Commentary on the management of epilepsy in sub-Saharan Africa

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The burden of noncommunicable diseases (NCDs) as a public health priority in sub-Saharan Africa is gaining prominence, with 60% increase projected by 2020 (World Health Organization, 2008). This increase is an ominous sign for the region amid the unabated mortality rate of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis, and malaria. Epilepsy is among the most common NCDs in the developing countries, accounting for 80% of the global prevalence (Scott et al., 2001). Although the specific prevalence of epilepsy varies by region among the countries of sub-Saharan Africa, the rate is generally higher than what is reported in developed countries (Diop et al., 2005). Reports indicate that about 90% of persons with active epilepsy in developing countries are not receiving appropriate treatment (Scott et al., 2001). This large proportion aggravates further the high mortality rates that hallmark the region.

Several factors contribute to treatment gaps in the region, including physical access to care, sociocultural appropriateness of the modality of care, availability of resources, and affordability of the care needed. The strategies that have shown good results in the management of epilepsy in the region are those that included multipronged approaches, as suggested in a 2001 International League Against Epilepsy (ILAE) Commission Report (Meinardi et al., 2001). However, numerous challenges abound, limiting adherence to these guidelines. Perhaps the major challenges invariably common to sub-Saharan Africa are the unique sociocultural meaning of epilepsy to treatment seekers and the dearth of trained healthcare professionals in the region.

The report by Kendall-Taylor et al. in this issue of Epilepsia addresses, from an anthropological perspective, the problems of access to epilepsy care in Kilfi, Kenya. Their findings illustrate the complexity of the symptoms of epilepsy and attribution of these symptoms to natural spirits that shape the health-belief model of the local populace. These beliefs are mediated through the traditional healers that have uniquely patterned actions in dealing with their patients. The healers provide explanations about the causation of epilepsy that are understandable to their patients, approach the treatment in a manner that is logically consistent with local beliefs of causation, enable participatory communication with their patients, and provide flexible methods of remuneration for the care they provide. Interestingly, the first three are components of shared decision-making, a process that has gained widespread appeal to both physicians and patients in the developed world in recent years (Charles et al., 1999). The main benefit of this approach is the empowerment it accords to patients, enhancing participation in their treatment. These lessons are important in developing the biomedical model of care in sub-Saharan Africa. Unfortunately, biomedical care provided in these underserved regions is the last resort for most epilepsy patients, particularly when their epilepsies are complicated by traumatic episodes and secondary conditions. For example, a practicing physician from Malawi indicated that he encountered patients with epilepsy almost exclusively in surgical wards, with 36% of the patients in the burn unit sustaining the burns during epileptic seizure (Watts, 1989).

While the approaches used by the traditional healers have some desirable qualities that the biomedical model has yet to espouse, the causal link of epilepsy to natural spirits has neither scientific basis nor allows rational approach for intervention. To the contrary, it wastes valuable time and the meager resources of the patients by interfering with a possible link with biomedical care providers until too late. In fact, there appears to be an adversarial relationship between the local healers and the biomedical providers, as reflected in the outright dismissive attitude of the latter group toward the former. Nonetheless, the traditional healers express strong interest in participating in improving the treatment of epilepsy, and this interest offers unparalleled opportunity to capitalize on their influence at the local communities. To better serve persons with epilepsy in sub-Saharan Africa, we need to be cognizant of the social forces that influence acceptance and receipt of care in the communities we serve. This goal requires flexibility in our approaches and adaptability to the social values cherished in these communities.

In a companion paper presented in this issue of Epilepsia, Kengne et al. highlight the high prevalence of epilepsy in the region and the large proportion of patients who are unable to get antiepileptic drugs (AEDs) due to limited access to doctor-run treatment facilities. In most of sub-Saharan Africa, there is a dearth of doctors, mostly created by the “brain drain” to the affluent West. According to the report by the International Organization for Migration (IOM, 2000), Africa has already lost one-third of its human capital, and the average loss per annum is 20,000 doctors, university lecturers, and engineers. Ghana alone lost 60% of its medical doctors since 1980, and Kenya is losing an average of 20 doctors per month. Amid this staggering figure lies the human toll in the region that results from the long wait to see a doctor for appropriate diagnosis and treatment. It is against this grim backdrop that the report by Kengne et al. offers a bright spot, offering an empirically proven solution to address the intense shortage of doctors through the training of nurses for the management of epilepsy.

Although nurses have been specifically trained to provide some care to epilepsy patients in some countries of sub-Saharan Africa including Ethiopia (Mamo et al., 2007), this study is the first to provide evidence of the effectiveness of a nurse-led approach for the management of epilepsy. In this study, the researchers employed a quasi-experimental design by training four nurses from two types of clinic—private and public—with an accrual of 224 patients followed over a period of 2 years. Despite the limited number of variables at baseline and the short period of follow-up, the researchers used a robust analytic approach to demonstrate significant control of seizures in both cohorts of the two clinics, by using phenobarbital and phenytoin as the preferred first line medication. The main lesson from this study is that the nurse-led epilepsy clinic is a viable and effective alternative in resource-limited countries to provide treatment to patients with epilepsy. This approach is worth replicating in most regions of sub-Saharan Africa.

Acknowledgments

Conflict of interest: I confirm that I have read the journal's position on issues involved in ethical publication and affirm that this commentary is consistent with those guidelines. I have no conflicts interest to report.