Neurological Disorders

NEUROLOGICAL
DISORDERS
public health challenges

WHO Library Cataloguing-in-Publication Data
Neurological disorders : public health challenges.
1.Nervous system diseases. 2.Public health. 3.Cost of illness. I.World Health Organization.
ISBN 92 4 156336 2

(NLM classiﬁ cation: WL 140)
ISBN 978 92 4 156336 9
© World Health Organization 2006
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Printed in Switzerland

iii
contents
Foreword v
Preface vii
Acknowledgements ix
Abbreviations xi
Introduction 1
Chapter 1
Public health principles and neurological disorders
7
Chapter 2
Global burden of neurological disorders:
estimates and projections
27
Chapter 3
Neurological disorders: a public health approach
41
3.1 Dementia
42
3.2 Epilepsy
56
3.3 Headache
disorders
70
3.4 Multiple
sclerosis
85
3.5 Neuroinfections
95
3.6 Neurological disorders associated with malnutrition
111
3.7 Pain associated with neurological disorders
127
3.8 Parkinson’s
disease
140
3.9 Stroke
151
3.10 Traumatic brain injuries
164
Chapter 4
Conclusions and recommendations
177
Annexes
Annex 1
List of WHO Member States by region and mortality stratum
183
Annex 2
Country income groups used for reporting estimates and projections
185
Annex 3
Global Burden of Disease cause categories, sequelae and case
deﬁ nitions for neurological disorders
186

iv
Neurological disorders: public health challenges
Annex 4
Table A.4.1 Burden of neurological disorders, in DALYs, by cause,
WHO region and mortality stratum, projections for 2005, 2015 and 2030
189
Table A.4.2 Burden of neurological disorders, in DALYs, by cause
and country income category, projections for 2005, 2015 and 2030
193
Table A.4.3 Deaths attributable to neurological disorders, by cause,
WHO region and mortality stratum, projections for 2005, 2015 and 2030
194
Table A.4.4 Deaths attributable to neurological disorders, by cause and
country income category, projections for 2005, 2015 and 2030
198
Table A.4.5 Burden of neurological disorders, in YLDs, by cause,
WHO region and mortality stratum, projections for 2005, 2015 and 2030
199
Table A.4.6 Burden of neurological disorders, in YLDs, by cause and
country income category, projections for 2005, 2015 and 2030
203
Table A.4.7 Prevalence (per 1 000) of neurological disorders, by cause,
WHO region and mortality stratum, projections for 2005, 2015 and 2030
204
Table A.4.8 Prevalence (per 1 000) of neurological disorders, by cause
and country income category, projections for 2005, 2015 and 2030
208
Annex 5
International nongovernmental organizations working
in neurological disorders
209

v
foreword
In the 19th century and at the beginning of the 20th,
brain research belonged to many different areas that dif-
fered in methodology and targets: the morphological, the
physiological and the psychological. The latter used to
consider the brain as a black box where only the input
and output were known but not at all the neuronal com-
ponents and the way they interact with each other.
At the beginning of the third millennium, due to pro-
longed ageing, neurodevelopmental disorders are growing and a much deeper
knowledge of the brain is necessary. Scientiﬁ c and technological research,
from molecular to behavioural levels, have been carried out in many different
places but they have not been developed in a really interdisciplinary way.
Research should be based on the convergence of different interconnected
scientiﬁ c sectors, not in isolation, as was the case in the past.
As this report demonstrates, the burden of neurological disorders is reach-
ing a signiﬁ cant proportion in countries with a growing percentage of the
population over 65 years old.
With this report go my best wishes that it be disseminated worldwide and
that it receive the deserved attention of the Global Health Community in all
the countries of the world.
Rita Levi-Montalcini
1986 Nobel Prize in Medicine

vii
preface
Within its remit to provide leadership on all matters concerning health, one of the core
functions of the World Health Organization (WHO) is to engage in partnerships where joint
action is needed. WHO plays an important role in bringing crucial health-related topics to
the agenda of policy-makers and health planners and in raising awareness of them among
health-care professionals and all who have an interest in health matters.
WHO’s Department of Mental Health and Substance Abuse carries out this role for
the three different sets of issues for which it is responsible: mental disorders, substance
abuse and alcohol-related issues, and neurological disorders. Two recent publications
have focused attention on its work. The world health report 2001 – Mental health: new
understanding, new hope is an advocacy instrument to shed light on the public health as-
pects of mental disorders, and the report Neuroscience of psychoactive substance use and
dependence produced by the department in 2004 tackles the area of substance abuse and
alcohol. We realized a similar exercise is needed in the ﬁ eld of neurological disorders.
The Global Burden of Disease study, the ongoing international collaborative project
between WHO, the World Bank and the Harvard School of Public Health, has produced evi-
dence that pinpoints neurological disorders as one of the greatest threats to public health.
A clear message emerges that unless immediate action is taken globally, the neurological
burden is expected to become an even more serious and unmanageable problem in all
countries. There are several gaps in understanding the many issues related to neurological
disorders, but we already know enough about their nature and treatment to be able to
shape effective policy responses to some of the most prevalent among them.
To ﬁ ll the vast gap in the knowledge concerning the public health aspects of neurologi-
cal disorders, this document Neurological disorders: public health challenges fulﬁ ls two
roles. On one hand, it provides comprehensive information to the policy-makers and on the
other hand, it can also be used as an awareness-raising tool. The document has unique
aspects that should be stressed. It is the result of a huge effort bringing together the most
signiﬁ cant international nongovernmental organizations working in the areas of various
neurological disorders, both in a professional capacity and in caring for people affected
by the conditions. It is the fruit of healthy interaction and collaboration between these
organizations and WHO, with its network of country and regional ofﬁ ces: health experts on

viii
Neurological disorders: public health challenges
one hand working together with the extensive and competent world of professionals and
researchers on the other. Some of these organizations have also contributed ﬁ nancially
to this endeavour. This exercise thus demonstrates that such collaboration is not only
possible but can also be very productive.
The document is distinctive in its presentation as it provides the public health per-
spective for neurological disorders in general and presents fresh and updated estimates
and predictions of the global burden borne by them. Separate sections discuss some of
the most important disorders in detail: dementia, epilepsy, headache disorders, multiple
sclerosis, neuroinfections, neurological disorders associated with malnutrition, pain as-
sociated with neurological disorders, Parkinson’s disease, stroke and traumatic brain
injuries.
The document makes a signiﬁ cant contribution to the furthering of knowledge about
neurological disorders. We hope it will facilitate increased cooperation and innovation
and inspire commitment to preventing these debilitating disorders and providing the best
possible care for people who suffer from them.
Benedetto Saraceno
Director, Department of Mental Health
and Substance Abuse

ix
1
acknowledgements
The following people, listed in alphabetical order, participated in the production of this document,
under the guidance and with the support of Catherine Le Galès-Camus (Assistant Director-General,
Noncommunicable Diseases and Mental Health, World Health Organization), to whom we express
our sincere gratitude.
PROJECT TEAM
WRITING GROUP
Johan A. Aarli, Tarun Dua, Aleksandar Janca, Anna Muscetta
MANAGEMENT GROUP
José Manoel Bertolote, Tarun Dua, Aleksandar Janca, Frances Kaskoutas-Norgan,
Anna Muscetta, Benedetto Saraceno, Shekhar Saxena, Rosa Seminario
EDITORIAL COMMITTEE
Johan A. Aarli, Giuliano Avanzini, José Manoel Bertolote, Hanneke de Boer, Harald Breivik,
Tarun Dua, Nori Graham, Aleksandar Janca, Jürg Kesselring, Colin Mathers, Anna Muscetta,
Leonid Prilipko, Benedetto Saraceno, Shekhar Saxena, Timothy J. Steiner
AUTHORS AND CONTRIBUTORS
INTRODUCTION
Tarun Dua, Aleksandar Janca, Anna Muscetta
CHAPTER 1. PUBLIC HEALTH PRINCIPLES
AND NEUROLOGICAL DISORDERS
Tarun Dua, Aleksandar Janca, Rajendra Kale, Federico Montero, Anna Muscetta, Margie Peden
CHAPTER 2. GLOBAL BURDEN OF NEUROLOGICAL DISORDERS:
ESTIMATES AND PROJECTIONS
Tarun Dua, Marco Garrido Cumbrera, Colin Mathers, Shekhar Saxena
CHAPTER 3. NEUROLOGICAL DISORDERS:
A PUBLIC HEALTH APPROACH
3.1 Dementia
Amit Dias, Cleusa Ferri, Nori Graham (chair), Bernard Ineichen, Martin Prince,
Richard Uwakwe
3.2 Epilepsy
Giuliano Avanzini (co-chair), Ettore Beghi, Hanneke de Boer (co-chair), Jerome Engel Jr.,
Josemir W. Sander, Peter Wolf
3.3 Headache disorders
Lorenzo Gardella, Zaza Katsarava, David Kernick, Hilkka Kettinen, Shireen Qureshi,
Krishnamurthy Ravishankar, Valerie South, Timothy J. Steiner (chair), Lars Jacob Stovner
3.4 Multiple sclerosis
Ian Douglas, Jürg Kesselring (chair), Paul Rompani, Bhim S. Singhal, Alan Thompson
3.5 Neuroinfections
Reyna M. Duron, Hector Hugo Garcia, Ashraf Kurdi, Marco T. Medina (chair),
Luis C. Rodriguez

x
Neurological disorders: public health challenges
3.6 Neurological disorders associated with malnutrition
Amadou Gallo Diop (chair), Athanase Millogo, Isidore Obot, Ismael Thiam, Thorkild Tylleskar
3.7 Pain associated with neurological disorders
Michael Bond, Harald Breivik (chair), Troels S. Jensen, Willem Scholten, Olaitan Soyannwo,
Rolf-Detlef Treede
3.8 Parkinson’s disease
Mary Baker (chair), Oscar S. Gershanik
3.9 Stroke
Julien Bogousslavsky (chair), Ming Liu, J. Moncayo, B. Norrving, A. Tsiskaridze,
T. Yamaguchi, F. Yatsu
3.10 Traumatic brain injuries
Armando Basso (chair), Ignacio Previgliano, Franco Servadei
CHAPTER 4. CONCLUSIONS AND RECOMMENDATIONS
José Manoel Bertolote, Tarun Dua, Aleksandar Janca, Anna Muscetta,
Benedetto Saraceno, Shekhar Saxena
EXTERNAL REVIEWERS
Mario A. Battaglia, Donna Bergen, Gretchen Birbeck, Carol Brayne, Vijay Chandra, Amit Dias,
M. Gourie-Devi, Rajendra Kale, Maria Lucia Lebrao, Itzhak Levav, Girish Modi, Theodore Munsat,
Donald Silberberg (whole document); Daniel O’Connor, Carlos Lima (Dementia); Satish
Jain, Bryan Kies (Epilepsy); Anne MacGregor, Fumihiko Sakai (Headache disorders); Chris
H. Polman, Ernie Willoughby (Multiple sclerosis); Peter G. E. Kennedy (Neuroinfections);
Redda Tekle Haimanot (Neurological disorders associated with malnutrition); Ralf Baron,
Maija Haanpää (Pain associated with neurological disorders); Zvezdan Pirtosek, Bhim S. Singhal,
Helio Teive (Parkinson’s disease); Vladimir Hachinski, David Russell (Stroke); Vladan Bajtajic,
Jacques Brotchi, Jeremy Ganz, Haldor Slettebø (Traumatic brain injuries)
PEER REVIEWERS IN WHO
Regional Ofﬁ ce for Africa: Thérèse Agossou
Regional Ofﬁ ce for the Americas: José Miguel Caldas De Almeida, Itzhak Levav
Regional Ofﬁ ce for South-East Asia: Vijay Chandra
Regional Ofﬁ ce for Europe: Matthijs Muijen
Regional Ofﬁ ce for the Eastern Mediterranean: R. Srinivasa Murthy, Mohammad Taghi Yasamy
Regional Ofﬁ ce for the Western Paciﬁ c: Xiandong Wang
Headquarters: Bruno de Benoist, Siobhan Crowley, Denis Daumerie, Dirk Engels,
Jean Georges Jannin, Daniel Olivier Lavanchy, Dermot Maher, Kamini Mendis, Shanthi Mendis,
François Meslin, William Perea, Pascal Ringwald, Oliver Rosenbauer, Michael J. Ryan,
Perez Simarro, Jos Vandelaer, Marco Vitoria
PRODUCTION TEAM
Production coordination: Caroline Allsopp
Editing: Barbara Campanini
Design and layout: Reda Sadki
Proofreading: Susan Kaplan
Indexing: David McAllister
Maps: Steve Ewart
Printing coordination: Raphaël Crettaz

xi
1
abbreviations
AD Alzheimer’s
disease
ADI
Alzheimer’s Disease International
AED antiepileptic
drug
AIDS
acquired immunodeﬁ ciency syndrome
ART antiretroviral
therapy
BPSD
behavioural and psychological symptoms of dementia
CNS central
nervous
system
CRPS
complex regional pain syndrome
CSF cerebrospinal
ﬂ
uid
CT computerized
tomography
DALY disability-adjusted
life
year
FAO
Food and Agriculture Organization of the United Nations
EEG electroencephalography
EMSP
European Multiple Sclerosis Platform
EPDA
European Parkinson’s Disease Association
EUREPA
European Epilepsy Academy
GBD
Global Burden of Disease
GDP
gross domestic product
GNI
gross national income
HAART
highly active antiretroviral therapy
HIV human
immunodeﬁ
ciency
virus
IBE
International Bureau for Epilepsy
IASP
International Association for the Study of Pain
ICF
International Classiﬁ cation of Functioning, Disability and Health
ICH intracerebral
haemorrhage
IHS
International Headache Society
ILAE
International League Against Epilepsy
MRI
magnetic resonance imaging
MS multiple
sclerosis
MSIF
Multiple Sclerosis International Federation
PD Parkinson’s
disease
PET
positron emission tomography
RTA
road trafﬁ c accident
SAH subarachnoid
haemorrhage
SMR
standardized mortality ratio
TBI
traumatic brain injury
TIA
transient ischaemic attack
UNESCO
United Nations Educational, Scientiﬁ c and Cultural Organization
UNICEF
United Nations Children’s Fund
UNFPA
United Nations Population Fund
VaD vascular
dementia
WFN
World Federation of Neurology
WFNS
World Federation of Neurosurgical Societies
WHA
World Headache Alliance
WHO
World Health Organization
YLD
years of healthy life lost as a result of disability
YLL
years of life lost because of premature mortality

xii
Neurological disorders: public health challenges

1
introduction
One of the key constitutional responsibilities of the World Health Organi-
zation (WHO) is to foster partnership and collaboration among scientiﬁ c
and professional groups in order to contribute to the advancement of
global health. To help prioritize health needs and design evidence-based
health programmes globally, WHO initiates a large number of interna-
tional projects and activities involving numerous governmental and non-
governmental organizations, health professionals and policy-makers.
The Global Burden of Disease (GBD) study, a collaborative endeavour of the World
Health Organization (WHO), the World Bank and the Harvard School of Public Health,
drew the attention of the international health community to the burden of neurological
disorders and many other chronic conditions. This study found that the burden of neuro-
logical disorders was seriously underestimated by traditional epidemiological and health
statistical methods that take into account only mortality rates but not disability rates. The
GBD study showed that over the years the global health impact of neurological disorders
had been underestimated (1).
With awareness of the massive burden associated with neurological disorders came
the recognition that neurological services and resources were disproportionately scarce,
especially in low income and developing countries. Furthermore, a large body of evidence
shows that policy-makers and health-care providers may be unprepared to cope with the
predicted rise in the prevalence of neurological and other chronic disorders and the dis-
ability resulting from the extension of life expectancy and ageing of populations globally
(2, 3).
In response to the challenge posed by neurological disorders, WHO launched a number
of global public health projects, including the Global Initiative on Neurology and Public
Health whose purpose is to increase professional and public awareness of the frequency,
severity and costs of neurological disorders and to emphasize the need to provide neuro-
logical care at all levels including primary health care. This global initiative has revealed
a paucity of information on the burden of neurological disorders and a lack of policies,
programmes and resources for their management (4–6).

2
Neurological disorders: public health challenges
In response to these ﬁ ndings, WHO and the World Federation of Neurology (WFN)
recently collaborated in an international Survey of Country Resources for Neurological
Disorders involving 109 countries and covering over 90% of the world’s population. The
survey collected information from experts on several aspects of the provision of neuro-
logical care around the world, ranging from frequency of neurological disorders to the
availability of neurological services across countries and settings. The ﬁ ndings show that
resources are clearly inadequate for patients with neurological disorders in most parts
of the world; they highlight inequalities in the access to neurological care across differ-
ent populations, especially in those living in low income countries and in the developing
regions of the world (7 ). The results of the survey, which include numerous tables, graphs
and commentaries, have been published in the WHO/WFN Atlas of Country Resources for
Neurological Disorders (8). The atlas is available at http://www.who.int/mental health/
neurology/ or on request from WHO.
This report takes the collaboration with nongovernmental organizations and the
Atlas Project one step further. It aims to inform governments, public health institutions,
nongovernmental organizations and others so as to help formulate public health policies
directed at neurological disorders and to guide informed advocacy. WHO has produced
this report in collaboration with several nongovernmental organizations, including (in
alphabetical order) Alzheimer’s Disease International, European Parkinson’s Disease As-
sociation, International Association for the Study of Pain, International Bureau for Epilepsy,
International Headache Society, International League Against Epilepsy, Multiple Sclerosis
International Federation, World Federation of Neurology, World Federation of Neurosurgi-
cal Societies and World Headache Alliance. It addresses the most important public health
aspects of the following neurological disorders: dementia, epilepsy, headache disorders,
multiple sclerosis, neuroinfections, neurological disorders associated with malnutrition,
pain associated with neurological disorders, Parkinson’s disease, stroke and traumatic
brain injuries. These common disorders were selected after discussion with several ex-
perts and nongovernmental organizations and represent a substantial component of the
global burden of neurological disorders.
The report is based on signiﬁ cant contributions by many individuals and organizations
spanning all continents. Their names are indicated in the Acknowledgements section, and
their input is acknowledged with thanks.

introduction
3
OUTLINE OF THE REPORT
Chapter 1 provides an overview of basic public health concepts and
general principles as they apply to neurological disorders,
including epidemiology and burden, health promotion, disease prevention, health policy,
service provision and delivery of care, disability and rehabilitation, stigma, and educa-
tion and training. Public health is deﬁ ned as the science and practice of protecting and
improving the health of the population through prevention, promotion, health education,
and management of communicable and noncommunicable diseases including neurological
disorders. In other words, public health is viewed as a comprehensive approach concerned
with the health of the community as a whole rather than with medical health care that
deals primarily with treatment of individuals. The focus of public health interventions
could be primary, secondary or tertiary prevention. The above-mentioned concepts are
illustrated by examples from the ﬁ eld of neurological disorders. Public health aspects of
individual neurological disorders covered by the report are discussed in greater detail in
Chapter 3.
Each chapter contains a numerical list of references to works
that are cited in the text. A second list, arranged alphabetically,
suggests reading material that is recommended to give an overview
of the subject matter of the section or chapter; some of the key
references may be repeated in the reading list.
Chapter 2 contains a series of tables and graphs that provide pro-
jected estimates of the global burden of neurological
disorders for 2005, 2015 and 2030. The illustrations are accompanied by a summary
of the GBD methodology, observations on its limitations and brief commentaries on the
ﬁ ndings of the GBD study. The results are presented according to WHO regions, epidemio-
logical subregions and World Bank income categories. Annex 1 lists WHO Member States
and Annex 2 presents countries according to World Bank categories. Annex 3 provides
the list of GBD cause categories, sequelae and case deﬁ nitions used for calculation of
estimates for neurological disorders. Annex 4 contains the GBD estimates for neurological
disorders for 2005, 2015 and 2030.
Chapter 3 consists of 10 sections that focus on the public heath
aspects of the speciﬁ c neurological disorders covered
by the report. Although notable differences exist between relevant public health issues
for each neurological disorder, most sections cover the following topics: diagnosis and
classiﬁ cation; etiology and risk factors; course and outcome; magnitude (prevalence,
incidence, distribution by age and sex, global and regional distribution); disability and
mortality; burden on patients’ families and communities; treatment, management and
rehabilitation; delivery and cost of care; gaps in treatment and other services; policies;

4
Neurological disorders: public health challenges
research; and education and training. Accompanying tables, graphs, boxes and other
graphic material illustrate speciﬁ c points made in the text. Details of relevant nongovern-
mental organizations, including their objectives, are given in Annex 5.
Chapter 4 gives the conclusions and recommendations of the re-
port, which are based on the following ﬁ ndings. Neuro-
logical disorders are a signiﬁ cant and increasing public health problem. Many of them can
be either prevented or treated at a relatively low cost. Resources for neurological disorders
are grossly inadequate in most parts of the world. Signiﬁ cant inequalities in provision of
neurological treatment and care exist between developing and developed countries. Stig-
ma and discrimination against people with neurological disorders are ubiquitous and need
to be eliminated through public education and global campaigns. Dignity of people with
neurological disorders needs to be preserved and their quality of life improved. Long-term
treatment and care of patients with chronic neurological disorders and conditions should
be incorporated into primary care. Public health aspects of neurological disorders should
be incorporated into undergraduate and postgraduate teaching and training curricula in
neurology. More research on neurological disorders is needed and it should be facilitated
through better funding, multidisciplinary approaches and international collaboration.

5
REFERENCES
1. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality
and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA,
Harvard School of Public Health on behalf of the World Health Organization and the World Bank,
1996 (Global Burden of Disease and Injury Series, Vol. I).
2. Sartorius N. Rehabilitation and quality of life. Hospital and Community Psychiatry, 1992, 43:1180–
1181.
3. Gwatkin DR, Guillot M, Heuveline P. The burden of disease among the global poor. Lancet, 1999,
354:586–589.
4. Janca A, Prilipko L, Costa e Silva JA. The World Health Organization’s global initiative on neurology
and public health. Journal of the Neurological Sciences, 1997, 145:1–2.
5. Janca A, Prilipko L, Costa e Silva JA. The World Health Organization’s work on public health
aspects of neurology. Journal of Neurology, Neurosurgery and Psychiatry, 1997, 63(Suppl 1):S6–7.
6. Janca A, Prilipko L, Saraceno B. A World Health Organization perspective on neurology and
neuroscience. Archives of Neurology, 2000, 57:1786–1788.
7. Janca A et al. WHO/WFN survey on neurological services: a world-wide perspective. Journal of the
Neurological Sciences, 2006, 247:29–34.
8. Atlas: Country resources for neurological disorders 2004. Geneva, World Health Organization, 2004.

6
Neurological disorders: public health challenges

7
CHAPTER 1
public health
principles
and
neurological disorders
in this chapter
8 Principles of public health
9 Epidemiology and burden
9 Health promotion and disease prevention
This chapter explains brieﬂ y the principles of
12 Health policy
public health, epidemiology and the burden of
14 Service provision and delivery of care
disease, and the ways in which health promo-
tion and disease prevention are achieved. It
16 Disability and rehabilitation
looks at risks to health and prevention strat-
20 Stigma
egies, and explains what health policy means.
22 Education and training
It then describes the goals and functions of
health systems and in particular considers
23 Conclusions
service provision for neurological disorders.
As many neurological disorders result in considerable morbidity, special attention
is paid to disability and rehabilitation. The all-important part played by stigma in
neurological disorders is assessed and, ﬁ nally, education and training in neurology
are discussed.
Many distinctions can be made between the practice of public
treat one patient at a time for a speciﬁ c neurological
health and that of clinical neurology. Public health professionals
condition. These two approaches could be seen as
approach neurology more broadly than neurologists by monitor-
being almost at the opposite ends of the health-care
ing neurological disorders and related health concerns of entire
spectrum. What this chapter aims to do is to help
communities and promoting healthy practices and behaviours
build bridges between these two approaches and
among them to ensure that populations stay healthy. Public health
serve as a useful guide to the chapter that follows
specialists focus on health and disease of entire populations
— on the public health aspects of speciﬁ c neurologi-
rather than on individual patients, whereas neurologists usually
cal disorders.

8
Neurological disorders: public health challenges
PRINCIPLES OF PUBLIC HEALTH
Public health is the science and art of disease prevention, prolonging life and promoting health
and well-being through organized community effort for the sanitation of the environment, the
control of communicable diseases, the organization of medical and nursing services for the early
diagnosis and prevention of disease, the education of the individual in personal health and the
development of the social machinery to ensure for everyone a standard of living adequate for the
maintenance or improvement of health (1). The goal of public health is to fulﬁ l every society’s
ambition to create conditions in which all people can be healthy. Public health addresses the health
of the population as a whole rather than the treatment of individuals. WHO deﬁ nes health as “a
state of complete physical, mental and social well-being and not merely the absence of disease
or inﬁ rmity” (2). “Healthy people in healthy communities” is the ultimate goal of all public health
interventions, which are aimed at promoting physical and mental health and preventing disease,
injury and disability (3). Public health is particularly concerned with threats to the overall health
of the community. As interventions are aimed primarily at prevention, monitoring the health of the
community through surveillance of cases assumes great importance as does the promotion of a
healthy lifestyle and healthy behaviour. In many cases, however, treating a disease can be vital
to preventing it in other people, such as during an outbreak of a communicable disease. Another
way of describing public health is “collective action for sustained population-wide health improve-
ment” (4). This deﬁ nition highlights the focus on actions and interventions that need collaborative
actions, sustainability (i.e. the need to embed policies within supportive systems) and the goals of
public health (population-wide health improvement and the reduction of health inequalities).
Since the 1980s, the focus of public health interventions has broadened towards population-level
issues such as inequity, poverty and education and has moved away from advocating for change in
the behaviour of individuals. The health of people is affected by many elements ranging from genetics
to socioeconomic factors such as where they live, their income, education and social relationships.
These are the social determinants of health, and they pervade every society in the world. Predictably,
poor people have more health problems and worse health than the better-off sections of populations
(5). Today public health seeks to correct these inequalities by advocating policies and initiatives that
aim to improve the health of populations in an equitable manner.
The extension of life expectancy and the ageing of populations globally are predicted to increase
the prevalence of many noncommunicable, chronic, progressive conditions including neurological
disorders. The increasing capacity of modern medicine to prevent death has also increased the
frequency and severity of impairment attributable to neurological disorders. This has raised the
issue of restoring or creating a life of acceptable quality for people who suffer from the sequelae
of neurological disorders.
Public health plays an important role in both the developed and developing parts of the world
through either the local health systems or the national and international nongovernmental organi-
zations. Though all developed and most developing countries have their own government health
agencies such as ministries or departments of health to respond to domestic health issues, a
discrepancy exists between governments’ public health initiatives and access to health care in
the developed and developing world. Many public health infrastructures are non-existent or are
being formed in the developing world. Often, trained health workers lack the ﬁ nancial resources
to provide even basic medical care and prevent disease. As a result, much of the morbidity and
mortality in the developing world results from and contributes to extreme poverty.
Though most governments recognize the importance of public health programmes in reducing
disease and disability, public health generally receives much less government funding compared
with other areas of medicine. In recent years, large public health initiatives and vaccination pro-
grammes have made great progress in eradicating or reducing the incidence of a number of
communicable diseases such as smallpox and poliomyelitis. One of the most important public

public health principles and neurological disorders
9
health issues facing the world nowadays is HIV/AIDS. Tuberculosis is also re-emerging and is a
major concern because of the rise of HIV/AIDS-related infections and the development of strains
resistant to standard antibiotics.
As the rate of communicable diseases in the developed world decreased throughout the 20th
century, public health began to put more focus on chronic diseases such as cancer, heart disease
and mental and neurological disorders. Much ill-health is preventable through simple, non-medical
methods: for example, improving the quality of roads and enforcing regulations about speed and
protective measures such as helmet use help to reduce disability as a result of head injuries.
To increase the awareness of professionals and people in general about the public health
aspects of neurological disorders, and to emphasize the need for the prevention of these disor-
ders and the necessity to provide neurological care at all levels including primary health care,
WHO launched a number of international public health projects including the Global Initiative on
Neurology and Public Health. The outcome of this large collaborative endeavour, which involved
many health professionals from all parts the world, clearly indicated that there was a paucity of
information about the prevalence and burden of neurological disorders and a lack of policies,
programmes and resources for their treatment and management (6–8).
EPIDEMIOLOGY AND BURDEN
In general, health statistics focus primarily on quantifying the health status of populations and
suffer from several limitations that reduce their practical value to policy-makers. The statistical
information is partial and fragmented and in many countries even the most basic data (e.g. the an-
nual number of deaths from particular causes) are not available. Further, the simple “head count”
approach does not allow policy-makers to compare the relative cost–effectiveness of different
interventions, for example the treatment of conditions such as acute stroke versus the long-term
care of patients with chronic disorders such as Parkinson’s disease or multiple sclerosis. At a
time when people’s expectations of health services are growing and funds are constrained, such
information is essential for the rational allocation of resources.
To address these limitations, a large collaborative project called the Global Burden of Disease
(GBD) Study was undertaken by WHO, the World Bank and the Harvard School of Public Health (9).
The objectives of this unique international undertaking were as follows: to incorporate nonfatal
conditions in the assessments of health status; to disentangle epidemiology from advocacy and
produce objective, independent and demographically plausible assessments and projections of the
burden of health conditions and diseases; and to measure disease and injury burden by develop-
ing a novel method that can also be used to assess the cost–effectiveness of interventions, in
terms of the cost per unit of disease burden averted. The GBD study developed an internationally
standardized and nowadays widely accepted single measurement index: the disability-adjusted
life year (DALY). For neurological disorders, perhaps the most important dimension of the GBD
study is the attention given to the total morbidity of populations by quantifying the contribution
of nonfatal, chronic disorders to the reduction of health status. The GBD study is discussed in
detail in Chapter 2, with its methodology and limitations and projected estimates for neurological
disorders for 2005, 2015 and 2030.
HEALTH PROMOTION AND DISEASE PREVENTION
Health promotion
Historically, the concepts of health promotion and disease prevention have been closely related.
According to WHO, health promotion is a process of enabling people to increase control over their
health and improve it. It refers to any activity destined to help people to change their lifestyle and
move towards a state of optimal health. Health promotion can be facilitated through a combination

10
Neurological disorders: public health challenges
of efforts aimed at raising awareness, changing behaviours, and creating environments that sup-
port good health practices, healthy public policies and community development (10). The nature
and scope of health promotion is illustrated in Figure 1.1.
Successful health promotion demands a coordinated
action by governments, the health sector and other
Figure 1.1 Nature and scope of health promotion
social and economic sectors, nongovernmental and
voluntary organizations, local authorities, industry and
the media. A list of required health promotion strategies
across sectors and settings is contained in the Bangkok
Health education
Charter for Health Promotion in a Globalized World (11)
Healthy
public
(see Box 1.1). For neurological disorders, health promo-
policy
tion is particularly important. In the case of traumatic
brain injuries, development of policies in countries to
prevent road trafﬁ c accidents and legislation to wear
Interventions
helmets are examples of health promotion strategies.
(disease prevention)
Community
development
Disease prevention
The concept of disease prevention is more speciﬁ c and
comprises primary, secondary and tertiary prevention
Health promotion
(12). Primary prevention is deﬁ ned as preventing the
disease or stopping individuals from becoming at high
risk. Universal and selective preventive interventions
are included in primary prevention. Universal primary prevention targets the general public or
a whole population group without an identiﬁ ed speciﬁ c risk (e.g. iodine supplementation pro-
grammes to prevent neurological and other disorders caused by iodine deﬁ ciency). Selective
primary prevention targets individuals or subgroups of the population whose risk of developing
disease is signiﬁ cantly higher than average, as evidenced by biological, psychological or social
risk factors (e.g. prevention of stroke through adequate management of hypertension, diabetes
and hypercholesterolemia). Secondary prevention aims at decreasing the severity of disease or
reducing risk level or halting progression of disease through early detection and treatment of
diagnosable cases (e.g. ensuring drug compliance in the treatment of epilepsy). Tertiary preven-
tion includes interventions that reduce premature death and disability, enhance rehabilitation and
prevent relapses and recurrence of the illness. Rehabilitation may mitigate the effects of disease
and thereby prevent it from resulting in impaired social and occupational functioning; it is an
important public health intervention that has long been neglected by decision-makers. Moreover,
rehabilitation is an essential aspect of any public health strategy for chronic diseases, including a
number of neurological disorders and conditions such as multiple sclerosis, Parkinson’s disease
and the consequences of stroke or traumatic brain injury. Box 1.2 describes some examples
illustrating the role of primary, secondary and tertiary preventive strategies for the neurological
disorders discussed in this document.
Box 1.1 Bangkok Charter for Health Promotion in a Globalized World
To make advances in implementing health promotion strat-
■ regulate and legislate to ensure a high level of pro-
egies, all sectors and settings must act to:
tection from harm and enable equal opportunities for
■ advocate for health based on human rights and solidarity;
health and well-being for all people;
■ invest in sustainable policies, actions and infrastructure
■ establish partnerships and build alliances with public,
to address the determinants of health;
private, nongovernmental and international organiza-
■ build capacity for policy development, leadership, health
tions and civil society to create sustainable actions.
promotion practice, knowledge transfer and research,
and health literacy;
Source: (11).

public health principles and neurological disorders
11
Health risks
Focusing on risks to health is a key to preventing any disease or injury. Many factors are relevant
in prioritizing strategies to reduce risks to health. These include the extent of the threat posed
by different risk factors, the availability of cost-effective interventions, and societal values and
preferences. Risk assessment and estimates of the burden of disease resulting from different risk
factors may be altered by many different strategies (13).
The chain of events leading to an adverse health outcome includes proximal (or direct) causes
and distal causes that are further back in the causal chain and act through a number of intermedi-
ary causal factors. It is therefore essential that the whole of the causal chain is considered in the
assessment of risks to health. Trade-offs also exist between assessments of proximal and distal
causes. As one moves further away from the direct causes of disease, there can be a decrease in
causal certainty and diagnostic consistency, which is often accompanied by an increase in com-
plexity of treatment. Distal causes, however, are likely to have an amplifying effect in that they can
affect many different sets of proximal causes and so can potentially make large differences (14).
Prevention strategies
Prevention strategies and interventions designed to reduce or prevent a particular disease are of two
types. In population or mass approaches, a whole population is asked to be involved in modifying
their behaviour in some way (e.g. being immunized against poliomyelitis). In targeted or high-risk
approaches, only high-risk individuals are involved, which necessitates some form of screening to
identify those who are at high risk (e.g. HIV testing) (13).
The distribution and determinants of risks in a population have major implications for strategies
of prevention. A large number of people exposed to a small risk may generate many more cases
than a small number exposed to a high risk. Thus, a preventive strategy focusing on high-risk
individuals will deal only with the margin of the problem and will not have any impact on the con-
siderable amount of disease occurring in the large proportion of people who are at moderate risk.
Box 1.2 Examples of preventive strategies for neurological disorders
PRIMARY PREVENTION
■ Medical treatment of epilepsy with ﬁ rst-line antiepilep-
(Measures to prevent the onset of disease or avoid a tar-
tic drugs can render up to 70% of patients seizure-free
geted condition)
when adequately treated.
■ Use of vaccine against poliomyelitis within the Global
■ Management of patients with stroke by an organized unit
Polio Eradication Initiative has led to elimination of indig-
signiﬁ cantly reduces mortality and disability in compari-
enous polioviruses from all but four countries.
son with standard care on a general medical ward.
■ Measures to control blood pressure, cholesterol lev-
els and diabetes mellitus, to reduce tobacco use, and
TERTIARY PREVENTION
to promote overall healthy eating patterns and physical
(Rehabilitation, palliative care, treatment of complications,
activity are advocated for primary prevention of stroke.
patient and caregiver education, self-support groups, re-
In Japan, government-led health education campaigns
duction of stigma and discrimination, social integration)
and increased treatment of high blood pressure have re-
■ Interventions targeting stress and depression among
duced blood pressure levels in the populations: stroke
carers of patients with dementia, including training,
rates have fallen by more than 70%.
counselling and support for caregivers, have shown
■ Wearing a helmet is the single most effective way to re-
positive results for the management of dementia.
duce head injuries and fatalities resulting from motor-
■ The strategy of community-based rehabilitation has
cycle and cycle crashes. For example, wearing a helmet
been implemented in many low-income countries
has been shown to decrease the risk and severity of in-
around the world; where it is practised, it has success-
juries among motorcyclists by about 70%, the likelihood
fully inﬂ uenced the quality of life and participation of
of death by almost 40%, and to substantially reduce the
persons with disabilities in their societies.
costs of health care associated with such crashes.
■ Methods to reduce stigma related to epilepsy in an
African community successfully changed attitudes to
SECONDARY PREVENTION
epilepsy: traditional beliefs were weakened, fears were
(Early and accurate diagnosis, appropriate treatment, man-
diminished, and community acceptance of people with
agement of risk factors, compliance)
epilepsy increased.

12
Neurological disorders: public health challenges
In contrast, population-based strategies that seek to shift the whole distribution of risk factors
have the potential to control the incidence of a disorder in an entire population (14).
With targeted approaches, efforts are concentrated on those who are most at risk of contract-
ing a disease (e.g. HIV-positive individuals). This has two beneﬁ ts: ﬁ rst, it avoids the waste of the
mass approach and, second, people who are identiﬁ ed as being at high risk are more likely to
comply with behaviour change. However, such an approach could increase the costs because of
the need to identify the high-risk group of people most likely to beneﬁ t. Which prevention approach
is the most cost effective in a particular setting will depend on the prevalence of high-risk people
in the population and the cost of identifying them compared with the cost of intervention.
Some areas of behavioural change beneﬁ t from active government intervention through legislation
or ﬁ nancial incentives. For example, road trafﬁ c safety is one area where government action can
make a big difference in preventing traumatic brain injuries. This can be achieved through control
and legislation on alcohol and drug use, better roads, speed control, better motor vehicle design, and
requirements to use seatbelts and helmets (see Table 1.1).
Table 1.1 Beneﬁ ts of wearing a motorcycle helmet
Not wearing a helmet
Wearing a helmet
• increases the risk of sustaining a head injury
• decreases the risk and severity of injuries by about 72%
• increases the severity of head injuries
• decreases the likelihood of death by up to 39%, the
• increases the time spent in hospital
probability depending on the speed involved
• increases the likelihood of dying from a head injury
• decreases the costs of health care associated with a crash
Source: (15 ).
A different set of interventions can be used to achieve the same goal, and some interventions
will reduce the burden associated with multiple risk factors and diseases. For example, interven-
tions to reduce blood pressure, cigarette smoking and cholesterol levels reduce cerebrovascular
and cardiovascular diseases and a number of others. The effect of using multiple interventions at
the same time might be more than would be expected by summing the beneﬁ ts of carrying out
the interventions singly. Risk reduction strategies are therefore generally based on a combination
of interventions. For example, a CVD Risk Management Package has been developed by WHO for
managing cardiovascular events (heart attacks and stroke). For cardiovascular disease preven-
tion and control activities to achieve the greatest impact, a paradigm shift is required from the
“treatment of risk factors in isolation” to “comprehensive cardiovascular risk management”. The
risk management package facilitates this shift. It has been designed primarily for the manage-
ment of cardiovascular risk in individuals found by opportunistic screening to have hypertension.
It could be adapted, however, to be used with diabetes or smoking as entry points. The package
is meant to be implemented in a range of health-care facilities in low and medium resource set-
tings, in both developed and developing countries. For this reason it has been designed for three
scenarios that reﬂ ect the commonly encountered resource availability strata in such settings
(16). The minimum conditions that characterize the three scenarios, in terms of the skill level of
the health worker, the diagnostic and therapeutic facilities and the health services available, are
described in Table 1.2.
HEALTH POLICY
Health policy usually refers to formal statements or procedures within institutions and govern-
ments that deﬁ ne health priorities and actions aimed at improving people’s health. It can have a
number of other goals in addition to preventing illness and promoting population health. In choos-

public health principles and neurological disorders
13
Table 1.2 Characteristics of three scenarios in the WHO CVD Risk Management
Package
Resource availability
Scenario one
Scenario two
Scenario three
Human resources
Non physician health worker
Medical doctor or specially
Medical doctor with access to
trained nurse
full specialist care
Equipment
Stethoscope
Stethoscope
Stethoscope
Blood pressure measurement
Blood pressure measurement
Blood pressure measurement
device
device
device
Measuring tape or weighing
Measuring tape or weighing
Measuring tape or weighing
scale
scale
scale
Optional: test tubes, holder,
Test tubes, holder, burner,
Electrocardiograph
burner, solution or test strips
solutions or test strips for
Ophthalmoscope
for checking urine glucose
checking urine glucose and
Urine analysis: fasting blood,
albumin
sugar, electrolytes, creatinine,
cholesterol and lipoproteins
General drugs
Essential: thiazide diuretics
Thiazide diuretics
Thiazide diuretics
Optional: metformin (for reﬁ ll)
Beta blockers
Beta blockers
Angiotensin converting
Angiotensin converting
enzyme inhibitors
enzyme inhibitors
Calcium channel blockers
Calcium channel blockers
(sustained release
(sustained release
formulations)
formulations)
(Reserpine and methyldopa if
(Reserpine and methyldopa if
the above antihypertensives
the above antihypertensives
are unavailable)
are unavailable)
Aspirin
Aspirin
Metformin (for reﬁ ll)
Insulin
Metformin
Glibenclamide
Statins (if affordable)
Angiotensin receptor blocker
(if affordable)
Other facilities
Referral facilities
Referral facilities
Access to full specialist care
Maintenance and calibration
Maintenance and calibration
Maintenance and calibration
of blood pressure measure-
of equipment
of equipment
ment devices
Source: (16).
ing appropriate combinations of interventions, governments are also concerned with reducing
poverty and other inequalities, with questions of human rights, acceptance by the community
and political needs. They must also consider how different types of interventions can be incor-
porated into the health infrastructure available in the country, or how the infrastructure could be
expanded or adapted to accommodate the desired strategies. This section discusses only health
policy issues related to health promotion and disease prevention.
A health policy paradox shows that preventive interventions can achieve large overall health
gains for whole populations but might offer only small advantages to each individual. This leads to
a misperception of the beneﬁ ts of preventive advice and services by people who are apparently in
good health. In general, population-wide interventions have the greatest potential for prevention.
For instance, in reducing risks from high blood pressure and cholesterol, shifting the mean values
of whole populations will be more cost effective in avoiding future heart attacks and strokes than
screening programmes that aim to identify and treat only those people with deﬁ ned hypertension
or raised cholesterol levels. Often both approaches are combined in one successful strategy.

