Introduction from Dr Markus Reuber, editor-in-chief of Seizure
As health budgets in many high-income countries (HICs) are being squeezed, and health services for less visible conditions such as epilepsy are under particular threat, a more global view of epilepsy and its treatment continues to produce a picture which is so unpalatable that most of us prefer to dissociate from it - or not to look in the first place. This may make us feel better, but it does nothing to change the facts that four out of five people with epilepsy live in low or middle income countries (LMICs) and that most people with epilepsy living in LMICs receive deeply suboptimal treatment for their condition.
The differences between healthcare provisions in Sub-Saharan Africa (SSA) and those in HICs are at least as large as the differences in gross domestic products (GDP) and mean personal wealth. A WHO brochure about the state of epilepsy provision in SSA summarises some of the problems any reforms would face: the mean personal GDP of HICs is 15 times that of countries in SSA. In SSA, neurologists can only be found in major cities. On average, one neurologist serves a population of 1 million (in Europe the mean ratio is 4/100,000). There are significant problems with maternal and child nutrition and health likely to affect the risk of developing epilepsy. Several studies have reported higher incidence rates of epilepsy in LMICs than HICs. Despite the Bamako Initiative, launched by several African governments in 1987 to ensure a reliable supply of essential, good quality drugs at low cost to most of their population, there are still major problems with the regular provision of medication in many areas (1).
My Editor's Choice in the current issue of Seizure by Ewan Hunter et al. provides a brief glimpse of the difficulties people with epilepsy (PWE) living in a LMIC continue to face. Over two thirds of the PWE they identified in their large house-to-house survey in Tanzania received inadequate or no treatment for their seizure disorder. Their study also suggests that this problem cannot simply be fixed by shipping in regular supplies of antiepileptic drugs (although this could perhaps help). The unexpectedly low prevalence of active epilepsy and the relatively large number of people who completed the survey but were not available for more detailed questioning may well indicate that epilepsy continues to carry significant stigma, and is a condition many people in Tanzania do not want to talk about - even to a researcher. These observations call for much broader educational initiatives - which would, of course, pose a particular challenge in SSA, where the mean illiteracy rate is 40%.
These challenges are so great that the people who read this in HICs may well choose to continue to look the other way. Nevertheless, I hope that many will read this article and that some will be inspired to help.
(1) The Global Campaign Epilepsy "Out of the Shadows". Epilepsy in the WHO African Region - bridging the gap. World Health Organisation 2004.
(2) Hunter E. et al. Prevalence of active epilepsy in rural Tanzania: a large community-based survey in an adult population. Seizure, Volume 21, Issue 9, November 2012, Pages 691-698