For LMICs, Strokes, Strokes and more Strokes

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!

Gretchen L. Birbeck, MD, MPH

Gretchen L. Birbeck, MD, MPH

Gretchen Birbeck is a neurologist who divides her time between the US and Africa. Her US academic home is the University of Rochester where she is the Rykenboer Professor of Neurology and Research Director for the Strong Epilepsy Center with adjunct appointments in the Center for Human Experimental Therapeutics and the Department of Public Health. Her additional skills in epidemiology, health services research, and tropical medicine are brought to bear during the 6-months annually she spends in Africa where she serves as Director for the Chikankata Epilepsy Care Team in rural Mazabuka, Zambia, an Honorary Lecturer at the University of Zambia and a consultant for the Paediatric Research Ward at Queen Elizabeth Central Hospital in Blantyre, Malawi. Gretchen’s research programs are aimed at identifying opportunities to prevent or ameliorate the medical and social morbidities of common neurologic conditions in low-income, tropical settings with the ultimate goal of developing successful interventions feasible for scale up and broad implementation. She has been recognized as an Ambassador for Epilepsy by the International League against Epilepsy, a Global Health Research Ambassador by the US Paul Rogers Society, a National Outreach Scholar by the WK Kellogg Foundation and a Leader in Medicine by the American Medical Students Association.

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