14
Neurological disorders: public health challenges
A critical health policy issue, especially for developing and resource-poor countries, concerns
the appropriate balance between primary and secondary prevention and between population
and high-risk approaches to primary prevention. If the goal is to increase the proportion of the
population at low risk and to ensure that all groups beneﬁ t, the strategy with the greatest potential
is the one directed at the whole population, not just at people with high levels of risk factors or
established disease. The ultimate goal of a health policy is the reduction of population risk; since
most of the population in most countries is not at the optimal risk level, it follows that the majority
of prevention and control resources should be directed towards the goal of reducing the entire
population’s risk. For example, policies for prevention of traumatic brain injuries such as wearing
of helmets need to be directed at the whole population. Thus, risk reduction through primary
prevention is clearly the preferred health policy approach, as it actually lowers future exposures
and the incidence of new disease episodes over time.
The choice may well be different, however, for different risks, depending to a large extent on
how common and how widely distributed is the risk and the availability and costs of effective
interventions. Large gains in health can be achieved through inexpensive treatments when primary
prevention measures have not been effective. An example is the treatment of epilepsy with a cheap
ﬁ rst-line antiepileptic drug such as phenobarbital.
One risk factor can lead to many outcomes, and one outcome can be caused by many risk
factors. When two risks inﬂ uence the same disease or injury outcomes, then the net effects may
be less or more than the sum of their separate effects. The size of these joint effects depends
principally on the amount of prevalence overlap and the biological results of joint exposures (13). For
example, in the case of neuroinfections such as HIV, one risk factor (i.e. HIV infection) leads to many
outcomes, as explained in Chapter 3.5. For some other neurological disorders, one outcome can
result from many risk factors: in the case of epilepsy, for example, from factors such as birth injury,
head trauma, central nervous system infections and infestations, as explained in Chapter 3.2.
SERVICE PROVISION AND DELIVERY OF CARE
Health systems
Health systems comprise all the organizations, institutions and resources that devote their ef-
forts and activities to promote, restore and maintain population health. These activities include
formal health care such as the professional delivery of personal medical attention, actions by
traditional practitioners, home care and self-care, public health activities such as health promo-
tion and disease prevention, and other health-enhancing interventions such as the improvement
of environmental safety.
Beyond the boundaries of this deﬁ nition, health systems also include activities whose primary
purpose is something other than health — education, for example — if they have a secondary,
health-enhancing beneﬁ t. Hence, while general education falls outside the deﬁ nition of health
systems, health-related education is included. In this sense, every country has a health system, no
matter how fragmented or unsystematic it may seem to be.
The World Health Report 2000 outlines three overall goals of health systems: good health,
responsiveness to the expectations of the population, and fairness of ﬁ nancial contribution (17 ).
All three goals matter in every country, and much improvement in how a health system performs
with respect to these responsibilities is possible at little cost. Even if we concentrate on the narrow
deﬁ nition of reducing excess mortality and morbidity — the major battleground — the impact will
be slight unless activities are undertaken to strengthen health systems for delivery of personal
and public health interventions.
Progress towards the above goals depends crucially on how well systems carry out four vital
functions: service provision, resource generation, ﬁ nancing and stewardship (17 ). The provision of

public health principles and neurological disorders
15
services is the most common function of a health-care system, and in fact the entire health system
is often identiﬁ ed and judged by its service delivery.
The provision of health services should be affordable, equitable, accessible, sustainable and
of good quality. Failure in any of these objectives adversely affects the care that is delivered.
Not much information is forthcoming from countries on these aspects of their health systems,
however. Based on available information, serious imbalances appear to exist in many countries in
terms of human and physical resources, technology and pharmaceuticals. Many countries have too
few qualiﬁ ed health personnel, while others have too many. Staff in health systems in many low
income countries are inadequately trained, poorly paid and work in obsolete facilities with chronic
shortages of equipment. One result is a “brain drain” of demoralized health professionals who go
abroad or move into private practice. The poorer sectors of society are most severely affected by
any constraints in the provision of health services.
Service delivery
Organization of services for delivery of neurological care has an important bearing on their effec-
tiveness. Because of their different social, cultural, political and economic contexts, countries have
various forms of service organization and delivery strategies. The differing availability of ﬁ nancial
and human resources also affects the organization of services. Certain key issues, however, need
to be taken into account for structuring services to provide effective care to people with neurologi-
cal disorders. Depending upon the health system in the country, there is a variable mix of private
and public provision of neurological care.
The three traditional levels of service delivery are primary, secondary and tertiary care. Primary
care includes treatment and preventive and promotional interventions conducted by primary care
professionals. These vary from a general practitioner, nurse, other health-care staff and non-
medical staff to primary care workers based in rural areas. Primary care represents the point of
entry for most people seeking care and is the logical setting where neurological disorders should
begin to be addressed. Many potential beneﬁ ts exist for providing services through primary care.
Users of primary care are more likely to seek early help because of the wide availability of facilities,
their easy accessibility, cultural acceptability and reduced cost, thus leading to early detection of
neurological disorders and better clinical outcome.
Integration of neurological services into the primary care system needs to be a signiﬁ cant
policy objective in both developing and developed countries. Providing neurological care through
primary care requires signiﬁ cant investment in training primary care professionals to detect and
treat neurological disorders. Such training should meet the speciﬁ c practical training needs of
different groups of primary care professionals such as doctors, nurses and community health
workers. Preferably, ongoing training is needed to provide subsequent support for reinforcing new
skills. In many countries, this has not been possible and thus suboptimal care is provided (18).
Primary care centres are limited in their ability to adequately diagnose and treat certain neuro-
logical disorders. For the management of severe cases and patients requiring access to diagnostic
and technological expertise, a secondary level of care is necessary. A number of neurological
services may be offered in district or regional hospitals that form part of the general health system.
Common facilities include inpatient beds in general medicine, specialist beds, emergency depart-
ments and outpatient clinics. The various types of services include consultation/liaison services,
diagnostic facilities such as electroencephalography (EEG) and computerized tomography (CT),
planned outpatient programmes, emergency care, inpatient care, intensive care, respite care,
referral facilities for primary care services, multidisciplinary neurological care and rehabilitation
programmes. These services require adequate numbers of general as well as specialist profes-
sionals who can also provide supervision and training in neurology to primary care staff.

16
Neurological disorders: public health challenges
Tertiary care is the most specialized form of neurological diagnosis, treatment and rehabilita-
tion, and is often delivered in teaching hospitals. In some countries, there are also other public or
private facilities offering various types of neurological services in inpatient wards and outpatient
clinics. These facilities are not expected to deliver primary neurological care but act as second-
ary and tertiary referral services. They also serve as facilities for clinical research, collection of
epidemiological data, and the creation and distribution of health educational materials. Neurologi-
cal specialist services require a large complement of trained specialist staff. Shortages of such
staff are a serious problem in low income countries, as are the lack of ﬁ nancial resources and
infrastructure.
Very few countries have an optimal mix of primary, secondary and tertiary care. Even within
countries, signiﬁ cant geographical disparities usually exist between regions. Little concerted ef-
fort has been made to use primary care as the principal vehicle of delivery of neurological services.
Some countries have good examples of intersectoral collaboration between nongovernmental
organizations, academic institutions, public sector health services and informal community-based
health services. At present, such activities are limited to small populations in urban areas; most
rural populations have no access to such services. Even in developed countries, more emphasis
is placed on providing specialist services than on approaches to integrate neurological services
into primary care.
Many neurological disorders run a chronic, relapsing or remitting course. Such disorders are
better managed by services that adopt a continuing care approach, emphasizing the long-term
nature of these neurological disorders and the need for ongoing care. The emphasis is on an inte-
grated system of service delivery that attempts to respond to the needs of people with neurological
disorders. Integrated and coordinated systems of service delivery need to be developed where
services based in primary, secondary and tertiary care complement each other. In order to address
the needs of persons with neurological disorders for health care and social support, a clear referral
and linkage system needs to be in place. The key principles for organizing such services include
accessibility, comprehensiveness, coordination and continuity of care, effectiveness, and equity
within the local social, economic and cultural contexts.
DISABILITY AND REHABILITATION
Disability
Many neurological disorders and conditions affect an individual’s functioning and result in disabilities
or limit activities and restrict participation. According to the International Classiﬁ cation of Functioning,
Disability and Health (ICF), the medical model views disability as a problem of the person, directly
caused by disease, trauma or other health condition that requires medical care provided in the form
of individual treatment by professionals (19). Management of the disability is aimed at cure or the
individual’s adjustment and behaviour change. The social model of disability sees the issue mainly
as a socially created problem and a matter related to the full integration of individuals into society.
According to the social model, disability is not an attribute of the individual, but rather a complex col-
lection of conditions, many of which are created by the social environment: the approach to disability
requires social action and is a responsibility of society.
Rehabilitation
WHO deﬁ nes rehabilitation as an active process by which those affected by injury or disease
achieve a full recovery or, if a full recovery is not possible, realize their optimal physical, mental
and social potential and are integrated into their most appropriate environment (19). Rehabilitation
is one of the key components of the primary health-care strategy, along with promotion, preven-
tion and treatment. While promotion and prevention primarily target risk factors of disease and

public health principles and neurological disorders
17
treatment targets ill-health, rehabilitation targets human functioning. As with other key health
strategies, it is of varying importance and is relevant to all other medical specialities and health
professions. Though rooted in the health sector, rehabilitation is also relevant to other sectors
including education, labour and social affairs. For example, building of ramps and other facilities to
improve access by disabled people falls beyond the purview of the health sector but is neverthe-
less very important for the comprehensive management of a person with a disability.
As a health-care strategy, rehabilitation aims to enable people who experience or are at risk
of disability to achieve optimal functioning, autonomy and self-determination in the interaction
with the larger physical, social and economic environment. It is based on the integrative model of
human functioning, disability and health, which understands human functioning and disability both
as an experience in relation to health conditions and impairments and as a result of interaction
with the environment.
Rehabilitation involves a coordinated and iterative problem-solving process along the continuum
of care from the acute hospital to the community. It is based on four key approaches integrating a
wide spectrum of interventions: 1) biomedical and engineering approaches; 2) approaches that build
on and strengthen the resources of the person; 3) approaches that provide for a facilitating envi-
ronment; and 4) approaches that provide guidance across services, sectors and payers. Speciﬁ c
rehabilitation interventions include those related to physical medicine, pharmacology and nutrition,
psychology and behaviour, education and counselling, occupational and vocational advice, social
and supportive services, architecture and engineering and other interventions.
Rehabilitation services are like a bridge between isolation and exclusion — often the ﬁ rst
step towards achieving fundamental rights. Health is a fundamental right, and rehabilitation is a
powerful tool to provide personal empowerment.
Rehabilitation strategy
Because of the complexity of rehabilitation based on the above-mentioned integrative model, re-
habilitation services and interventions applying the rehabilitation strategy need to be coordinated
along the continuum of care across specialized and non-specialized services, sectors and payers.
Figure 1.2 illustrates the iterative problem-solving process sometimes called Rehab-CYCLE (20).
The Rehab-CYCLE involves four steps: assess, assign, intervene and evaluate. The process is
applied on two levels. The ﬁ rst refers to the guidance along the continuum of care and the second
to the provision of a speciﬁ c service.
From the guidance perspective, the assessment step in-
Figure 1.2 The Rehab-CYCLE
cludes the identiﬁ cation of the person’s problems and needs,
the valuation of rehabilitation potential and prognosis and the
Assessment
deﬁ nition of long-term service and goals of the intervention
programme. The assignment step refers to the assignment to
a service and an intervention programme. From the guidance
perspective, the intervention step is not further speciﬁ ed. The
Evaluation
Assignment
evaluation step refers to service and the achievement of the
intervention goal.
From the service perspective, the assessment step includes
the identiﬁ cation of a person’s problems, the review and po-
Intervention
tential modiﬁ cation of the service or goals of the intervention
programme and the deﬁ nition of the ﬁ rst Rehab-CYCLE goals
and intervention targets. The assignment step refers to the as-
signment of health professionals and interventions to the intervention targets. The intervention
step refers to the speciﬁ cation of the intervention techniques, the deﬁ nition of indicator measures
to follow the progress of the intervention, and the deﬁ nition of target values to be achieved within a

18
Neurological disorders: public health challenges
predetermined time period. The evaluation step refers to the evaluation of the achievement of the
goal with respect to the speciﬁ ed target values of the indicator measures, the Rehab-CYCLE goals
and ultimately the goals of the intervention programme. It also includes the decision regarding the
need for another intervention cycle based on a reassessment.
Rehabilitation of neurological disorders
Rehabilitation should start as soon as possible after the diagnosis of a neurological disorder or
condition and should focus on the community rehabilitation perspective. The type and provision of
services is largely dependent on the individual health-care system. Therefore no generally agreed
principles currently exist regarding the provision of rehabilitation and related services.
Rehabilitation is often exclusively associated with well-established and coordinated multi-
disciplinary efforts by specialized rehabilitation services. While availability and access to these
specialized inpatient or outpatient services are at the core of successful rehabilitation, a need also
exists for rehabilitation service provision, from the acute settings through the district hospital and
the community, often by health professionals not specialized in rehabilitation but working closely
with the rehabilitation professionals. It is important to recognize that rehabilitation efforts in the
community can be delivered by professionals outside the health sector, ideally in collaboration with
rehabilitation professionals.
Rehabilitation services are limited or nonexistent in many developing countries for people with
disabilities attributable to neurological disorders or other causes. This means that many individuals
with disabilities will depend totally on other people, usually family members, for help with daily
activities, and this situation enhances poverty. Impoverished communities throughout the world
are affected by a disproportionate number of disabilities and, in turn, people with disabilities
become more vulnerable to poverty because of a lack of access to, or availability of, health care,
social care and rehabilitation services. When rehabilitation services are available, the lack of hu-
man resources limits considerably the transfer of knowledge from specialized centres to district
and community settings.
To address this situation, a community-based rehabilitation strategy has been introduced by
WHO as a complement to existing rehabilitation models and to look beyond the medical needs. The
strategy of community-based rehabilitation has been implemented in many low income countries
around the world and has successfully inﬂ uenced the quality of life and participation of persons
with disabilities in societies where it is in practice.
The philosophy of rehabilitation emphasizes patient education and self-management and is well
suited for a number of neurological conditions. The basis for successful neurorehabilitation is the
in-depth understanding and sound measurement of functioning and the application of effective
interventions, intervention programmes and services. A wide range of rehabilitation interventions,
intervention programmes and services has been shown to contribute effectively to the optimal
functioning of people with neurological conditions.
Effective neurorehabilitation is based on the involvement of expert and multidisciplinary as-
sessment, realistic and goal-oriented programmes, and evaluation of the impact on the patient’s
rehabilitation achievements; evaluation using scientiﬁ cally sound and clinically appropriate out-
Box 1.3 Case-study: Giovanni
Giovanni is a 20-year-old man who was beaten by a mob
ing letter by letter with a ﬁ nger, the only part of his body he
two years ago after a football game and suffered traumatic
controls partially. Giovanni is totally dependent in all daily
brain injury. He was slow to recover with severe physical
activities and needs assistance 24 hours a day. He has a
limitations, fully conscious but with severe communication
standard wheelchair (though he requires an electrical one);
problems. He needs an assistive communication device
he has no way of leaving his house to access community
which is not provided by the health system and is not pos-
facilities, he cannot return to his previous job, and he has
sible for his family to purchase, so his family made a basic
no relocation option in view.
communication table he uses to spell out words by point-

public health principles and neurological disorders
19
come measures should also incorporate the patient’s and the family’s perspectives. There are a
number of complexities in the process of neurorehabilitation, as patients can present with diverse
sequelae, including the following:
■ Physical functioning limitations can be evident in many ways — such as paralysis of the left
or right side of the body, or both sides — which limit severely the person’s capacity for many
daily living activities, as well as mobility in the community and, eventually, the capacity to
return to work or school. Patients can also present with rigidity, uncoordinated movements,
and/or weakness. This is evident in the case-studies of Giovanni and Juan given below in
Box 1.3 and Box 1.4, respectively. In developing countries, people with disabilities have very
limited access not only to rehabilitation services but also to appropriate assistive technology,
such as adequate wheelchairs: persons with head injury who require wheelchairs for adequate
positioning and mobility may be severely impaired in their possibility to leave their house and
participate in community activities, access educational facilities, or work.
■ Cognitive impairments can manifest in the form of memory and attention problems, mild to
severe intellectual deﬁ ciency, lack of perseverance and a limited ability to learn, all of which
can make it impossible to return to work, may affect emotional stability, and limit performance
at work or at home. All of these problems will affect the person’s emotional status, as well as
that of the family and friends. It can also mean social isolation in the long term, aggravating
depression.
■ Behavioural problems such as poor impulse control, uncontrolled anger and sexual impulses,
lack of insight and perseverance, and the impossibility to learn from past errors are only some
of the behavioural sequelae that affect the person’s capacity to get involved and be accepted
socially, and further limit the possibility of returning to educational or vocational services.
Behavioural problems can also become evident when the person affected realizes the severity
of his or her limitations, and the fact that they may be permanent.
■ Communication impairments in the form of speech problems, poor vocalization or stomas,
in combination with lack of access to augmentative or alternative communication devices in
developing countries, as in Giovanni’s case (Box 1.3), are a sure means of social isolation.
■ Basic daily living activities are affected by functional and cognitive limitations. For a man like
Giovanni (Box 1.3), such things as getting dressed or getting a spoonful of food to his mouth
can be impossible.
■ Psychosocial limitations, such as limited access to education, the impossibility to return to
vocational status or be relocated vocationally, are consequences of previously mentioned limi-
tations, all of which further impact on the behavioural, physical and cognitive aspects of the
person affected by a neurological disorder that causes disability.
Costs of rehabilitation services
The National Head and Spinal Cord Injury Survey (21) divided costs into direct and indirect. Direct
costs were associated with the monetary values of real goods and services that were provided
for health care, while indirect costs were the monetary loss incurred by society because of inter-
rupted productivity by the injured person. In 1974, the total cost for all head injuries studied was
Box 1.4 Case-study: Juan
Juan is a 32-year-old man, a former alcohol and drug addict
and was supported by his mother, who had to ﬁ nd a job to
who sustained a car accident eight years ago. He recov-
maintain them both. Finally, on his own, Juan adapted his
ered well from his physical limitations, except for a total
tools to be able to function as a shoe-shiner in a park. At
paralysis of his right arm and uncoordinated movements of
his last appointment, he was newly wed and attended with
his left arm and legs. He was depressed for years, refus-
his wife and child. He was ﬁ nally happy with himself and
ing medical treatment for his former addiction problem. He
his life, although conscious of his deﬁ cits.
could not return to his former job as an agricultural labourer

20
Neurological disorders: public health challenges
US$ 2384 million, of which 29% was related to the direct costs of care and 71% to indirect costs.
The largest annual cost was found to be in the 25–44-year age group, where the loss incurred
due to productivity was maximal. Payments for indirect costs are by far the greatest share, and
legal charges are only slightly less than the cost for the entire medical, hospital and rehabilitation
services provided.
STIGMA
Stigma has been deﬁ ned as a deeply discrediting attribute that reduces a person to one who is in
some way tainted and can therefore be denigrated. It is a pervasive problem that affects health
globally, threatening an individual’s psychological and physical well-being. It prevents individuals
from coming forward for diagnosis and impairs their ability to access care or participate in research
studies designed to ﬁ nd solutions.
Stigmatization of certain diseases and conditions is a universal phenomenon that can be seen
across all countries, societies and populations. It refers to the relation between “the differentness
of an individual and the devaluation society places on that particular differentness”. For stigma-
tization to be consistently effective, however, the stigmatized person must acquiesce to society’s
devaluation. When people with “differentness” internalize society’s devaluation, they do not feel
empowered to change the situation and the negative stereotypes become an accepted part of their
concept of the disorder. The labelling, stereotyping, separation from others and consequent loss
of status highlight the role of power relations in the social construction of stigma (22).
People differentiate and label socially important human differences according to certain pat-
terns that include: negative stereotypes, for example that people with epilepsy or other brain
disease are a danger to others; and pejorative labelling, including terms such as “crippled”, “dis-
abled” and “epileptic”.
In neurology, stigma primarily refers to a mark or characteristic indicative of a history of
neurological disorder or condition and the consequent physical or mental abnormality. For most
chronic neurological disorders, the stigma is associated with the disability rather than the disorder
per se. Important exceptions are epilepsy and dementia: stigma plays an important role in forming
the social prognosis of people with these disorders. The amount of stigma associated with chronic
neurological illness is determined by two separate and distinct components: the attribution of
responsibility for the stigmatizing illness and the degree to which it creates discomfort in social
interactions. An additional perspective is the socially structured one, which indicates that stigma
is part of chronic illness because individuals who are chronically ill have less “social value” than
healthy individuals. Some additional aspects and dimensions of stigma are given in Box 1.5.
Stigma leads to direct and indirect discriminatory behaviour and factual choices by others
that can substantially reduce the opportunities for people who are stigmatized. Whatever the
mechanisms involved, stigma is an important public health problem. Stigma increases the toll of
illness for many people with brain disorders and their families; it is a cause of disease, as people
Box 1.5 Dimensions of stigma
Concealability
The extent to which the condition becomes obvious or can be hidden from others.
Course of the mark
The way the condition changes over time and its ultimate outcome.
Disruptiveness
The degree of strain and difﬁ culty stigma adds to interpersonal relationships.
Aesthetics
How much the attribute makes the character repellant or upsetting to others.
Origin
Who was responsible for the acquired stigmatizing condition and how.
Peril
Perceived dangers, both real and symbolic, of the stigmatizing condition to others.
Source: (23).

public health principles and neurological disorders
21
who are stigmatized have high exposure to health risks and low access to protective factors and
treatment.
Sometimes coping with stigma surrounding the disorder is more difﬁ cult than living with any
limitations imposed by the disorder itself. Stigmatized individuals are often rejected by neighbours
and the community, and as a result suffer loneliness and depression. The psychological effect of
stigma is a general feeling of unease or of “not ﬁ tting in”, loss of conﬁ dence, increasing self-doubt
leading to depreciated self-esteem, and a general alienation from the society. Moreover, stigmati-
zation is frequently irreversible so that, even when the behaviour or physical attributes disappear,
individuals continue to be stigmatized by others and by their own self-perception.
People with some neurological disorders (e.g. epilepsy) and their families may also be sub-
jected to other forms of social sanction, such as being excluded from community activities or
from societal opportunities such as education or work. One of the most damaging results of stig-
matization is that affected individuals or those responsible for their care may not seek treatment,
hoping to avoid the negative social consequences of diagnosis. This leads in turn to delayed or
lost opportunities for treatment and recovery. Underreporting of stigmatizing conditions can also
reduce efforts to develop appropriate strategies for their prevention and treatment.
Epilepsy carries a particularly severe stigma because of misconceptions, myths and stereo-
types related to the illness. In some communities, children who do not receive treatment for this
disorder are removed from school. Lacking basic education, they may not be able to support
themselves as adults. In some African countries, people believe that saliva can spread epilepsy
or that the “epileptic spirit” can be transferred to anyone who witnesses a seizure. These mis-
conceptions cause people to retreat in fear from someone having a seizure, leaving that person
unprotected from open ﬁ res and other dangers they might encounter in cramped living conditions.
Recent research has shown that the stigma people with epilepsy feel contributes to increased
rates of psychopathology, fewer social interactions, reduced social capital, and lower quality of
life in both developed and developing countries (22).
Efforts are needed to reduce stigma but, more importantly, to tackle the discriminatory attitudes
and prejudicial behaviour that give rise to it. Fighting stigma and discrimination requires a multilevel
approach involving education of health professionals and public information campaigns to educate
and inform the community about neurological disorders in order to avoid common myths and
promote positive attitudes. Methods to reduce stigma related to epilepsy in an African community
by a parallel operation of public education and comprehensive treatment programmes successfully
changed attitudes: traditional beliefs about epilepsy were weakened, fears were diminished, and
community acceptance of people with epilepsy increased (24).
The provision of services in the community and the implementation of legislation to protect
the rights of the patients are also important issues. Legislation represents an important means of
dealing with the problems and challenges caused by stigmatization. Governments can reinforce
efforts with laws that protect people with brain disorders and their families from abusive practices
and prevent discrimination in education, employment, housing and other opportunities. Legislation
can help, but ample evidence exists to show that this alone is not enough.
The emphasis on the issue of prejudice and discrimination also links to another concept where
the need is to focus less on the person who is stigmatized and more on those who do the stigma-
tizing. The role of the media in perpetrating misconceptions also needs to be taken into account.
Stigmatization and rejection can be reduced by providing factual information on the causes and
treatment of brain disorder; by talking openly and respectfully about the disorder and its effects;
and by providing and protecting access to appropriate health care.

22
Neurological disorders: public health challenges
EDUCATION AND TRAINING
Education in neurology contains important aspects of quality assurance and continuing improve-
ment in the delivery of the best care to people with neurological disorders. Training in neurology
does not refer only to postgraduate specialization but also the component of training offered to
undergraduates, general physicians and primary health-care workers. To reduce the global burden
of neurological disorders, an adequate focus is needed on training, especially of primary health
workers in countries where neurologists are few or nonexistent.
Training of primary care providers
As front line caregivers in many resource-poor countries, primary care providers need to receive
basic training and regular continuing education in basic diagnostic skills and in treatment and
rehabilitation protocols. Such training should cover general skills (such as interviewing the patient
and recording the information), diagnosis and management of speciﬁ c disorders (including the use
of medications and monitoring of side-effects) and referral guidelines. Training manuals tailored
to the needs of speciﬁ c countries or regions must be developed. Primary care providers need to
be trained to recognize the need for referral to more specialized treatment rather than trying to
make a diagnosis.
Training of nurses is particularly important globally. In low income countries, where few physi-
cians exist, nurses may be involved in making diagnostic and treatment decisions. They are also
an important source of advice on promoting health and preventing disease, such as providing
information on diet and immunization.
Training of physicians
The points to be taken into consideration in relation to education in neurology for physicians
include:
■ core curricula (undergraduate, postgraduate and others);
■ continuous medical education;
■ accreditation of training courses;
■ open facilities and international exchange programmes;
■ use of innovative teaching methods;
■ training in the public health aspects of neurology.
Teaching of neurology at undergraduate level is important because 20–30% of the population
are susceptible to neurological disorders (25 ). The postgraduate period of training is the most
active and important for the development of a fully accredited neurologist. The following issues
need consideration: mode of entry, core training programmes, evaluation of the training institu-
tions, access to current literature, rotation of trainees between departments, and evaluation of the
trainees during training and by a ﬁ nal examination. The central idea is to build both the curriculum
and an examination system that ensure the achievement of professional competence and social
values and not merely the retention and recall of information.
Neurological curricula vary considerably across countries. This is not necessarily undesirable
because the curriculum must take into account local differences in the prevalence of neurologi-
cal disorders. Some standardization in the core neurological teaching and training curricula and
methods of demonstrating competency is desirable, however. The core curriculum should be
designed to cover the practical aspects of neurological disorders and the range of educational
settings should include all health resources in the community. The core curriculum also needs to
reﬂ ect national health priorities and the availability of affordable resources.
Continuous medical education is an important way of updating the knowledge of specialists on
an ongoing basis and providing specialist courses to primary care physicians. Specialist neurolo-

public health principles and neurological disorders
23
gists could be involved in training of primary care doctors, especially in those countries where few
specialists in neurology exist. Regional and international neurological societies and organizations
have an important role to play in providing training programmes: the emphasis should be on active
problem-based learning. Guidelines for continuous medical education need to be set up to ensure
that educational events and materials meet a high educational standard, remain free of the inﬂ u-
ence of the pharmaceutical industry and go through a peer review system. Linkage of continuous
medical education programmes to promotion or other incentives could be a strategy for increasing
the number of people attending such courses.
Neurologists play an increasingly important part in providing advice to government and ad-
vocating better resources for people with neurological disorders. Therefore training in public
health, service delivery and economic aspects of neurological care need to be stressed in their
curricula.
Most postgraduate neurology training programmes, especially those in developed countries, are
resource intensive and lengthy — usually taking about six years to complete. Whether adequate
specialist training in neurology might be undergone in less time in certain countries or regions
would be a useful subject for study. The use of modern technology facilities and strategies such as
distance-learning courses and telemedicine could be one way of decreasing the cost of training.
An important issue, as for other human health-care resources, is the “brain drain”, where
graduates sent abroad for training do not return to practise in their countries of origin. This public
health challenge still needs to be faced with innovative means.
CONCLUSIONS
Public health is the science and practice of protecting and improving the population’s health
through prevention, promotion, health education, control of communicable and noncommunicable
diseases and monitoring of environmental hazards. It is a comprehensive approach that is con-
cerned with the health of the community as a whole. Public health is community health: “Health
care is vital to all of us some of the time, but public health is vital to all of us all of the time” (3).
The mission of public health is to fulﬁ l society’s interest in assuring conditions in which people
can be healthy. The three core public health functions are:
■ the assessment and monitoring of the health of communities and populations at risk to identify
health problems and priorities;
■ the formulation of public policies designed to solve identiﬁ ed local and national health problems
and priorities;
■ ensuring that all populations have access to appropriate and cost-effective care, including
health promotion and disease prevention services, and evaluation of the effectiveness of that
care.
Public health comprises many professional disciplines such as medicine, nutrition, social work,
environmental sciences, health education, health services administration and the behavioural
sciences. In other words, public health activities focus on entire populations rather than on indi-
vidual patients. Specialist neurologists usually treat individual patients for a speciﬁ c neurological
disorder or condition; public health professionals approach neurology more broadly by monitoring
neurological disorders and related health concerns in entire communities and promoting healthy
practices and behaviours so as to ensure that populations stay healthy. Although these approaches
could be seen as two sides of the same coin, it is hoped that this chapter contributes to the
process of building the bridges between public health and neurology and thus serves as a useful
guide for the chapters to come.

24
Neurological disorders: public health challenges
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RECOMMENDED READING
■ Bergen DC. Preventable neurological diseases worldwide. Neuroepidemiology, 1998, 17:67–73.
■ Bergen DC, Silberberg D. Nervous system disorders: a global epidemic. Archives of Neurology, 2002;
59:1194–1196.
■ Hewer RL. The economic impact of neurological illness on the health and wealth of the nation and of
individuals. Journal of Neurology, Neurosurgery and Psychiatry, 1997, 63(Suppl. 1):19–23.
■ Institute of Medicine. Neurological, psychiatric, and developmental disorders. Meeting the challenge in
the developing world. Washington, DC, National Academy Press, 2001.
■ Menken M, Munsat TL, Toole JF. The Global Burden of Disease study: implications for neurology.
Archives of Neurology, 2002; 57:418–420.
■ Singhal BS. Neurology in developing countries. A population perspective. Archives of Neurology, 1998;
55:1019–1021.
■ Werner D. Disabled village children: a guide for health workers, rehabilitation workers and families.
Berkeley, CA, The Hesperian Foundation, 1987.
■ International classiﬁ cation of functioning, disability and health. Geneva, World Health Organization,
2001.
■ Primary prevention of mental, neurological and psychosocial disorders. Geneva, World Health Organiza-
tion, 1998.
■ The Bangkok Charter for Health Promotion in a Globalized World. Geneva, World Health Organization,
2005.
■ The world health report 2000 – Health systems: improving performance. Geneva, World Health Organiza-
tion, 2000.
■ The world health report 2002 – Reducing risks, promoting healthy life. Geneva, World Health Organiza-
tion, 2002.
■ WHO CVD-risk management package for low- and medium-resource settings. Geneva, World Health
Organization, 2002.

26
Neurological disorders: public health challenges

27
CHAPTER 2
global burden of
neurological
disorders
estimates and projections
in this chapter
Ever-increasing demand for health services
27 GBD studies and their key results
forces health planners to make choices about
29 Estimates and projections for neurological disorders
resource allocation. Information on relative
burden of various health conditions and risks
30 Data presentation
to health is an important element in strategic
37 Conclusions
health planning. What is needed to provide
this information is a framework for integrat-
ing, validating, analysing, and disseminating the fragmentary, and at times contra-
dictory, data that are available on a population’s health, along with some under-
standing of how that population’s health is changing over time.
The Global Burden of Disease (GBD) approach is one of the most
(4). The main purpose was to convert partial, often
widely used frameworks for information on summary measures
nonspeciﬁ c, data on disease and injury occurrence
of population health across disease and risk categories. The GBD
into a consistent description of the basic epidemio-
framework is based on the use of a common metric to summarize
logical parameters.
the disease burden from diagnostic categories of the International
Many conditions including neuropsychiatric disor-
Classiﬁ cation of Diseases and the major risk factors that cause
ders and injuries cause considerable ill-health but no
those health outcomes.
or few direct deaths. Therefore separate measures
of survival and of health status among survivors
GBD STUDIES AND THEIR KEY RESULTS
needed to be combined to provide a single, holistic
In 1993, the World Bank, WHO and the Harvard School of Public
measure of overall population health. To assess the
Health carried out a study to assess the global burden of disease
burden of disease, the 1990 GBD study used a time-
for the year 1990. The methods and ﬁ ndings of the 1990 GBD
based metric that measures both premature mortal-
study have been widely published (1–3). To prepare internally
ity (years of life lost because of premature mortality
consistent estimates of incidence, prevalence, duration and mor-
or YLL) and disability (years of healthy life lost as a
tality for almost 500 sequelae of the diseases and injuries under
result of disability or YLD, weighted by the severity
consideration, a mathematical model, DisMod, was developed
of the disability). The sum of these two components,

28
Neurological disorders: public health challenges
disability-adjusted life years (DALYs), provides a measure of the future stream of healthy life (years
expected to be lived in full health) lost as a result of the incidence of speciﬁ c diseases and injuries
(2). One DALY can be thought of as one lost year of healthy life and the burden of disease as a
measure of the gap between current health status and an ideal situation where everyone lives into
old age free from disease and disability.
The results of the 1990 GBD study conﬁ rmed that noncommunicable diseases and injuries
were a signiﬁ cant cause of health burden in all regions of the world. Neuropsychiatric disorders
and injuries in particular were major causes of lost years of healthy life as measured by DALYs,
and were signiﬁ cantly underestimated when measured by mortality alone (2).
The 1990 GBD study represented a major advance in the quantiﬁ cation of the impact of dis-
eases, injuries and risk factors on population health globally and by region. Government and
nongovernmental agencies alike have used these results to argue for more strategic allocations of
health resources to disease prevention and control programmes that are likely to yield the greatest
gains in terms of population health. Following publication of the initial results of the GBD study,
several national applications of its methods were used, which led to substantially more data in
the area of descriptive epidemiology of diseases and injuries.
As a follow-up to the 1990 GBD study, WHO undertook a new global assessment of the burden
of disease for the year 2000 and subsequent years in 2002. The GBD 2000 study drew on a
wide range of data sources to develop internally consistent estimates of incidence, health state
prevalence, severity and duration, and mortality for over 130 major causes, for 14 epidemiological
subregions of the world (5).
Projections of global mortality and burden of disease
In order to address the need for updated projections of mortality and burden of disease by region
and cause, updated projections of future trends for mortality and burden of disease between 2002
and 2030 have also been prepared by WHO (6). These have been based on methods similar to
those used in the original GBD 1990 study, but use the latest available estimates for 2002 and the
latest available projections for HIV/AIDS, income, human capital and other inputs (7 ). Relatively
simple models were used to project future health trends under various scenarios, based largely on
projections of economic and social development, and using the historically observed relationships
of these with cause-speciﬁ c mortality rates.
Rather than attempt to model the effects of the many separate direct determinants or risk
factors for diseases from the limited data that are available, the GBD methodology considered a
certain number of socioeconomic variables including: average income per capita, measured as
gross domestic product (GDP) per capita; average number of years of schooling in adults, referred
to as “human capital”; and time, a proxy measure for the impact of technological change on
health status. This latter variable captures the effects of accumulating knowledge and technologi-
cal development, allowing the implementation of more cost-effective health interventions, both
preventive and curative, at constant levels of income and human capital. These socioeconomic
variables show clear historical relationships with mortality rates, and may be regarded as indirect,
or distal, determinants of health. In addition, a fourth variable, tobacco use, was included in the
projections for cancer, cardiovascular diseases and chronic respiratory diseases, because of its
overwhelming importance in determining trends for these causes.
Projections were carried out at country level, but aggregated into regional or income groups
for presentation of results. Baseline estimates at country level for 2002 were derived from the
GBD analyses published in The world health report 2004 (8). Mortality estimates were based on
analysis of latest available national information on levels of mortality and cause distributions as at
late 2003. Incidence, prevalence, duration and severity estimates for conditions were based on the
GBD analyses for the relevant epidemiological subregion, together with national and sub-national

global burden of neurological disorders: estimates and projections
29
level information available to WHO. These baseline estimates represent the best estimates of WHO,
based on the evidence available in mid-2004, and have been computed using standard categories
and methods to maximize cross-national comparability.
Limitations of the Global Burden of Disease framework
By their very nature, projections of the future are highly uncertain and need to be interpreted with
caution. Three limitations are brieﬂ y discussed: uncertainties in the baseline data on levels and
trends in cause-speciﬁ c mortality, the “business as usual” assumptions, and the use of a relatively
simple model based largely on projections of economic and social development (9).
For regions with limited death registration data, such as the Eastern Mediterranean Region,
sub-Saharan Africa and parts of Asia and the Paciﬁ c, there is considerable uncertainty in esti-
mates of deaths by cause associated with the use of partial information on levels of mortality
from sources such as the Demographic and Health Surveys, and from the use of cause-speciﬁ c
mortality estimates for causes such as HIV/AIDS, malaria, tuberculosis and vaccine-preventable
diseases. The GBD analyses have attempted to use all available sources of information, together
with an explicit emphasis on internal consistency, to develop consistent and comprehensive esti-
mates of deaths and disease burden by cause, age, sex and region.
The projections of burden are not intended as forecasts of what will happen in the future but
as projections of current and past trends, based on certain explicit assumptions and on observed
historical relationships between development and mortality levels and patterns. The methods used
base the disease burden projections largely on broad mortality projections driven to a large extent
by World Bank projections of future growth in income per capita in different regions of the world.
As a result, it is important to interpret the projections with a degree of caution commensurate with
their uncertainty, and to remember that they represent a view of the future explicitly resulting from
the baseline data, choice of models and the assumptions made. Uncertainty in projections has
been addressed not through an attempt to estimate uncertainty ranges, but through preparation
of pessimistic and optimistic projections under alternative sets of input assumptions.
The results depend strongly on the assumption that future mortality trends in poor countries
will have the same relationship to economic and social development as has occurred in higher
income countries in the recent past. If this assumption is not correct, then the projections for low
income countries will be over-optimistic in the rate of decline of communicable and noncommuni-
cable diseases. The projections have also not taken explicit account of trends in major risk factors
apart from tobacco smoking and, to a limited extent, overweight and obesity. If broad trends in risk
factors are towards worsening of risk exposures with development, rather than the improvements
observed in recent decades in many high income countries, then again the projections for low and
middle income countries presented here will be too optimistic.
ESTIMATES AND PROJECTIONS
FOR NEUROLOGICAL DISORDERS
This document presents the GBD estimates for neurological disorders from the projected esti-
mates for 2005, 2015 and 2030. The complete set of tables is contained in Annex 4.
Cause categories
The cause categories used in the GBD study have four levels of disaggregation and include 135
speciﬁ c diseases and injuries. At the ﬁ rst level, overall mortality is divided into three broad groups
of causes: Group I consists of communicable diseases, maternal causes, conditions arising in
the perinatal period and nutritional deﬁ ciencies; Group II encompasses the noncommunicable
diseases (including neuropsychiatric conditions); and Group III comprises intentional and uninten-
tional injuries. Deaths and health states are categorically attributed to one underlying cause using

30
Neurological disorders: public health challenges
the rules and conventions of the International Classiﬁ cation of Diseases. In some cases these rules
are ambiguous, in which event the GBD 2000 followed the conventions used in the GBD 1990. It
also lists the sequelae analysed for each cause category and provides relevant case deﬁ nitions.
Methodology
For the purpose of calculation of estimates of the global burden of disease, the neurological
disorders are included from two categories: neurological disorders within the neuropsychiatric
category, and neurological disorders from other categories. Neurological disorders within the
neuropsychiatric category refer to the cause category listed in Group II under neuropsychiatric
disorders and include epilepsy, Alzheimer and other dementias, Parkinson’s disease, multiple
sclerosis and migraine. Neurological disorders from other categories include diseases and injuries
which have neurological sequelae and are listed elsewhere in cause category Groups I, II and III
(10). The complete list used for calculation of GBD estimates for neurological disorders is given in
Annex 3. Among the various neurological disorders discussed in this report, please note that for
headache disorders, GBD includes migraine only (see Chapter 3.3). Also, GBD does not describe
separately the burden associated with pain (see Chapter 3.7). There are also some diseases and
injuries, which have neurological sequelae that have not been separately identiﬁ ed by the GBD
study, and are not presented in this report; these include tuberculosis, HIV/AIDS, measles, low
birth weight, birth asphyxia and birth trauma. The burden estimates for these conditions include
the impact of neurological and other sequelae which are not separately estimated.
DATA PRESENTATION
This chapter summarizes data with the important ﬁ ndings presented as charts and maps for
DALYs, deaths, YLDs and prevalence as estimated for neurological disorders in the GBD study. The
complete set of tables is given in Annex 4. The data are presented for the following variables.
DALYs
Absolute numbers
Percentage of total DALYs
DALYs per 100 000 population
Deaths
Absolute numbers
Percentage of total deaths
Deaths per 100 000 population
YLDs
Absolute numbers
Percentage of total YLDs
YLDs per 100 000 population
Point prevalence
Total number of cases with different neurological disorders
Prevalence per 1000 population of individual neurological disorders
Please note that prevalence and YLDs are available for the neurological cause – sequela combina-
tions. These data are therefore provided for all neurological disorders within the neuropsychiatric cat-
egory, cerebrovascular disease, combined for neuroinfections and neurological sequelae of infections
(poliomyelitis, tetanus, meningitis, Japanese encephalitis, syphilis, pertussis, diphtheria, malaria),
neurological sequelae associated with nutritional deﬁ ciencies and neuropathies (protein–energy
malnutrition, iodine deﬁ ciency, leprosy, and diabetes mellitus), and neurological sequelae associated
with injuries (road trafﬁ c accidents, poisonings, falls, ﬁ res, drownings, other unintentional injuries,
self-inﬂ icted injuries, violence, war, and other intentional injuries) (see Table 2.1).
While YLDs are separately estimated for each sequela, death (and hence YLLs and DALYs)
are only estimated at the cause level, and for many causes it is not possible to describe sequela-
speciﬁ c deaths. The tables for DALYs and deaths therefore only describe data for neurological
cause categories (Table 2.2).

global burden of neurological disorders: estimates and projections
31
Table 2.1 Neurological disorder groupings used for YLDs and prevalence data
Neurological disorders in neuropsychiatric category
Disorders/injuries with neurological sequelae in other
categories
Epilepsy
Cerebrovascular disease
Alzheimer and other dementias
Neuroinfections
Parkinson’s disease
Nutritional deﬁ ciencies and neuropathies
Multiple sclerosis
Neurological injuries
Migraine
Table 2.2 Neurological disorder groupings used for DALYs and deaths data
Neurological disorders in neuropsychiatric category
Disorders/injuries with neurological sequelae in other
categories
Epilepsy
Cerebrovascular disease
Alzheimer and other dementias
Poliomyelitis
Parkinson’s disease
Tetanus
Multiple sclerosis
Meningitis
Migraine
Japanese encephalitis
Regional and income categories
Projections of mortality and burden of disease are summarized according to two groupings of
countries, as follows.
■ WHO regions. WHO Member States are grouped into six regions (Africa, the Americas,
South-East Asia, Europe, Eastern Mediterranean and Western Paciﬁ c, see http://www.who.
int/about/regions/en/index.html). WHO regions are organizational groupings and, while they
are largely based on geographical terms, are not synonymous with geographical areas. For
further disaggregation of the global burden of disease, the regions have been further divided
into 14 epidemiological subregions, based on levels of child (under ﬁ ve years of age) and adult
(aged 15–59 years) mortality for WHO Member States (Table 2.3). When these mortality strata
are applied to the six WHO regions, they produce 14 mortality subregions. These are listed in
Annex 1, together with the WHO Member States in each group.
Table 2.3 Deﬁ nitions of mortality strata used to deﬁ ne subregions
Mortality stratum
Child mortality
Adult mortality
A
Very low
Very low
B
Low
Low
C
Low
High
D
High
High
E
High
Very high
■ Income categories. The income categories are based on World Bank estimates of gross
national income (GNI) per capita in 2001 (11). Each country is classiﬁ ed as low income (GNI
US$ 745 or less), lower middle income (GNI US$ 746–2975), upper middle income (GNI US$
2976–9205), and high income (GNI $ 9206 or more). Annex 2 lists countries according to the
World Bank income categories.
The following tables and text describe the estimates for DALYs, deaths and YLDs for neurologi-
cal disorders as estimated and projected for 2005, 2015 and 2030.

