The published literature in global neurology over the past 1-2 months sure seems to be one sad tale of stroke woe after another for low income countries and populations. In Neurology, Kaddumukasa at al. in “Influence of sodium consumption and associated knowledge on post-stroke hypertension in Uganda” delineated gaps in care and patient knowledge that offer some direction in terms of the health education needs for post-stroke patients. In our associated editorial, Dr. Luciano Sposato and I share our perspectives on what this may mean for secondary stroke prevention efforts in Africa. In the Lancet, Healey and colleagues’ prospective cohort study of people presenting to Emergency Departments with atrial fibrillation or flutter from 47 countries provided further evidence that people with stroke in low and lower-middle income countries (LMICs) have worse outcomes. At 1-year follow-up, people from South America and Africa had 20% mortality compared to only 10% in more developed settings with untreated hypertension likely accounting for a substantial proportion of the excess mortality. Hypertension is quite the ubiquitous culprit in Africa. The Nigerian Journal of Clinical Practice published an epidemiological survey of hypertension in the Anambra state of Nigeria. In this church-based cross sectional study of adults from 17-79 years of age, 23% had hypertension with only 10% having a prior diagnosis. Hypertension was associated with several potentially modifiable risk factors including smoking, low levels of physical activity, alcohol consumption, and a poor diet.
Certainly primary and secondary stroke prevention efforts including population reductions in blood pressure are a central intervention needed to stem the tide of stroke-related morbidity and mortality in low income settings. But what about acute stroke therapies? Treatments such a tPA are likely cost prohibitive for low income settings. Would a clinical trial of a cheaper agent such as streptokinase, be ethical even if it isn’t as safe as tPA? In the August 27th issue of the Lancet, bioethicists Govind Persad and Ezekiel Emanuel argue that based upon the principals of utility, equality and priority, there is an imperative to provide a larger number of people with access to some treatment than to restrict treatments with a more expensive agent to a smaller group of individuals. They point out that although the equality principal emphasis similar treatment for similar cases, “this approach reduces inequality among treated patients at the expense of causing far greater inequality between treated and untreated patients.” Important food for thought as we contemplate how to best deal with the stroke epidemic hitting hard in less developed settings.
In closing, let me thank all of the contributors to this min-page over the past month. Mamta Singh shared some wonderful insights on her experience as a PALFER. Anindita Deb and colleagues from Boston outlined the relative efficiencies of working as a neurologist in India and Dr. Jose Cavazos reported on the 9th Biennial Latin American Epilepsy Congress. Much appreciated!