 Neurology study he conducted. Neurologists often make their diagnosis based on a history and examination but they often don't have access to the laboratory tests and imaging studies such as MRI, or myelography, blood tests, EEG, EMG, and other diagnostic equipment.

Even when these diagnostic tools are available, testing is often not done in 25-to 33-percent of patients, he said, because of technical problems, patient refusal, or cost concerns.

Treatment is also hampered by shortages of medication and other therapies, said Dr. Bower. Doctors may be hard-pressed to prescribe effective medicines that are not affordable for their patients. Some are affordable but not widely available, like phenobarbital, with an average cost of $5 USD per person per year (the annual per capita income is currently estimated to be $100 USD), according to a review article by Guta Zenebe, MD, a neurologist in Addis Ababa.

Neurologists do not have IV thrombolytic therapy for ischemic strokes, a common reason for hospital admission, or “the capacity for stenting and clipping surgery for subarachnoid hemorrhages,” said Yohannes Woubishet W/amanuel, MD, a first-year neurology resident at Addis Ababa University Medical Faculty.

Figure. ETHIOPIAN NE...
Figure. ETHIOPIAN NE...
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“The usual mainstay of our treatment is avoiding complications arising from the stroke, aggressive physiotherapy, and preventing recurrence,” Dr. W/amanuel said. “The post-stroke outcome on follow up is not as good as in the US because rehabilitation and early interventions are much better in the US.”

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PUBLIC MISCONCEPTIONS

Public misconceptions about neurologic disorders, particularly epilepsy and movement disorders, are rampant. Many view these conditions as curses, caused by supernatural powers and evil spirits, and they often hide those affected. If patients do seek treatment, they often go to ‘traditional healers,’ who apply holy water and herb treatments; once they get to a medical doctor, it may be too late.

Dr. W/amanuel described a situation where a bus driver in Addis Ababa had an absence seizure while driving his bus. Not until he had gone around a roundabout five times did passengers realize something was wrong, and they had to physically stop him from driving. It took three separate incidents before he was ordered to have an EEG at the hospital and diagnosed. Currently taking valproic acid, he has a different job.

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HIV/AIDS

Neurological complications occur in 39-to 70-percent of patients with HIV here. But there is still a lot of stigma associated with having HIV/AIDS, and those with AIDS tend to shy away from treatment. However, the situation has improved recently, and highly active antiretroviral therapy (HAART) is a standard component of care in Ethiopia now, said Sisay Gizaw G. Michael, MD, a chief resident at the Addis Ababa Faculty of Medicine who is in the final year of his clinical neurology residency.

HAART is free in all hospitals and some private clinics all over the country, Dr. Michael said. But the only available neurologists to treat HIV-neurology patients are in Addis Ababa.

Before HAART became so accessible, people with the disease were skeptical about its efficacy; now that it is widely available, the benefits of the drugs are public knowledge, and people with HIV are now much more willing to step forward for health care treatment, Dr. Michael said.

The high prevalence of HIV/AIDS — almost every household experiences it — has also intensified public education activities through the media and government health ministries, said Dr. Michael, and this has greatly reduced stigma and HIV/AIDS health risks.

Toxoplasma encephalitis is a common neurological complication from HIV/AIDS in Ethiopia, and is more common there than in the US, said David B. Clifford, MD, Melba and Forest Seay Professor of Clinical Neuropharmacology in Neurology at Washington University School of Medicine in St. Louis, MO. “Cryptococcal meningitis is also a very common issue in this region of Africa,” he said.

AIDS patients with neurological complications are given standard drug treatments that work for those illnesses in the US, with a few exceptions due to limited drug availability. For example, amphotericin B, an important part of initial therapy for cryptococcal meningitis, is sometimes not available due to cost restrictions, said Dr. Clifford.

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INADEQUATE HEALTH INFRASTRUCTURE

“The big picture is that the health infrastructure is simply vastly inadequate to address the needs of this country,” said Dr. Clifford. “The physicians there are remarkably skilled and dedicated, but ultimately get overwhelmed by the difficulty of practice, and lack of available interventions. Outreach to build the health infrastructure and develop the society is needed.”

Overcoming the frequent barriers to care — financial constraints, lack of facilities, social stigmas — will require public health, local government, and international intervention, said Dr. Bower.

The Ethiopian government recognizes that it needs to do more to reform the health care system and enhance the growth of neurology, said Medhin Zewdu, MD, chief of staff at the Ministry of Health. Their goals related to neurologic care include increasing recruitment to the specialty; preventing communicable diseases; and reducing mortality from malaria, HIV/AIDS, and tuberculosis.

Help toward those objectives has come from international efforts organized by organizations like People to People and the World Neurology Foundation (WNF). WNF President Michael Finkel, MD, of Naples, FL, was part of the delegation traveling to Ethiopia in May, and he donated 28 toolkits for neurologists containing a reflex hammer, U-Fork, NINDS Stroke Scale, stethoscope, eye chart, and scissors.

“Medical equipment in general and bedside physical examination aids are either scarcely available or expensive here in Ethiopia,” said Dr. Michael.

“Dr. Finkel's toolkit is so valuable for us here as there is no place that sells neurologic examination tools, including the tuning forks, the hammer, and the pupillary gauges,” agreed Dr. W/amanuel.

Still more international help is needed to conduct epidemiological research, link Western and Ethiopian institutions for student exchange, training, and telemedicine, and donate equipment and educational materials.

Said Steve Brown, neurology coordinator at Pleasant Valley Hospital in Point Pleasant, West Virginia, and director of neurology training for People to People: “Making a difference in Ethiopia gives those from the West an accomplished feeling, knowing that they are mentoring and sharing knowledge for a greater cause.”

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REFERENCES

• Arash BD, Mehila Z, Zenebe G, et al. Neurology training and pactice in Ethiopia. Sudanese J Public Health 2008;3 (2) 49–60.

• World Foundation of Neurology in Ethiopia: www.worldneurology.org/projectsToolKit.asp

• People to People: www.peopletopeople.com

©2009 American Academy of Neurology

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