32
Neurological disorders: public health challenges
Estimates of disability-adjusted life years (DALYs)
Neurological disorders included in the neuropsychiatric category contribute to 2% of the global
burden of disease, while cerebrovascular disease and some of the neuroinfections (poliomyelitis,
tetanus, meningitis and Japanese encephalitis) contribute to 4.3% of the global burden of disease
in 2005. Thus neurological disorders constitute 6.3% of the global burden of disease (see Table
2.4). The term “neurological disorders” henceforth used in this chapter includes those conditions
in the neuropsychiatric category as well as in other categories. Figure 2.1 presents selected
diseases as a percentage of total DALYs, in order to compare the burden constituted by them with
that of neurological disorders. For example, HIV/AIDS and malignant neoplasm each constitute
slightly over 5% of total burden.
Table 2.4 presents the total number of DALYs in thousands associated with neurological disor-
ders and as percentage of total DALYs for 2005, 2015 and 2030. Neurological disorders contribute
to 92 million DALYs in 2005 projected to increase to 103 million in 2030 (approximately a 12%
increase). While Alzheimer and other dementias are projected to show a 66% increase from 2005
to 2030, there is an estimated 57% decrease in DALYs associated with poliomyelitis, tetanus,
meningitis and Japanese encephalitis combined.
Table 2.4 Number of DALYs for neurological disorders and as percentage of global
DALYs projected for 2005, 2015 and 2030
Cause category
2005
2015
2030
No. of
Percentage
No. of
Percentage
No. of
Percentage
DALYs
of total
DALYs
of total
DALYs
of total
(000)
DALYs
(000)
DALYs
(000)
DALYs
Epilepsy
7 308
0.50
7 419
0.50
7 442
0.49
Alzheimer and other dementias
11 078
0.75
13 540
0.91
18 394
1.20
Parkinson’s disease
1 617
0.11
1 762
0.12
2 015
0.13
Multiple sclerosis
1 510
0.10
1 586
0.11
1 648
0.11
Migraine
7 660
0.52
7 736
0.52
7 596
0.50
Cerebrovascular disease
50 785
3.46
53 815
3.63
60 864
3.99
Poliomyelitis
115
0.01
47
0.00
13
0.00
Tetanus
6 423
0.44
4 871
0.33
3 174
0.21
Meningitis
5 337
0.36
3 528
0.24
2 039
0.13
Japanese encephalitis
561
0.04
304
0.02
150
0.01
Total
92 392
6.29
94 608
6.39
103 335
6.77
Figure 2.1 Percentage of total DALYs for selected diseasesa and neurological
disordersb
7
6
5
4
3
2
% of total DALYs
1
0
Neurological
Tuberculosis
HIV/AIDS
Malignant
Ischaemic heart
Respiratory
Digestive
disorders
neoplasms
disease
disease
diseases
a GBD cause categories
b Neuropsychiatric plus other categories

global burden of neurological disorders: estimates and projections
33
Among neurological disorders, more than half of the burden in DALYs is contributed by cerebro-
vascular disease, 12% by Alzheimer and other dementias and 8% each by epilepsy and migraine
(see Figure 2.2).
Neurological disorders contribute to 10.9%, 6.7%, 8.7% and 4.5% of the global burden of
disease in high, upper middle, lower middle and low income countries, respectively, in 2005 (see
Figure 2.3). The higher burden in the lower middle category reﬂ ects the double burden of commu-
nicable diseases and noncommunicable diseases. DALYs per 100 000 population for neurological
disorders are highest for lower middle and low income countries (1514 and 1448, respectively) as
estimated for 2005 (see Table 2.5).
Table 2.5 DALYs per 100 000 population for neurological disorders global y and by
World Bank income category, 2005
Cause category
World
Income category
(100 000
population)
Low
Lower middle
Upper middle
High
Epilepsy
113.4
158.3
80
139.2
51.3
Alzheimer and other dementias
172
90.7
150.7
166.9
457.3
Parkinson’s disease
25.1
15.1
19.7
17.5
70.8
Multiple sclerosis
23.4
20.1
23.3
24.9
32.5
Migraine
118.9
114
106.8
147.1
146.3
Cerebrovascular disease
788.4
662.5
1 061.2
612.2
592
Poliomyelitis
1.8
2.6
1.6
0.9
0.6
Tetanus
99.7
228.6
10.8
1.3
0.1
Meningitis
82.9
143.2
51.2
39.7
10.7
Japanese encephalitis
8.7
13
9
0.4
0.6
Total
1 434.3
1 448.1
1 514.3
1 150.1
1 362.2
As shown in Table 2.6, neurological disorders contribute most to the global burden of disease in
the European Region (11.2%) and the Western Paciﬁ c Region (10%) compared with 2.9% in the
African Region in 2005. DALYs per 100 000 population as estimated for 2005 are highest for Eur-C
epidemiological subregion (2920) and lowest for Emr-B (751) (see Figure 2.4).
Figure 2.2 DALYs for individual neurological
Figure 2.3 Neurological disorders as percentage

disorders as percentage of total

of total DALYs for 2005, 2015 and 2030
neurological
disorders

across World Bank income category
14
Cerebrovascular
2005
2015 2030
disease 55.0%
12
10
Alzheimer
Ys
and other
dementias
DAL
8
12.0%
total
6
of
%
4
Migraine
8.3%
2
Poliomyelitis 0.1%
Epilepsy 7.9%
Japanese encephalitis 0.6%
0
Low
Lower middle
Upper middle
High
Multiple sclerosis 1.6%
Tetanus 7.0%
Income category
Parkinson's disease 1.8%
Meningitis 5.8%

34
Neurological disorders: public health challenges
Figure 2.4 DALYs per 100 000 population associated with neurological Region Mortality
DALYS per 100 000
stratum
population
disorders by WHO region and mortality stratum, 2005
for neurological
disorders
Africa (AFR)
Afr-D
1 536.73
Afr-E
1 361.41
Americas
Amr-A
1
214.18
(AMR)
Amr-B
1
135.56
Amr-D 1
251.09
South-East
Sear-B
750.50
Asia (SEAR)
Sear-D
1 480.39
Europe (EUR)
Eur-A
1 463.53
Eur-B
1 665.33
Eur-C
2 920.22
Eastern
Emr-B
1 089.68
Mediterranean
Emr-D
1 377.09
(EMR)
Western
Wpr-A
1 543.28
Paciﬁ c (WPR)
Wpr-B
1 470.80
<1000
1000–1200
1200.1–1400
1400.1–1600
>1600
The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers
WHO 06.154
or boundaries. Dashed lines represent approximate border lines for which there may not yet be full agreement.
Table 2.6 Neurological disorders as percentage of total DALYs by WHO region, 2005
Cause category
World
WHO region
(%)
AFR
AMR
SEAR
EUR
EMR
WPR
(%)
(%)
(%)
(%)
(%)
(%)
Epilepsy
0.50
0.46
0.73
0.46
0.40
0.54
0.44
Alzheimer and other dementias
0.75
0.10
1.47
0.26
2.04
0.42
1.32
Parkinson’s disease
0.11
0.02
0.22
0.07
0.30
0.06
0.15
Multiple sclerosis
0.10
0.03
0.17
0.08
0.20
0.09
0.15
Migraine
0.52
0.13
0.97
0.41
0.80
0.51
0.73
Cerebrovascular disease
3.46
1.11
3.10
1.93
7.23
2.69
6.81
Poliomyelitis
0.01
0.00
0.00
0.01
0.00
0.01
0.01
Tetanus
0.44
0.77
0.01
0.81
0.00
0.54
0.10
Meningitis
0.36
0.24
0.39
0.81
0.24
0.43
0.24
Japanese encephalitis
0.04
0.00
0.00
0.05
0.00
0.06
0.09
Total
6.29
2.86
7.06
4.90
11.23
5.34
10.04

global burden of neurological disorders: estimates and projections
35
Estimates of deaths
Neurological disorders are an important cause of mortality and constitute 12% of total deaths
globally (see Table 2.7). Within these, cerebrovascular diseases are responsible for 85% of the
deaths due to neurological disorders (see Figure 2.5). Neurological disorders constitute 16.8%
of the total deaths in lower middle income countries compared with 13.2% of the total deaths
in high income countries (Figure 2.6). Among the neurological disorders, Alzheimer and other
dementias are estimated to constitute 2.84% of the total deaths in high income countries in 2005.
Cerebrovascular disease constitute 15.8%, 9.6%, 9.5% and 6.4% of the total deaths in lower
middle, upper middle, high and low income countries respectively (Table 2.8).
Table 2.7 Deaths attributable to neurological disorders as percentage
of total deaths, 2005, 2015 and 2030
Cause category
2005
2015
2030
(%)
(%)
(%)
Epilepsy
0.22
0.21
0.19
Alzheimer and other dementias
0.73
0.81
0.92
Parkinson’s disease
0.18
0.20
0.23
Multiple sclerosis
0.03
0.03
0.02
Migraine
0.00
0.00
0.00
Cerebrovascular disease
9.90
10.19
10.63
Poliomyelitis
0.00
0.00
0.00
Tetanus
0.33
0.23
0.13
Meningitis
0.26
0.17
0.10
Japanese encephalitis
0.02
0.01
0.01
Total
11.67
11.84
12.22
Figure 2.5 Deaths from selected neurological
Figure 2.6 Neurological disorders as percentage

disorders as percentage of total

of total deaths for 2005, 2015 and 2030
neurological
disorders

across World Bank income category
18
Cerebrovascular
2005 2015 2030
disease
16
85%
14
12
ths
10
dea
8
total
6
of
Japanese
%
encephalitis 0.17%
4
Multiple
2
sclerosis 0.24%
0
Parkinson's
Low
Lower middle
Upper middle
High
disease 1.55%
Income category
Epilepsy 1.86%
Alzheimer and other
Meningitis 2.24%
dementias 6.28%
Tetanus 2.83%

36
Neurological disorders: public health challenges
Table 2.8 Deaths attributable to neurological disorders as percentage of total deaths by
World Bank income category, 2005
Cause category
World
Income category
(%)
Low
Lower middle Upper middle
High
(%)
(%)
(%)
(%)
Epilepsy
0.22
0.28
0.17
0.20
0.11
Alzheimer and other dementias
0.73
0.41
0.34
0.46
2.84
Parkinson’s disease
0.18
0.06
0.18
0.15
0.60
Multiple sclerosis
0.03
0.01
0.02
0.05
0.10
Migraine
0.00
0.00
0.00
0.00
0.00
Cerebrovascular disease
9.90
6.41
15.81
9.64
9.48
Poliomyelitis
0.00
0.00
0.00
0.00
0.01
Tetanus
0.33
0.64
0.04
0.01
0.00
Meningitis
0.26
0.39
0.18
0.16
0.04
Japanese encephalitis
0.02
0.03
0.01
0.00
0.00
Total
11.67
8.23
16.77
10.67
13.18
Table 2.9 YLDs per 100 000 population associated with neurological disorders and
other diseases and injuries with neurological sequelae and as percentage
of total YLDs projected for 2005, 2015 and 2030
Cause category/sequelae
2005
2015
2030
YLDs
Percentage
YLDs
Percentage
YLDs
Percentage
(100 000
of total
(100 000
of total
(100 000
of total
population)
YLDs
population)
YLDs
population)
YLDs
Epilepsy
64.7
0.73
60.9
0.73
55.6
0.71
Alzheimer and other dementias
147.4
1.66
165.4
1.98
203.9
2.60
Parkinson’s disease
17.7
0.20
17.3
0.21
17.1
0.22
Multiple sclerosis
20
0.23
19.3
0.23
18.4
0.23
Migraine
118.9
1.34
108.9
1.31
96
1.22
Cerebrovascular disease
176.8
2.00
174.9
2.10
177.8
2.27
Neuroinfections
98.4
1.11
71.8
0.86
45.6
0.58
Nutritional deﬁ ciencies and
194.9
2.20
174.3
2.09
133.9
1.71
neuropathies
Neurological injuries
425.4
4.80
393.5
4.72
360.8
4.60
Total
1264.2
14.27
1186.3
14.23
1109.1
14.14
Estimates of years of healthy life lost as a result
of disability (YLDs)
Table 2.9 describes the estimates for YLDs per 100 000 population associated with neurological
disorders and other diseases and injuries with neurological sequelae and as percentage of totals
projected for 2005, 2015 and 2030 in the world. The number of YLDs per 100 000 population

global burden of neurological disorders: estimates and projections
37
associated with neurological disorders and other diseases and injuries with neurological sequelae
is projected to decline from 1264 in 2005 to 1109 in 2030. This decline is expected to be attribut-
able to a decrease in YLDs associated with cerebrovascular disease, neuroinfections, nutritional
deﬁ ciencies and neuropathies, and neurological injuries. YLDs associated with Alzheimer and other
dementias, however, are projected to increase by 38%. When expressed as a percentage of the
total, YLDs associated with neurological disorders and other diseases and injuries with neurological
sequelae comprise 14% of the total in 2005 and are projected to remain the same by 2030.
Figure 2.7 presents the top ﬁ ve categories of YLDs per 100 000 population globally and for
World Bank income categories. YLDs per 100 000 population for neuroinfections, and the nutritional
deﬁ ciencies and neuropathies category are highest for low income countries, while for neurological
injuries, epilepsy and migraine, they are highest in upper middle income countries. For Alzheimer
and other dementias, they are highest for high income countries. For cerebrovascular disease,
YLDs are similar in lower middle and high income countries, demonstrating the epidemiological
transition taking place in the lower middle income group of countries. Figure 2.8 demonstrates that
almost half of the burden in terms of YLDs attributable to neurological disorders is in low income
countries followed by lower middle income countries (31.7%). The higher burden is also a reﬂ ection
of a higher percentage of population in low and lower middle income countries.
CONCLUSIONS
Burden of disease analyses as presented above are useful for informing health policy. They help
in identifying not only the fatal but also the nonfatal outcomes for diseases that are especially
important for neurological disorders. The above analyses demonstrate that neurological disorders
cause a substantial burden because of noncommunicable conditions such as cerebrovascular
disease, Alzheimer and other dementias as well as communicable conditions such as meningitis
and Japanese encephalitis. As a group they cause a much higher burden than digestive diseases,
respiratory diseases and malignant neoplasms.
The GBD framework provides a common denominator that can be used to judge progress over
time within a single country or region or relative performance across countries and regions. It is
clearly demonstrated, by comparing 2005 data with the previous GBD study (2), that neurological
disorders continue to represent a signiﬁ cant burden. The GBD framework, for all its limitations,
Figure 2.7 Top ﬁve causes of YLDs among
Figure 2.8 YLDs associated with neurological

neurological disorders, by World Bank

disorders by World Bank income

income category, 2005
category,
2005
600
13.7%
tion 500
8.3%
popula 400
000
46.3%
300
100
per 200
YLDs
of 100
No
0
31.7%
World
Low
Lower middle Upper middle
High
Income category
Income category
World population (%)
■ Epilepsy
■ Alzheimer and other dementias
■ Migraine
■ Low 41.9
■ Cerebrovascular disease
■ Neuroinfections
■ Lower middle
35.2
■ Nutritional and neuropathies
■ Neurological injuries
■ Upper middle
8.2
■ High
14.7

38
Neurological disorders: public health challenges
is a useful approach for projecting future trends of mortality and burden of disease, which help
in planning the strategy for control and prevention of diseases. A clear message emerges from
the projections discussed in this chapter that — unless immediate action is taken globally — the
neurological burden will continue to remain a serious threat to public health.
The double burden of communicable and noncommunicable neurological disorders in low and
middle income countries needs to be kept in mind when formulating the policy for neurological
disorders in these countries. In absolute terms, since most of the burden attributable to neu-
rological disorders is in low and lower middle income countries, international efforts need to
concentrate on these countries for maximum impact. Also the burden is particularly devastating
in poor populations. Some of the impact on poor people includes the loss of gainful employment,
with the attendant loss of family income; the requirement for caregiving, with further potential loss
of wages; the cost of medications; and the need for other medical services.
The above analysis is useful in identifying priorities for global, regional and national attention.
Some form of priority setting is necessary as there are more claims on resources than there are
resources available. Traditionally, the allocation of resources in health organizations tends to be
conducted on the basis of historical patterns, which often do not take into account recent changes
in epidemiology and relative burden as well as recent information on the effectiveness of interven-
tions. This can lead to suboptimal use of the limited resources. Economic evaluations consider
marginal costs and beneﬁ ts and use outcome measures such as DALYs to inform decisions.
For example, phenobarbital is by far the most cost-effective intervention for managing epilepsy
and therefore needs to be recommended for widespread use in public health campaigns against
epilepsy in low and middle income countries. A population-level analysis of cost-effectiveness
of ﬁ rst-line antiepileptic drug treatment is illustrated in the discussion on epilepsy (Chapter 3.2).
Aspirin is the most cost-effective intervention both for treating acute stroke and for preventing
a recurrence. It is easily available in developing countries, even in rural areas (12). The disease-
speciﬁ c sections discuss in detail the various public health issues associated with neurological
disorders. This chapter strengthens the evidence provided earlier that increased resources are
needed to improve services for people with neurological disorders. It is also hoped that analyses
such as the above will be adopted as an essential component of decision-making and will be
adapted to planning processes at global, regional and national levels, so as to utilize the available
resources more efﬁ ciently.

global burden of neurological disorders: estimates and projections
39
REFERENCES

1. Murray CJL, Lopez AD, Jamison DT. The global burden of disease in 1990: summary results, sensitivity
analyses, and future directions. Bulletin of the World Health Organization, 1994, 72:495–508.
2. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and
disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard
School of Public Health on behalf of the World Health Organization and The World Bank, 1996 (Global Burden
of Disease and Injury Series, Vol. I).
3. Lopez AD, Murray CJL. The global burden of disease, 1990–2020. Nature Medicine, 1998, 4:1241–1243.
4. Barendregt JJ et al. A generic model for the assessment of disease epidemiology: the computational basis of
DisMod II. Population Health Metrics, 2003, 1:e4.
5. Mathers CD et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health
Organization, 2004 (GPE Discussion Paper No. 54, rev. February 2004).
6. Mathers CD, Loncar D. Updated projections of global mortality and burden of disease, 2002–2030: data
sources, methods and results. Geneva, World Health Organization, 2005 (Evidence and Information for Policy
Working Paper).
7. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause, 1990–2020: Global
Burden of Disease Study. Lancet, 1997, 349:1498–1504.
8. The world health report 2004 – Changing history. Geneva, World Health Organization, 2004.
9. Mathers CD et al. Sensitivity and uncertainty analyses for burden of disease and risk factor estimates. In:
Lopez AD et al., eds. Global burden of disease and risk factors. Washington, DC, The World Bank and Oxford
University Press, 2006.

10. Mathers CD et al. Deaths and disease burden by cause: global burden of disease estimates for 2001 by World
Bank country groups. Washington, DC, World Health Organization/World Bank/Fogarty International Center,
United States National Institutes of Health, 2004 (Disease Control Priorities in Developing Countries (DCPP)
Working Papers Series, No. 18; http://www.ﬁ c.nih.gov/dcpp/wps.html, accessed 25 July 2005).
11. World development indicators. Washington, DC, The World Bank, 2003.

12. Chandra V et al. Neurological disorders. In: Jamison DT et al., eds. Disease control priorities in developing
countries, 2nd ed. Washington, DC, The World Bank and Oxford University Press, 2006.
RECOMMENDED READING
■ Jamison DT et al., eds. Disease control priorities in developing countries, 2nd ed. Washington, DC, The World
Bank and Oxford University Press, 2006.
■ Lopez AD et al., eds. Global burden of disease and risk factors. Washington, DC, The World Bank and Oxford
University Press, 2006.
■ Mathers CD et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World
Health Organization, 2004 (GPE Discussion Paper No. 54, rev. February 2004).
■ Mathers CD et al. Deaths and disease burden by cause: global burden of disease estimates for 2001 by
World Bank country groups. Washington, DC, World Health Organization/World Bank/Fogarty International
Center, United States National Institutes of Health, 2004 (Disease Control Priorities in Developing Countries
(DCPP) Working Papers Series, No. 18; http://www.ﬁ c.nih.gov/dcpp/wps.html, accessed 25 July 2005).
■ Mathers CD, Loncar D. Updated projections of global mortality and burden of disease, 2002–2030: data
sources, methods and results. Geneva, World Health Organization, 2005 (Evidence and Information for
Policy Working Paper).
■ Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and
disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard
School of Public Health on behalf of the World Health Organization and The World Bank, 1996 (Global
Burden of Disease and Injury Series, Vol. I).

40
Neurological disorders: public health challenges

41
CHAPTER 3
neurological
disorders
a public health approach
in this chapter
42 3.1 Dementia
56 3.2 Epilepsy
70 3.3 Headache disorders
85 3.4 Multiple sclerosis
This chapter consists of 10 sections
95 3.5 Neuroinfections
that focus on the public health aspects
111 3.6 Neurological disorders associated with
of the common neurological disorders
malnutrition
as outlined in the box. Although nota-
127 3.7 Pain associated with neurological disorders
ble differences exist between relevant
public health issues for each neuro-
140 3.8 Parkinson’s disease
logical disorder, most sections cover
151 3.9 Stroke
the following topics: diagnosis and
classiﬁ cation; etiology and risk fac-
164 3.10 Traumatic brain injuries
tors; course and outcome; magnitude
(prevalence, incidence, distribution
by age and sex, global and regional distribution); disability and mortality; burden
on patients’ families and communities; treatment, management and rehabilitation;
delivery and cost of care; gaps in treatment and other services; policies; research;
and education and training.

42
Neurological disorders: public health challenges
3.1 Dementia
43 Etiology and risk factors
43 Course and outcome
Dementia is a syndrome caused by disease of the
44 Epidemiology and burden
brain, usually of a chronic or progressive nature, in
46 Treatment and care
which there is disturbance of multiple higher corti-
cal functions, including memory, thinking, orienta-
50 A public health framework
tion, comprehension, calculation, learning capac-
52 Conclusions and recommendations
ity, language and judgement. Consciousness is not
54 Case-studies
clouded. Dementia mainly affects older people: only
2% of cases start before the age of 65 years. After
this the prevalence doubles with every ﬁ ve-year increment in age. Dementia
is one of the major causes of disability in later life.
There are very many underlying causes of dementia. Alzheimer’s disease (AD), characterized by
cortical amyloid plaques and neuroﬁ brillary tangles is the most common, accounting for one half to
three quarters of all cases. Vascular dementia (VaD) is diagnosed when the brain’s supply of oxygen-
ated blood is repeatedly disrupted by strokes or other blood vessel pathology, leading to signiﬁ cant
accumulated damage to brain tissue and function. The distinction between AD and VaD has been
called into question, given that mixed pathologies are very common. Perhaps vascular damage is
no more than a cofactor accelerating the onset of clinically signiﬁ cant symptoms in people with AD.
There are a few rare causes of dementia that may be treated effectively by timely medical or surgical
intervention— these include hypercalcaemia, subdural haematoma, normal pressure hydrocephalus,
and deﬁ ciencies of thyroid hormone, vitamin B12 and folic acid. For the most part, altering the pro-
gressive course of the disorder is unfortunately not possible. Symptomatic treatments and support
can, however, transform the outcome for people with dementia and their caregivers.
Alzheimer and other dementias have been reliably identiﬁ ed in all countries, cultures and races
in which systematic research has been carried out, though levels of awareness vary enormously.
In India, for example, while the syndrome is widely recognized and named, it is not seen as a
medical condition. Indeed, it is often regarded as part of normal ageing (1).
For the purpose of making a diagnosis, clinicians focus in their assessments upon impairment
in memory and other cognitive functions, and loss of independent living skills. For carers and,
arguably, for people with dementia, it is the behavioural and psychological symptoms of dementia
(BPSD) that are most relevant. Nearly all studies indicate that BPSD are an important cause of
caregiver strain. They are a common reason for institutionalization as the family’s coping reserves
become exhausted. Problem behaviours may include agitation, aggression, calling out repeatedly,
sleep disturbance (day–night reversal), wandering and apathy. Common psychological symptoms
include anxiety, depression, delusions and hallucinations. BPSD occur most commonly in the
middle stage of dementia (see also the section on Course and outcome, below). Despite their sig-
niﬁ cance, there has been relatively little research into BPSD across cultures. One might anticipate
that cultural and environmental factors could have a strong inﬂ uence upon both the expression

neurological disorders: a public health approach
43
of BPSD and their perception by caregivers as problematic (2). Behavioural and psychological
symptoms appear to be just as common in dementia sufferers in developing countries (3). In
some respects the developing country caregivers were more disadvantaged. Given the generally
low levels of awareness about dementia as an organic brain condition, family members could not
understand their relative’s behaviour, and others tended to blame the carers for the distress and
disturbance of the person they were looking after.
ETIOLOGY AND RISK FACTORS
The main risk factor for most forms of dementia is advanced age, with prevalence roughly doubling
every ﬁ ve years over the age of 65 years. Onset before this age is very unusual and, in the case
of AD, often suggests a genetic cause. Single gene mutations at one of three loci (beta amyloid
precursor protein, presenilin1 and presenilin2) account for most of these cases. For late-onset
AD both environmental (lifestyle) and genetic factors are important. A common genetic polymor-
phism, the apolipoprotein E (apoE) gene e4 allele greatly increases risk of going on to suffer from
dementia; up to 25% of the population have one or two copies (4, 5). However, it is not uncommon
for one identical twin to suffer from dementia and the other not. This implies a strong inﬂ uence
of the environment (6). Evidence from cross-sectional and case–control studies suggests as-
sociations between AD and limited education (7 ) and head injury (8, 9), which, however, are only
partly supported by longitudinal (follow-up) studies (10). Depression is a risk factor in short-term
longitudinal studies, but this may be because depression is an early presenting symptom rather
than a cause of dementia (11). Recent research suggests that vascular disease predisposes to AD
as well as to VaD (12). Smoking seems to increase the risk for AD as well as VaD (13). Long-term
follow-up studies show that high blood pressure (14, 15) and high cholesterol levels (15) in middle
age each increase the risk of going on to develop AD in later life.
Reports from epidemiological studies of protective effects of certain prescribed medication,
non-steroidal anti-inﬂ ammatory drugs, hormone replacement therapy (HRT) and cholesterol-
lowering therapies are now being investigated in randomized controlled trials. The randomized
controlled trial of HRT in postmenopausal women indicated, against expectation, that it increased
rather than lowered the incidence of dementia.
Despite many investigations, far too little is still understood about the environmental and
lifestyle factors linked to AD and other dementias. It may be that the focus on research in devel-
oped countries has limited possibilities to identify risk factors. Prevalence and incidence of AD
seem to be much lower in some developing regions (see the section on Epidemiology and burden,
below). This may be because some environmental risk factors are much less prevalent in these
settings. For example, African men tend to be very healthy from a cardiovascular point of view with
low cholesterol, low blood pressure and low incidence of heart disease and stroke. Conversely,
some risk factors may only be apparent in developing countries, as they are too infrequent in the
developed economies for their effects to be detected; for example, anaemia has been identiﬁ ed
as a risk factor in India (16).
COURSE AND OUTCOME
Dementia is usually a progressive disease and can be cured only if a reversible condition is identi-
ﬁ ed as a cause and treated effectively. This happens in a small number of cases in the developed
world, but could be more common in developing countries, where relevant underlying physical
conditions (including marked nutritional and hormonal deﬁ ciencies) are more common.
Dementia affects every person in a different way. Its impact can depend on what the individuals
were like before the disease: their personality, lifestyle, signiﬁ cant relationships and physical health.
The problems linked to dementia can be best understood in three stages (see Box 3.1.1).

44
Neurological disorders: public health challenges
Times are given as guidelines only — sometimes people can deteriorate more quickly
and sometimes more slowly. Dementia reduces the lifespan of affected persons. In the
developed, high income countries, a person with dementia can expect to live for ap-
proximately 5–7 years after diagnosis. In low and middle income countries, diagnosis is
often much delayed, and survival in any case may be shorter. Again, of course, there is
much individual variation — some may live for longer, and some may live for shorter times
because of interacting health conditions.
Symptoms of dementia in early, middle and late stage of the disease are given in Box
3.1.1. It should be noted that not all persons with dementia will display all the symptoms.
Nevertheless, a summary of this kind can help caregivers to be aware of potential prob-
lems and can allow them to think about future care needs. At the same time, one must not
alarm people in the early stages of the disease by giving them too much information.
EPIDEMIOLOGY AND BURDEN
In 2005, Alzheimer’s Disease International commissioned a panel of experts to review
all available epidemiological data and reach a consensus estimate of prevalence in each
region and the numbers of people affected. Evidence from well-conducted, representative
epidemiological surveys was lacking in many regions. The panel estimated that, globally,
24.3 million people have dementia today, with 4.6 million new cases annually. Numbers
of people affected will double every 20 years to 81.1 million by 2040. Most people with
dementia live in developing countries: 60% in 2001 rising to an estimated 71% by 2040.
Rates of increase are not uniform; numbers in developed countries are forecast to increase
by 100% between 2001 and 2040, but by more than 300% in China, India and neighbour-
ing countries in South-East Asia and the Western Paciﬁ c. The detailed estimates contained
Box 3.1.1 Stages and symptoms of dementia (Alzheimer’s disease)
Early stage
Middle stage
Late stage
The early stage is often overlooked.
As the disease progresses, limitations
The late stage is one of nearly total
Relatives and friends (and sometimes
become clearer and more restricting.
dependence and inactivity. Memory
professionals as well) see it as “old
The person with dementia has
disturbances are very serious and the
age”, just a normal part of the ageing
difﬁ culty with day-to-day living and:
physical side of the disease becomes
process. Because the onset of the
■ may become very forgetful,
more obvious. The person may:
disease is gradual, it is difﬁ cult to
especially of recent events and
■ have difﬁ culty eating
be sure exactly when it begins. The
people’s names
■ be incapable of communicating
person may:
■ can no longer manage to live alone
■ not recognize relatives, friends and
■ have problems talking properly
without problems
familiar objects
(language problems)
■ is unable to cook, clean or shop
■ have difﬁ culty understanding what
■ have signiﬁ cant memory
■ may become extremely dependent
is going on around them
loss — particularly for things that
on family members and caregivers
■ be unable to ﬁ nd his or her way
have just happened
■ needs help with personal hygiene,
around in the home
■ not know the time of day or the day
i.e. washing and dressing
■ have difﬁ culty walking
of the week
■ has increased difﬁ culty with
■ have difﬁ culty swallowing
■ become lost in familiar places
speech
■ have bladder and bowel
■ have difﬁ culty in making decisions
■ shows problems with wandering
incontinence
■ become inactive and unmotivated
and other behaviour problems
■ display inappropriate behaviour in
■ show mood changes, depression
such as repeated questioning and
public
or anxiety
calling out, clinging and disturbed
■ be conﬁ ned to a wheelchair or bed
■ react unusually angrily or
sleeping
aggressively on occasion
■ becomes lost at home as well as
■ show a loss of interest in hobbies
outside
and activities
■ may have hallucinations (seeing or
hearing things that are not there)

neurological disorders: a public health approach
45
in this document (17 ) constitute the best available basis for policy-making, planning and allocation
of health and welfare resources.
There is a clear and general tendency for prevalence to be somewhat lower in developing
countries than in the industrialized world (18), strikingly so in some studies (19, 20). This trend
was supported by the consensus judgement of the expert panel convened by Alzheimer’s Disease
International, reviewing all available evidence (17 ). It does not seem to be explained merely by
differences in survival, as estimates of incidence are also much lower than those reported in
developed countries (21, 22). It may be that mild dementia is underdetected in developing coun-
tries because of difﬁ culties in establishing the criterion of social and occupational impairment.
Differences in level of exposure to environmental risk factors might also have contributed. The
strikingly different patterns of mortality in early life might also be implicated; older people in very
poor countries are exceptional survivors — this characteristic may also confer protection against
AD and other dementias.
Long-term studies from Sweden and the United States of America suggest that the age-
speciﬁ c prevalence of dementia has not changed over the last 30 or 40 years (23). Whatever
the explanation for the current discrepancy between prevalence in developed and developing
countries, it seems probable that, as patterns of morbidity and mortality converge with those of
the richer countries, dementia prevalence levels will do likewise, leading to an increased burden
of dementia in poorer countries.
Studies in developed countries have consistently reported AD to be more prevalent than VaD.
Early surveys from South-East Asia provided an exception, though more recent work suggests
this situation has now reversed. This may be due to increasing longevity and better physical
health: AD, whose onset is in general later than that of VaD, increases as the number of very old
people increases, while better physical health reduces the number of stroke sufferers and thus
the number with VaD. This change also affects the sex distribution among dementia sufferers,
increasing the number of females and reducing the number of males.
Disability, burden and cost
Dementia is one of the main causes of disability in later life. In a wide consensus consultation for
the Global Burden of Disease (GBD) report, disability from dementia was accorded a higher weight
than that for almost any other condition, with the exception of spinal cord injury and terminal
cancer. Of course, older people are particularly likely to have multiple health conditions — chronic
physical diseases affecting different organ systems, coexisting with mental and cognitive dis-
orders. Dementia, however, has a disproportionate impact on capacity for independent living,
yet its global public health signiﬁ cance continues to be underappreciated and misunderstood.
According to the GBD estimates in The world health report 2003, dementia contributed 11.2%
of all years lived with disability among people aged 60 years and over: more than stroke (9.5%),
musculoskeletal disorders (8.9%), cardiovascular disease (5.0%) and all forms of cancer (2.4%).
However, the research papers (since 2002) devoted to these chronic disorders reveal a starkly
different ordering of priorities: cancer 23.5%, cardiovascular disease 17.6%, musculoskeletal
disorders 6.9%, stroke 3.1% and dementia 1.4%.
The economic costs of dementia are enormous. These can include the costs of “formal care”
(health care, social and community care, respite care and long-term residential or nursing-home
care) and “informal care” (unpaid care by family members, including their lost opportunity to earn
income).
In the United Kingdom, direct formal care costs alone have been estimated at US$ 8 billion, or
US$ 13 000 per patient. In the United States, costs have been estimated at US$ 100 billion per year,
with patients with severe dementia costing US$ 36 794 each (1998 prices) (23, 24). A more recent
estimate is of US$ 18 billion annually in the United States for informal costs alone. In developed

46
Neurological disorders: public health challenges
countries, costs tend to rise as dementia progresses. When people with dementia are cared for at
home, informal care costs may exceed direct formal care costs. As the disease progresses, and the
need for medical staff involvement increases, formal care costs will increase. Institutionalization is
generally the biggest single contributor to costs of care.
Very little work has been done on evaluating the economic costs of dementia in developing
countries. Shah et al. (25) list ﬁ ve reasons for this: the absence of trained health economists, the
low priority given to mental health, the poorly developed state of mental health services, the lack
of justiﬁ cation for such services, and the absence of data sets. Given the inevitability that the
needs of frail older persons will come to dominate health and social care budgets in these regions,
more data are urgently needed.
Detailed studies of informal costs outside western Europe and North America are rare, but a
careful study of a sample of 42 AD patients in Denizli, Turkey, provides interesting data (26). For-
mal care for the elderly was rare: only 1% of old people in Turkey live in residential care. Families
therefore provide most of the care. The average annual cost of care (excluding hospitalization) was
US$ 4930 for severe cases and US$ 1766 for mild ones. Most costs increased with the severity
of the disease, though outpatient costs declined. Carers spent three hours a day looking after the
most severely affected patients.
The 10/66 Dementia Research Group also examined the economic impact of dementia in its
pilot study of 706 persons with dementia and their caregivers living in China, India, Latin America
and Nigeria (27 ). The key ﬁ ndings from this study are summarized in Box 3.1.2.
TREATMENT AND CARE
Early diagnosis is helpful so that the caregiver can be better equipped to deal with the disease
and to know what to expect. A diagnosis is the ﬁ rst step towards planning for the future. There
is no simple test to make a diagnosis. The diagnosis of AD is made by taking a careful account
of the person’s problems from a close relative or friend, together with an examination of the
person’s physical and mental state. It is important to exclude other conditions or illnesses that
cause memory loss, including depression, alcohol problems and some physical illnesses with
organic brain effects.
Currently there are no treatments that cure dementia. There is, however, evidence that drugs
(cholinesterase inhibitors), in some cases but not all, temporarily decelerate the progressive cogni-
tive decline that occurs in AD, and maybe in other forms of neurodegenerative dementia. These
drugs act on the symptoms but not on the disease itself; they make only a small contribution to
maintaining function. Evidence-based drug therapies are available for psychological symptoms
such as depression, anxiety, agitation, delusions and hallucinations that can occur in people
with dementia. There are modestly effective drugs (neuroleptics) available for the treatment of
associated behavioural problems such as agitation. All of these drugs should be used with cau-
tion (the doctrine being “start low, go slow”), particularly tricyclic antidepressants (because of
anticholinergic side-effects, therefore SSRI antidepressants — selective serotonin reuptake in-
hibitors — should always be preferred) and neuroleptics (because of anticholinergic side-effects,
sedation, and an increased risk of stroke and higher all-cause mortality).
It is important to recognize that non-drug interventions are often highly effective, and should
generally be the ﬁ rst choice when managing behavioural problems. The ﬁ rst step is to try to iden-
tify and treat the cause, which could be physical, psychological or environmental. Psychosocial
interventions, particularly the provision of information and support to carers, have been shown
to reduce the severe psychological distress often experienced by carers. Carers are also greatly
assisted by a network of community health and social services; self-help organizations, especially
Alzheimer associations, can also help them to ﬁ nd appropriate help. Carers can be educated about

neurological disorders: a public health approach
47
dementia, countering lack of understanding and awareness about the nature of the problems
faced. They can also be trained to manage better most of the common behavioural symptoms,
in such a way that the frequency of the symptoms and/or the strain experienced by the carer is
reduced. Above all, the person with dementia and the family carers need to be supported over
the longer term. People with dementia need to be treated at all times with patience and respect
for their dignity and personhood; carers needs unconditional support and understanding — their
needs should also be determined and attended to.
Resources and prevention
Developing-country health services are generally ill-equipped to meet the needs of older persons.
Health care, even at the primary care level, is clinic-based; the older person must attend the clinic,
often involving a long journey and waiting time in the clinic, to receive care. Even if they can get to
the clinic the assessment and treatment that they receive are orientated towards acute rather than
chronic conditions. The perception is that the former are treatable, the latter intractable and not
within the realm of responsibility of health services. The 10/66 Dementia Research Group’s care-
giver pilot study in 2004 indicated that people with dementia were using primary and secondary
care health services. Only 33% of people with dementia in India, 11% in China and South-East Asia
and 18% in Latin America had used no health services at all in the previous three months. In all
centres, particularly in India and Latin America, there was heavy use of private medical services.
One may speculate that this reﬂ ects the caregivers’ perception of the relative unresponsiveness
of the cheaper government medical services.
The gross disparities in resources within and between developed and developing countries are
leading to serious concerns regarding the ﬂ outing of the central ethical principle of distributive
justice. New drug treatments are very expensive. Anticholinesterase therapies for AD are beyond
the reach of all but the richest families in most developing countries. The same would be true
for most SSRI antidepressants and “atypical” antipsychotic drugs, both of which are generally
favoured in the West for use in older patients over the older and cheaper tricyclic antidepressants
and “typical” antipsychotic drugs because of their better safety and side-effect proﬁ les. The ad-
vent of a disease-modifying, as opposed to symptomatic, treatment for AD would introduce similar
ethical concerns regarding accessibility to those that have arisen in relation to the management of
HIV/AIDS in low income countries. Equity is also an important issue within developing countries.
Access to care is often entirely dependent upon means to pay. Quite apart from economic con-
straints, health-care resources are grossly unevenly distributed between rural and urban districts.
Most specialists, indeed most doctors, work in cities. Provision of even basic services to far-ﬂ ung
rural communities is an enormous challenge.
Box 3.1.2 The 10/66 Dementia Research Group: key ﬁ ndings
From the development perspective, one of the key ﬁ ndings
Caregivers were commonly in paid employment, and
from the study was that caregiving in the developing world
almost none received any form of caring allowance. The
is associated with substantial economic disadvantage. A
combination of reduced family incomes and increased
high proportion of caregivers had to cut back on their paid
family expenditure on care is obviously particularly stress-
work in order to care. Many caregivers needed and obtained
ful in lower income countries where so many households
additional support, and while this was often informal unpaid
exist at or near subsistence level. While health-care ser-
care from friends and other family members, paid caregiv-
vices are cheaper in low income countries, in relative
ers were also relatively common.
terms families from the poorer countries spend a greater
People with dementia were heavy users of health ser-
proportion of their income on health care for the person
vices, and associated direct costs were high. Compensa-
with dementia. They also appear to be more likely to use
tory ﬁ nancial support was negligible; few older people in
the more expensive services of private doctors, in pref-
developing countries receive government or occupational
erence to government-funded primary care, presumably
pensions, and virtually none of the people with dementia in
because this fails to meet their needs.
the 10/66 study received disability pensions.
Source: (1).

48
Neurological disorders: public health challenges
Future development of services for older people needs to be tailored to suit the health systems
context. “Health systems” here can be taken to include macroeconomic factors, social structures,
cultural values and norms, and existing health and welfare policy and provision.
Specialists — neurologists, psychiatrists, psychologists and geriatricians — are far too scarce
a resource to take on any substantial role in the ﬁ rst-line care for people with dementia. The focus
must be upon primary care. Many developing countries have in place comprehensive community-
based primary care systems staffed by doctors, nurses and generic multipurpose health workers.
The need is for:
■ more training in the basic curriculum regarding diagnostic and needs-based assessments;
■ a paradigm shift beyond the current preoccupation with prevention and simple curative inter-
ventions to encompass long-term support and chronic disease management;
■ outreach care, assessing and managing patients in their own homes.
For many low income countries, the most cost-effective way to manage people with dementia
will be through supporting, educating and advising family caregivers. This may be supplemented
by home nursing or paid home-care workers; however, to date most of the growth in this area has
been that of untrained paid carers operating in the private sector. The direct and indirect costs
of care in this model therefore tend to fall upon the family. Some governmental input, whether
in terms of allowances for people with dementia and/or caregivers or subsidized care would be
desirable and equitable. The next level of care to be prioritized would be respite care, both in day
centres and (for longer periods) in residential or nursing homes. Such facilities (as envisaged in
Goa, for example) could act also as training resource centres for caregivers. Day care and resi-
dential respite care are more expensive than home care, but nevertheless basic to a community’s
needs, particularly for people with more advanced dementia.
Residential care for older people is unlikely to be a priority for government investment, when the
housing conditions of the general population remain poor, with homelessness, overcrowding and
poor sanitation. Nevertheless, even in some of the poorest developing countries (e.g. China and
India), nursing and residential care homes are opening up in the private sector to meet the demand
from the growing afﬂ uent middle class. Good quality, well-regulated residential care has a role to
play in all societies, for those with no family support or whose family support capacity is exhausted,
both as temporary respite and for provision of longer-term care. Absence of regulation, staff training
and quality assurance is a serious concern in developed and developing countries alike.
Similarly, low income countries lack the economic and human capital to contemplate wide-
spread introduction of more sophisticated services; specialist multidisciplinary staff and com-
munity services backed up with memory clinics and outpatient, inpatient and day care facilities.
Nevertheless, services comprising some of these elements are being established as demonstra-
tion projects. The ethics of health care require that governments take initial planning steps, now.
The one certainty is that “in the absence of clear strategies and policies, the old will absorb
increasing proportions of the resources devoted to health care in developing countries” (28). This
shift in resource expenditure is, of course, likely to occur regardless. At least, if policies are well
formulated, its consequences can be predicted and mitigated.
Prevention, where it can be achieved, is clearly the best option, with enormous potential
beneﬁ ts for the quality of life of the individual, the family and carers, and for society as a whole.
Primary preventive interventions can be highly cost effective, given the enormous costs associated
with the care and treatment of those with dementia (see the section on Disability, burden and
cost, above). The primary prevention of dementia is therefore a relatively neglected area. Evidence
from the developed world suggests that risk factors for vascular disease, including hypertension,
smoking, type II diabetes, and hypercholesterolaemia may all be risk factors for AD as well as
VaD. The epidemic of smoking in developing countries (with 13% of African teenagers currently

neurological disorders: a public health approach
49
smoking), and the high and rising prevalence of type II diabetes in South-East Asia (a forecast 57%
increase in prevalence between 2000 and 2010, compared with a 24% increase in Europe) should
therefore be particular causes of concern. It is as yet unclear whether the improvements in control
of hypertension, diet and exercise, and particularly the decline in smoking seen in developed
Western countries that has led to rapid declines in mortality from ischaemic heart disease and
stroke, will lead to a later decline in the age-speciﬁ c incidence of AD and other dementias. Many
of these preventive measures are also likely to improve general health (29).
Delivery of care
All over the world the family remains the cornerstone of care for older people who have lost the capacity
for independent living, whether as a result of dementia or other mental disorder. However, stereotypes
abound and have the potential to mislead. Thus, in developed countries with their comprehensive
health and social care systems, the vital caring role of families, and their need for support, is often
overlooked. This is true for example in the United Kingdom, where despite nuclear family structures
and contrary to supposition, there is a strong tradition that persists today for local children to provide
support for their inﬁ rm parents. Conversely, in developing countries the reliability and universality of
the family care system is often overestimated. Older people are among the most vulnerable groups in
the developing world, in part because of the continuing myths that surround their place in society (30).
It is often assumed that their welfare is assured by the existence of the extended family. Arguably, the
greatest obstacle to providing effective support and care for older persons is the lack of awareness
of the problem among policy-makers, health-care providers and the community. Mythologizing the
caring role of the family evidently carries the risk of perpetuating complacency.
The previously mentioned 10/66 Dementia Research Group’s multicentre pilot study was the
ﬁ rst systematic, comprehensive assessment of care arrangements for people with dementia in
the developing world, and of the impacts upon their family caregivers (27 ). As in the EUROCARE
study with data from 14 European countries (31), most caregivers in developing countries were
older women caring for their husbands or younger women caring for a parent. Caring was associ-
ated with substantial psychological strain as evidenced by high rates of psychiatric morbidity and
high levels of caregiver strain. These parameters were again very similar to those reported in the
EUROCARE study. Some aspects, however, were radically different. People with dementia in de-
veloping countries typically live in large households, with extended families. Larger families were
associated with lower caregiver strain; however, this effect was small and applied only where the
principal caregiver was co-resident. Indeed, it seemed to operate in the opposite direction where
the caregiver was non-resident, perhaps because of the increased potential for family conﬂ ict.
In many developing countries, traditional family and kinship structures are widely perceived as
under threat from the social and economic changes that accompany economic development and
globalization (30). Some of the contributing factors include the following:
■ Changing attitudes towards older people.
■ The education of women and their increasing participation in the workforce (generally seen
as key positive development indicators); tending to reduce both their availability for caregiving
and their willingness to take on this additional role.
■ Migration. Populations are increasingly mobile as education, cheap travel and ﬂ exible labour
markets induce young people to migrate to cities and abroad to seek work. In India, Venkoba
Rao has coined an acronym to describe this growing social phenomenon: PICA — parents in
India, children abroad. “Push factors” are also important. In the economic catastrophe of the
1980s, two million Ghanaians left the country in search of economic betterment; 63% of older
persons have lost the support of one or more of their children who have migrated to distant
places in Ghana or abroad. Older people are particularly vulnerable after displacement as a
result of war or natural disaster.

50
Neurological disorders: public health challenges
■ Declining fertility in the course of the ﬁ nal demographic transition. Its effects are perhaps most
evident in China, where the one-child family law leaves increasing numbers of older people,
particularly those with a daughter, bereft of family support.
■ In sub-Saharan Africa, changing patterns of morbidity and mortality are more relevant; the
ravages of the HIV/AIDS epidemic have “orphaned” parents as well as children, as bereaved
older persons are robbed of the expectation of economic and practical support into later life.
A PUBLIC HEALTH FRAMEWORK
At its 20th annual conference held in Kyoto, Japan, Alzheimer’s Disease International released a Kyoto
Declaration, benchmarking progress in ten key areas using a public health framework developed by
WHO (see Table 3.1.1). The framework addresses treatment gaps, policies, research and training and
identiﬁ es three levels of attainment for countries with low, medium and high levels of resources, hence
suggesting a feasible, pragmatic series of actions and objectives for health systems at all levels of
development.
Table 3.1.1 Minimum actions required for dementia carea
Ten overall
Scenario A
Scenario B
Scenario C
recommendations
Low level of resources
Medium level of resources
High level of resources
1. Provide
Recognize dementia care as a
Develop locally relevant training
Improve effectiveness of
treatment in
component of primary health
materials
management of dementia in
primary care
care
Provide refresher training to
primary health care
Include the recognition and
primary care physicians (100%
Improve referral patterns
treatment of dementia in
coverage in ﬁ ve years)
training curricula of all health
personnel
Provide refresher training to
primary care physicians (at least
50% coverage in ﬁ ve years)
2. Make
Increase availability of essential
Ensure availability of essential
Provide easier access to newer
appropriate
drugs for the treatment of
drugs in all health-care settings
drugs (e.g. anticholinesterase
treatments
dementia and associated
Make effective caregiver
agents) under public or private
available
psychological and behavioural
interventions generally available
treatment plans
symptoms
Develop and evaluate basic
educational and training
interventions for caregivers
3. Give care in
Establish the principle that
Initiate pilot projects on
Develop alternative residential
the community
people with dementia are best
integration of dementia care
facilities
assessed and treated in their
with general health care
Provide community care
own homes
Provide community care
facilities (100% coverage)
Develop and promote standard
facilities (at least 50%
Give individualized care in the
needs assessments for use in
coverage with multidisciplinary
community to people with
primary and secondary care
community teams, day care,
dementia
Initiate pilot projects on
respite and inpatient units
development of multidisciplinary for acute assessment and
community care teams, day
treatment)
care and short-term respite
According to need, encourage
care
the development of residential
Move people with dementia out
and nursing-home facilities,
of inappropriate institutional
including regulatory framework
settings
and system for staff training
and accreditation

neurological disorders: a public health approach
51
Ten overall
Scenario A
Scenario B
Scenario C
recommendations
Low level of resources
Medium level of resources
High level of resources
4. Educate the
Promote public campaigns
Use the mass media to promote
Launch public campaigns for
public
against stigma and
awareness of dementia, foster
early help-seeking, recognition
discrimination
positive attitudes, and help
and appropriate management of
Support nongovernmental
prevent cognitive impairment
dementia
organizations in public
and dementia
education
5. Involve
Support the formation of self-
Ensure representation of
Foster advocacy initiatives
communities,
help groups
communities, families, and
families and
Fund schemes for
consumers in policy-making,
consumers
nongovernmental organizations
service development and
implementation
6. Establish
Revise legislation based on
Implement dementia care
Ensure fairness in access to
national
current knowledge and human
policies at national and
primary and secondary health
policies,
rights considerations
subnational levels
care services, and to social
programmes
Formulate dementia care
Establish health and social care
welfare programmes and
and legislation
programmes and policies:
budgets for dementia care
beneﬁ ts
– Legal framework to support
Increase the budget for mental
and protect those with impaired
health care
mental capacity
– Inclusion of people with
dementia in disability beneﬁ t
schemes
– Inclusion of caregivers in
compensatory beneﬁ t schemes
Establish health and social care
budgets for older persons
7. Develop human Train primary health-care
Create a network of national
Train specialists in advanced
resources
workers
training centres for physicians,
treatment skills
Initiate higher professional
psychiatrists, nurses,
training programmes for
psychologists and social
doctors and nurses in geriatric
workers
psychiatry and medicine
Develop training and resource
centres
8. Link with other Initiate community, school and
Strengthen community
Extend occupational health
sectors
workplace dementia awareness
programmes
services to people with early
programmes
dementia
Encourage the activities of
Provide special facilities in the
nongovernmental organizations
workplace for caregivers of
people with dementia
Initiate evidence-based mental
health promotion programmes
in collaboration with other
sectors
9. Monitor
Include dementia in basic health Institute surveillance for early
Develop advanced monitoring
community
information systems
dementia in the community
systems
health
Survey high-risk population
Monitor effectiveness of
groups
preventive programmes
10. Support more Conduct studies in primary
Institute effectiveness and
Extend research on the causes
research
health-care settings on the
cost–effectiveness studies for
of dementia
prevalence, course, outcome
community management of
Carry out research on service
and impact of dementia in the
dementia
delivery
community
Investigate evidence on the
prevention of dementia
a Based on overall recommendations from The world health report 2001 (32).

52
Neurological disorders: public health challenges
CONCLUSIONS AND RECOMMENDATIONS
1
Dementia is a disease and not a part of normal ageing.
2
Dementia affects some 24 million people, most of them elderly, worldwide. Up to two
thirds live in low and middle income countries.
3
Awareness of dementia is very low in all world regions, a problem leading to
stigmatization and inefﬁ cient help-seeking.
4
No cure is currently available for the most common causes of dementia, but much can
and should be done to improve the quality of life of people with dementia and their
carers.
5
Governments should be urged to take account of the needs of people with dementia, as
an integral part of a comprehensive programme of health and welfare services for older
people.
6
The priority should be to strengthen primary care services, through training and
reorientation from clinic-based acute treatment services to provision of outreach and
long-term support.
7
Governments, nongovernmental organizations working in the area of Alzheimer and other
dementias, professionals and carers need to work together to raise awareness, counter
stigma and improve the quality and coverage of care services.

neurological disorders: a public health approach
53
REFERENCES

1. Shaji KS et al. Caregivers of patients with Alzheimer’s disease: a qualitative study from the Indian 10/66
Dementia Research Network. International Journal of Geriatric Psychiatry, 2002, 18:1–6.
2. Shah A, Mukherjee S. Cross-cultural issues in measurement of BPSD. Aging and Mental Health, 2000,
4:244–252.
3. Ferri CP, Ames D, Prince M. Behavioral and psychological symptoms of dementia in developing countries.
International Psychogeriatrics, 2004, 16:441–459.
4. Saunders AM et al. Association of apolipoprotein E allele e4 with late-onset familial and sporadic Alzheimer’s
disease. Neurology, 1993, 43:1467–1472.
5. Nalbantoglu J et al. Predictive value of apolipoprotein E genotyping in Alzheimer’s disease: results of an
autopsy series and an analysis of several combined studies. Annals of Neurology, 1994, 36:889–895.
6. Breitner JC et al. Alzheimer’s disease in the National Academy of Sciences-National Research Council
Registry of Aging Twin Veterans. III. Detection of cases, longitudinal results, and observations on twin
concordance. Archives of Neurology, 1995, 52:763–771.
7. Ott A et al. Prevalence of Alzheimer’s disease and vascular dementia: association with education. The
Rotterdam study. BMJ, 1995, 310:970–973.
8. Mortimer JA et al. Head trauma as a risk factor for Alzheimer’s disease: a collaborative re-analysis of
case-control studies. EURODEM Risk Factors Research Group. International Journal of Epidemiology, 1991,
20(Suppl. 2):S28–S35.
9. Mayeux R. Synergistic effects of traumatic head injury and apolipoprotein-epsilon 4 in patients with
Alzheimer’s disease. Neurology, 1995, 45:555–557.

10. Stern Y et al. Inﬂ uence of education and occupation on the incidence of Alzheimer’s disease. JAMA, 1994,
271:1004–1010.

11. Devanand DP et al. Depressed mood and the incidence of Alzheimer’s disease in the elderly living in the
community. Archives of General Psychiatry, 1996, 53:175–182.

12. Hofman A et al. Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer’s disease in the
Rotterdam Study. Lancet, 1997, 349:151–154.

13. Ott A et al. Smoking and risk of dementia and Alzheimer’s disease in a population-based cohort study: the
Rotterdam Study. Lancet, 1998, 351:1841–1843.

14. Skoog I et al. 15-year longitudinal study of blood pressure and dementia. Lancet, 1996, 347:1141–1145.

15. Kivipelto M et al. Midlife vascular risk factors and Alzheimer’s disease in later life: longitudinal, population
based study. BMJ, 2001, 322:1447–1451.

16. Pandav RS et al. Hemoglobin levels and Alzheimer disease: an epidemiologic study in India. American
Journal of Geriatric Psychiatry, 2004, 12:523–526.

17. Ferri CP et al. Global prevalence of dementia: a Delphi consensus study. Lancet, 2005, 366:2112–2117.

18. Prince M. Methodological issues in population-based research into dementia in developing countries. A
position paper from the 10/66 Dementia Research Group. International Journal of Geriatric Psychiatry, 2000,
15:21–30.

19. Chandra V et al. Prevalence of Alzheimer’s disease and other dementias in rural India. The Indo-US study.
Neurology, 1998, 51:1000–1008.

20. Hendrie HC et al. Prevalence of Alzheimer’s disease and dementia in two communities: Nigerian Africans and
African Americans. American Journal of Psychiatry, 1995, 152:1485–1492.

21. Hendrie HC et al. Incidence of dementia and Alzheimer disease in 2 communities: Yoruba residing in Ibadan,
Nigeria, and African Americans residing in Indianapolis, Indiana. JAMA, 2001, 285:739–747.

22. Chandra V et al. Incidence of Alzheimer’s disease in a rural community in India: the Indo-US study.
Neurology, 2001, 57:985–989.
23. Prince M. Epidemiology of dementia. Vol. 3 Psychiatry. Abingdon, Medicine Publishing Company Ltd., 2004
(Part 12:11–13).

24. Sadik K, Wilcock G. The increasing burden of Alzheimer disease. Alzheimer Disease and Associated
Disorders, 2003, 17(Suppl. 3):S75–S79.

25. Shah A, Murthy S, Suh GK. Is mental health economics important in geriatric psychiatry in developing
countries? International Journal of Geriatric Psychiatry, 2002, 17:758–764.

26. Zencir M et al. Cost of Alzheimer’s disease in a developing country setting. International Journal of Geriatric
Psychiatry, 2005, 20:616–622.

27. 10/66 Dementia Research Group. Care arrangements for people with dementia in developing countries.
International Journal of Geriatric Psychiatry, 2004, 19:170–177.

54
Neurological disorders: public health challenges

28. Kalache A. Ageing is a Third World problem too. International Journal of Geriatric Psychiatry, 1991, 6:617–
618.

29. Lautenschlager NT, Almeida OP, Flicker L. Preventing dementia: why we should focus on health promotion
now. International Psychogeriatrics, 2003, 15:111–119.
30. Tout K. Ageing in developing countries. Oxford, Oxford University Press, 1989.

31. Schneider J et al. EUROCARE: a cross-national study of co-resident spouse carers for people with
Alzheimer’s disease. I: Factors associated with carer burden. International Journal of Geriatric Psychiatry,
1999, 14:651–661.
32. The world health report 2001 – Mental health: new understanding, new hope. Geneva, World Health
Organization, 2001.
RECOMMENDED READING
For professionals
■ Burns A, O’Brien J, Ames D, eds. Dementia, 3rd ed. London, Hodder Arnold, 2005.
■ Draper B, Melding P, Brodaty H, eds. Psychogeriatric service delivery: an international perspective. New York,
Oxford University Press, 2004.
For carers and non-medical readers
■ Cayton H, Graham N, Warner J. Dementia – Alzheimer’s and other dementias, 2nd ed. London, Class
Publishing, 2003 (translated into several languages).
■ Shenk D. The forgetting. Understanding Alzheimer’s disease: a biography of disease. London, Harper Collins,
2003.
■ Bryden C. Dancing with dementia. My story of living positively with dementia. London, Jessica Publishers,
2005.
Box 3.1.3 Case-study: Brazil
Brazil has among the 11 largest populations of elderly peo-
The majority of Brazilians (75%) are cared for by the
ple in the world; eight of these populations are in develop-
federal programme SUS (Uniﬁ ed Health System) while the
ing countries. According to the Brazilian 2000 census, there
remainder are in the hands of a private system. Primary
are 10 million people aged 65 years and over, correspond-
care is provided primarily by the Family Health Programme,
ing to about 6% of the whole population. It is predicted
in which health professionals go to the patient’s home for
that by 2050 the elderly population will have increased by
periodic health evaluation and management; however, this
over 300%, whereas the population as a whole will have in-
programme covers only 40% of the population. Specialists
creased only by over 30%. Brazil has also one of the highest
(geriatricians, psychiatrists and neurologists) see referred
rates of urbanization in the world with almost one third of
patients as outpatients and inpatients. Long-term care is
the whole population living in only three metropolitan ar-
scarce and is mostly provided by religious organizations
eas (São Paulo, Rio de Janeiro and Belo Horizonte), as well
for those with severe disability and limited family support.
as one of the highest levels of inequality between the rich
Community care is generally available in metropolitan
and the poor with almost 50% of the national income con-
areas, but only from private providers for those who can
centrated among the richest 10% of the population. Most
afford the charges. Home care provided by SUS is being
elderly people live in large cities in poverty.
introduced but still covers only a small proportion of the
According to a recent consensus on the global preva-
elderly population.
lence of dementia, Brazil has today 729 000 people with
While the current health system does not meet the needs
dementia; this number is estimated to increase to 1.4 mil-
of older people, there are encouraging developments. The
lion by 2020 and to 3.2 million by 2040. Dementia in Brazil
Brazilian Psychiatric Association has a Geriatric Psychia-
is still a hidden problem and there is little awareness of it.
try section promoting training in dementia assessment
Most elderly people live with their spouses or extend-
and care; the geriatricians and neurologists have similar
ed family (only 15% live alone and fewer than 1% live in
initiatives. Four universities have research programmes in
institutions). Families with one or more elderly members
dementia. Several regional nongovernmental organizations
are relatively advantaged because of the means-tested
work to support people with dementia and their caregivers;
non-contributory pension beneﬁ ts for older Brazilians, in-
these are united in a federation — Federação Brasileira de
troduced in the 1990s. However, the informal support that
Associaçãoes de Alzheimer (FEBRAZ) — which is a mem-
family caregivers can offer to their relations in more need
ber of Alzheimer’s Disease International.
is still difﬁ cult because of impoverishment.

neurological disorders: a public health approach
55
Box 3.1.4 Case-study: India
In India, life expectancy has gone up from 20 years at the
(which includes home visits) is preferred and this leads to a
beginning of the 20th century to 62 years at present. Bet-
higher out-of-pocket cost for dementia care. Carers experi-
ter medical care and low fertility have made the elderly
ence signiﬁ cant burdens and health strain. More than 80%
population the fastest growing section of society. India has
of carers are female and around 50% are spouses who are
over one billion people, 16% of the world’s population: it
themselves quite old. People with dementia are often ne-
is estimated that the growth in the elderly population is
glected, ridiculed and abused. Old-age homes do not admit
5–8% higher than growth in the total population. The con-
people with dementia.
sequence is that, while in 2001 there were 70 million peo-
These research ﬁ ndings led to the implementation of
ple aged over 60 years, by 2025 there will be an estimated
the Dementia Home Care Project which was supported by
177 million.
WHO. In this project, a ﬂ exible, stepped-care intervention
According to a recent consensus, the prevalence of de-
was adopted to empower the carers with knowledge and
mentia in India is 1.9% over the age of 60 years. In the
skills to manage the person with dementia at home. The
context of the large population and demographic transition,
intervention was implemented by locally trained home
the total numbers are estimated to more than treble in the
care advisers under supervision. This not only helped in
next 35 years, reaching over six million by 2040. The public
decreasing the stress of looking after a person with demen-
health and socioeconomic implications are enormous.
tia, but also helped the caregivers to manage behavioural
The joint family system — the traditional support sys-
problems and thus reduced the number of deaths in the
tem for frail elderly people — is crumbling because of the
intervention group.
migration of the younger generation to the cities in search
Evidence from research has helped the advocacy cam-
of better prospects. The women who traditionally took on
paign in India. There is a need to make dementia a public
the role of caregivers are also working and cannot spend
health priority and create a network of home care advisers
as much time caring for the elderly. Dementia is considered
to provide supportive and educational interventions for the
as a normal part of ageing and is not perceived as requiring
family caregivers through the primary health-care system
medical care. Thus primary health-care physicians rarely
in India.
see this condition in their clinical work. Private medical care
Box 3.1.5 Case-study: Nigeria
Nigeria is the most populous African country, with about
Usually record-keeping, accountability and political will
130 million inhabitants. According to United Nations es-
are poor, so that many elderly people who retire do not re-
timates, it is likely that the ﬁ gure of 0.5 million (4.7% of
ceive their beneﬁ ts. Recently the Federal Government has
the whole population) people over 60 years of age in 2000
introduced a contributory pension scheme, but in the past
will have more than trebled by 2040 (1.8 million people, i.e.
elderly people found it difﬁ cult to learn about and access
7.5% of the population). Old people have traditionally been
their entitlements. Elderly Nigerians are among the poorest
cared for within the extended family. Social and economic
groups in the country.
changes have disrupted this system, however, especially
A national policy on elderly care was published in 2003,
by young people moving into the towns and leaving the old
and a National Implementation Plan is now under way, but
people to cope on their own. No effective alternatives have
is being piloted only among certain Federal civil servants.
been provided for their care.
Assessing the extent of dementia among this huge,
Specialist health services are in short supply. In 2005
varied and shifting population is not easy, but what little
there were only about 77 psychiatrists and three occupa-
research has been done suggests prevalence rates for de-
tional therapists in the country. Industrial therapy was not
mentia may be low. Interest in the mental health of elderly
offered anywhere. Specialist social workers are few and
Nigerians is only just beginning: for example in the past
work under severe limitations. There are no specialist ser-
three years, old-age mental health clinics have been es-
vices for the elderly (geriatric or psychogeriatric services,
tablished at two universities. There is no formal training
meals on wheels, respite care or drop-in centres) and few
for geriatric medicine and psychiatry. Anti-dementia drugs
nursing homes. There is no insurance cover for medical
are rarely available.
services for elderly people.

56
Neurological disorders: public health challenges
3.2 Epilepsy
57 Course and outcome
58 Epidemiology
59 Burden on patients, families and communities
Epilepsy is a chronic neurological disorder affecting
62 Treatment, rehabilitation and cost
both sexes and all ages, with worldwide distribu-
tion. The term is also applied to a large group of
63 Research
conditions characterized by common symptoms
64 Education and training
called “epileptic seizures”, which may occur in the
65 Partnerships within and beyond the health system
context of a brain insult that can be systemic, toxic
67 Conclusions and recommendations
or metabolic. These events (called provoked or acute
symptomatic seizures) are presumed to be an acute
manifestation of the insult and may not recur when the underlying cause has
been removed or the acute phase has elapsed.
Epilepsy has been deﬁ ned as “a disorder of the brain characterized by an enduring predisposition
to generate epileptic seizures, and by the neurobiological, cognitive, psychological and social
consequences of this condition. The deﬁ nition of epilepsy requires the occurrence of at least
one epileptic seizure” (1). An epileptic seizure is deﬁ ned as “a transient occurrence of signs
and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain” (1).
These deﬁ nitions recognize that a diagnosis of epilepsy implies the existence of a persistent
epileptogenic abnormality that is present whether seizures occur or not, as well as that there
may be consequences of this persistent abnormality other than the occurrence of seizures that
can cause continuous disability between seizure occurrence (interictally). Because it is often dif-
ﬁ cult to identify deﬁ nitively an enduring predisposition to generate epileptic seizures, a common
operational deﬁ nition of epilepsy is the occurrence of two or more non-provoked epileptic seizures
more than 24 hours apart.
Differential diagnosis of transient events that could represent epileptic seizures involves ﬁ rst
determining that the events are epileptic, then distinguishing between provoked epileptic seizures
and a chronic epileptic condition. Febrile seizures in infants and young children and withdrawal
seizures in alcoholics are common examples of provoked seizures that do not require a diagnosis
of epilepsy. If seizures are recurrent, it is next necessary to search for an underlying treatable
cause. If such a cause cannot be found, or if it is treated and seizures persist, then treatment of
seizures is guided by diagnosis of the speciﬁ c seizure type(s), and syndrome if present (see Box
3.2.1).
Etiology and risk factors
Epileptic conditions are multifactorial disorders, and it is useful to discuss three important factors.
The ﬁ rst factor is predisposition, or threshold. Anyone with a functioning brain is capable of having
a seizure; however, seizures occur more easily in some people than in others. The ease with which
a seizure can be provoked, or an epileptic condition can be induced, is referred to as a threshold.
Individual differences in threshold are largely attributable to genetic variations but could also be
acquired, such as certain types of perinatal injuries, which can alter threshold. Threshold is a dy-
namic phenomenon; it varies throughout the day, it also changes in relation to hormonal inﬂ uences

neurological disorders: a public health approach
57
during the menstrual cycle in women. Stimulant drugs lower seizure threshold and sedative drugs
increase it; however, withdrawal from sedative drugs can lower threshold and provoke seizures.
Antiepileptic drugs work by increasing seizure threshold.
The second important factor for epilepsy is the epileptogenic abnormality itself. Epilepsies
attributable to identiﬁ able brain defects are referred to as symptomatic epilepsies. Symptomatic
epilepsies can be caused by a variety of disorders, including brain malformations, infections,
vascular disturbances, neoplasms, scars from trauma, including strokes, and disorders of cerebral
metabolism. Treatment for symptomatic epilepsy is most effective if it is directed at the underlying
cause. The most common symptomatic epilepsy is temporal lobe epilepsy, usually associated
with a characteristic lesion called “hippocampal sclerosis”. Hippocampal sclerosis appears to be
caused by cerebral injury within the ﬁ rst few years of life in individuals with a genetic predisposi-
tion to this condition. Some forms of epilepsy are unassociated with identiﬁ able structural lesions
or diseases and are usually unassociated with other neurological or mental deﬁ cits. These are
genetically transmitted, generally easily treated with medications without sequelae, and referred
to as idiopathic epilepsies.
The third important factor is the precipitating condition, which determines when seizures occur.
Common precipitating factors include fever for children with febrile seizures, alcohol and sedative
drug withdrawal, sleep deprivation, stimulant drugs and — in some patients — stress. Reﬂ ex
seizures are precipitated by speciﬁ c sensory stimuli. The most common are photosensitive seizures
induced by ﬂ ickering light, but some patients have very speciﬁ c reﬂ ex epilepsy with seizures precip-
itated by such stimuli as being startled, particular types of music, certain visual patterns, reading,
eating and hot-water baths. Identiﬁ cation of precipitating factors is helpful if they can be avoided,
but in most patients speciﬁ c precipitating factors are not apparent, and may not exist at all.
Patients with a high seizure threshold can experience severe epileptogenic brain injuries and
precipitating factors but never have seizures, while those with low seizure thresholds can develop
epilepsy with minimal insults and, in many, from precipitating factors alone (provoked seizures).
COURSE AND OUTCOME
Because there are many types of seizures and epilepsy, there is no single course or outcome.
Prognosis depends on the seizure type, the underlying cause, and the syndrome when this can
be determined. Approximately one in 10 individuals will experience at least one epileptic seizure
in their lifetime, but only one third of these will go on to have epilepsy. There are a number of
idiopathic epilepsy syndromes characterized by onset at a certain age, and speciﬁ c seizure types.
Those that begin in infancy and childhood, such as benign familial neonatal seizures, benign
childhood epilepsy with centrotemporal spikes, and childhood absence epilepsy, usually remit
spontaneously, while those that begin in adolescence, the juvenile idiopathic epilepsies, are often
lifelong. Most of these are easily treated with antiepileptic drugs (AEDs), with no neurological or
Box 3.2.1 Types of epileptic seizure
I. Generalized onset
II. Focal onset
III. Neonatal
A. Clonic and tonic seizures
A Local
B Absences
1
Neocortical
C Myoclonic seizure types
2
Limbic
D Epileptic spasms
B With ipsilateral propagation
E Atonic
seizures
C With
contralateral
spread
D Secondarily generalized
Source: adapted from (2).

58
Neurological disorders: public health challenges
mental sequelae. Slowly, the genetic basis of these idiopathic epilepsies is being revealed, and
there appears to be considerable diversity in that single-gene mutations can give rise to more than
one syndrome, while single syndromes can be caused by more than one gene mutation.
The prognosis of symptomatic epilepsies depends on the nature of the underlying cause.
Epilepsies attributable to diffuse brain damage, such as West syndrome and Lennox–Gastaut
syndrome, are characterized by severely disabling medically refractory “generalized” seizures,
mental retardation and often other neurological deﬁ cits. Epilepsies resulting from smaller lesions
may be associated with “focal” seizures that are more easily treated with drugs and can remit
spontaneously as well. When pharmacoresistant focal seizures are due to localized structural
abnormalities in one hemisphere, such as hippocampal sclerosis in temporal lobe epilepsy, they
can often be successfully treated by localized resective surgery. Some patients with more diffuse
underlying structural lesions that are limited to one hemisphere can also be treated surgically with
hemispherectomy or hemispherotomy.
Whereas 80–90% of patients with idiopathic epilepsies can expect to become seizure free, and
many will undergo spontaneous remission, the ﬁ gure is much lower for patients with symptomatic
epilepsy, and perhaps only 5–10% of patients with temporal lobe epilepsy and hippocampal scle-
rosis will have seizures that can be controlled by pharmacotherapy. Of these patients, however,
60–80% can become free of disabling seizures with surgery. Advances in neurodiagnostics,
particularly neuroimaging, are greatly facilitating our ability to determine the underlying causes
of seizures in patients with symptomatic epilepsies and to design more effective treatments,
including surgical interventions.
EPIDEMIOLOGY
Incidence of epilepsy and unprovoked seizures
The annual incidence of unprovoked seizures is 33–198 per 100 000, and the incidence of epilepsy
is 23–190 per 100 000 (3). The overall incidence of epilepsy in Europe and North America ranges
from 24 and 53 per 100 000 per year, respectively (4–6). The incidence in children is eventually
higher and even more variable, ranging from 25 to 840 per 100 000 per year, most of the differ-
ences being explained by the differing populations at risk and by the study design (3). In developing
countries, the incidence of the disease is higher than that in industrialized countries and is up to 190
per 100 000 (3, 7 ). Although one might expect a higher exposure to perinatal risk factors, infections
and traumas in developing countries, the higher incidence of epilepsy may be also explained by the
different structure of the populations at risk, which is characterized by a predominant distribution
of young individuals and a short life expectancy.
Incidence by age, sex and socioeconomic status
In industrialized countries, epilepsy tends to affect mostly the individuals at the two extremes
of the age spectrum. The peak in the elderly is not detected in developing countries, where the
disease peaks in the 10–20-year age group (8). This may depend on the age structure of the
population and on a relative under-ascertainment of the disease in older individuals.
The incidence of epilepsy and unprovoked seizures has been mostly reported to be higher in men
than in women in both industrialized and developing countries, though this ﬁ nding has rarely attained
statistical signiﬁ cance. The different distribution of epilepsy in men and women can be mostly ex-
plained by the differing genetic background, the different prevalence of the commonest risk factors
in the two sexes, and the concealment of the disease in women for sociocultural reasons.
The incidence of epilepsy is higher in the lower socioeconomic classes. This assumption is sup-
ported by the comparison between industrialized and developing countries and by the comparison,
within the same population, of people of different ethnic origin (9).

neurological disorders: a public health approach
59
Prevalence of epilepsy
The overall prevalence of epilepsy ranges from 2.7 to 41 per 1000 population, though in the major-
ity of reports the rate of active epilepsy (i.e. at least one seizure in the preceding ﬁ ve years) is in the
range 4–8 per 1000 (5, 10). The prevalence of active epilepsy is generally lower in industrialized
countries than in developing countries, which may reﬂ ect a lower prevalence of selected risk
factors (mostly infections and traumas), a more stringent case veriﬁ cation, and the exclusion of
provoked and unprovoked isolated seizures.
Prevalence by age, sex and socioeconomic status
In industrialized countries, the prevalence of epilepsy is lower in infancy and tends to increase
thereafter, with the highest rate occurring in elderly people (10). Where available, age-speciﬁ c
prevalence rates of lifetime and active epilepsy from developing countries tend to be higher in the
second (254 vs 148 per 1000) and third decades of life (94 vs 145 per 1000) (8). The differences
between industrialized and developing countries may be mostly explained by the differing distribu-
tion of the risk factors and by the shorter life expectancy in the latter.
As with incidence, prevalence of epilepsy tends to be higher in men. However, this ﬁ nding is
not consistent across studies and, with few exceptions, is not statistically signiﬁ cant.
Socioeconomic background has been found to affect the frequency of epilepsy reports in
both industrialized and developing countries. In developing countries, prevalence rates have been
shown to be greater in the rural compared with the urban context (11, 12) or in the lower compared
with the higher socioeconomic classes. However, opposite ﬁ gures were reported in a meta-analy-
sis of epidemiological studies from India (13), which suggests that rural and urban environments
should not be invariably used as proxies of lower vs higher socioeconomic conditions.
Mortality
The mortality rate of epilepsy ranges from 1 to 8 per 100 000 population per year, but international
vital statistics give annual mortality rates of 1–2 per 100 000 (14). Based on a meta-analysis of
studies investigating mortality in the past 100 years, the standardized mortality ratio (SMR) for
epilepsy, which is the ratio between the deaths observed among patients with epilepsy and the
deaths expected in a reference population with a similar age distribution, was found to range
from 1.3 to 9.3 (15). The SMR for epilepsy ranges from 1.6 to 5.3 in children and adults and is
inversely correlated with age (16). The higher SMRs may be partly explained by the inclusion of
provoked seizures. The highest mortality risk in the youngest age groups can be interpreted in
part in the light of the underlying epileptogenic conditions and the lower number of competing
causes of death.
It is extremely difﬁ cult to analyse the epilepsy death rate in the general population of a devel-
oping country because incidence studies of epilepsy are difﬁ cult to perform, death certiﬁ cates
are unreliable and often unavailable, and the cause of death is difﬁ cult to determine. Based on
available data, it seems that the mortality rate of epilepsy in developing countries is generally
higher than that reported in developed countries. These data cannot be generalized, however, as
they have been obtained from selected populations (17 ).
BURDEN ON PATIENTS, FAMILIES AND COMMUNITIES
Worldwide, 50 million people have epilepsy. Many more people, however — an estimated
200 000 000 — are also affected by this disorder, as they are the family members and friends of
those who are living with epilepsy. Around 85% of people with epilepsy live in developing coun-
tries. There are two million new cases occurring in the world every year. Up to 70% of people with
epilepsy could lead normal lives if properly treated, but for an overwhelming majority of patients
this is not the case (18).

60
Neurological disorders: public health challenges
Epilepsy is among the disorders that are strongly associated with signiﬁ cant psychological
and social consequences for everyday living (19). People with hidden disabilities such as epilepsy
are among the most vulnerable in any society. While their vulnerability may be partly attributed
to the disorder itself, the particular stigma associated with epilepsy brings a susceptibility of its
own. Stigmatization leads to discrimination, and people with epilepsy experience prejudicial and
discriminatory behaviour in many spheres of life and across many cultures (20).
People with epilepsy experience violations and restrictions of both their civil and human rights.
Civil rights violations such as unequal access to health and life insurance or prejudicial weighting
of health insurance provisions, withholding of the right to obtain a driving licence, limitations
to the right to enter particular occupations and the right to enter into certain legal agreements,
in some parts of the world even marriage, are severely aggravated by epilepsy. Discrimination
against people with epilepsy in the workplace and in respect of access to education is not uncom-
mon for many people affected by the condition. Violations of human rights are often more subtle
and include social ostracism, being overlooked for promotion at work, and denial of the right
to participate in many of the social activities taken for granted by others in the community. For
example, ineligibility for a driving licence frequently imposes restrictions on social participation
and choice of employment.
Informing people with epilepsy of their rights and recourse is an essential activity. Considering
the frequency of rights violations, the number of successful legal actions is very small. People
are often reluctant to be brought into the public eye, so a number of cases are settled out of
court. The successful defence of cases of rights abuse against people with epilepsy will serve
as precedents, however, and will be helpful in countries where there are actions afoot to review
and amend legislation.
Epidemiological assessment of the global burden of epilepsy
Overall, epilepsy contributed more than seven million DALYs (0.5%) to the global burden of disease
in 2000 (21, 22). Figure 3.2.1 shows the distribution of DALYs or lost years of healthy life attribut-
able to epilepsy, both by age group and by level of economic development. It is apparent that
close to 90% of the worldwide burden of epilepsy is to be found in developing regions, with more
than half occurring in the 39% of the global population living in countries with the highest levels
of premature mortality (and lowest levels of income). An age gradient is also apparent, with the
vast majority of epilepsy-related deaths and disability in childhood and adolescence occurring in
developing regions, while later on in the life-course the proportion drops on account of relatively
greater survival rates into older age by people living in more economically developed regions.
Figure 3.2.1 Distribution of the global burden of epilepsy, by age group and

level of economic development
100
90
80
40%
42%
41%
40%
37%
burden
70
55%
56%
64%
60
78%
global
26%
50
of
29%
33%
ge
40
42%
35%
30
34%
32%
29%
20
P
ercenta
31%
37%
18%
26%
10
17%
22%
11%
12%
4%
7%
0 0–4
5–14
15–29
30–44
45–59
60–69
70–79
80+
Total
Age group
Developed regions
Low mortality developing regions
High mortality developing regions
Source (22).

neurological disorders: a public health approach
61
Economic assessment of the national burden of epilepsy
Economic assessments of the national burden of epilepsy have been conducted in a number of high
income countries (e.g. 23, 24) and more recently in India (25), all of which have clearly shown the
signiﬁ cant economic implications the disorder has in terms of health-care service needs, premature
mortality and lost work productivity. For example, the Indian study calculated that the total cost per
case of these disease consequences for epilepsy amounted to US$ 344 per year (equivalent to 88%
of average income per capita), and that the total cost for the estimated ﬁ ve million cases resident
in India was equivalent to 0.5% of gross national product. Since such studies differ with respect to
the exact methods used, as well as underlying cost structures within the health system, they are
currently of most use at the level of individual countries, where they can serve to draw attention to
the wide-ranging resource implications and needs of people living with epilepsy.
The avertable burden of epilepsy
Having established the attributable burden of epilepsy, two subsequent questions for decision-
making and priority setting relate to avertable burden (the proportion of attributable burden that
is averted currently or could be avoided via scaled-up use of proven efﬁ cacious treatments) and
resource efﬁ ciency (determination of the most cost-effective ways of reducing burden). Figure
3.2.2 provides a schematic overview of these concepts.
As part of a wider WHO cost–effectiveness work programme (26), information has been gener-
ated concerning the amount of burden averted by the current or scaled-up use of treatment with
AEDs, together with estimates of cost and cost–effectiveness (27 ). Effectiveness was expressed
in terms of DALYs averted and costs were expressed in international dollars. Compared with a
“do nothing” scenario (i.e. the untreated natural history of epilepsy), results from nine developing
epidemiological subregions suggest that extending AED treatment coverage to 50% of primary
epilepsy cases would avert 150–650 DALYs per million population (equivalent to 13–40% of the
current burden), at an annual cost per case of International $ 55–192. Older ﬁ rst-line AEDs (phe-
nobarbitone, phenytoin) were most cost effective on account of their similar efﬁ cacy but lower
acquisition cost (International $ 800–2000 for each DALY averted). In all nine developing regions,
the cost of securing one extra healthy year of life was less than average per capita income.
Extending coverage further to 80% or even 95% of the target population would evidently avert
more of the burden still, and would remain an efﬁ cient strategy despite the large-scale investment
in manpower, training and drug supply/distribution that would be required to implement such a
programme. The results for one developing subregion in Africa — consisting of 20 countries with
a high rate of child mortality and a very high level of adult mortality — are depicted in Figure 3.2.2
Figure 3.2.2 Attributable and avertable burden of epilepsy in an

epidemiological subregion of Africa
100
(%)
Not avertable with first line AEDs (40%)
60
fectiveness
Already averted
Avertable via scaling up of
ef
(current AEDs)
cost effective AEDs*
19%
+13%
+19%
+9%
Combined
0
25
50
80
100
Effective coverage in population (%)
* Each DALY averted costs less than average per capita income.
Source: schema (28); data (27 ).

62
Neurological disorders: public health challenges
(27, 28), which divides the total attributable burden of epilepsy into three categories: burden that is
averted by AEDs at current levels of effective treatment coverage (19%); burden that is avertable
via the scaling-up of AEDs (to a further 41% if complete coverage is reached); and burden that is
not avertable via AEDs (estimated to be 40%, though this assumes that the current level of drug
compliance would prevail).
TREATMENT, REHABILITATION AND COST
The primary focus of care for patients with epilepsy is the prevention of further seizures, which may,
after all, lead to additional morbidity or even mortality (29). The goal of treatment should be the
maintenance of a normal lifestyle, preferably free of seizures and with minimal side-effects of the
medication. Up to 70% of people with epilepsy could become seizure free with AED treatment.
In 25–30% of people with epilepsy the seizures cannot be controlled with drugs. Epilepsy
surgery is a safe and effective alternative treatment in selected cases. Investment in epilepsy
surgery centres, even in the poorest regions, could greatly reduce the economic and human
burden of epilepsy. There is a marked treatment gap with respect to epilepsy surgery, however,
even in industrialized countries.
Attention to the psychosocial, cognitive, educational and vocational aspects is an important
part of comprehensive epilepsy care (30). Epilepsy imposes an economic burden both on the
affected individual and on society, e.g. the disorder commonly affects young people in the most
productive years of their lives, often leading to avoidable unemployment.
Over the past years, it has become increasingly obvious that severe epilepsy-related difﬁ culties
can be seen in people who have become seizure free as well as in those with difﬁ cult-to-treat
epilepsies. The outcome of rehabilitation programmes would be a better quality of life, improved
general social functioning and better functioning in, for instance, performance at work and im-
proved social contacts (31).
In 1990, WHO identiﬁ ed that the average cost of medication (phenobarbitone) could be as low
as US$ 5 per person per year (32). From an economic point of view also, therefore, it is an urgent
public health challenge to make effective epilepsy care available to all who need it, regardless of
national and economic boundaries.
Prevention
Currently, epilepsy tends to be treated once the condition is established, and little is done in
terms of prevention. In a number of people with epilepsy the cause for the condition is unknown;
prevention of this type of epilepsy is therefore currently not possible (33, 34). A sizeable number of
people with epilepsy will have known risk factors, but some of these are not currently amenable to
preventive measures. These include cases of epilepsy attributable to cerebral tumours or cortical
malformations and many of the idiopathic forms of epilepsy.
One of the most common causes of epilepsy is head injury, particularly penetrating injury. Pre-
vention of the trauma is clearly the most effective way of preventing post-traumatic epilepsy, with
use of head protection where appropriate (for example, for horse riding and motorcycling) (34).
Epilepsy can be caused by birth injury, and the incidence should be reduced by adequate
perinatal care. Fetal alcohol syndrome may also cause epilepsy, so advice on alcohol use before
and during pregnancy is important. Reduction of childhood infections by improved public hygiene
and immunization can lessen the risk of cerebral damage and the subsequent risk of epilepsy
(33, 34).
Febrile seizures are common in children under ﬁ ve years of age and in most cases are benign,
though a small proportion of patients will develop subsequent epilepsy. The use of drugs and other
methods to lower the body temperature of a feverish child may reduce the chance of having a
febrile convulsion and subsequent epilepsy, but this remains to be seen.

neurological disorders: a public health approach
63
Epilepsy may be a complication of various infections of the central nervous system (CNS),
such as cysticercosis and malaria (35, 36). These conditions are more prevalent in the tropical
belt, where low income countries are concentrated. Elimination of the parasite in the environ-
ment would be the most effective way to reduce the burden of epilepsy worldwide, but education
concerning how to avoid infection can also be effective.
To sum up, currently the prevention of epilepsy may be possible in cases caused by head
trauma and by infections and infestations of the CNS, but would require intensive efforts to
improve basic sanitation, education and practice. Most cases of epilepsy at the current state of
knowledge are probably not preventable but, as research improves our understanding of genetics
and structural abnormalities of the brain, this may change.
Treatment gap
Worldwide, the proportion of patients with epilepsy who at any given time remain untreated is
large, and is greater than 80% in most low income countries (33, 34). The size of this treatment
gap reﬂ ects either a failure to identify cases or a failure to deliver treatment. In most situations,
however, both factors will apply. Inadequate case-ﬁ nding and treatment have various causes,
some of which are speciﬁ c to low income countries. They include people’s attitudes and beliefs,
government health policies and priorities (or the lack of them), treatment costs and drug avail-
ability, as well as the attitude, knowledge and practice of health workers. In addition, there is
clear scarcity of epilepsy-trained health workers in many low income countries. The lack of trained
personnel and a proper health delivery infrastructure are major problems, which contribute to
the overall burden of epilepsy. For instance, in most sub-Saharan countries there is no resident
neurologist and there are no scanning facilities using magnetic resonance imaging (MRI) (35 ).
This situation is found in many other resource-poor countries and is usually more acute in rural
areas. The lack of trained specialists and medical facilities needs to be seen in the context of
severe deﬁ ciencies in health delivery that apply not only to epilepsy but also to the whole gamut
of medical conditions. Training medical and paramedical personnel and providing the necessary
investigatory and treatment facilities will require tremendous effort and ﬁ nancial expenditure
and will take time to achieve. The aim should be to provide high standards of epilepsy care with
equitable access to all who need them throughout the world.
There is a dearth of epilepsy services, trained personnel and AEDs, which contributes to a mas-
sive diagnostic and treatment gap in epilepsy that is more pronounced in low income countries.
A huge effort is required to equalize care for people with epilepsy around the world. Improvement
of the care delivery system and infrastructure alone are not a sufﬁ cient strategy but need to be
supplemented by education of patients, their families and the general public.
RESEARCH
Despite the signiﬁ cant advances in understanding epileptogenic mechanisms and in counteracting
their pathological consequences, the problem still has to be faced of treating more effectively the se-
vere epilepsies and of preventing their unfavourable evolution (37). So far, research has been unsuc-
cessful in developing effective strategies capable of preventing the development of the pathogenic
process, set in motion by different etiological factors, that leads ultimately to chronic epilepsies (38).
To do so, it is important to take advantage of the results that are continuously being made available to
the scientiﬁ c community thanks to the synergy of basic and clinical multidisciplinary research. This
means that the clinical applicability of neurobiological results should be evaluated, the way in which
the new information can be translated into diagnostic and therapeutic terms should be assessed,
and ad hoc guidelines and recommendations should be produced accordingly.
In elaborating their health-care strategies, regional and national communities should not simply
refer to the available scientiﬁ c information, but should also contribute to it by means of their own

64
Neurological disorders: public health challenges
original investigations. This is mandatory if they are to meet speciﬁ c local requirements taking into
account the socioeconomic situations in which health-care policy is to be formulated. Important
actions have been undertaken by the International League Against Epilepsy (ILAE) through its vari-
ous commissions (on genetics, neurobiology, psychobiology, epidemiology, therapeutic strategies,
diagnostic methods and health-care policy) to help developing countries in establishing research
projects oriented to their speciﬁ c problems. Moreover, ILAE is active in promoting international
collaborative research networks, facilitating partnerships between developed and developing
countries, promoting fellowships and grant programmes and in sensitizing the relevant interna-
tional institutions such as the World Bank, WHO and the United Nations Educational, Scientiﬁ c
and Cultural Organization (UNESCO) to epilepsy research (39). A speciﬁ c project for collaborative
studies involving developed and developing countries is part of the triennial action plan of the
Global Campaign Against Epilepsy. The project aims to stimulate and facilitate the synergy be-
tween countries in different economic situations that is particularly important for epidemiological
and genetic studies and clinical trials of new AEDs.
The main point here is that research is not a matter of technology; rather, it is the result of
an intellectual attitude aimed at understanding and improving the principles upon which every
medical activity should be based. Therefore, everybody whose work concerns epilepsy can and
should contribute to the advancement of epileptology to the beneﬁ t of the millions of human
beings suffering from epilepsy, no matter how advanced the technological context of his or her
current work.
EDUCATION AND TRAINING
Education and training programmes aimed at improving the expertise of health-care providers
play an essential role in fostering epilepsy care throughout the world. The need for an integrated,
multidisciplinary approach to epilepsy care prompted several countries to organize annual epilepsy
courses for neurologists, general practitioners, technicians and nurses at national level.
Multinational programmes are being implemented on the basis of the pioneering experience
of ILAE’s European Epilepsy Academy (EUREPA), which has developed two innovative educational
models: train-the-trainers courses and European Epileptology Certiﬁ cation. The aim of the train-
the-trainers courses is to turn experienced personnel into qualiﬁ ed teachers of epileptology. It
signiﬁ cantly contributes to raising the proﬁ le of epilepsy care across Europe and is now being
implemented in other regions. European Epileptology Certiﬁ cation can be obtained by completing
an 18-month educational programme based on periods of training in selected institutions that
allow the accumulation of credits.
EUREPA is also developing an important project of distance education in epileptology. Some mod-
ules have been completed and successfully tested: the course on genetics of epilepsy has already
been evaluated (40). An annual residential Epilepsy Summer School for young epileptologists from
all over the world exists at Venice’s International School of Neurological Sciences; since 2002, it has
trained students from 64 countries. The interaction between students and teachers and among the
students themselves resulted in several ongoing international collaborative projects that are further
contributing to raising the proﬁ le of epilepsy care in several developing areas (41).
The philosophy on which the educational initiatives of ILAE and EUREPA are based is an
interactive relationship that stimulates the active participation of students. The theoretical teach-
ing, based either on residential courses or distance education systems, includes an interactive
discussion of clinical cases and practical training programmes in qualiﬁ ed epilepsy centres. A
further effort is needed to expand exchange programmes for visiting students from economically
disadvantaged countries.

neurological disorders: a public health approach
65
PARTNERSHIPS WITHIN AND BEYOND THE HEALTH SYSTEM
Partnerships within and beyond the health system are essential in order to achieve a world in which
no person’s life is limited by epilepsy. As the President of ILAE put it, “we all have a shared interest
in that we want to improve epilepsy care throughout the world”. Such partnerships include:
■ nongovernmental organizations, which are themselves partnerships as they are made up of
individuals who have common goals and interests;
■ patients and professionals at national, regional and global levels, in order to raise awareness
of epilepsy and stimulate research;
■ patient and professional nongovernmental organizations and WHO, in order to decrease the
treatment gap;
■ patients, professionals and politicians, for example to develop national health-care pro-
grammes;
■ foundations and charitable organizations, who support the work of the nongovernmental or-
ganizations both ﬁ nancially and with human resources;
■ health-care providers, to try to improve the availability, accessibility and affordability of treat-
ment;
■ the private sector, especially the pharmaceutical industry.
ILAE/IBE/WHO Global Campaign Against Epilepsy
The problems related to provision of care and treatment to people with epilepsy are too complex
to be solved by individual organizations, therefore the three leading international organizations
working in the ﬁ eld of epilepsy (ILAE, the International Bureau for Epilepsy (IBE) and WHO) joined
forces to create the Global Campaign Against Epilepsy. The Campaign aims to provide better
information about epilepsy and its consequences and to assist governments and those concerned
with epilepsy to reduce the burden of the disorder. Its strategy, speciﬁ c objectives and activities
are summarized in Box 3.2.2.
To date, over 90 countries are involved in the Campaign. As part of general awareness-raising,
regional conferences on public health aspects of epilepsy have been organized in all six regions
of WHO with the participation of over 1300 delegates from the epilepsy organizations (IBE and
Box 3.2.2 ILAE/IBE/WHO Global Campaign Against Epilepsy
Objectives
Strategy
Activities
■ To increase public and profes-
■ To provide a platform for general
■ Organization of regional con-
sional awareness of epilepsy as
awareness
ferences followed by Regional
a universal and treatable brain
■ To assist departments of health in
Declarations
disorder
the development of national pro-
■ Assessment of country resources
■ To raise epilepsy to a new plane
grammes on epilepsy
for epilepsy worldwide
of acceptability in the public
■ Assistance with the development
domain
of regional reports
■ To promote public and profes-
■ Development of educational
sional education about epilepsy
materials
■ To identify the needs of people
■ Coordination of demonstration
with epilepsy at national and re-
projects
gional levels
■ To encourage governments and
departments of health to address
the needs of people with epilepsy,
including awareness, education,
diagnosis, treatment, care, ser-
vices and prevention

66
Neurological disorders: public health challenges
ILAE), public health experts from governments and universities and representatives from WHO
headquarters and regions.
The goals of the conferences were to review the present situation of epilepsy care in the region,
to identify the country’s needs and resources to control epilepsy at a community level, and to
discuss the involvement of countries in the Campaign. As a result of these consultations, Regional
Declarations summarizing perceived needs and proposing actions to be taken were developed and
adopted by the conference participants.
In order to make an inventory of country resources for epilepsy worldwide, a questionnaire
was developed by an international group of experts in the ﬁ eld. On the basis of the data collected
through this questionnaire, regional reports were developed. These reports provide a panoramic
view of the epilepsy situation in each region, outline the various initiatives that were taken to
address the problems, deﬁ ne the current challenges and offer appropriate recommendations
(32, 42).
The next logical step in the assessment of country resources was the comprehensive analysis
of the data. Within the framework of the WHO Atlas Project, launched by WHO in 2002 to provide
information about health resources in different countries, the analysis was summarized in the
Atlas of Epilepsy Care in the World (30). The epilepsy atlas has been produced in collaboration
with the ILAE/IBE/WHO Global Campaign Against Epilepsy using ILAE and IBE chapters and WHO
networks. The atlas provides global and regional analyses on epilepsy resources and is another
result of the fruitful collaboration between ILAE, IBE and WHO (43).
One of the main activities aiming to assist countries in the development of their national pro-
grammes on epilepsy is the initiation and implementation of demonstration projects. The ultimate
goal of these projects is the development of a variety of successful models of epilepsy control
that may be integrated into the health-care systems of the participating countries and regions. In
general terms, each demonstration project has four aspects:
■ assessing whether knowledge and attitudes of the population are adequate, correcting misin-
formation and increasing awareness of epilepsy and how it can be treated;
■ assessing the number of people with epilepsy and estimating how many of them are appro-
priately treated;
■ ensuring that people with epilepsy are properly served by health personnel equipped for their
task;
■ analysing the outcome and preparing recommendations for those who wish to apply the ﬁ nd-
ings to the improvement of epilepsy care in their own and other countries.
In summary, it may be concluded that the collaboration of ILAE, IBE and WHO within the frame
of the Global Campaign has been very successful and led to signiﬁ cant achievements in various
areas such as raising public and professional awareness and education, development of effective
modules for epilepsy control, and assessment and analysis of epilepsy resources in all countries
of the world.

neurological disorders: a public health approach
67
CONCLUSIONS AND RECOMMENDATIONS
1
Epilepsy is one of the most common serious neurological disorders worldwide with no
age, racial, social class, national or geographic boundaries.
2
Worldwide, 50 million people have epilepsy. Around 85% of these live in developing
countries.
3
Up to 70% of people with epilepsy could lead normal lives if properly treated, but for an
overwhelming majority of patients this is not the case.
4
The worldwide incidence, prevalence and mortality of epilepsy are not uniform and
depend on several factors, which include the structure of the local population, the basic
knowledge of the disease, the socioeconomic and cultural background, the presence of
environmental risk factors, and the distribution of infrastructure, ﬁ nancial, human and
material resources.
5
Some forms of epilepsy, particularly those associated with CNS infections and trauma,
may be preventable.
6

As epileptic seizures respond to drug treatment, the outcome of the disease depends on
the early initiation and continuity of treatment. Difﬁ culties with availability of or access
to treatment (the treatment gap) may seriously impair the prognosis of epilepsy and
aggravate the social and medical consequences of the disease.
7
In low income countries the treatment gap needs to be seen in the context of the local
situation, with inadequate resources for all forms of health delivery as well as education
and sanitation.
8
The treatment gap is not only a matter of the lack of availability of AEDs, but
encompasses the lack of infrastructure, training and public awareness of the condition. All
these areas need to be confronted.
9
Integration of epilepsy care in national health systems needs to be promoted by
developing models for epilepsy control worldwide.
REFERENCES

1. Fisher RS et al. Epileptic seizures and epilepsy. Deﬁ nitions proposed by the International League against
Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia, 2005, 46:470–472.
2. Engel J Jr. Report of the ILAE Classiﬁ cation Core Group. Epilepsia, 2006, 47:1558–1568.
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comprehensive textbook. Philadelphia, PA, Lippincott-Raven, 1997:105–118.
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13. Sridharan R, Murthy BN. Prevalence and pattern of epilepsy in India. Epilepsia, 1999, 40:631–636.

14. Massey EW, Schoenberg BS. Mortality from epilepsy. International patterns and changes over time.
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15. Shackleton DP et al. Survival of patients with epilepsy: an estimate of the mortality risk. Epilepsia, 2002,
43:445–450.

16. Jallon P. Mortality in patients with epilepsy. Current Opinion in Neurology, 2004, 17:141–146.

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19. Baker GA. The psychosocial burden of epilepsy. Epilepsia, 2002, 43(Suppl. 6):26–30.

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population-based studies. Epilepsy research, 1994, 18:249–260.

25. Thomas SV et al. Economic burden of epilepsy in India. Epilepsia, 2001, 42:1052–1060.

26. Tan Torres T et al. Making choices in health: a WHO guide to cost–effectiveness analysis. Geneva, World
Health Organization, 2003.

27. Chisholm D. Cost-effectiveness of ﬁ rst-line anti-epileptic drug treatments in the developing world: a
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Future Intervention Options. Geneva, World Health Organization, 1996.

29. Kwan P, Brodie MJ. Refractory epilepsy: a progressive, intractable but preventable condition? Seizure, 2002,
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31. Brodie MJ, Boer HM de, Johannessen SI (Guest editors). European White Paper on epilepsy. Epilepsia, 2003,
44(Suppl. 6):1–88.
32. Epilepsy in the Western Paciﬁ c Region – A call to action. Manila, World Health Organization Regional Ofﬁ ce
for the Western Paciﬁ c, 2004.

33. Sander JW. Prevention of epilepsy. In: Shorvon SD et al., eds. The management of epilepsy in developing
countries: an ICBERG manual. London, Royal Society of Medicine, 1991. International Congress and
Symposium Series, No. 175:19–21.

34. Dreifuss FE. Critical review of health care for epilepsy. In: Engel J Jr, Pedley T, eds. Epilepsy: a
comprehensive textbook. Philadelphia, PA, Lippincott-Raven, 1997:2903–2906.

35. Pal DK, Carpio A, Sander JW. Neurocysticercosis and epilepsy in developing countries. Journal of
Neurology, Neurosurgery and Psychiatry, 2000, 68:137–143.

36. Carter JA et al. Increased prevalence of epilepsy associated with severe falciparum malaria in children.
Epilepsia, 2004, 45:978–981.

37. Arroyo S et al. Is refractory epilepsy preventable? Epilepsia, 2002, 43:437–444.

38. Walker MC, White HS, Sander JWAS. Disease modiﬁ cation in partial epilepsy. Brain, 2002, 125:1937–1950.
39. ILAE strategic plan. Brussels, International League Against Epilepsy, 2005 (http://www.ILAE.org).

40. May T, Pfäfﬂ in M. Evaluation of the distance learning course on Genetics of Epilepsy. Bielefeld, European
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42. Global Campaign Against Epilepsy. Epilepsy in the WHO African Region: bridging the gap. Brazzaville, World
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neurological disorders: a public health approach
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RECOMMENDED READING
■ Annegers JF et al. Incidence of acute symptomatic seizures in Rochester, Minnesota: 1935–1984. Epilepsia,
1995, 36:327–333.
■ Beghi E. Aetiology of epilepsy. In: Shorvon SD et al., eds. The treatment of epilepsy, 2nd ed. Malden, MA,
Blackwell Science, 2004:50–63.
■ Engel J Jr. Report of the ILAE Classiﬁ cation Core Group. Epilepsia, 2006, 47:1558–1568.
■ Engel J Jr, Pedley TA. The comprehensive CD-ROM on epilepsy. Philadelphia, PA, Lippincott, Williams &
Wilkins, 1999.
■ Engel J Jr. Epilepsy: global issues for the practicing neurologist. New York, Demos Medical Publishing, 2005
(World Federation of Neurology: Seminars in Clinical Neurology).
■ Hauser WA. Epidemiology of epilepsy. In: Gorelick PB, Alter M, eds. Handbook of neuroepidemiology. New
York, Marcel Dekker, 1994:315–353.
■ Hauser WA, Hesdorffer DC, eds. Epilepsy: frequency, causes and consequences. New York, Demos Medical
Publishing, 1990.
■ Shorvon SD, Farmer PJ. Epilepsy in developing countries: a review of epidemiological, sociocultural and
treatment aspects. Epilepsia, 1988, 29(Suppl. 1):S36–S54.
■ Tomson T. Mortality studies in epilepsy. In: Jallon P et al., eds. Prognosis of epilepsies. Paris, John Libbey,
2003:12–21.
■ Tomson T et al. Medical risks in epilepsy: a review with focus on physical injuries, mortality, trafﬁ c ac-
cidents and their prevention. Epilepsy Research, 2004, 60:1–16.
■ Atlas: Epilepsy care in the world. Geneva, World Health Organization, 2005.
■ The world health report 2001 – Mental health: new understanding, new hope. Geneva, World Health
Organization, 2001.

70 Neurological disorders: public health chal enges
3.3 Headache disorders
72 Types of headache disorders
Headache is a painful feature of a relatively small
74 Epidemiology and burden
number of primary headache disorders, some of
75 Barriers to care
which are widespread and are often life-long con-
76 Management and prevention
ditions. Headache also occurs as a characteris-
78 Therapeutic interventions
tic symptom of many other conditions; these are
80 Fol ow-up and referral
termed secondary headache disorders. Col ectively,
80 Health-care policy
headache disorders are among the most common
disorders of the nervous system, causing substan-
81 Partnerships within and beyond the health system
tial disability in populations throughout the world.
81 Research
82 Conclusions and recommendations
Figure 3.3.1 Popul P
atopulation-based epidemiological studies of migraine
ion-based epidemiological studies of migraine
13.2
11.6
10.0
14.7
15.5
14.7
14.3
11.7
23.2
10.2
8.4
8.2
14.0
9.6
13.3
16.7
5.9
11.6
12.2
8.5
22.3
7.7
10.0
13.5
10.1
8.5
3.0
9.0
9.3
8.2
5.0
5.3
12.6
16.3
Africa
4.0 (2 studies)
7.3
Asia
10.6 (6 studies
5.0
Europe
13.8 (9 studies)
N. America 12.6 (8 studies)
Oceania
–
1 year prevalence %
S. America 9.6 (10 studies)
WHO 06.156
Note: All studies used International Headache Society criteria (or reasonable modifications of these criteria) for diagnosing migraine and were conducted
in general population or community-based adult samples of at least 500 participants. Numbers are estimated 1-year prevalences.
Source: (3).

neurological disorders: a public health approach
71
Despite the widespread and incapacitating nature of headache, it is underestimated in scope and
scale, and headache disorders remain under-recognized and under-treated everywhere (1). Table
3.3.1 classifies headache disorders into primary, secondary, and neuralgias and other headaches,
with their symptoms (2).
The worldwide epidemiology of headache disorders is only partly documented. Population-
based studies have mostly focused on migraine (Figure 3.3.1) which, though the most frequently
studied, is not the most common headache disorder. Others, such as the more prevalent tension-
type headache and the more disabling so-cal ed chronic daily headache syndromes, have received
less attention. Furthermore, few population-based studies exist for developing countries, where
limited funding and large and often rural (and therefore less accessible) populations, coupled
with the low profile of headache disorders compared with communicable diseases, prevent the
systematic col ection of information.
Nevertheless, despite regional variations, headache disorders are thought to be highly preva-
lent throughout the world, and recent surveys add support to this belief. Sufficient studies have
been conducted to establish that headache disorders affect people of al ages, races, income
levels and geographical areas (Figure 3.3.2). Four of them — three primary headache disorders
and one secondary — have particular public health importance.
Figure 3.3.2 Pop Puopulation-based epidemiological studies of headache disorders
lation-based epidemiological studies of headache disordersa
(all headache disorders or unspeciﬁed headache)
77.0
63.0
37.7
87.3
76.0
71.0
49.4
55.6
13.4
59.7
46.0
28.5
29.0
68.0
62.0
35.9
78.8
23.1
28.7
63.1
37.3
20.0
Africa
21.6 (2 studies)
Asia
58.6 (5 studies)
Europe
56.1 (8 studies)
N. America 53.5 (3 studies)
Oceania
50.0 (1 study)
50.0
1 year prevalence %
S. America 41.3 (4 studies)
WHO 06.155
aall headache disorders or unspecified headache.
Note: All studies were conducted in general population or community-based adult samples of at least 500 participants. Numbers are estimated
1-year prevalences.
Source: (3).

72
Neurological disorders: public health challenges
Table 3.3.1 Classiﬁ cation of headache disorders
Type
Symptoms
Primary
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal autonomic cephalalgias
4. Other primary headaches
Secondary
5. Headache attributed to head and/or neck trauma
6. Headache attributed to cranial or cervical vascular disorder
7. Headache attributed to non-vascular intracranial disorder
8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homoeostasis
11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses,
teeth, mouth or other facial or cranial structures
12. Headache attributed to psychiatric disorder
Neuralgias and
13. Cranial neuralgias, central and primary facial pain and other headaches
other headaches
14. Other headache, cranial neuralgia, central or primary facial pain
Source: (1).
TYPES OF HEADACHE DISORDERS
Migraine
Migraine is a primary headache disorder. It almost certainly has a genetic basis (4), but environmental
factors play a signiﬁ cant role in how the disorder affects those who suffer from it. Pathophysiologi-
cally, activation of a mechanism deep in the brain causes release of pain-producing inﬂ ammatory
substances around the nerves and blood vessels of the head. Why this happens periodically, and
what brings the process to an end in spontaneous resolution of attacks, are uncertain.
Usually starting at puberty, migraine is recurrent throughout life in many cases. Adults with
migraine describe episodic disabling attacks in which headache and nausea are the most charac-
teristic features; others are vomiting and dislike or intolerance of normal levels of light and sound.
Headaches are typically moderate or severe in intensity, one-sided and pulsating, aggravated by
routine physical activity; they usually last from several hours to 2–3 days. In children, attacks
tend to be of shorter duration and abdominal symptoms more prominent. Attack frequency is
typically once or twice a month but can be anywhere between once a year and once a week, often
subject to lifestyle and environmental factors that suggest people with migraine react adversely
to change in routine.
Migraine is most disabling to people aged 35–45 years, but it can trouble much younger
people, including children. Studies in Europe and the United States have shown that migraine
affects 6–8% of men and 15–18% of women (5, 6). A similar pattern probably exists in Central
America: in Puerto Rico, for example, 6% of men and 17% of women were found to have migraine
(7 ). In South America, prevalences appear only slightly lower (8).
A recent survey in Turkey suggested even greater prevalence in that country: 9% in men and 29%
in women (9). Similarly, in India, although major studies are still to be conducted, anecdotal evidence
suggests migraine is very common. High temperatures and high light levels for more than eight months
of the year, heavy noise pollution and the Indian habits of omitting breakfast, fasting frequently and
eating rich, spicy and fermented food are thought to be common triggers (10). Migraine appears less
prevalent, but still common, elsewhere in Asia (around 8%) and in Africa (3–7% in community-based
studies) (3). In these areas also, major studies have yet to be carried out.
The higher rates in women everywhere (2–3 times those in men) are hormonally driven.

neurological disorders: a public health approach
73
Tension-type headache
The mechanism of tension-type headache is poorly understood, though it has long been regarded
as a headache with muscular origins (11). It may be stress related or associated with musculo-
skeletal problems in the neck.
Tension-type headache has distinct subtypes. As experienced by very large numbers of people,
episodic tension-type headache occurs, like migraine, in attack-like episodes. These usually last
no more than a few hours but can persist for several days. Chronic tension-type headache, one
of the chronic daily headache syndromes, is less common than episodic tension-type headache
but is present most of the time: it can be unremitting over long periods. This variant is much more
disabling.
Headache in either case is usually mild or moderate and generalized, though it can be one-
sided. It is described as pressure or tightness, like a band around the head, sometimes spreading
into or from the neck. It lacks the speciﬁ c features and associated symptoms of migraine.
Tension-type headache pursues a highly variable course, often beginning during the teenage
years and reaching peak levels around the age of 30–40 years. It affects three women to every
two men. Episodic tension-type headache is the most common headache disorder, reported by
over 70% of some populations (12), though its prevalence appears to vary greatly worldwide (3).
In Japan, for example, Takeshima et al. (13) found 22% of the population to be affected, while
Abduljabbar et al. (14) recorded only 3.1% with tension-type headache in a rural population of
Saudi Arabia (though it was still the most common headache type). Lack of reporting and under-
diagnosis were thought to be factors here, and it may be that cultural attitudes to reporting a
relatively minor complaint explain at least part of the variation elsewhere. Chronic tension-type
headache affects 1–3% of adults (3).
Cluster headache
Cluster headache is one of a group of primary headache disorders (trigeminal autonomic cepha-
lalgias) of uncertain mechanism that are characterized by frequently recurring, short-lasting but
extremely severe headache (1).
Cluster headache also has episodic and chronic forms. Episodic cluster headache occurs in
bouts (clusters), typically of 6–12 weeks’ duration once a year or two years and at the same time
of year. Strictly one-sided intense pain develops around the eye once or more daily, mostly at night.
Unable to stay in bed, the affected person agitatedly paces the room, even going outdoors, until
the pain diminishes after 30–60 minutes. The eye is red and watery, the nose runs or is blocked
on the affected side and the eyelid may droop. In the less common chronic cluster headache there
are no remissions between clusters. The episodic form can become chronic, and vice versa.
Though relatively uncommon, probably affecting no more than 3 per 1000 adults, cluster head-
ache is clearly highly recognizable. It is unusual among primary headache disorders in affecting six
men to each woman. Most people developing cluster headache are 20–30 years of age or older;
once present, the condition may persist intermittently for 40 years or more.
Medication-overuse headache
Chronic excessive use of medication to treat headache is the cause of medication-overuse head-
ache (15), another of the chronic daily headache syndromes.
Medication-overuse headache is oppressive, persistent and often at its worst on awakening
in the morning. A typical history begins with episodic headache — migraine or tension-type
headache. The condition is treated with an analgesic or other medication for each attack. Over
time, headache episodes become more frequent, as does medication intake. In the end-stage,
which not all patients reach, headache persists all day, ﬂ uctuating with medication use repeated
every few hours. This evolution occurs over a few weeks or much, much longer. A common and

74
Neurological disorders: public health challenges
probably key factor at some stage in the development of medication-overuse headache is a switch
to pre-emptive use of medication, in anticipation of the headache.
All medications for the acute or symptomatic treatment of headache, in overuse, are associ-
ated with this problem, but what constitutes overuse is not clear in individual cases. Suggested
limits are the regular intake of simple analgesics on 15 or more days per month or of codeine- or
barbiturate-containing combination analgesics, ergotamine or triptans on more than 10 days a
month (1). Frequency of use is important: even when the total quantities are similar, low daily
doses carry greater risk than larger weekly doses.
In terms of prevalence, medication-overuse headache far outweighs all other secondary
headaches (16). It affects more than 1% of some populations (17 ), women more than men, and
children also. In others for whom there are no published data, in Saudi Arabia for example, clini-
cal experience suggests this disorder is not uncommon, with a tendency to be more evident in
afﬂ uent communities.
Serious secondary headaches
Some headaches signal serious underlying disorders that may demand immediate intervention
(see Box 3.3.1). Although they are relatively uncommon, such headaches worry nonspecialists
because they are in the differential diagnosis of primary headache disorders. The reality is that
intracranial lesions give rise to histories and physical signs that should bring them to mind.
Over-diagnosed headaches
Headache should not be attributed to sinus disease in the absence of other symptoms indicative
of it. Many patients with headache visit an optician, but errors of refraction are overestimated as
a cause of headache. Dental problems may cause jaw or facial pain but rarely headache.
EPIDEMIOLOGY AND BURDEN
Taken together, headache disorders are extraordinarily common. In developed countries, tension-
type headache alone affects two thirds of adult males and over 80% of females (12). Extrapolation
from ﬁ gures for migraine prevalence and attack incidence suggests that 3 000 migraine attacks
occur every day for each million of the general population (6). Less well recognized is the toll of
chronic daily headache: up to one adult in 20 has headache on more days than not (17, 18). Fur-
Box 3.3.1 Serious secondary headaches (headaches to worry about)
Intracranial tumours rarely produce headache until quite
Primary angle-closure glaucoma, rare before middle
large, when raised intracranial pressure is apparent in the
age, may present dramatically with acute ocular hyperten-
history and, in all likelihood, focal neurological signs are
sion, a painful red eye with the pupil mid-dilated and ﬁ xed,
present. Because of the infrequency of intracranial tu-
and, essentially, impaired vision. In other cases headache
mours, brain scanning is not justiﬁ ed as a routine investi-
or eye pain may be episodic and mild.
gation in patients with headache (18).
Idiopathic intracranial hypertension is a rare cause of
Meningitis, and its associated headache, occur in an obvi-
headache not readily diagnosed on the history alone. Pap-
ously ill patient. The signs of fever and neck stiffness, later
illoedema indicates the diagnosis in adults, but is not seen
accompanied by nausea and disturbed consciousness, re-
invariably in children with the condition.
veal the cause.
More commonly encountered in the tropics are the acute
The headache of subarachnoid haemorrhage, commonly
infections, viral encephalitis, malaria and dengue haem-
but not always of sudden onset, is often described as the
orrhagic fever, all of which can present with sudden se-
worst ever. Neck stiffness may take some hours to develop.
vere headache with or without a neurological deﬁ cit. These
Unless there is a clear history of similar uncomplicated epi-
infections need to be recognized wherever they are likely
sodes, these characteristics demand urgent investigation.
to occur.
New headache in any patient over 50 years of age should
Other disorders seen more in the tropics that may pres-
raise the suspicion of giant cell (temporal) arteritis.
ent with subacute or chronic headache are tuberculosis,
Headache can be severe. The patient, who does not feel
neurocysticercosis, neurosarcoidosis and HIV-related
entirely well, may complain of marked scalp tenderness.
infections. These are often diagnosed only on imaging or
Jaw claudication is highly suggestive.
by speciﬁ c laboratory tests.

neurological disorders: a public health approach
75
thermore, several (though not all) follow-up studies in developed countries suggest that headache
prevalence and burden are increasing (19).
No signiﬁ cant mortality is associated with headache disorders, which is one reason why they
are so poorly acknowledged. Nevertheless, among the recognizable burdens imposed on people
affected by headache disorders are pain and personal suffering, which may be substantial, im-
paired quality of life and ﬁ nancial cost. Above all, headache disorders are disabling: worldwide,
WHO ranks migraine alone at 19th among all causes of years of life lost to disability (YLDs) (20).
Collectively, all headache disorders probably account for double this burden (3), which would put
them among the top ten causes of disability. Repeated headache attacks, and often the constant
fear of the next, damage family life, social life and employment (21). For example, social activ-
ity and work capacity are reduced in almost all people with migraine and in 60% of those with
tension-type headache. Headache often results in the cancellation of social activities while, at
work, people who suffer frequent attacks are likely to be seen as unreliable — which they may
be — or unable to cope. This can reduce the likelihood of promotion and undermine career and
ﬁ nancial prospects.
While people actually affected by headache disorders bear much of their burden, they do not
carry it all: employers, fellow workers, family and friends may be required to take on work and
duties abandoned by headache sufferers. Because headache disorders are most troublesome in
the productive years (late teens to 60 years of age), estimates of their ﬁ nancial cost to society
are massive — principally from lost working hours and reduced productivity because of impaired
working effectiveness (22). In the United Kingdom, for example, some 25 million working or school
days are lost every year because of migraine alone (6). Tension-type headache, less disabling
but more common, and chronic daily headache, less common but more disabling, together cause
losses that are almost certainly of similar magnitude.
Therefore, while headache rarely signals serious underlying illness, its public health importance
lies in its causal association with these personal and societal burdens of pain, disability, damaged
quality of life and ﬁ nancial cost. Not surprisingly, headache is high among causes of consulting
both general practitioners and neurologists (23, 24). One in six patients aged 16–65 years in a
large general practice in the United Kingdom consulted at least once because of headache over
an observed period of ﬁ ve years, and almost 10% of them were referred to secondary care (25). A
survey of neurologists found that up to a third of all their patients consulted because of headache
— more than for any other single complaint (26).
Far less is known about the public health aspects of headache disorders in developing and
resource-poor countries. Indirect ﬁ nancial costs to society may not be so dominant where labour
costs are lower but the consequences to individuals of being unable to work or to care for children
may be severe. There is no reason to believe that the burden of headache in its personal elements
weighs any less heavily where resources are limited, or where other diseases are also prevalent.
BARRIERS TO CARE
Headache ought to be a public health concern, yet there is good evidence that very large numbers
of people troubled, even disabled, by headache do not receive effective health care (2). For ex-
ample, in representative samples of the general populations of the United States and the United
Kingdom, only half the people identiﬁ ed with migraine had seen a doctor for headache-related
reasons in the last 12 months and only two thirds had been correctly diagnosed (27 ). Most were
solely reliant on over-the-counter medications, without access to prescription drugs. In a separate
general-population questionnaire survey in the United Kingdom, two thirds of respondents with
migraine were searching for better treatment than their current medication (28). In Japan, aware-
ness of migraine and rates of consultation by those with migraine are noticeably lower (29). Over

76
Neurological disorders: public health challenges
80% of Danish tension-type headache sufferers had never consulted a doctor for headache (30).
It is highly unlikely that people with headache fare any better in developing countries.
The barriers responsible for this lack of care doubtless vary throughout the world, but they may
be classiﬁ ed as clinical, social, or political and economic.
Clinical barriers
Lack of knowledge among health-care providers is the principal clinical barrier to effective head-
ache management. This problem begins in medical schools where there is limited teaching on the
subject, a consequence of the low priority accorded to it. It is likely to be even more pronounced
in countries with fewer resources and, as a result, more limited access generally to doctors and
effective treatments.
Social barriers
Poor awareness of headache extends similarly to the general public. Headache disorders are not
perceived by the public as serious since they are mostly episodic, do not cause death and are not
contagious. In fact, headaches are often trivialized as “normal”, a minor annoyance or an excuse to
avoid responsibility. These important social barriers inhibit people who might otherwise seek help
from doctors, despite what may be high levels of pain and disability. Surprisingly, poor awareness
of headache disorders exists among people who are directly affected by them. A Japanese study
found, for example, that many patients were unaware that their headaches were migraine, or that
this was a speciﬁ c illness requiring medical care (31). The low consultation rates in developed
countries may indicate that many headache sufferers are unaware that effective treatments exist.
Again, the situation is unlikely to be better where resources are more limited.
Political and economic barriers
Many governments, seeking to constrain health-care costs, do not acknowledge the substantial
burden of headache on society. They fail to recognize that the direct costs of treating headache are
small in comparison with the huge indirect cost savings that might be made (for example by reduc-
ing lost working days) if resources were allocated to treat headache disorders appropriately.
MANAGEMENT AND PREVENTION
Successful management of headache disorders follows ﬁ ve essential steps:
■ the sufferer must seek medical treatment;
■ a correct diagnosis should be made;
■ the treatment offered must be appropriate to the diagnosis;
■ the treatment should be taken as directed;
■ the patient should be followed up to assess the outcome of treatment, which should be changed
if necessary.
Therefore the key to successful health care for headache is education (31), which ﬁ rst should
create awareness that headache disorders are a medical problem requiring treatment. Education
of health-care providers should encompass both the elements of good management (see Box
3.3.2) and the avoidance of mismanagement.
Diagnosis
Committing sufﬁ cient time to taking a systematic history of a patient presenting with headache
is the key to getting the diagnosis right. The history-taking must highlight or elicit description of
the characteristic features of the important headache disorders described above. The correct
diagnosis is not always evident initially, especially when more than one headache disorder is
present, but the history should awaken suspicion of the important secondary headaches. Once it
is established that there is no serious secondary headache, a diary kept for a few weeks to record

neurological disorders: a public health approach
77
the pattern of attacks, symptoms and medication use will usually clarify the diagnosis. Physical
examination rarely reveals unexpected signs after an adequately taken history, but should include
blood pressure measurement and a brief but comprehensive neurological examination including
the optic fundi; more is not required unless the history is suggestive. Examination of the head and
neck may ﬁ nd muscle tenderness, limited range of movement or crepitation, which suggest a need
for physical forms of treatment but do not necessarily elucidate headache causation.
Investigations, including neuroimaging, rarely contribute to the diagnosis of headache when
the history and examination have not suggested an underlying cause.
Realistic objectives
There are few patients troubled by headache whose lives cannot be improved by the right medical
intervention with the objective of minimizing impairment of life and lifestyle (32). Cure is rarely
a realistic aim in primary headache disorders, but people disabled by headache should not have
unduly low expectations of what is achievable through optimum management.
Medication-overuse headache and other secondary headaches are, at least in theory, resolved
through treatment of the underlying cause.
Predisposing and trigger factors
Migraine, in particular, is said to be subject to certain physiological and external environmental
factors. While predisposing factors increase susceptibility to attacks, trigger factors may initiate
them. The two may combine. Attempts to control migraine by managing either are often disap-
pointing. A few predisposing factors (stress, depression, anxiety, menopause, and head or neck
trauma) are well recognized but not always avoidable or treatable. Trigger factors are important
and their inﬂ uence is real in some patients, but generally less so than is commonly supposed.
Dietary triggers are rarely the cause of attacks: lack of food is a more prominent trigger. Many
attacks have no obvious trigger and, again, those that are identiﬁ ed are not always avoidable.
Diaries may be useful in detecting triggers but the process is complicated as triggers appear to
be cumulative, jointly overﬂ owing the “threshold” above which attacks are initiated. Too much
effort in seeking triggers causes introspection and can be counter-productive. Enforced lifestyle
change to avoid triggers can itself adversely affect quality of life.
In tension-type headache, stress may be obvious and likely to be etiologically implicated.
Musculoskeletal involvement may be evident in the history or on examination. Sometimes, neither
of these factors is apparent. An interesting variation in the Muslim world is the marked rise,
observed in people ordinarily susceptible to headache, in tension-type headache incidence on the
ﬁ rst day of fasting (33).
Box 3.3.2 Seven elements of good headache management
1
Evident interest and investment of time to inform, explain, reassure and educate
2
Correct and timely diagnosis
3
Agreed high but realistic objectives
4

Identiﬁ cation of predisposing and/or trigger factors and their avoidance through appropriate lifestyle
modiﬁ cations
5

Intervention (optimal management of most primary headaches combines adequate but not excessive use of ef-
fective and cost-effective pharmaceutical remedies with non-pharmacological approaches; secondary headaches
generally require treatment of the underlying cause)
6

Follow-up to ensure optimum treatment has been established
7
Referral to specialist care when these measures fail

78
Neurological disorders: public health challenges
Cluster headache is usually but not always a disease of smokers, many of them heavy consum-
ers of tobacco. However, patients with cluster headache who still smoke cannot be promised that
giving up will end or even improve their headaches. Alcohol potently triggers cluster headache
and most patients have learnt to avoid it during cluster periods.
THERAPEUTIC INTERVENTIONS
The purpose of pharmacotherapy of primary headache, once non-drug measures have been fully
exploited, is to control symptoms so that the impact of the disorder on each individual patient’s life
and lifestyle is minimized. This requires a therapeutic plan tailored for each patient, and patients with
two or more coexisting headache disorders are likely to require separate plans for each disorder.
Migraine
Most people with migraine require drugs for the acute attack. These may be symptomatic or spe-
ciﬁ c. The desirable goal of acute therapy with drugs currently available — resolution of symptoms
and full return of function within two hours — is not attainable by all. When symptom control
with best acute therapy is inadequate, it can be supplemented with prophylactic medication (34),
usually for 4–6 months, aiming to reduce the number of attacks.
General population surveys indicate that large numbers of people with migraine manage
themselves, with no more than symptomatic over-the-counter remedies (27 ). For many this ap-
pears adequate. Simple oral analgesia — acetylsalicylic acid or ibuprofen — is used to best
advantage in soluble formulations taken early because gastric stasis develops as the migraine
attack progresses and this impedes absorption. A prokinetic antiemetic — metoclopramide or
domperidone — enhances the analgesic effect by promoting gastric emptying and is most suit-
able for nausea and vomiting. When oral symptomatic therapy fails, it is logical to bypass the gut
using a non-steroidal anti-inﬂ ammatory drug such as diclofenac, with or without domperidone,
given as rectal suppositories (35).
Speciﬁ c drugs — triptans and, in certain circumstances, ergotamine tartrate — should not
be withheld from those who need them. There are speciﬁ c contraindications to these drugs,
particularly coronary disease (and multiple risk factors thereof) and uncontrolled hypertension,
but triptans as a class show higher efﬁ cacy rates than symptomatic treatments. Population-based
needs assessments suggest many more people with migraine should receive triptans than cur-
rently do. Cost has much to do with this, and this constraint must be more evident in resource-
poor countries where triptans are unlikely to be available. Denial of the best treatment available
is difﬁ cult to justify for patients generally, however, and therefore for individuals: unnecessary
pain and disability are the result. In addition, increasingly it is being demonstrated in developed
countries that under-treatment of migraine is not cost effective: the time lost by sufferers and
their carers is expensive, as are repeated consultations in the search for better therapy. On this
basis some specialists believe that disability assessment should be the means to select patients
to receive triptans. Where disability is the basis of choice, however, it should be noted that over
80% of people with migraine report disability because of it (36).
Which triptan to choose is an individual matter because different patients respond differently
to them: one may work where another does not. In countries where more than one is available,
patients may reasonably try each in turn to discover which suits them best. Relapse (return of
headache within 6–48 hours) in 20–50% of patients who have initially responded is a troublesome
limitation of triptans. A second dose is usually effective for relapse but, occasionally in some pa-
tients and often in a few, induces further relapse. This problem may underlie medication-overuse
headache attributable to triptan overuse (37 ).
Drugs in a range of pharmacological classes have limited but often useful prophylactic efﬁ cacy
against migraine through mechanisms that are presumably not identical but are unclear. The choice

neurological disorders: a public health approach
79
of agent is guided by comorbidities and contraindications. Because poor compliance is a major
factor impairing effectiveness, drugs given once daily are preferable, all else being equal. Beta-
blockers without partial agonism (such as atenolol, metoprolol, and propranolol in a long-acting
formulation) are likely to be ﬁ rst-line prophylactics in many countries. Cardioselectivity and hydro-
philicity do not affect efﬁ cacy but both improve the side-effect proﬁ le, so atenolol may be preferred.
Certain antiepileptic drugs (AEDs), notably divalproex or sodium valproate and topiramate, have
good evidence of efﬁ cacy. Amitriptyline is useful especially when migraine and tension-type head-
ache occur together. Relatively low doses are often sufﬁ cient. Among calcium channel blockers,
only ﬂ unarizine has efﬁ cacy. Methysergide, a synthetic ergot alkaloid, is effective but recommended
for use only under specialist supervision, and not for more than six months continuously.
In some women, hormonal inﬂ uences are important in driving attack frequency, and a special
approach may be taken to menstruation-related migraine (38).
Tension-type headache
Reassurance and over-the-counter analgesics (acetylsalicylic acid or ibuprofen rather than
paracetamol) (39) are sufﬁ cient for infrequent episodic tension-type headache. Most people with
this condition manage themselves: episodic tension-type headache is self-limiting and, though it
may be temporarily disabling, it rarely raises anxieties. If medication usage is on fewer than two
days per week there is little risk of escalating consumption.
People consult doctors because of episodic tension-type headache when it is becoming fre-
quent and, in all likelihood, is no longer responding to painkillers. Long-term remission is then the
objective of management, as it is for chronic tension-type headache. Symptomatic medication is
contra indicated for tension-type headache occurring on more than two days per week: where it is
already being taken at high frequency a diagnosis of chronic tension-type headache rather than
medication-overuse headache cannot be made with conﬁ dence. Whichever condition is present
(and it can be both), frequently taken symptomatic medication must be withdrawn as the ﬁ rst step
(see below).
Physiotherapy is the treatment of choice for musculoskeletal symptoms accompanying fre-
quent episodic or chronic tension-type headache. In stress-related illness, lifestyle changes to
reduce stress, and relaxation and/or cognitive therapy to develop stress-coping strategies, are
the treatment mainstays. Prophylactic medication has a limited role. Amitriptyline is ﬁ rst-line
in most cases, withdrawn after improvement has been maintained for 4–6 months. Long-term
remission is not always achievable, especially in long-standing chronic tension-type headache. A
pain management clinic may be the ﬁ nal option.
Cluster headache
Because of its relative rarity, cluster headache has a tendency to be misdiagnosed, sometimes
for years. It is the one primary headache that may not be best managed in primary care, but the
primary care physician has an important role not only in recognizing it at once but also in discour-
aging inappropriate “treatments” (tooth extraction is not infrequent).
Medication-overuse headache
Prevention is the ideal management of medication-overuse headache, which means avoidance of
acute medication for headache on more than 2–3 days per week on a regular basis. Education is
the key factor: many patients with medication-overuse headache are unaware of it as a medical
condition (40). Once this disorder has developed, early intervention is important since the long-
term prognosis depends on the duration of medication overuse (41).
Treatment is withdrawal of the suspected medication(s). Although this will lead initially to
worsening headache and sometimes nausea, vomiting and sleep disturbances, with forewarning
and explanation it is probably most successful when done abruptly (42).

80
Neurological disorders: public health challenges
Serious secondary headaches
All the serious secondary headaches described above require specialist referral. In most cases,
this should be immediate or urgent.
FOLLOW-UP AND REFERRAL
Neither the ﬁ rst diagnosis, nor the ﬁ rst proposed treatment plan, may be correct. Follow-up
is essential, at intervals balanced on the one hand to allow time for treatment interventions to
achieve observable effect and on the other to meet patients’ natural desires for a quick solution
to a painful and often debilitating problem.
For migraine and episodic tension-type headache, attack frequency is likely to be the principal
determinant. For chronic tension-type headache, follow-up provides the psychological support
that is often needed while recovery is slow.
In medication-overuse headache, early review is essential once withdrawal from medication
has begun, in order to check that it is being achieved: nothing is less helpful than discovering, three
months later, that the patient ran into difﬁ culties and gave up the attempt. During later follow-up,
the underlying primary headache condition is likely to re-emerge and require re-evaluation and a
new therapeutic plan. Most patients with medication-overuse headache require extended support:
the relapse rate is around 40% within ﬁ ve years (41).
Urgent referral for specialist management is recommended at each onset of cluster headache.
Weekly review is unlikely to be too frequent and allows dosage incrementation of potentially toxic
drugs to be as rapid as possible. Patients commencing lithium therapy, or changing their dose,
need levels checked within one week.
In all other cases, specialist referral is appropriate when the diagnosis remains (or becomes)
unclear or these standard management options fail.
HEALTH-CARE POLICY
The volume of headache referrals to neurologists seen in developed countries is difﬁ cult to justify,
and should not be repeated in countries where headache-related health services are being devel-
oped. The common headache disorders require no special investigation and they are diagnosed
and managed with skills that should be generally available to physicians. Management of headache
disorders therefore belongs in primary care for all but a very small minority of patients. Models of
health care vary but, in most countries, primary care has an acknowledged and important role.
It is a role founded on recognition that decisions in primary care take account of patient-related
factors — family medical history and patients’ individual expectations and values — of which the
continuity and long-term relationships of primary care generate awareness (43) while promoting
trust and satisfaction among patients (44).
Even in primary care, however, the needs of the headache patient are not met in the time usu-
ally allocated to a physician consultation in many health systems. Nurses and pharmacists can
complement the delivery of health care.
■ The evident burden of headache disorders on individuals and on society is sufﬁ cient to justify
a strategic change in the approach to headache management (31, 45). In order to implement
beneﬁ cial change, public health policy in all countries must embrace the following elements.
■ The prevalence of the common headache disorders in each region of the world needs to be
known, through further epidemiological research where necessary, in order to gain a complete
picture of headache disorders and their clinical, social and economic implications locally.
■ This information, as it is accumulated, should be employed to combat stigma and increase
public awareness of headache as a real and substantial health problem.

neurological disorders: a public health approach
81
■ Education, as the key to effective headache management, needs improving at all levels. In
the case of the medical profession, this should begin in medical schools by giving headache
disorders a place in the undergraduate curriculum that matches their clinical importance as
one of the most common causes of consultation. Nowhere is this the case at present.
■ The health economics of headache disorders and their effective treatment generally support
investment of health-care resources in headache management programmes, set up in collabo-
ration with key stakeholders to create services appropriate to local systems and local needs.
Their outcomes should be evaluated in terms of measurable reductions in population burden
attributable to headache disorders.
PARTNERSHIPS WITHIN AND BEYOND THE HEALTH SYSTEM
The elements listed above form the framework of WHO’s Global Campaign to Reduce the Burden
of Headache Worldwide (45 ). Launched in March 2004, this campaign — known as “Lifting
the Burden” — is a formal partnership between WHO and the international nongovernmental
organizations for headache: the lay World Headache Alliance and the professional International
Headache Society and European Headache Federation. The objectives of Lifting the Burden are,
region by region throughout the world, to:
■ measure the burden of headache disorders;
■ raise awareness of headache disorders among local health policy-makers;
■ work with people and agencies locally to plan locally appropriate health-care solutions;
■ put these solutions in place, providing clinical management supports;
■ test them, and modify and re-test if necessary, for optimal beneﬁ cial change.
Aside from this partnership, lay and professional groups in countries around the world play im-
portant, though often less formal, roles in education and in sharing information and experience.
RESEARCH
Five research fronts are currently important in the ﬁ eld of headache medicine.
■ Basic research concentrates on elucidating disease mechanisms, particularly those that re-
spond to environmental inﬂ uences and those with a genetic basis. The ﬁ ndings will guide the
development of new treatments.
■ Pharmaceutical research and clinical trials support the translation of new discoveries into
better treatments for people with headache disorders.
■ Epidemiological research will establish the scope and scale of headache-related burden of ill-
ness around the world. The results will guide appropriate allocation of health-care resources by
policy-makers. Epidemiological studies may also identify preventable risk factors for headache
disorders.
■ Health services research, backed by health economics studies, may show that the reallocation
of resources towards improving health-care delivery offers greater beneﬁ ts for people with
headache disorders — by more effectively using treatments already available — than the
search for new pharmacological interventions. This is particularly so given the prevalence of
medication misuse (both underuse and overuse). Community intervention studies may lead to
better prevention of headache disorders.
■ Outcomes research is needed to guide optimal health care and its delivery through organized
health services.
The importance of patient and public involvement in deﬁ ning research objectives should be
emphasized: lay people have experience and skills that complement those of researchers.

82
Neurological disorders: public health challenges
CONCLUSIONS AND RECOMMENDATIONS
1
Headache disorders are common and ubiquitous. They have a neurological basis,
but headache rarely signals serious underlying illness. The huge public health
importance of headache disorders arises from their causal association with
personal and societal burdens of pain, disability, damaged quality of life and
ﬁ nancial cost.
2
Headache disorders have many types and subtypes, but a very small number of
them impose almost all of these burdens. They are diagnosed clinically, requiring
no special investigations in most of the cases.
3
Although headache disorders can be treated effectively, globally they are not,
because health-care systems fail to make treatment available.
4
Management of headache disorders everywhere in the world has low priority,
which abjectly fails to match headache-related health-care provision and delivery
to people’s needs.
5
Effective management of headache disorders can be provided in primary care for
all but a very small minority of patients. Nurses and pharmacists can complement
the delivery of health care by primary care physicians.
6
Good management, at whatever level, requires education of doctors and of people
affected by headache disorders. Mismanagement, and overuse of medications to
treat acute headache, are major risk factors for disease aggravation.
7
Every government should acknowledge the humanitarian arguments for effective
health care for headache disorders.
8
Every government should be aware of the ﬁ nancial cost to the country of
headache disorders in its population. Cost-of-illness studies will create
awareness of the potential savings that better health care for headache disorders
may achieve through mitigated productivity losses.
9
Partnerships between health policy-makers, health-care providers and people
affected by headache disorders and their advocacy groups may be the best
vehicle for determining, and bringing about, the changes that people with
headache need.

neurological disorders: a public health approach
83
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2. Headache Classiﬁ cation Subcommittee of the International Headache Society. The international
classiﬁ cation of headache disorders, 2nd ed. Cephalalgia, 2004, 24(Suppl. 1):1–160.
3. Stovner LJ et al. The global burden of headache: a documentation of headache prevalence and disability
worldwide. Cephalalgia (accepted for publication).
4. Ferrari MD. Migraine. Lancet, 1998, 351:1043–1051.
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Epidemiology of pain. Seattle, WA, IASP Press, 1999:159–170.
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8. Morillo LE et al. Prevalence of migraine in Latin America. Headache, 2005, 45:106–117.
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10. Ravishankar K. Barriers to headache care in India and efforts to improve the situation. Lancet Neurology,
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11. Kellgren JH. Observations on referred pain arising from muscle. Clinical Science, 1938,
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12. Rasmussen BK. Epidemiology of headache. Cephalalgia, 1995, 15:45–68.

13. Takeshima T et al. Population-based door-to-door survey of migraine in Japan: the Daisen study. Headache,
2004, 44:8–19.

14. Abduljabbar M et al. Prevalence of primary headache syndrome in adults in the Qassim region of Saudi
Arabia. Headache, 1996, 36:385–388.

15. Diener H-C et al. Analgesic-induced chronic headache: long-term results of withdrawal therapy. Journal of
Neurology, 1989, 236:9–14.

16. Srikiatkhachorn A, Phanthurachinda K. Prevalence and clinical features of chronic daily headache in a
headache clinic. Headache, 1997, 37:277–280.

17. Castillo J et al. Epidemiology of chronic daily headache in the general population. Headache, 1999,
39:190–196.

18. Frishberg BM et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with
nonacute headache. Saint Paul, MN, American Academy of Neurology, 2001
(http://www.aan.com/professionals/practice/pdfs/gl0088.pdf).

19. Scher AI et al. Prevalence of frequent headache in a population sample. Headache, 1998, 38:497–506.

20. Stovner LJ, Hagen K. Prevalence, burden and cost of headache disorders. Current Opinion in Neurology,
2006, 19:281–285.
21. The world health report 2001 – Mental health: new understanding, new hope. Geneva, World Health
Organization, 2001:22–24.

22. Lipton RB et al. The family impact of migraine: population-based studies in the US and UK. Cephalalgia,
2003, 23:429–440.

23. Schwartz BS, Stewart WF, Lipton RB. Lost workdays and decreased work effectiveness associated with
headache in the workplace. Journal of Occupational and Environmental Medicine, 1997, 39:320–327.

24. Hopkins A, Menken M, De Friese GA. A record of patient encounters in neurological practice in the United
Kingdom. Journal of Neurology, Neurosurgery and Psychiatry, 1989, 52:436–438.

25. Wiles CM, Lindsay M. General practice referrals to a department of neurology. Journal of the Royal College of
Physicians, 1996, 30:426–431.

26. Laughey WF et al. Headache consultation and referral patterns in one UK general practice. Cephalalgia,
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27. Hopkins A. Neurological services and the neurological health of the population in the United Kingdom.
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28. Lipton RB et al. Patterns of health care utilization for migraine in England and in the United States.
Neurology, 2003, 60:441–448.

29. Dowson A, Jagger S. The UK Migraine Patient Survey: quality of life and treatment. Current Medical Research
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39. Steiner TJ, Lange R, Voelker M. Aspirin in episodic tension-type headache: placebo-controlled dose-ranging
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41. Schnider P et al. Long-term outcome of patients with headache and drug abuse after inpatient withdrawal:
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42. Hering R, Steiner TJ. Abrupt outpatient withdrawal of medication in analgesic-abusing migraineurs. Lancet,
1991, 337:1442–1443.

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44. Mainous AG et al. Continuity of care and trust in one’s physician: evidence from primary care in the United
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45. Steiner TJ. Lifting the burden: the global campaign against headache. Lancet Neurology, 2004, 3:204–205.
RECOMMENDED READING
■ American Association for the Study of Headache and International Headache Society. Consensus statement
on improving migraine management. Headache, 1998, 38: 736.
■ Frishberg BM et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with
nonacute headache. Saint Paul, MN, American Academy of Neurology, 2001
(http://www.aan.com/professionals/practice/pdfs/gl0088.pdf).
■ Headache Classiﬁ cation Subcommittee of the International Headache Society. The international classiﬁ ca-
tion of headache disorders, 2nd ed. Cephalalgia, 2004, 24(Suppl. 1):1–160.
■ Lipton RB et al. The family impact of migraine: population-based studies in the US and UK. Cephalalgia,
2003, 23:429–440.
■ Olesen J et al., eds. The headaches, 3rd ed. Philadelphia, PA, Lippincott, Williams & Wilkins, 2006.
■ Schwartz BS, Stewart WF, Lipton RB. Lost workdays and decreased work effectiveness associated with
headache in the workplace. Journal of Occupational and Environmental Medicine, 1997, 39:320–327.
■ Steiner TJ. Lifting the burden: the global campaign against headache. Lancet Neurology, 2004, 3:204–205.
■ Steiner TJ, Fontebasso M. Headache. BMJ, 2002, 325:881–886.
■ Steiner TJ et al. The prevalence and disability burden of adult migraine in England and their relationships to
age, gender and ethnicity. Cephalalgia, 2003, 23:519–527.
■ Guidelines for all doctors in the diagnosis and management of migraine and tension-type headache. London,
British Association for the Study of Headache, 2004 (http://www.bash.org.uk).
■ Headache disorders and public health: education and management implications. Geneva, World Health
Organization, 2000.
■ The world health report 2001 – Mental health: new understanding, new hope. Geneva, World Health
Organization, 2001:22–24.

neurological disorders: a public health approach
85
3.4 Multiple sclerosis
85 Diagnosis and classiﬁ cation
86 Course and outcome
87 Epidemiology and burden
89 Impact
Multiple sclerosis affects around 2.5 million people worldwide:
90 Prevention and treatment
it is one of the most common neurological disorders and cause
92 Research
of disability of young adults, especially in Europe and North
93 Training
America. There is a lack of epidemiological studies from Asia
93 Conclusions and recommendations
where the prevalence is reported to be low, though, with the
availability of more neurologists and magnetic resonance imag-
ing, a larger number of patients are being diagnosed. Although some people experience little
disability during their lifetime, up to 60% are no longer fully ambulatory 20 years after onset,
with signiﬁ cant implications for their quality of life and the ﬁ nancial cost to society.
Multiple sclerosis (MS) is an inﬂ ammatory demyelinating condition of the central nervous system
(CNS) that is generally considered to be autoimmune in nature. In people with MS, the immune
trigger is unknown, but the targets are myelinated CNS tracts. In regions of inﬂ ammation, break-
down of the blood–brain barrier occurs and destruction of myelin ensues, with axonal damage,
gliosis and the formation of sclerotic plaques.
Plaques (MS lesions) may form in the CNS white matter in any location (and also in grey mat-
ter); thus, clinical presentations may be diverse. Continuing lesion formation in MS often leads to
physical disability and, not infrequently, to cognitive decline.
DIAGNOSIS AND CLASSIFICATION
As the above deﬁ nition suggests, MS can lead to a wide variety of symptoms, affecting different
parts of the body and with varying severity. Diagnosis of MS has always been clinically based,
but many tests — notably magnetic resonance imaging (MRI) and more speciﬁ c diagnostic cri-
teria — are now available to assist the clinician. MRI, the examination of the cerebrospinal ﬂ uid
(CSF) and visual evoked potentials are helpful in conﬁ rming the clinical suspicion of MS. In Asia,
where the prevalence is reported to be low (1–5 per 100 000), the clinical presentation may be
similar to that seen in Europe and North America, with manifestations suggesting cerebral, brain-
stem, cerebellar, optic nerve and spinal cord involvement (western type of MS) or may present
with more restricted recurrent optic nerve and spinal cord involvement (opticospinal form or the
Asian variant). The reason for this variation is not known.
Typically, the clinician takes a detailed neurological history and carries out a neurological ex-
amination to assess how the nervous system has been affected. To establish the diagnosis of MS,
a neurologist must demonstrate that involvement of the CNS is disseminated in time and space
and exclude any other diagnostic possibility. Deﬁ ned criteria are used to conclude whether the
features fulﬁ l the clinical diagnosis and allow for more precision, thus lessening the likelihood of
an incorrect diagnosis. Currently, the most widely accepted guidelines to the diagnosis of MS are
the “McDonald criteria” (1). These criteria incorporate MRI to provide evidence of dissemination in

86
Neurological disorders: public health challenges
time and space and enable the clinician to make an early diagnosis of MS. They also facilitate the
diagnosis of MS after a ﬁ rst attack (a clinically isolated syndrome) and in disease with insidious
progression (the primary progressive form of MS), see below.
While these criteria have proved to be useful in a typical adult Caucasian population of western
European ethnic origin, their validity remains to be proven in other regions such as Asia where
some studies still use Poser’s criteria. As the experience with MRI in MS builds up, it is expected
that the McDonald criteria with minor modiﬁ cations will become applicable worldwide. It is always
essential that other conditions mimicking MS (such as vascular disorders, Sjogren’s disease and
sarcoid) are excluded.
COURSE AND OUTCOME
Just as the symptoms of MS are varied, so too is the course of the disease. Although some people
with MS experience little disability during their lifetime, up to 60% are no longer fully ambulatory
20 years after onset. In rare cases MS is so malignantly progressive it is terminal, but most people
with MS have a normal or near-normal life expectancy.
Typical patterns of progression, illustrated in Figure 3.4.1, are explained below.
■ Relapsing/remitting MS. Approximately 80% of patients will initially present this form of
MS, in which there are unpredictable attacks (relapses) during which new symptoms appear
or existing symptoms become more severe. The relapses can last for varying periods (days
or months) and there is partial or total recovery (remission). The disease may appear to be
clinically inactive for months or years, though MRI studies show that asymptomatic inﬂ am-
matory activity is usually more frequent. Over time, however, symptoms may become more
severe with less complete recovery of function after each attack, possibly because of gliosis
and axonal loss in repeatedly affected plaques. People with MS may then enter a progressive
phase, characterized by a step-like downhill course.
Figure 3.4.1 Patterns of progression of multiple sclerosis
Disability
Disability
Time
Time
Relapsing/remitting MS (2 typical courses)
Secondary progressive MS (2 typical courses)
Disability
Time
Source (2).
Primary progressive MS (2 typical courses)

neurological disorders: a public health approach
87
■ Secondary progressive MS is characterized by progression that is not relapse related. Ap-
proximately 50% of patients with relapsing/remitting MS will develop secondary progressive MS
within 10 years, and 80% will have developed this form of MS within 20 years of disease onset.
■ Primary progressive MS, which affects around 10–15% of all MS patients, is characterized by
a lack of distinct attacks, but with slow onset and then steadily worsening symptoms. There is an
accumulation of deﬁ cits and disability which may level off at some point or continue over years.
■ Benign MS. A diagnosis of benign MS is retrospective, when the accumulated disability from
relapsing/remitting MS is either mild or non-existent after a long period (usually considered
to be 15–20 years). Given that follow-up studies show that most patients of this type will
eventually enter a disabling secondary progressive phase, the term “benign” is somewhat
misleading.
Prognostic factor
Although MS is an unpredictable condition, some studies have suggested that onset with sensory
symptoms or optic neuritis may have a better outlook. It has also been shown that multisite
presentations and poor recovery from an initial episode may indicate a worse outcome. Studies
that have observed a difference by sex usually indicate that males experience a more severe
course than females.
EPIDEMIOLOGY AND BURDEN
The incidence and prevalence of MS have been studied extensively (3). Some features of the
disease are generally accepted and are discussed further in this section.
■ The frequency of MS varies by geographical region throughout the world, apparently increasing
with distance from the equator in both hemispheres.
■ The disease is more common among women than men.
■ Peak onset is at around 30 years of age.
■ The disease is less common among non-white individuals than whites.
Etiology and risk factors
The distributions of MS by geography, sex, age, and race or ethnicity have all been explored for
clues to etiology. Most early research focused on the possible role of an environmental factor that
varied with latitude. To date no such risk factor for the disease has been unequivocally identiﬁ ed,
though researchers continue to believe that one exists. There is substantial evidence of a genetic
predisposition to the disease based on familial aggregation, and some debate over whether genet-
ics or exposure to an environmental trigger primarily accounts for its geographical distribution.
Relatively little is known about factors that predict the course of MS.
The worldwide distribution of MS can be only an indirect reﬂ ection of its cause, implicating
some environmental factor that varies with latitude, and can be interpreted in at least three differ-
ent ways in the search for clues to a speciﬁ c etiology. First, an environmental risk factor may be
more common in temperate than tropical climates. Second, such a factor may be more common
in tropical climates, where it is acquired at an earlier age and consequently has less impact.
Third, this factor may be equally common in all regions, but the chance of its acquisition or of the
manifestation of symptoms is either increased by some enhancing factor present in temperate
climates or reduced by a protective factor present in tropical areas.
Among those factors that have been most closely scrutinized are:
■ infections, including a number of viral infections such as measles and Epstein–Barr virus;
■ climate and solar conditions;
■ living conditions;
■ diet and trace elements.

88
Neurological disorders: public health challenges
It is now generally accepted that the etiology of MS involves some interplay of genetic and
environmental factors. Evidence of racial or ethnic resistance, the increased risk among MS family
members, and elevated monozygotic twin concordance rate all favour a genetic contribution to
acquisition of the disease. The studies from which this evidence is derived, however, also indicate
that heredity cannot entirely explain the occurrence of MS. This is underlined by the fact that no
population-based study of monozygotic twins has found a concordance rate in excess of 30%.
Some environmental factor, such as a virus or toxin, must still play a role.
Global and regional distribution
The fact that there is an uneven geographical distribution of MS has been known since early in the
20th century. The prevalence of MS has been shown to vary with latitude, with rates broadly rising
as distance from the equator increases, in both the northern and southern hemispheres. While
there is some truth to this, it belies the complex interaction of geography, genes and environment
that larger scale epidemiological studies have uncovered.
As a recent meta-analysis of the epidemiology of MS put it “The updated distribution of MS
[in Europe], showing many exceptions to the previously described north-south gradient, requires
more explanation than simply a prevalence-latitude relationship. Prevalence data imply that racial
and ethnic differences are important in inﬂ uencing the worldwide distribution of MS and that its
geography must be interpreted in terms of the probable discontinuous distribution of genetic
susceptibility alleles, which can however be modiﬁ ed by environment. Because the environmental
and genetic determinants of geographic gradients are by no means mutually exclusive, the race
versus place controversy is, to some extent, a useless and sterile debate” (4).
There is substantial literature on the relationship between migration and the prevalence and
incidence of MS. Studies both between and within countries invariably show that immigrants mov-
ing from high-risk to low-risk areas have a higher rate than that in their new homeland, but often
somewhat lower than that in their place of origin. (Note that if this observation were based only
on prevalence data, it might simply reﬂ ect the fact that sick and disabled people are less likely to
move, rather than less frequent exposure to a risk factor or more frequent exposure to a protective
factor in the new place of residence. However, data for the United States are based primarily on
incidence and document the same decline in risk as found in prevalence studies.)
There are fewer studies of immigrants from low-risk to high-risk areas, but most ﬁ ndings indi-
cate that immigrants retain the same risk as in their countries of origin. This may be because they
carry some protective factor with them, but these studies frequently involve non-white immigrants
in whom the disease is known to be rare and who may be genetically resistant.
All areas at medium to high risk for MS throughout the world have predominantly white popula-
tions. In countries with both white and non-white populations, MS rates are lower among non-
whites. For example, the disease is virtually non-existent among Australian Aborigines, New
Zealand Maoris and Black people in South Africa. In the United States, incidence and prevalence
rates are twice as high among whites as among African Americans regardless of latitude. Fur-
thermore, MS is also less frequent among North American Indians, Latin Americans, and people
of the Western Paciﬁ c Region than among whites.
Childhood multiple sclerosis
While MS is predominantly an illness of young to middle-aged adults, it is also increasingly appar-
ent that the disease can occur in children. Interest in, and knowledge of, paediatric MS has been
increasing, and as a consequence the number of children diagnosed has also risen considerably
over the last 10 years. At least 2.5–5% of all patients with MS experience their ﬁ rst clinical attack
prior to their 16th birthday, though this may be an underestimate.
Typically, with paediatric MS, the sex difference is not as marked as it is with adults, the ratio
of female to male being closer to 1:1 than the 2:1 that is normally cited for adults. This suggests

neurological disorders: a public health approach
89
that, while the genetic implication of being female may inﬂ uence MS risk, it appears to do so
much more after puberty.
Further evidence of the role that environmental factors play comes from the studies of children
of migrants. For example, the prevalence rates among the British-born children of immigrants from
India, Pakistan, and parts of Africa and the West Indies were very much higher than those recorded
for their parents and approximately equal to the expected rate for England.
IMPACT
Multiple sclerosis has a profound impact on patients’ social roles and the well-being of their
families. Varying degrees of functional decline typically accompany MS. Because the onset is
usually at about 30 years of age, the loss in productivity of people with MS can be substantial.
Such functional decline will often interfere with the opportunities for people with MS to perform
their customary roles. For example, physical disability — complicated by fatigue, depression and
possibly cognitive impairment — contributes to an unemployment rate as high as 70% among
people with MS; to replace lost earnings, they frequently collect disability beneﬁ ts and social
welfare. People with MS use more health-care resources than the general population (5). Together
with their family members, they may also bear a ﬁ nancial burden related to home and transport
modiﬁ cations and the need for additional personal services.
The socioeconomic impact of MS on the individual is well illustrated by a recent United King-
dom study (6). In this population-based survey of all known patients with MS and their relatives
in the county of Hampshire, England, about 53% of those who were employed at the time of diag-
nosis gave up their jobs, and the standard of living of 37% of patients and their families declined
as a direct result of the disease. The ability to continue in gainful employment or to maintain
social contacts and leisure activities correlates with the course and severity of the disease and
cognitive function. Most carers reported symptoms that clearly related to organic pathologies,
anxiety and symptoms of depression. The occurrence of these symptoms was associated with
disease severity. The professional careers of 57% of relatives were also adversely affected by
the patient’s illness.
The economic cost to society is also great (7 ). A recent economic analysis for the Australian
MS Society (Acting Positively) illustrated the impact of the disease, which is considered typical
(so far no global economic impact studies have been published). The Australian study found that
the burden of the disease is likely to grow. Prevalence is expected to grow by 6.7% in the next ﬁ ve
years, faster than population growth attributable to demographic ageing. The total ﬁ nancial costs
of MS in 2005 are estimated at more than US$ 450 m (0.07% of GDP) and US$ 29 070 per person
with MS, or US$ 23 per Australian per year. Lost productive capacity and the replacement value
of informal community care are the two largest cost components (8). The following key economic
factors were highlighted by the Australian study.
■ Informal care for people with MS in the community represents 43% of total costs, with an
average of 12.3 hours per week of informal care required per person with MS.
■ Aids and modiﬁ cations for people with physical disability were estimated to represent a further
4.6% of total ﬁ nancial costs.
■ Production losses stemming from reduced work hours, temporary absences, early retirement
and premature death are responsible for around 26% of total economic costs.
■ Pharmaceuticals for people with MS, mainly beta-interferons, are estimated to represent 14%
of total costs.
■ Nursing home accommodation accounts for around 4.3% of total economic costs. Of the
estimated 730 people with MS in (high care) nursing homes 37% are under 65 years of age.
■ Other health-care costs — including hospitalizations, specialist and primary care and allied
health expenses — account for 4.4%. Research is 1.9% of health expenditure, below the aver-

90
Neurological disorders: public health challenges
age of 2.4%. Deadweight losses arising from taxation revenue foregone and welfare payment
transfers are estimated as US$ 10.5 million or 2.3% of total costs in 2005.
■ The burden of disease — the suffering and premature death experienced by people with
MS — is estimated to cost an additional 8968 DALYs (years of healthy life lost), with two thirds
attributable to disability and one third to premature death.
■ Last but not least, in Australia MS causes more disability and loss of life than all chronic back
pain, slipped discs, machinery accidents, rheumatic heart disease or mental retardation.
PREVENTION AND TREATMENT
Uncertainty over the cause or development of MS implies that prevention is not currently a realistic
option. Furthermore, there are no curative treatments available for MS (9). A number of disease-
modifying drugs have been developed in the past 20 years, however, which reduce the number
of attacks in the relapsing/remitting form of the disease. The extent to which eventual disease
burden and disability are limited by use of the drugs is less clear. The most widely used disease-
modifying drugs for MS are the beta-interferons (1a and 1b) and glatiramer acetate, which reduce
the frequency and perhaps the severity of relapses. Although these drugs have been introduced in
the developing regions, their high cost means many patients are unable to have access to them.
The United States National MS Society also has developed several guidelines and recommenda-
tions, mainly for medical treatment (such as changing therapy and early intervention). To date,
no medical treatments for the progressive forms of the disease exist, and results from studies
focusing on neuroprotection and repair are eagerly awaited.
Corticosteroids are the medications of choice for treating exacerbations and can be admin-
istered in the hospital or community setting (the latter is usually preferred) (10). In addition to
strategies aimed at the impact of the disease, drugs to ameliorate common MS symptoms — such
as urinary dysfunction, spasticity and neuropathic pain — are relatively well established and
widely used. European guidelines have been developed for both the use of the established dis-
ease-modifying drugs and the treatment of symptoms (11, 12).
Even though drug treatment options are relatively limited, signiﬁ cant improvements in the qual-
ity of life of people with MS can be supported by improved rehabilitation approaches. For patients
with relatively moderate disability, exercise (both aerobic and non-aerobic) has been found to be
useful, as has physiotherapy. There have been few, if any, studies evaluating the rehabilitation
needs of those with more severe disability.
Neurorehabilitation
The philosophy of neurorehabilitation, which emphasizes patient education and self-manage-
ment, is well suited to meet the complex and variable needs of MS (13). Neurorehabilitation aims
to improve independence and quality of life by maximizing ability and participation. It has been
deﬁ ned by WHO as “an active process by which those disabled by injury or disease achieve a
full recovery or, if a full recovery is not possible, realize their optimal physical, mental and social
potential and are integrated into their most appropriate environment”. Together with Rehabilitation
in Multiple Sclerosis, the European Multiple Sclerosis Platform (EMSP) developed useful guidance
on this issue in their recommendations on MS rehabilitation services (14), one of the reference
guidelines for their European Code of Good Practice in MS.
The essential components of successful neurorehabilitation include expert multidisciplinary
assessment, goal-oriented programmes and evaluation of impact on patient and goal achievement
through the use of clinically appropriate, scientiﬁ cally sound outcome measures incorporating the
patient’s perspective (14).
While these principles are intuitively sound, the evidence underpinning multidisciplinary as-
sessment and goal-orientated programmes is weak. Fundamental to the provision of robust

neurological disorders: a public health approach
91
evidence of the beneﬁ ts of rehabilitation interventions is the use of scientiﬁ cally sound outcome
measures. In the ﬁ eld of MS, the limitations of the Expanded Disability Status Scale have been
well aired and it can be argued that the scale is even less relevant to neurorehabilitation as it fails
to incorporate the views of the patient.
The issues relating to the management of symptoms that affect people with MS are identical
to those concerning neurorehabilitation: the need for robust clinical trials based on scientiﬁ -
cally sound outcome measures, multidisciplinary expertise and the involvement of patients. The
frequency with which these symptoms affect people with MS has been documented for a range
of symptoms including fatigue, spasticity, pain and cognitive impairment. The need for a multi-
disciplinary and multimodal approach to symptom management is described in a recent review
(15) and is exempliﬁ ed in the case of spasticity (16).
Service delivery
Evaluating service delivery may be considered the most important and relevant issue in the man-
agement of MS. This is because it incorporates acute hospital and neurorehabilitation services
with community-based activities and has to bring together medical and social services in a way
that meets the complex and ever-changing needs of the person with MS.
Ideally, most services should be community-based with supporting expertise from the acute
hospital or rehabilitation centre at times of particular need (such as at diagnosis or during a severe
relapse) or complexity (when multiple symptoms interact and intensive inpatient rehabilitation is
required). The optimum method of service delivery has not yet been deﬁ ned, and little comparison
has been made of existing services.
A recently published study (17 ) compared two forms of service delivery in a randomized con-
trolled trial. One group received what was described as “hospital home care”, in which patients
remained in the community but had immediate access to the hospital-based multidisciplinary team
when required, while the other group received routine care. No difference was seen in the level
of disability between the two groups after 12 months, but the “hospital home care” patients, who
were more intensely treated, had signiﬁ cantly less depression and improved quality of life.
There continue to be major problems worldwide in delivering a model of care that provides
truly coordinated services. There is serious inequity of service provision both within and across
countries, and an inordinate and unacceptable reliance on family and friends to provide essential
care. Establishing guidance, such as has been done by the National Institute for Clinical Excellence
(18), is a step forward but a global initiative such as that of the Multiple Sclerosis International
Federation (MSIF) to promote the quality of life of people with MS may be more effective (19). The
key challenge will be ensuring the translation of these guidelines into practice.
Delivery of care to people with MS varies signiﬁ cantly around the world. In part this reﬂ ects
the differences in incidence and therefore the relative importance afforded to the disease within
a country’s health system. Given the importance of expensive diagnostic equipment (scanners)
and the cost of the existing treatments, however, the variation also reﬂ ects different national
income levels. In the developed countries, the cost of the treatment is borne by the government
or insurance companies but in some regions the patients have to pay for drugs, making it difﬁ cult
for them to take advantage of emerging new treatments.
The delivery of care for people with long-term illnesses is becoming increasingly “patient cen-
tred”, and a culture of treatment by interdisciplinary teams is emerging. Within this model, the aim
is to offer patients a seamless service, which typically involves bringing together various health
professionals including doctors, nurses, physiotherapists, occupational therapists, speech and
language therapists, clinical psychologists and social workers. Other professionals with expertise
in treating neurologically disabled people cover dietetics, continence advisory and management
services, pain management, chiropody, podiatry and ophthalmology services.

92
Neurological disorders: public health challenges
Quality of life issues
MS will usually have a substantial adverse effect on a person’s quality of life. Improving quality
of life should be a key goal for policy-makers as well as those who advocate on behalf of people
with MS. A recent key step has been the publication by MSIF of its quality of life principles (19),
as mentioned above. The development of these principles was based on a series of interviews, a
literature review, the clinical, programmatic, and research experience of the authors, and review
by a work group and a technical oversight group organized by MSIF.
The principles are designed to be used by international organizations, national MS societies,
people with MS and their families, governments, health, social and continuing care providers,
employers, researchers, businesses and others to evaluate existing and proposed services and
programmes and to advocate for improvements. The areas covered include:
■ independence and empowerment;
■ medical care;
■ continuing care (long-term or social);
■ health promotion and disease prevention;
■ support for family members;
■ transport;
■ employment and volunteer activities;
■ disability beneﬁ ts and cash assistance;
■ education;
■ housing and accessibility of buildings in the community.
Treatment gap
There is no doubt that a signiﬁ cant treatment gap exists in approaches to MS between countries
(and possibly within countries). Until a cure is found, people with MS have to rely on reducing
the inﬂ ammation during an acute phase by the use of corticosteroids and providing symptomatic
relief. The disease-modifying agents such as beta-interferon and glatiramer acetate can be offered
to decrease the relapses and disease burden. Ideally, this treatment programme requires early
diagnosis and adequate human resources and equipment. The situation is especially problematic
in the developing countries, as often equipment such as an MRI scanner is not available or is too
expensive. The disease-modifying agents are also costly and beyond the reach of many patients.
In addition, rehabilitation centres for people with MS are not available.
A further illustration of the treatment gap between rich and less developed countries in their
treatment of MS is apparent from data currently being collected by WHO, the MSIF and the EMSP.
These data, which will in time be integrated into an international comparative and interactive data-
base (MSIF/WHO Atlas of MS and European Map of MS), have been sourced by surveying neurolo-
gists and patient organizations across 98 geographically and economically diverse countries.
For example, in response to the key treatment question “What percentage of people with MS
who fulﬁ l the clinical prescription criteria for disease-modifying drugs [in your country] receive
treatment?” the average answer from 15 responding members of the European Union was 64%.
This compares with (for example) 45% for Brazil, 50% for the Russian Federation, 10–15% for
Turkey and less than 5% for India.
RESEARCH
As with many neurological diseases, MS is extremely difﬁ cult to study. Even after several decades
of intense research activity, it remains a mysterious condition with no known pathogen or ac-
cepted determinants of its severity or course. Nonetheless, optimism amongst the MS research
community is high. Advances in non-invasive investigative techniques, particularly MRI, have led

neurological disorders: a public health approach
93
to signiﬁ cant improvements in the ability to create images and track the course of the disease. Key
areas of current research encompass immunology, genetics, virology/bacteriology, and the biology
of the cells that make, maintain and repair myelin in the CNS (including developments in neural
stem cells). The key outcome of the research effort to date has been an improved understanding
of the pathology and the evolution of the disease and, as a consequence, new approaches to
treatment including repair and neuroprotection.
In addition to the advances being made at the therapeutic level, signiﬁ cant improvements are
being made in the management of the disease. In large part this has been stimulated by research-
ers adopting a more patient-centred approach. Whereas MS research used to be conducted by
physicians on behalf of people with MS, today’s research protocols are more likely to be driven
by patient perspectives. This is leading to research being carried out into factors determining the
quality of life of people with MS, such as health-care policy, employment and welfare matters and
the wider familial impact of the disease. Fortunately, there are active multiple sclerosis support
groups in several regions of the world that are involved in improving the quality of life of people
with MS.
TRAINING
There is a speciﬁ c lack of public and professional awareness of the dimension of MS in the
domains of epidemiology and impact of disease on individuals, carers and society, including
impact on individual loss of independence, and cost of long-term care. In particular, the chronic
progressive nature of the condition must be better conveyed to all. MSlF, through its member
organizations, has proven very effective and capable of concerted action in the ﬁ eld of patient
and lay public education.
CONCLUSIONS AND RECOMMENDATIONS
1
MS is the most prevalent inﬂ ammatory demyelinating disease of the central nervous
system in young adults.
2
The cause is (as yet) unknown.
3
Initially, MS most often runs a relapsing/remitting course, later becoming progressive.
4
Depending on the site and extent of the lesions, a variety of symptoms may occur, often
in parallel.
5
Many of the symptoms may be treated effectively with drugs and rehabilitation measures.
6
Immunomodulating therapies may reduce relapse frequency and progression of MRI
abnormalities.
7
Rehabilitation is most important and aims at leading individuals to adapt their lifestyle.
8
Burden and costs, including the costs of treatment, are considerable for the persons
affected, their relatives and society.

94
Neurological disorders: public health challenges
REFERENCES
1. Polman CH et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the “McDonald criteria”. Annals
of Neurology, 2005, 58:840–846.
2. Update on medical management of multiple sclerosis to staff of the Multiple Sclerosis Society of New South
Wales. Lidcombe, Multiple Sclerosis Society of New South Wales, 2003.
3. Warren S, Warren KG. Multiple sclerosis. Geneva, World Health Organization, 2001.
4. Rosati G. The prevalence of multiple sclerosis in the world: an update. Neurological Sciences, 2001,
22:117–139.
5. Sternfeld L. Utilization and perceptions of healthcare services by people with MS. New York, US National
Multiple Sclerosis Society, 1995.
6. Hakim EA et al. The social impact of multiple sclerosis – a study of 305 patients and their relatives. Disability
and Rehabilitation, 2000, 22:288–293.
7. Kobelt G, Pugliatti M. Cost of multiple sclerosis in Europe. European Journal of Neurology, 2005, 12(Suppl.
1):63–67.
8. Acting positively: strategic implications of the economic costs of multiple sclerosis in Australia. Canberra,
Access Economics Pty Ltd. for Multiple Sclerosis Australia, 2005.
9. Polman CH et al. Multiple sclerosis – The guide to treatment and management. London, Multiple Sclerosis
International Federation, 2006.

10. Chataway J et al. Treating multiple sclerosis relapses at home or in hospital: a randomised controlled trial of
intravenous steroid delivery. Lancet Neurology, 2006, 5:565–571.

11. Multiple Sclerosis Therapy Consensus Group. Escalating immunotherapy of multiple sclerosis. Journal of
Neurology, 2004, 251:1329–1339.

12. Henze T, Rieckmann P, Toyka KV and Multiple Sclerosis Therapy Consensus Group of the German Multiple
Sclerosis Society. Symptomatic treatment of multiple sclerosis. European Neurology, 2006, 56:78–105.

13. Thompson AJ. Neurorehabilitation in multiple sclerosis: foundations, facts and ﬁ ction. Current Opinion in
Neurology, 2005, 18:267–271.
14. Recommendations on rehabilitation services for persons with multiple sclerosis in Europe. Brussels, European
Multiple Sclerosis Platform and Rehabilitation in Multiple Sclerosis, 2004 (European Code of Good Practice
in Multiple Sclerosis).

15. Crayton H, Heyman R, Rossman H. A multimodal approach to managing the symptoms of multiple sclerosis.
Neurology, 2004, 11(Suppl. 5):S12–S18.

16. Thompson AJ et al. Clinical management of spasticity (Editorial review). Journal of Neurology, Neurosurgery
and Psychiatry, 2005, 76:459–463.

17. Pozzilli C et al. Home based management in multiple sclerosis: results of a randomised controlled trial.
Journal of Neurology, Neurosurgery and Psychiatry, 2002, 73:250–255.
18. Multiple sclerosis: management of multiple sclerosis in primary and secondary care. London, National
Institute for Health and Clinical Excellence, 2003.
19. Principles to promote the quality of life of people with multiple sclerosis. London, Multiple Sclerosis
International Federation, 2005.
RECOMMENDED READING
■ Compston A et al., eds. Multiple sclerosis. Amsterdam, Elsevier, 2005.
■ Goodin DS et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and
Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for
Clinical Practice Guidelines. Neurology, 2002, 58:169–178.
■ Joy JE, Johnston RB, eds. Multiple sclerosis: current status and strategies for the future. Washington, DC,
Institute of Medicine, 2001.
■ Murray TJ. Multiple sclerosis: the history of a disease. New York, Demos Medical Publishing, 2005.
■ Polman CH et al. Multiple sclerosis – The guide to treatment and management. London, Multiple Sclerosis
International Federation, 2006.
■ Warren S, Warren KG. Multiple sclerosis. Geneva, World Health Organization, 2001.
■ Multiple sclerosis: management of multiple sclerosis in primary and secondary care. London, National
Institute for Health and Clinical Excellence, 2003.
■ Principles to promote the quality of life of people with multiple sclerosis. London, Multiple Sclerosis
International Federation, 2005.
■ Recommendations on rehabilitation services for persons with multiple sclerosis in Europe. Brussels,
European Multiple Sclerosis Platform and Rehabilitation in Multiple Sclerosis, 2004 (European Code of Good
Practice in Multiple Sclerosis).

neurological disorders: a public health approach
95
3.5 Neuroinfections
96 Viral diseases
100 Mycobacterial and other bacterial diseases
103 Parasitic diseases
Infectious diseases that involve the nerv-
107 Implications and prevention
ous system affect millions of people
around the world. They constitute the sixth
108 Conclusions and recommendations
cause of neurological consultation in pri-
mary care services and are reported globally by a quarter of WHO’s Member
States and by half the countries in some parts of Africa and South-East Asia.
Neuroinfections are of major importance since ancient times and, even with the
advent of effective antibiotics and vaccines, still remain a major challenge in
many parts of the world, especially in developing nations.
Approximately 75% of the world population live in developing countries where the worst health
indicators are found. Their major health problems are generally related to warm climate, over-
crowding, severe poverty, illiteracy and high infant mortality which induce a burden of illness
from communicable diseases that differs drastically from the rest of the world. Added to these
problems, the health budgets are low and opportunities for community interventions very small.
A demographic transition is under way throughout the world: as populations age, the burden of
noncommunicable diseases (cardiovascular illnesses, stroke and cancer) increases, particularly
in the least favoured regions. Thus, the majority of least-developed countries are facing a double
burden from communicable and noncommunicable diseases. The global public health community
is now faced with a more complex and diverse pattern of adult disease than previously expected
and proposes a “double response” that integrates prevention and control of both communicable
and noncommunicable diseases within a comprehensive health-care system (1).
Some diseases that used to be found in the developed world but have virtually disappeared,
such as poliomyelitis, leprosy and neurosyphilis, are still taking their toll in developing regions.
In addition, some of the protozoan and helminthic infections that are so characteristic of the
tropics are now being seen with increasing frequency in developed countries owing to migration,
large-scale military ventures and rapid means of transport that have the undesirable potential to
introduce disease vectors. Although some infectious diseases have been nearly wiped out, the
vast majority of them will not be eliminated in the foreseeable future. Indeed, WHO reports that at
least 30 new diseases have been scientiﬁ cally recognized around the world in the last 20 years
(2). These emerging diseases include hantavirus (ﬁ rst identiﬁ ed in the United States in 1993),
cryptosporidiosis (a waterborne cause of diarrhoea that recently affected more than 400 000
people in a single outbreak in the United States), the Ebola virus from Africa and the human im-
munodeﬁ ciency virus (HIV), among others. Re-emerging diseases are the infections once thought

96
Neurological disorders: public health challenges
under control and that re-emerge: diseases such as tuberculosis, malaria, cholera and even
diphtheria are making a comeback.
Other main concerns are the development of drug-resistant organisms, the increasing number
of immunocompromised populations such as those affected by the acquired immunodeﬁ ciency
syndrome (AIDS) and malnutrition, and the rising number of diseases previously considered rare
(Lyme disease, rickettsioses, Creutzfeldt–Jakob disease and Ebola). Most of these diseases can
cause high mortality rates in some populations and produce severe complications, disability and
economic burden for individuals, families and health systems. Education, surveillance, develop-
ment of new drugs and vaccines, and other policies are in constant evolution to ﬁ ght against old
and emerging infectious diseases of the nervous system.
This chapter covers some of the more frequent neuroinfections that have a major impact on
health systems, especially in the developing world. Infectious diseases that involve the nervous
system are reported globally by 26.5% of WHO’s Member States and by 50% of countries in some
parts of Africa and South-East Asia (3).
■ Viral diseases: HIV/AIDS, viral encephalitis, poliomyelitis and rabies.
■ Mycobacterial and other bacterial diseases: tuberculosis, leprosy neuropathy, bacterial men-
ingitis and tetanus.
■ Parasitic diseases: neurocysticercosis, cerebral malaria, toxoplasmosis, American trypano-
somiasis (Chagas disease), African trypanosomiasis (sleeping sickness), schistosomiasis and
hydatidosis.
VIRAL DISEASES
HIV/AIDS
The acquired immunodeﬁ ciency syndrome (AIDS) is caused by a retrovirus known as the hu-
man immunodeﬁ ciency virus (HIV), which attacks and impairs the body’s natural defence system
against disease and infection. HIV is a slow-acting virus that may take years to produce illness
in a person. During this period, an HIV-infected person’s defence system is impaired, and other
viruses, bacteria and parasites take advantage of this “opportunity” to further weaken the body
and cause various illnesses, such as pneumonia, tuberculosis and mycosis. When a person starts
having such opportunistic infections, he or she has AIDS. The amount of time it takes for HIV
infection to become full-blown AIDS depends on the person’s general health and nutritional status
before and during the time of HIV infection. The average time for an adult is approximately 10
years without antiretroviral therapy (ART). Women are more likely to be infected with HIV than
men. Children are also at risk (4).
The number of people living with HIV globally has reached its highest level with an estimated
40.3 million people, rising from an estimated 37.5 million in 2003. More than three million people
died of AIDS-related illnesses in 2005; more than 500 000 of them were children. Sub-Saharan
Africa continues to be the most affected region globally, with 64% of new infections occurring
there. HIV treatment has improved markedly, however, and hundreds of thousands of people are
now living longer in better health because they are receiving ART: an estimated 250–350 000
deaths were averted in 2005 because of expanded access to HIV treatment (5).
Neurological complications occur in 39–70% of patients with AIDS and signiﬁ cantly impact on
functional capacity, quality of life and survival. Neuropathological examination identiﬁ es abnormal
neurological conditions in more than 90% of autopsies but is not always demonstrated clinically
(6). The main etiological considerations include primary HIV-related syndromes, opportunistic
conditions, inﬂ ammatory conditions, and medications (7 ) (see Table 3.5.1).

neurological disorders: a public health approach
97
Table 3.5.1 Neurological diseases in the HIV-infected individual
Type of condition
Examples
Primary HIV-related syndromes
HIV-associated cognitive–motor complex
HIV-associated myelopathy
HIV-associated polyneuropathy
HIV-associated myopathy
Opportunistic conditions
Toxoplasma encephalitis
Cryptococcal meningitis
Cytomegalovirus encephalitis/polyradiculitis
Progressive multifocal leukoencephalopathy
Primary central nervous system lymphoma
Inﬂ ammatory conditions
Acquired demyelinating neuropathies
Aseptic meningitis
Treatment-associated conditions
Zidovudine-induced myopathy
Nucleoside analog-induced neuropathy
Source: (7 ).
Multiple investigations in recent years suggest that the effects of neurological complications
and opportunistic infections related to HIV have a clear trend to diminish since the introduction of
new and more powerful antiretroviral agents. Nevertheless, prolonging the life of patients infected
by the virus, attributable to therapeutic success, paradoxically favours the emergence of some
neurological affections as treatment-associated neuropathy/myopathy; these affections can be
more important than the beneﬁ ts of therapy to achieve viral suppression.
Accurately diagnosing neurological disease in the HIV-infected individual is crucial for several
reasons. First, many complications are treatable and their treatment can lead to either increased
survival or improved quality of life. Second, identifying currently untreatable conditions provides
the patient with the opportunity to participate in a growing number of therapeutic trials. Further,
an accurate and focused diagnostic assessment and treatment plan will limit therapeutic misad-
ventures and lead to cost-effective care delivery.
The worldwide use of highly active antiretroviral therapy (HAART) has played an important
role in changing the incidence of neurological complications in AIDS patients. Recent studies
have shown that HAART has produced both quantitative and qualitative changes in the pattern
of HIV neuropathology: an overall decrease in the incidence of some cerebral opportunistic infec-
tions such as toxoplasmosis and cytomegalovirus encephalitis, for which successful treatment is
available, whereas other uncommon types and new variants of brain infections, such as varicella-
zoster encephalitis, herpes simplex virus encephalitis or HIV encephalitis, are being reported more
frequently as ART promotes some immune recovery and increases survival (8). In developing
countries, some endemic infections such as tuberculosis and Chagas disease have re-emerged in
direct association with the spreading of HIV, and are now being considered as markers of AIDS.
Unfortunately, some patients may develop paradoxical clinical outcomes after starting treat-
ment with HAART, known as neurological immune restoration inﬂ ammatory syndrome (NIRIS).
Some treatment-related neurological disorders, like zidovudine-induced myopathy, nucleoside
analog-induced neuropathy and efavirenz-induced neuropsychiatric disorders, can be more im-
portant than the beneﬁ ts of the therapy of viral suppression (9).
Some therapies can prevent, treat or even cure many of the opportunistic infections and relieve
the symptoms associated with them, but there is no cure for HIV/AIDS. The core beneﬁ t of HAART
lies in its ability to reduce the rate of opportunistic infections by enhancing immune function,

98
Neurological disorders: public health challenges
slowing viral replication in the body and thereby improving patients’ quality of life and diminishing
mortality. The cost of antiretroviral drugs is declining but, unfortunately, the treatments are still
not affordable or accessible for most people.
Nevertheless, these important advances over the last decade have transformed HIV infection
from a short-term, inevitably fatal disease to a chronic condition amenable to medical manage-
ment, similar to diabetes or congestive heart failure.
It is important to integrate HIV prevention and care, and the challenges are immense: world-
wide, fewer than one in ﬁ ve people at risk of becoming infected with HIV has access to basic
prevention services. Of people living with HIV, only one in ten has been tested and is aware of the
infection. For prevention interventions to achieve the results necessary to get ahead of the epi-
demic, projects with short-term horizons must translate into long-term programmatic strat egies.
In settings in which HIV is largely sexually transmitted, information and education campaigns
can save lives. For example, intensive prevention programmes in the Mbeya region of the United
Republic of Tanzania led to an increase in the use of condoms and the treatment of sexually trans-
mitted infections between 1994 and 2000; those changes were accompanied by a decline in HIV
prevalence among 15–24-year-old women from 21% to 15% in the same period (10). In settings
in which HIV transmission is linked more closely to injecting drug use, harm-reduction strategies
(for example, the provision of clean injecting equipment as well as adequate therapy for drug de-
pendence) have proved to be effective. Other measures include voluntary counselling and testing,
and improving women’s health — including access to family planning and safe childbirth — in
order to prevent HIV transmission from mother to infant. There is no cure for HIV/AIDS.
Viral encephalitis
Acute viral encephalitis is often an unusual manifestation of common viral infections and most
commonly affects children and young adults. Every day, more types of viruses are being as-
sociated with encephalitis (see Box 3.5.1), and its variable presence depends on the age group,
geographical zone, season of the year and the state of health of patients. In the United States,
epidemiological studies calculate the incidence of viral encephalitis approximately at 3.5–7.4 per
100 000 population. Estimates have been given for some causes of viral encephalitis: for example,
it has been estimated that herpes simplex encephalitis (HSE) has an annual incidence of about
one per million.
Herpes simplex encephalitis is the most important and common cause of fatal sporadic viral
encephalitis in the industrialized world. At a global level, it seems that the most common cause
of epidemic encephalitis is actually Japanese B encephalitis, with 10–15 000 deaths per year,
markedly more than for herpes simplex encephalitis. It must be considered, however, that in up
to about 50% of cases of viral encephalitis no speciﬁ c cause can be found, so the predominant
type is difﬁ cult to determine (11).
Box 3.5.1 Causes of viral encephalitis
■ Herpes simplex virus (HSV-1, HSV-2)
■ Arboviruses, e.g.
■ Other herpes viruses:
› Japanese B encephalitis virus
› varicella zoster vírus (VZV)
› St Louis encephalitis virus
› cytomegalovirus (CMV)
› West Nile encephalitis virus
› Epstein–Barr vírus (EBV)
› Eastern, Western, and Venezuelan equine encephalitis virus
› human herpes vírus 6 (HHV6)
› Tick-borne encephalitis viruses
■ Adenoviruses
■ Bunyoviruses, e.g. La Crosse strain of California virus
■ Inﬂ uenza A
■ Reoviruses, e.g. Colorado tick fever virus
■ Enteroviruses, poliovirus
■ Arenaviruses, e.g. lymphocytic choriomeningitis virus
■ Measles, mumps and rubella viruses
■ Retroviruses, e.g. HIV-1
■ Rabies
■ Papovavirus, e.g. JC virus
Source: adapted from (11).

neurological disorders: a public health approach
99
Viruses enter the central nervous system (CNS) through two distinct routes: hematogenous
dissemination or neuronal retrograde dissemination. Hematogenous spread is the most common
path. Humans are usually incidental terminal hosts of many viral encephalitides. Arbovirus en-
cephalitides are zoonoses, with the virus surviving in infection cycles involving biting arthropods
and various vertebrates, especially birds and rodents. The virus can be transmitted by an insect
bite and then undergoes local replication in the skin.
Patients with viral encephalitis are marked by acute onset of a febrile illness and can experi-
ence signs and symptoms of meningeal irritation, focal neurological signs, seizures, alteration of
consciousness and behavioural and speech disturbances. The diagnosis is made by immunologi-
cal tests, neuroimaging techniques, electroencephalography and, sometimes, brain biopsy. No
speciﬁ c treatment is available for every encephalitis, and the illness often requires only medical
support. The mortality rate and severity of sequelae depend largely on the etiological agent.
Herpes virus encephalitis carries a mortality rate of 70% in untreated patients, with severe se-
quelae among survivors. Pharmacotherapy for herpes virus encephalitis consists of acyclovir and
vidarabine. Effective preventive measures include control of vectors by removing water-holding
containers and discarded tyres. Vaccines are available for eastern equine encephalitis, western
equine encephalitis, and Venezuelan equine encephalitis in horses. Despite control efforts and
disease surveillance, the 1999 outbreak of West Nile virus in New York with subsequent spread
to other states showed that different viruses may spread because of increased international travel
and trade (12).
Japanese encephalitis is a leading cause of viral encephalitis in Asia, with 30–50 000 clini-
cal cases reported annually. It occurs from the islands of the Western Paciﬁ c in the east to the
Pakistan border in the west, and from the Democratic People’s Republic of Korea in the north to
Papua New Guinea in the south. Japanese encephalitis virus is transmitted by mosquitoes, which
breed particularly in ﬂ ooded rice ﬁ elds. Pigs are the amplifying hosts. Distribution of the infection
is thus very signiﬁ cantly linked to irrigated rice production combined with pig-rearing. An effective
killed vaccine is available, but it is expensive and requires one primary vaccination followed by
two boosters. It provides adequate protection for travellers but has limited public health value in
areas where health service resources are scarce.
Poliomyelitis
Poliomyelitis is a crippling disease caused by any one of three related viruses, poliovirus types 1,
2 or 3. The primary way to spread poliovirus is through the faecal–oral route: the virus enters the
body through the mouth when people eat food or drink water that is contaminated with faeces.
The virus then multiplies in the intestine, enters the bloodstream, and may invade certain types
of nerve cells which it can damage or destroy. Polioviruses spread very easily in areas with poor
hygiene. In any child under 15 years of age with acute ﬂ accid paralysis or any person of any age
with paralytic illness, poliomyelitis always has to be suspected.
In 1963, Cuba began using an oral vaccine in a series of nationwide polio campaigns. Shortly
thereafter, indigenous wild poliovirus transmission was interrupted. Through an extraordinary in-
ternational effort that begun 18 years ago, indigenous polioviruses have now been eliminated from
all but four countries of the world, down from over 125 when the collaboration started (13). This
progress is the result of a unique partnership forged between governments and the spearheading
partners of the Global Polio Eradication Initiative — WHO, Rotary International, the United States
Centers for Disease Control and Prevention (CDC) and UNICEF — to take up key challenges to
reach all children, everywhere. The most visible element of the polio eradication initiative has
been the National Immunization Days, as they require the immunization of every child under ﬁ ve
years of age (nearly 20% of a country’s population) several times a year for a number of years in
a row. As the result of an aggressive, deliberate and internationally coordinated effort, endemic

100
Neurological disorders: public health challenges
poliomyelitis has changed from being a devastating disease with a global distribution to one that
is now endemic in four countries. In 2005, 1951 cases were reported worldwide.
Rabies
Rabies is one of the oldest and most feared diseases reported in medical literature. Rabies is a
viral zoonosis (an animal disease transmissible to humans) caused by rhabdoviruses of the genus
Lyssavirus. The disease is maintained in nature by several domestic and wild animal reservoir
species, including dogs, foxes, mongooses, raccoons, skunks and many species of bat. Human
infection is incidental to the epidemiology of rabies. In terms of risks to human health, dogs are
the most dangerous reservoir: more than 99.9 % of human deaths from rabies worldwide result
from the bite of a rabid dog. It is estimated that 50 000 persons die of rabies each year, mainly
in Africa and Asia.
Human infection occurs when the virus, contained in the saliva of a rabid animal, is transmitted
through penetrating bite wounds, open cuts in the skin, or contact with mucous membranes. The
severity of the bite determines the risk of infection. The virus slowly travels up the nerve to reach
the CNS where it replicates and then travels down nerves to the salivary glands where there is
further replication. Man is occasionally infected, and once infection is established in the CNS the
outcome is almost invariably fatal.
Second-generation vaccines consisting of highly puriﬁ ed vaccines prepared on primary and
continuous cell lines and in embryonating eggs are available, though expensive, to prevent the
occurrence of the disease in persons exposed to an animal suspected of rabies. The vaccines
are usually administered according to regimens involving fewer doses (usually ﬁ ve or six) than
those used for brain tissue vaccines. The regimens most commonly applied in the world are those
recommended by WHO.
Control of rabies depends on education, vaccination of dogs, cats and farm animals and noti-
ﬁ cation of suspected cases to local authorities (14).
MYCOBACTERIAL AND OTHER BACTERIAL DISEASES
Tuberculosis
With nine million new cases in 2004, resulting in 1.7 million deaths, tuberculosis is a leading
infectious cause of morbidity and mortality worldwide (15 ). The resurgence of tuberculosis in
many countries is attributable to its interaction with HIV infection, which has pernicious effects.
Tuberculosis is the leading cause of death among people with HIV, while infection with HIV is the
most potent risk factor for a latent tuberculosis infection to convert to active disease (16). Although
tuberculosis most commonly affects the lungs (the usual site of primary infection), it can cause
disease in any part of the body as a consequence of haematogenous spread from the lung. The
proportion of all cases of tuberculosis that are extrapulmonary (i.e. in sites other than the lungs)
varies between countries but is typically about 10–20%. Among extrapulmonary cases, the most
common sites involved are the lymph nodes and the pleura, but the sites of tuberculosis associ-
ated with neurological disorders (meninges, brain and vertebrae) also constitute an important
group. Meningeal tuberculosis has a high case-fatality rate, and neurological sequelae are com-
mon among survivors. Cerebral tuberculoma usually presents as a space-occupying lesion with
focal signs depending on the location in the brain. Vertebral tuberculosis usually presents with
local pain, swelling and deformity, and there is risk of neurological impairment because of spinal
cord or cauda equina compression.
The diagnosis of nervous system tuberculosis is often difﬁ cult, because of its nature of great
simulator and also because of limited access to methods to conﬁ rm it (17 ). Diagnosis depends on
epidemiological and clinical data and ﬁ ndings during cerebrospinal ﬂ uid (CSF), neuroimaging and

neurological disorders: a public health approach
101
bacteriological studies. Although not a direct consequence of tuberculosis, peripheral neuropathy
can occur in tuberculosis patients as a side-effect of treatment with isoniazid, especially among
patients who are malnourished, abuse alcohol, or are infected with HIV.
There are important public health approaches to the primary prevention of these tuberculosis-
related conditions and to the secondary prevention of their adverse consequences. The most
important overall approach to primary prevention consists of cutting the chain of transmission by
case-ﬁ nding and treatment. This approach is the basis of the international tuberculosis control
strategy known as DOTS, which forms a central pillar of WHO’s new strategy for its Stop TB
campaign (16). Although BCG vaccination has little impact in reducing the number of adults with
infectious pulmonary tuberculosis, it is of crucial importance in preventing disseminated and
severe cases of disease (including tuberculosis meningitis) in children. Therefore, in countries
with high tuberculosis prevalence, WHO recommends a policy of routine BCG immunization for
all neonates as part of the Expanded Programme on Immunization (EPI). It is estimated that the
100 million BCG vaccinations given to infants worldwide in 2002 will have prevented 30 000
cases of tuberculosis meningitis in children during their ﬁ rst ﬁ ve years of life (18). The primary
prevention of isoniazid-induced peripheral neuropathy is by routine administration of pyridoxine
to tuberculosis patients.
The main public health approach to the secondary prevention of the adverse consequences of
tuberculosis disease of the meninges, brain and vertebrae is through promoting the application of
the International Standards for Tuberculosis Care (19) to ensure prompt diagnosis and effective
treatment. High-quality tuberculosis care will result not only in patients having the best possible
outcome of treatment, but also in the public health beneﬁ t of decreased tuberculosis transmission by
infectious cases and thereby, ultimately, an impact on the global burden of all tuberculosis cases, in-
cluding those associated with neurological disorder. The key steps in diminishing the global burden of
neurological disorder associated with tuberculosis are to promote: investment in full implementation
of the Stop TB strategy and International Standards for Tuberculosis Care; full immunization cover-
age so that all neonates are protected by BCG from risk of disseminated and severe tuberculosis;
and better understanding of the epidemiology of tuberculosis disease associated with neurological
disorder through improved surveillance in countries with high tuberculosis prevalence.
Leprosy neuropathy
Leprosy is the cause of the most common treatable neuropathy in the world, caused by Myco-
bacterium leprae. The incubation period of the disease is about ﬁ ve years: symptoms, however,
can take as long as 20 years to appear. The infection could affect nerves by direct invasion or
during immunological reactions. In rare instances, the diagnosis can be missed, because leprosy
neuropathy may present without skin lesions (neuritic form of leprosy). Patients with this form of
disease display only signs and symptoms of sensory impairment and muscle weakness, posing
difﬁ culties for diagnosis, particularly in services where diagnostic facilities such as bacilloscopy,
electroneuromyography and nerve biopsy are not available.
Delay in treatment is a major problem, because the disease usually progresses and the resulting
disability if untreated may be severe, even though mycobacteria may be eliminated. Delay in treat-
ment is, however, usually a result of delayed presentation because of the associated stigma. People
with long-term leprosy may lose the use of their hands or feet because of repeated injury resulting
from lack of sensation. Early diagnosis and treatment with the WHO-recommended multidrug therapy
(MDT) is essential in order to prevent the disease from progressing and resulting in disability.
Bacterial meningitis
Bacterial meningitis is a very common cause of morbidity, mortality and neurological compli-
cations in both children and adults, especially in children. It has an annual incidence of 4–6

102
Neurological disorders: public health challenges
cases per 100 000 adults (deﬁ ned as patients older than 16 years of age), and Streptococcus
pneumoniae and Neisseria meningitidis are responsible for 80% of all cases (20). In developing
countries, overall case-fatality rates of 33–44% have been reported, rising to over 60% in adult
groups (21). Bacterial meningitis can occur in epidemics that can have a serious impact on large
populations.
The highest burden of meningococcal disease occurs in sub-Saharan Africa, which is known
as the “meningitis belt”, an area that stretches from Senegal in the west to Ethiopia in the east,
with an estimated total population of 300 million people. The hyperendemicity in this area is at-
tributable to the particular climate (dry season between December and June, with dust winds) and
social habits: overcrowded housing at family level and large population displacements for pilgrim-
ages and traditional markets at regional level. Because of herd immunity (whereby transmission
is blocked when a critical percentage of the population had been immunized, thus extending
protection to the unvaccinated), the epidemics occur in a cyclical fashion.
Meningitis is characterized by acute onset of fever and headache, together with neck stiffness,
altered consciousness and seizures. The diagnosis can be conﬁ rmed by its clinical characteristics
and bacteriological and immunological analyses of the CSF. Antibiotic treatment is effective in
most cases but several neurological complications can remain, such as cognitive difﬁ culties, mo-
tor disabilities, hypoacusia and epilepsy. In a recent review, treatment with corticosteroids was
associated with a signiﬁ cant reduction in neurological sequelae and mortality (22).
Progress is more likely to come from investigations into preventive measures, especially the
use of available vaccines and the development of new vaccines. Meningitis caused by Haemophilus
inﬂ uenzae type B has been nearly eliminated in developed countries since routine vaccination with
the H. inﬂ uenzae type B conjugate vaccine was initiated. The introduction of conjugate vaccines
against S. pneumoniae may substantially reduce the burden of childhood pneumococcal menin-
gitis and may even produce herd immunity among adults. The approval in 2005 of a conjugate
meningococcal vaccine against serogroups A, C, Y and W135 is also an important advance that
may decrease the incidence of this devastating infection. Local and nationwide surveillance, in-
cluding the laboratory investigation of suspected cases, is critical for early detection of epidemics
and the formulation of appropriate responses.
Tetanus
Tetanus is acquired through exposure to the spores of the bacterium Clostridium tetani which are
universally present in the soil. The disease is caused by the action of a potent neurotoxin produced
during the growth of the bacteria in dead tissues, e.g. dirty wounds or — for neonatal tetanus —
in the umbilicus following non-sterile delivery. Tetanus is not transmitted from person to person:
infection usually occurs when dirt enters a wound or cut. At the end of the 1980s, neonatal tetanus
was considered a major public health problem. WHO estimated that, in 1988, 787 000 newborn
children died of neonatal tetanus, a rate of 6.5 cases per 1000 live births. In 2004 the number of
reported cases was 13 448. A worldwide total of 213 000 deaths were estimated to have occurred
in 2002, 198 000 of them concerning children younger than ﬁ ve years of age (23).
Unlike poliomyelitis and smallpox, the disease cannot be eradicated because tetanus spores are
present in the environment. Once infection occurs, mortality rates are extremely high, especially in
areas where appropriate medical care is not available. However, this death toll can be prevented.
Neonatal tetanus can be prevented by immunizing pregnant women and improving the hygienic
conditions of delivery. Adult tetanus can be prevented by immunizing people at risk, such as work-
ers manipulating soil; others at risk of cuts should be also included in the prevention measures.
Some forms of toxoid are available (DTP, DT, TT or Td) and at least three primary doses should be
given by the intramuscular route. Vaccination coverage with three doses of DTP is more than 80%
for most countries around the world. The Maternal and Neonatal Tetanus elimination initiative was

neurological disorders: a public health approach
103
launched by UNICEF, WHO and the United Nations Population Fund (UNFPA) in 1999, revitalizing
the goal of elimination of maternal and neonatal tetanus as a public health problem, deﬁ ned as
less than one case of neonatal tetanus per 1000 live births in every district of every country.
PARASITIC DISEASES
Neurocysticercosis
Cysticercosis is infection by the larvae of the pork tapeworm Taenia solium. The adult tapeworm
(ﬂ at, ribbon-like, approximately 2–4 m long) lives only in the small intestine of humans, who
acquire it (taeniasis) by eating undercooked pork containing the viable larvae or cysticerci. A
tapeworm carrier passes microscopic Taenia eggs with the faeces, contaminating the close en-
vironment and contacts and causing cysticercosis to pigs and humans. Human beings therefore
acquire cysticercosis through faecal–oral contamination with T. solium eggs (24). Thus, vegetar-
ians and other people who do not eat pork can acquire cysticercosis. Recent epidemiological
evidence suggests that the most common source of infective eggs is a symptom-free tapeworm
carrier in the household. Therefore, cysticercosis should be seen as a disease mostly transmitted
from person to person (25). In the CNS, the larvae or cysticerci can cause epilepsy, hydrocephalus,
spinal cord involvement, stroke, etc. (24, 26).
Cysticercosis is the parasitic disease that most frequently affects the CNS and is one of the
major health problems of developing countries in Africa, Asia and Latin America. In addition,
because of high immigration rates from endemic to non-endemic areas and tourism, neurocys-
ticercosis is now commonly seen in countries that were previously free of the disease. Despite
the advances in diagnosis and therapy, neurocysticercosis remains endemic in most low income
countries, where it represents one of the most common causes of acquired epilepsy (27 ). Almost
50 000 deaths attributable to neurocysticercosis occur every year. Many more patients survive
but are left with irreversible brain damage — with all the social and economic consequences that
this implies (28). Seizures occur in up to 70% of patients. Several articles from different countries
in Latin America consistently showed an association between around 30% of all seizures and
cysticercosis (29).
Accurate diagnosis of neurocysticercosis is based on assessment of the clinical and epidemio-
logical data and the results of neuroimaging studies and immunological tests (30). Therapy must
be individualized according to the location of parasites and the degree of disease activity: this
implies symptomatic therapy, anticysticidal drugs (albendazole/praziquantel), antiepileptic drugs
and surgical treatment of complications such as hydrocephalus.
Neurocysticercosis is one of a few conditions included in a list of potentially eradicable infec-
tious diseases of public health importance (31). The control strategy that seems promising at the
moment is a combination of different available tools in order to interrupt or reduce the cycle of di-
rect person-to-person transmission: mass human chemotherapy to eliminate the tapeworm stage,
enforced meat inspection and control, improvement of pig husbandry and inspection, treatment of
infected animals, surveillance, identiﬁ cation and treatment of individuals who are direct sources
of contagion (human carriers of adult tapeworm) and their close contacts, combined with hygiene
education and better sanitation. Animal vaccines are under development. Major obstacles include
the lack of basic sanitary facilities in endemic areas, the extent of domestic pig-rearing, the costs
of the interventions, and their cultural acceptability. Multiple genotypes of T. solium ramiﬁ cations
have been discovered in different regions, which could explain some of the possible differences
in pathology of T. solium worldwide. Recently, a proposal was published to declare neurocysticer-
cosis an international reportable disease (32). WHO suggests that all endemic countries should
recognize the importance of taeniasis and cysticercosis, collect epidemiological data and adopt
policies and strategies for their control. So far, the infection has not been eliminated from any

104
Neurological disorders: public health challenges
region by a speciﬁ c programme and no national control programmes are yet in place. Successful
pilot demonstrations of control measures have been or are being conducted in Cameroon, Ecuador,
Mexico and Peru, and a regional action plan developed in 2002 for eastern and southern Africa
is now under way.
Cerebral malaria
Malaria remains a serious public health problem in the tropics, mostly in Africa. There exist four
Plasmodium species that affect humans; of these, only Plasmodium falciparum can sequester in
capillaries of the CNS and cause cerebral malaria. The infection is acquired when the parasite is
inoculated through the skin during the sting of an infected Anopheles mosquito. Some patients
with cerebral malaria present with diffuse cerebral oedema, small haemorrhages and occlusion
of cerebral vessels by parasitized red cells. The burden of falciparum malaria is not only because
of infection and mortality: the neurocognitive sequelae add signiﬁ cantly to this burden (33).
P. falciparum is identiﬁ ed by examination of blood smears with Giemsa stain. Since parasitae-
mia is cyclical, repeated examinations may be required. The CSF is normal in cerebral malaria.
Neuroimaging studies may demonstrate brain swelling, cerebral infarcts, or small haemorrhages
in severe cases. Artemisinin derivatives and quinine are the drugs of choice for cerebral malaria.
Despite therapy, mortality remains high in severe or complicated malaria (34).
Preventive strategies relied upon are: the early treatment of malaria infections with effective
medicines (artemisinin-based combination therapies) to prevent the progression of the disease to
severe malaria; and vector control through different practices to reduce the rate of infection (use
of insecticide-treated nets, bednets, insecticide sprays and mosquito coils). All these methods
have been found to be highly cost effective. At present, multiple studies are under way to modify
Plasmodium genes in order to diminish parasite virulence and consequently the morbidity and
mortality attributable to malaria.
Toxoplasmosis
Toxoplasmosis is a disease caused by an obligate intracellular protozoal parasite termed Toxo-
plasma gondii. Human infection usually occurs via the oral or transplacental route. Consumption
of raw or undercooked meat containing viable tissue cysts (principally lamb and pork) and direct
ingestion of infective oocysts in other foods (including vegetables contaminated by feline faeces)
are common sources of infection. Transplacental infection may occur if the mother acquires an
acute infection or if a latent infection is reactivated during immunosuppression. In immunocom-
petent women a primary infection during early pregnancy may lead to fetal infection, with death of
the fetus or severe postnatal manifestations. Later in pregnancy, maternal infection results in mild
or subclinical fetal disease. In adults, most T. gondii infections are subclinical, but severe infection
can occur in patients who are immunocompromised, such as those with AIDS and malignancies.
Affected organs include both the grey and white matter of the brain, retina, alveolar lining of the
lungs, heart, and skeletal muscle.
Patients with AIDS are at particular risk for developing disseminated toxoplasmosis, which more
often manifests as CNS abnormalities. As many as 50% of patients with AIDS who are seropositive
for T. gondii develop encephalitis. Toxoplasmosis is the most common cause of a focal brain lesion
in patients with AIDS. The disease commonly localizes to the basal ganglia, though other sites in
the brain and spinal cord may be affected. A solitary focus may be seen in one third of patients, but
multiple foci are more common. In AIDS-related Toxoplasma encephalitis, a well-circumscribed
indolent granulomatous process or features of diffuse necrotizing encephalitis occur.
For most people, prevention of toxoplasmosis is not a serious concern, as infection generally
causes no symptoms or mild symptoms. High-risk groups, however, should consider being tested
for Toxoplasma infection. HIV-infected individuals who test positive should receive drugs to prevent

neurological disorders: a public health approach
105
development of toxoplasmosis when their CD4 count falls below 100 (35 ). Pregnant women,
women who plan to become pregnant, and immunocompromised individuals who test negative
for Toxoplasma infection should take precautions against becoming infected. Precautions consist
in measures such as consuming only properly frozen or cooked meats, avoiding cleaning cats’
litter pans and avoiding contact with cats of unknown feeding history.
American trypanosomiasis: Chagas disease
Chagas disease is a serious problem of public health in Latin America, and is becoming more
important in developed nations owing to the high ﬂ ow of immigrants from endemic areas. Chagas
disease is caused by Trypanosoma cruzi, a protozoan that it is transmitted by means of triatomine
insects. Up to 8% of the population in Latin America are seropositive, but only 10–30% of them
develop symptomatic disease (36).
The disease is a major cause of congestive heart failure, sudden death related to chronic
Chagas disease, and cerebral embolism (stroke). Chagas disease can be diagnosed by demonstra-
tion of T. cruzi in blood smears and CSF samples or by serological testing. Neuroimaging usually
demonstrates the location and extent of the cerebral infarct. Secondary prevention of stroke with
long-term anticoagulation is recommended for all chagasic patients with stroke and heart failure,
cardiac arrhythmias or ventricular aneurisms.
Traditional control programmes in Latin American countries have focused on the spraying of
insecticides on houses, household annexes and other buildings. National programmes aimed at
the interruption of the domestic and peridomestic cycles of transmission involving vectors, animal
reservoirs and humans are feasible and have proved to be very effective. A prime example is the
programme that has been operating in Brazil since 1975, when 711 municipalities had triato-
mine-infested dwellings: 10 years later only 186 municipalities remained infested, representing
a successful accomplishment of the programme’s objectives in 74% of the originally infested
areas (37 ).
African trypanosomiasis: sleeping sickness
African trypanosomiasis, also known as sleeping sickness, is a severe disease that is fatal if left
untreated. The causative agents are protozoan parasites of the genus Trypanosoma, which enter
the bloodstream via the bite of blood-feeding tsetse ﬂ ies (Glossina spp.). The acute form of the
disease attributable to Trypanosoma brucei rhodesiense, widespread in eastern and southern
Africa, is closely related to a common infection of cattle known as N’gana, which restricts cattle-
rearing in many prime areas of Africa. The chronic form caused by T.b. gambiense is found in
western and central Africa.
Cattle and other wild mammals act as reservoir hosts of the parasites. Tsetse ﬂ ies can acquire
parasites by feeding on these animals or on an infected person. Incubation time usually varies from
three days to a few weeks for T.b. rhodesiense, and several weeks to months for T.b. gambiense.
Inside the human host, trypanosomes multiply and invade most tissues. Infection leads to malaise,
lassitude and irregular fevers. Early symptoms, which include fever and enlarged lymph glands
and spleen, are more severe and acute in T.b. rhodesiense infections. Advanced symptoms include
neurological and endocrine disorders. As the parasites invade the CNS, mental deterioration be-
gins, leading to coma and death.
Sleeping sickness claims comparatively few lives annually, but the risk of major epidemics
means that surveillance and ongoing control measures must be maintained, especially in sub-
Saharan Africa where 36 countries have epidemiological risk. Control relies mainly on systematic
surveillance of at-risk populations, coupled with treatment of infected people. In addition, reduc-
tion of tsetse ﬂ y numbers plays a signiﬁ cant role, especially against the rhodesiense form of the
disease. In the past, this has involved extensive clearance of bush to destroy tsetse ﬂ y breeding

106
Neurological disorders: public health challenges
and resting sites, and widespread application of insecticides. More recently, efﬁ cient traps and
screens have been developed that, usually with community participation, can keep tsetse popula-
tions at low levels in a cost-effective manner (38).
Schistosomiasis
Schistosomiasis is an infection with a relatively low mortality rate but a high morbidity rate; it
is endemic in 74 developing countries, with more than 80% of infected people living in sub-Sa-
haran Africa. Infection is caused by trematode ﬂ atworms (ﬂ ukes) of the genus Schistosoma: in
freshwater, intermediate snail hosts release infective forms of the parasite. There are ﬁ ve spe-
cies of schistosomes able to infect humans: Schistosoma haematobium (the urinary form) and S.
japonicum, S. mekongi, S. mansoni and S. intercalatum (the “intestinal” forms).
If people are in contact with water where infected snails live, they become infected when larval
forms of the parasites penetrate their skin. Later, adult male and female schistosomes pair and
live together in human blood vessels. The females release eggs, some of which are passed out in
the urine (in S. haematobium infection) or stools (S. mansoni and S. japonicum), but some eggs
are trapped in body tissues. Immune reactions to eggs lodged in tissues are the cause of disease.
Systemic complications are bladder cancer, progressive enlargement of the liver and spleen,
intestinal damage due to ﬁ brotic lesions around eggs lodged in these tissues, and hypertension
of the abdominal blood vessels. Most cases of cerebral schistosomiasis are observed with S.
japonicum, constituting 2–4% of all S. japonicum infections. However, CNS schistosomiasis also
can occur with other species and involves seizures, headache, back pain, bladder dysfunction,
paresthesias and lower limb weakness. Death is most often caused by bladder cancer associated
with urinary schistosomiasis and by bleeding from varicose veins in the oesophagus associated
with intestinal schistosomiasis. Children are especially vulnerable to infection, which develops
into chronic disease if not treated. Diagnosis is made by using urine ﬁ ltration and faecal smear
techniques, antigen detection in endemic areas and antibody tests in non-endemic areas.
The disease is controlled through an integrated approach: drug treatment with praziquantel
or oxamniquine (effective only against S. mansoni), provision of an adequate safe water supply,
sanitation and health education (39).
Hydatidosis
Cystic hydatidosis/echinococcosis is an important zoonosis caused by the tapeworm Echino-
coccus granulosus. At present, four species of Echinococcus are recognized: E. granulosus, E.
multilocularis, E. oligarthrus and E. vogeli. The parasite is distributed worldwide and about 2–3
million patients are estimated in the world (40). It causes serious human suffering and consider-
able losses in agricultural and human productivity. General lack of awareness of transmission
factors and prevention measures among the population at risk, abundance of stray dogs, poor
meat inspection in abattoirs, improper disposal of offal and home slaughtering practices play a
role in the persistence of the disease.
The incidence of surgical cases ranges from 0.1 to 45 cases per 100 000 people. The real
prevalence ranges between 0.22% and 24% in endemic areas. Ultrasounds have been very use-
ful in large-scale prevalence surveys. Large prevalence studies have been conducted in many
countries: in the Libyan Arab Jamahiriya, Morocco and Tunisia, the prevalence ranged from 1%
to 2%.
In the normal life-cycle of Echinococcus species, adult tapeworms (3–6 mm long) inhabit the
small intestine of carnivorous deﬁ nitive hosts, such as dogs, coyotes or wolves, and echinococcal
cyst stages occur in herbivorous intermediate hosts, such as sheep, cattle and goats. In most
infected countries there is a dog–sheep cycle in which grazing sheep ingest tapeworm eggs
passed in the faeces of an infected dog. Dogs ingest infected sheep viscera, mainly liver and lungs,

neurological disorders: a public health approach
107
containing larval hydatid cysts in which numerous tapeworm heads are produced. These attach
to the dog’s intestinal lining and develop into mature adult tapeworms. Humans become infected
by ingesting food or drink contaminated with faecal material containing tapeworm eggs passed
from infected carnivores, or when they handle or pet infected dogs. Oncospheres released from
the eggs penetrate the intestinal mucosa and lodge in the liver, lungs, muscle, brain and other
organs, where the hydatid cysts form. In the CNS, hydatidosis produces spinal disease and also
is a potential cause of intracranial hypertension.
To control the parasite, a number of antihelminthic drugs have proved to be effective against
adult stages of E. granulosus in the ﬁ nal host. The best drug currently available is praziquantel
which exterminates all juvenile and adult echinococci from dogs. Several of the benzimidazole
compounds have been shown to have efﬁ cacy against the hydatid cyst in the intermediate host.
Echinococcosis can be controlled through preventive measures that break the cycle between the
deﬁ nitive and the intermediate host. These measures include dosing dogs, inspecting meat and
educating the public on the risk to humans and the necessity to avoid feeding offal to dogs.
IMPLICATIONS AND PREVENTION
Infectious diseases that involve the nervous system affect millions of people around the world,
especially in some regions in Africa and South-East Asia. Most of these diseases can cause high
mortality rates in some populations and produce severe complications, disability and economic
burden for individuals, families and health systems. Even with the advent of effective antibiot-
ics and vaccines, they still remain a major challenge in many parts of the world, especially in
developing countries where the worst health indicators are found. Some diseases that had been
found in the developed world but have virtually disappeared, such as poliomyelitis, leprosy and
neurosyphilis, are still taking their toll in developing regions. Conversely, some of the protozoan
and helminthic infections that are so characteristic of the tropics are now being seen with increas-
ing frequency in developed countries. Other major concerns are the development of drug-resistant
organisms, the increasing number of immunocompromised populations and the rising number
of diseases previously considered rare. Education, surveillance, development of new drugs and
vaccines, and other policies are in constant evolution to ﬁ ght against old and emerging infectious
diseases of the nervous system.
Some preventive measures have a more rapid impact and are more cost effective than others.
Regular, large-scale treatment to prevent disease is cheap, by treating carriers (i.e. humans or
dogs) to prevent humans from getting infected as an intermediate host, or to regularly lower the
worm load so that the person does not suffer from infection. Large-scale treatment in humans can
be combined for several diseases (the “preventive chemotherapy” concept), and can be packaged
in domestic animals — such as dogs — with other interventions such as rabies vaccination. The
basic idea is to deliver such public health treatment packages regularly, to enable people to avoid
the worst effects of infection, even with an ongoing lack of water, sanitation and hygiene. It has
to be said that environmental measures would eventually solve the problem, but require a much
more substantial investment and commitment. Some diseases are easily controlled and prevented
with basic, inexpensive measures that are available worldwide, but their effectiveness entails a
massive education effort and steady surveillance.

108
Neurological disorders: public health challenges
CONCLUSIONS AND RECOMMENDATIONS
1
Neuroinfections constitute the sixth cause of neurological consultation in primary care
services worldwide and, even with the advent of effective antibiotics and vaccines, still
remain a major challenge in many parts of the world.
2
The global public health community is now faced with a more complex and diverse
pattern of adult disease than previously expected and proposes a double response that
integrates prevention and control of both communicable diseases and noncommunicable
diseases within a comprehensive health-care system.
3
Some diseases that had virtually disappeared from the developed world are still taking
their toll in developing regions. Conversely, some of the protozoan and helminthic
infections that are so characteristic of the tropics are now being seen with increasing
frequency in developed countries.
4
Other major concerns are the development of drug-resistant organisms, the increasing
number of immunocompromised populations and the rising number of diseases previously
considered rare.
5
Education, surveillance, development of new drugs and vaccines and other public policies
are in constant evolution to ﬁ ght against old and emerging infectious diseases of the
nervous system.

neurological disorders: a public health approach
109
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RECOMMENDED READING
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zoonoses: cystic echinococcosis, alveolar echinococcosis and neurocysticercosis. Advances in Parasitology,
1996, 38:169–250.
■ Eckert MA et al., eds. Manual on echinococcosis in humans and animals: a public health problem of global
concern. Paris, World Health Organization and Ofﬁ ce International des Epizooties, 2001.
■ García HH, Del Brutto OH. The Cysticercosis Working Group in Peru. Neurocysticercosis: updated concepts
about an old disease. Lancet Neurology, 2005, 4:653–661.
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■ AIDS epidemic update 2005. Geneva, Joint United Nations Programme on HIV/AIDS and World Health
Organization, 2005.
■ Atlas: Country resources for neurological disorders 2004. Geneva, World Health Organization (2004).
■ The Stop TB strategy. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.368).

neurological disorders: a public health approach
111
3.6 Neurological disorders
associated with
malnutrition
111 Etiology, risk factors and burden
112 Main neurological complications of
malnutrition
In low income countries, inadequate amounts of food (causing
118 Toxiconutritional disorders
conditions such as child malnutrition and retarded growth) and
121 Prevention of nutritional deﬁ ciencies
inadequate diversity of food (causing deﬁ ciency of vital micronu-
123 A public health framework
trients such as vitamins, minerals or trace elements) continue to
124 Conclusions and recommendations
be priority health problems. Malnutrition in all its forms increases
the risk of disease and early death. Nearly 800 million people in
the world do not have enough to eat. Malnutrition affects all age groups, but it is espe-
cially common among poor people and those with inadequate access to health educa-
tion, clean water and good sanitation. Most of the malnutrition-related neurological
disorders are preventable.
Chronic food deﬁ cits affect about 792 million people in the world (1). Malnutrition directly or indirectly
affects a variety of organ systems including the central nervous system (CNS). A number of nutritional
conditions are included in the Global Burden of Disease (GBD) study, such as protein–energy malnutri-
tion, iodine deﬁ ciency, vitamin A deﬁ ciency, and iron deﬁ ciency anaemia. Over 15% of the disability-
adjusted life years (DALYs) lost globally are estimated to be from malnutrition (2).
This section focuses on neurological disorders associated with malnutrition. In addition, it touches
brieﬂ y on the ingestion of toxic substances in food or alcohol, as these also contribute to neurological
disorders.
Most of the malnutrition-related neurological disorders can be prevented and therefore they are of
public health concern. Raising awareness in the population, among leaders and decision-makers and in
the international community is important in order to adopt an appropriate health policy.
ETIOLOGY, RISK FACTORS AND BURDEN
The major dietary nutrients needed by living organisms, especially human beings, can be grouped into
macronutrients and micronutrients. The macronutrients are the energy-yielding nutrients — proteins,
carbohydrates and fat — and micronutrients are the vitamins and minerals. The macronutrients have a
double function, being both “ﬁ rewood” and “building blocks” for the body, whereas the micronutrients
are special building items, mostly for enzymes to function well. The term “malnutrition” is used for
both macronutrient and micronutrient deﬁ ciencies. Macronutrient and micronutrient problems often
occur together, so that the results in humans are often confounded and impossible to separate out.
Table 3.6.1 outlines which of the nutrients may contribute to neurological disorders if not provided in
sufﬁ cient amounts, together with their recommended daily allowances. Table 3.6.2 outlines some of the

112
Neurological disorders: public health challenges
neurological consequences attributable, in certain circumstances, to ingestion of toxic substances
in food and alcohol.
Table 3.6.1 Neurological disorders caused by nutrient deﬁ ciency
Nutrient
RDAa
Neurological disorder when deﬁ cient
Macronutrients
Total energy
2200 (kcal)
In childhood: long-term mental deﬁ cit
Vitamins
Vitamin B1 Thiamine
1.1 mg
Beri-beri, polyneuropathy, Wernicke’s encephalopathy
Vitamin B3 Niacin
15 mg NE
Pellagra including dementia and depression
Vitamin B6 Pyridoxine
1.6 mg
Polyneuropathy
Vitamin B12 Cobalamine
2.0 μg
Progressive myelopathy with sensory disturbances in the legs
Folate
180 μg
Neural tube defects (myelomeningocele) of the fetus, cognitive
dysfunction in children and elderly?
Minerals
Iodine
150 μg
Iodine deﬁ ciency disorders
Iron
15 mg
Delayed mental development in children
Zinc
12 mg
Delayed motor development in children, depression
Selenium
55 mg
Adverse mood states
a Recommended daily allowance for an adult.
Table 3.6.2 Potential y toxic food compounds that may contribute
to neurological disorders
Food compound
Potential neurological disorder when ingested
Alcohol
Fetal alcohol syndrome, retarded mental development in childhood, Wernicke’s
encephalopathy, visual problems (amblyopia), peripheral neuropathy
Lathyrus sativus
Spastic paraparesis (lathyrism)
Cyanogenic glucosides from
Konzo, tropic ataxic neuropathy
insufﬁ ciently processed cassava roots
MAIN NEUROLOGICAL COMPLICATIONS
OF MALNUTRITION
Macronutrient deﬁ ciency (general malnutrition)
The nervous system develops in utero and during infancy and childhood, and in these periods it
is vulnerable to macronutrient deﬁ ciencies. As a rule, general malnutrition among adults does not
cause speciﬁ c neurological damage, whereas among children it does.
Undernutrition can be assessed most commonly by measurement of the body weight and
the body height. With these two measurements, together with age and sex, it will be possible to
evaluate the energy stores of the individual. The aims of the anthropometric examination are:
■ to assess the shape of the body and identify if the subject is thin, ordinary or obese;

neurological disorders: a public health approach
113
■ to assess the growth performance (this applies only to growing subjects, i.e. children).
A person who is too thin is said to be “wasted” and the phenomenon is generally called
“wasting”. Children with impaired growth are said to be “stunted” and the phenomenon is called
“stunting”. Both these conditions may cause neurological disturbances in children.
The percentage of wasted children in low income countries is 8%, ranging from 15% in Bangla-
desh and India down to 2% in Latin America (3). Different kinds of disasters may raise the ﬁ gures
dramatically in affected areas. This presents a disturbing picture of malnutrition among children
under ﬁ ve years of age in underprivileged populations. These children should be an important
target group for any kind of nutritional intervention to be undertaken in these countries.
Stunting is also widespread among children in low income countries. Its prevalence ranges
from 45% in Bangladesh and India to 16% in Latin America. The global average for stunting
among children in low income countries is 32% (3). Increasing evidence shows that stunting is
associated with poor developmental achievement in young children and poor school achieve-
ment or intelligence levels in older children. “The causes of this growth retardation are deeply
rooted in poverty and lack of education. To continue to allow underprivileged environments to
affect children’s development not only perpetuates the vicious cycle of poverty but also leads to
an enormous waste of human potential. … Efforts to accelerate economic development in any
signiﬁ cant long-term sense will be unsuccessful until optimal child growth and development are
ensured for the majority” (3).
Long-term effects of malnutrition
Apart from the risk of developing coronary heart disease, diabetes and high blood pressure later
in life owing to malnutrition in early life, there is now accumulating evidence of long-term adverse
effects on the intellectual capacity of previously malnourished children. It is methodologically
difﬁ cult, however, to differentiate the biological effects of general malnutrition and those of the
deprived environment on a child’s cognitive abilities. It is also methodologically difﬁ cult to dif-
ferentiate the effect of general malnutrition from the effect of micronutrient deﬁ ciencies, such
as iodine deﬁ ciency during pregnancy and iron deﬁ ciency in childhood, which also cause mental
and physical impairments. Malnourished children lack energy, so they become less curious and
playful and communicate less with the people around them, which impairs their physical, mental
and cognitive development.
Two recent reviews highlight the evidence of general malnutrition per se causing long-term
neurological deﬁ cits (4, 5). An increasing number of studies consistently show that stunting at
a young age leads to a long-term deﬁ cit in cognitive development and school achievement up to
adolescence. Such studies include a wide range of tests including IQ, reading, arithmetic, reason-
ing, vocabulary, verbal analogies, visual-spatial working memory, simple and complex auditory
working memory, sustained attention and information processing. Episodes in young childhood of
acute malnutrition (wasting) also seem to lead to similar impairments. The studies also indicate
that the period in utero and up to two years of age represents a particularly vulnerable time for
general malnutrition (4).
In addition to food supplementation, it has been nicely demonstrated that stimulation of the
child has long-term beneﬁ cial effects on later performance. One such study is from Jamaica,
where stunted children who were both supplemented and stimulated had an almost complete
catch-up with non-stunted children (6), see Figure 3.6.1.
Treatment of severe malnutrition
If a child becomes seriously wasted, this in itself is a life-threatening condition. Even if the child
is brought to hospital, the risk of dying still remains very high. WHO has issued a manual for the
management of severe malnutrition that is available on its web site (7 ). An important element, in

114
Neurological disorders: public health challenges
addition to initial treatment similar to intensive care, is to stimulate the child in order to prevent
the negative long-term effect on the cognitive capacity of the child.
Micronutrient deﬁ ciencies
Micronutrients is the term used for those essential nutrients that are needed in small amounts for
human growth and functioning. They are essentially used as cofactors for enzymes engaged in
various biochemical reactions. They comprise vitamins, fat-soluble as well as water-soluble, and
trace elements (= minerals). Iron, vitamin A, zinc and iodine are most discussed today, but other
important micronutrients are vitamin C and the vitamin B complex. Diets that supply adequate
energy and have an acceptable nutrient density will usually also cover the needs for micronutri-
ents. When the diet is otherwise monotonous, however, it is recommended to supplement it with
micronutrient-rich foods. Food preservation methods, high temperature and exposure to sunlight
can reduce the activity of many vitamins. Most of these deﬁ ciencies are strongly linked to poverty
and human deprivation. Some of these conditions are much more signiﬁ cant with regard to their
global occurrence and their impact on the nervous system than other micronutrient deﬁ ciencies,
so this section focuses on deﬁ ciencies of vitamin A, vitamin B complex, iodine and iron.
Vitamin A deﬁ ciency
Vitamin A assumes two types of function in the body: systemic functions (in the whole body) and
local functions in the eye.
Vitamin A is very important for the mucous membranes as it is needed for the proper produc-
tion of mucopolysaccharides, which help to protect against infections. If vitamin A is deﬁ cient, the
wetness of the mucous membranes will decrease and the membranes will become more like skin
than mucous membranes. This can be seen in the eye as xerophthalmia (dry eye in Greek). Inside
the eye, vitamin A is used in the rods (the receptors for low intensities of light). If there is too little
vitamin A, the person will not be able to see in low light intensity: he or she will become night-
blind. Vitamin A deﬁ ciency has long been identiﬁ ed as the major cause of nutritional blindness.
This is still an important problem around the world: it is estimated that 250–500 000 children are
blinded each year because of eye damage brought about by severe vitamin A deﬁ ciency. It is the
single most important cause of blindness in low and middle income countries.
Figure 3.6.1 Mean developmental quotients of stunteda and non-stuntedb children:
results of intervention over two years
110
Non-stunted
● Stimulated and
supplemented
105
●
quotient
✖ Stimulated
100
●
■ Supplemented
Stunted
●
✖
✖
✖
■
■
Developmental
95
■
▲
▲ Controls
▲
▲
a Adjusted for initial age
90
and score.
Enrolment
8
12
18
24
b Adjusted for age only.
Months
Source: (6).

neurological disorders: a public health approach
115
Vitamin A deﬁ ciency does not only cause eye damage: it also increases mortality owing to
increased vulnerability and impaired immune function, especially to diarrhoeal diseases and
measles. Vitamin A deﬁ ciency develops quite quickly in children with measles, as infections make
the body consume its vitamin A stores much more quickly. Children between six months and four
years old are most vulnerable to vitamin A deﬁ ciency. An estimated 100 million pre-school children
globally are estimated to have vitamin A deﬁ ciency and 300 000 are estimated to die each year
because of vitamin A deﬁ ciency.
In order to prevent child deaths and childhood blindness, many low income countries have inte-
grated vitamin A supplementation into their immunization programmes. Children at risk are given
vitamin A capsules every six months. The cost of the capsules is low (currently US$ 0.05 each).
Vitamin B complex deﬁ ciencies
The B vitamins generally are coenzymes in the energy metabolism in the body. Vitamin B deﬁ cien-
cies have occurred in extreme situations in the past, such as in the 19th century when the steam
mills in South-East Asia started to provide polished rice. Suddenly, people had enough energy but
insufﬁ cient supply of B vitamins and developed beri-beri, a Sinhalese word for “I cannot”. It may
also occur today in refugee populations, if they are provided with a very limited choice of food
items with enough energy but deﬁ cient in B vitamins. Similarly, it may also happen to alcoholics
and people with other types of very monotonous diets.
The different deﬁ ciency syndromes of vitamin B overlap and are sometimes very difﬁ cult to dis-
tinguish from one another. A recent example is the Cuban neuropathy in the mid-1990s, in which
over 50 000 people suffered from a gait and visual disturbance, technically a polyneuropathy
(8, 9). Massive research resources were put in to ﬁ nd the exact cause. It is now known that the
population that experienced the epidemic had an extreme diet (tea with sugar as the main source
of energy; which is likely to generate a vitamin B deﬁ ciency) and the epidemic stopped as soon
as universal distribution was made of tablets with vitamin B complex. This led the scientists to
conclude that it was a vitamin B complex deﬁ ciency, without being able to distinguish the vitamins
from each other. From a public health perspective, therefore, the B vitamins may as well be treated
together, the only exceptions being vitamin B12 and folate.
Vitamin B1 (thiamine). Beri-beri is one form of vitamin B1 deﬁ ciency, and the main symptom is
a polyneuropathy in the legs (10). In severe cases, one can suffer from cardiovascular complica-
tions, tremor, and gait and visual disturbances. An acute form of the syndrome seen in alcoholics
is Wernicke’s encephalopathy (discussed in the section on alcohol). It is characterized by a seri-
ous confusion, unsteadiness and eye movement disorders. It can be rapidly reversed if correctly
diagnosed and immediately treated with high-dose thiamine.
Vitamin B3 (niacin). Deﬁ ciency of niacin leads to “pellagra”, an Italian word for “rough skin”,
which was common in Italy and Spain in the 19th century when large populations were sustained
on a maize diet. In its classic form it appears with three Ds: dermatitis, diarrhoea and dementia;
that is with cutaneous signs, erythema, pigmentation disorders, diarrhoea and neuropsychiatric
disturbances such as confusion and psychomotor agitation.
Vitamin B6 (pyridoxine). Vitamin B6 is involved in the regulation of mental function and mood.
Neuropsychiatric disorders including seizures, migraine, chronic pain and depression have been
linked to vitamin B6 deﬁ ciency (11). Some studies have suggested that neurological development
in newborns could be improved by supplementation in pregnancy, but this is still a hypothesis (12).
Vitamin B6 deﬁ ciency may occur especially during intake of some drugs which antagonize with
the vitamin (i.e. isoniazid, penicillamine).
Folate. Folate (or folic acid) plays an important role for rapidly dividing cells such as the blood
cells, and a folate deﬁ ciency causes a special type of anaemia called megaloblastic anaemia which
is reversible when folate is given. In recent years, it has been found that folate deﬁ ciency during

116
Neurological disorders: public health challenges
pregnancy increases the risk of fetal malformation in the form of neural tube defects (NTDs =
myelo-meningocele) (13). Folate supplementation for women at the time of conception protects
against neural tube defects (13). Supplementation of folate in wheat ﬂ our is therefore common in
Europe and North America, with the objective of reducing the risk of neural tube defect (14–16).
In Canada, Chile and the United States, mandatory fortiﬁ cation of ﬂ our substantially improved
folate and homocysteine status, and neural tube defect rates fell by between 31% and 78% (17 ).
Nevertheless, many countries do not choose mandatory folic acid fortiﬁ cation, in part because
expected additional health beneﬁ ts are not yet scientiﬁ cally proven in clinical trials, in part because
of feared health risks, and because of the issue of freedom of choice. Thus additional creative
public health approaches need to be developed to prevent neural tube defects and improve the
folate status of the general population.
Vitamin B12 (cobalamine). The vitamin B12 or cobalamine is — like folate — important in the
formation of blood cells, particularly the red blood cells. Vitamin B12 is different from the other
B vitamins because it needs an “intrinsic factor” produced by the gut in order to be absorbed.
This means that people with gut disorders and also elderly people may experience vitamin B12
deﬁ ciency. Vitamin B12 deﬁ ciency also causes a megaloblastic anaemia which is reversible when
vitamin B12 is given. What is worse is an insidious irreversible damage to the central and periph-
eral nervous systems. In a severe form it may also cause a psychiatric disorder with irritability,
aggressiveness and confusion. It has been suggested that vitamin B12 deﬁ ciency might contribute
to age-related cognitive impairment; low serum B12 concentrations are found in more than 10%
of older people (18) but so far there is insufﬁ cient proof of beneﬁ cial effects of supplementation.
The most serious problem with vitamin B12 deﬁ ciency still seems to be the irreversible progressive
myeloneuropathy, which is difﬁ cult to diagnose.
Iodine deﬁ ciency disorders
Iodine deﬁ ciency does not cause one single disease, but many disturbances in the body. These
are denoted by the term iodine deﬁ ciency disorders: their effects range from increased mortality
of fetuses and children, constrained mental development — in its worst form, cretinism — to
impaired school performance and socioeconomic development, as detailed in Table 3.6.3.
WHO has estimated that 1.6 billion people in 130 countries live in areas where they are at risk
of being deﬁ cient in iodine. Goitre — indicated by a swelling of the thyroid gland — is present in
740 million people, and some 300 million suffer from lowered mental ability as a result of a lack
of iodine. Iodine deﬁ ciency disorders
today constitute the single greatest
Figure 3.6.2 Tol of iodine deﬁ ciency worldwide
cause of preventable brain damage in
the fetus and infant and retarded psy-
Cretinism: 16 million
chomotor development in young chil-
dren. At least 120 000 children every
Brain damage: 49 million
year are born cretins — mentally re-
tarded, physically stunted, deaf-mute
or paralysed — as a result of iodine
deﬁ ciency. In addition, an estimated
annual total of at least 60 000 miscar-
riages, stillbirths and neonatal deaths
Goitre: 740 million
stem from severe iodine deﬁ ciency in
early pregnancy, as shown in Figure
3.6.2 (19).
Total population at risk: 1.6 billion (30% of the world’s population)
Source: adapted from (19).

neurological disorders: a public health approach
117
Table 3.6.3 Spectrum of disorders caused by iodine deﬁ ciency
Iodine deﬁ ciency disorder
Effect
Goitre
Enlargement of the thyroid gland
Hypothyroidism
Decreased production of thyroid hormones
Miscarriages
Early death of fetuses in the womb
Stillbirths
Late death of fetuses (the child is dead at birth)
Perinatal mortality
Increased number of deaths among newborn children
Congenital abnormalities
Abnormalities of the newborn child
Cretinism
Severe mental retardation, growth retardation, deaf-mutism and physical
disability
Decrease in IQ
Impaired educability
Lower school performance
Impaired social and human development
At the World Summit for Children in 1990, the problem of iodine deﬁ ciency disorders was
highlighted and a strong political will to eliminate them was demonstrated. At that time, the scale
and severity of the iodine problem was only just being realized. Since then, several surveys have
shown even more severe damage than was estimated from this deﬁ ciency in many regions of the
world. Work to eliminate iodine deﬁ ciency disorders has made enormous progress and is becoming
a success story in the prevention of a nutritional deﬁ ciency. WHO has issued a useful guide to help
programme managers assess the problem and monitor progress towards its elimination (20).
The main intervention strategy for control of iodine deﬁ ciency disorders is universal salt io-
dization. Salt was chosen as the commodity to be fortiﬁ ed for a number of reasons: it is widely
consumed in fairly equal amounts by most people in a population, it is usually produced centrally
or in a few factories, and the cost of iodizing is low (about US$ 0.05 per person per year). Over the
last decade, extraordinary progress has been made in increasing the number of people consuming
iodized salt. In 1998, more than 90 countries had salt iodization programmes. Now, more than two
thirds of households living in countries affected by iodine deﬁ ciency disorders consume iodized
salt. Universal salt iodization ranges from 63–90% in Africa, the Americas, South-East Asia and
the Western Paciﬁ c, whereas in Europe it is only 27%, thus leaving Europeans at risk of iodine de-
ﬁ ciency disorders. Because of active programmes of salt fortiﬁ cation, iodine deﬁ ciency disorders
are rapidly declining in the world. In 1990, 40 million children were born with mental impairment
attributable to iodine deﬁ ciency and 120 000 cretins were born, which was substantially more
than just seven years later. WHO has estimated that the number of people with goitre will decrease
to 350 million by the year 2025 as a result of iodine enrichment and supplementation programmes.
A challenge is to enforce the legislation that has been passed in all but seven of the countries of the
world with a recognized iodine-deﬁ ciency public health problem. All the salt producers, from large
industries to small-scale producers, need to be encouraged to use the more expensive procedure
to fortify their salt production, and the consumers also need to be informed. Quality control and
monitoring of the impact of the procedures are other continuing tasks related to the world’s most
widespread preventable cause of mental impairment (20).
Iron deﬁ ciency anaemia
Iron deﬁ ciency anaemia affects more than 3.5 billion people globally, making it the most frequent
micronutrient deﬁ ciency in the world. Iron deﬁ ciency seems to be the only micronutrient deﬁ ciency
that high income and low income countries have in common. Of the total burden of disease in

118
Neurological disorders: public health challenges
DALYs, over 2% is attributable to anaemia. Iron deﬁ ciency anaemia depresses human productivity
by tiredness, breathlessness, decreased immune function and impaired learning in children. The
effect of iron deﬁ ciency on learning is difﬁ cult to study because iron deﬁ ciency is also closely
related to poverty and socioeconomic disadvantage. The indirect productivity effects of improved
iron status are on cognitive ability and achievement, through impact on mental and motor skills
in infants and on cognition, learning and behaviour in children and adolescents. An early severe
chronic iron deﬁ ciency leads to poorer overall cognitive functioning and lower school achievements
(21, 22). Thus, macronutrient, iodine and iron deﬁ ciencies all have a substantial negative effect on
cognition, behaviour and achievement; in all three cases, the effects produced by chronic deﬁ cien-
cies in the early years are manifested later in life (23). The estimated losses of GDP attributable
to iron deﬁ ciency in three countries are considerable (Figure 3.6.3).
The most affected populations are children in the pre-school years and pregnant women in low
and middle income countries. In these populations, deﬁ ciencies of dietary iron are aggravated by
repeated episodes of parasitic diseases such as malaria, hookworm infestation or schistosomiasis
in children, and by menstruation, repeated pregnancies or blood loss at delivery in women. A
low dietary intake of iron and the inﬂ uence of factors affecting absorption also contribute to iron
deﬁ ciency. About 40% of the women in low and middle income countries and up to 15% in high
income countries suffer from anaemia.
Better nutrition, iron supplementation or fortiﬁ cation, child spacing and the prevention and
treatment of malaria and hookworms can all prevent iron deﬁ ciency. Iron is found naturally in
meat, ﬁ sh, liver and breastmilk. Vitamin C increases iron absorption, and coffee and tea decrease
absorption. Correction of iron deﬁ ciency anaemia is cheap, but a functioning health service is
needed to promote the measures among the most vulnerable groups. There is, however, some
evidence to suggest that iron supplementation at levels recommended for otherwise healthy chil-
dren carries the risk of increased severity of infectious disease in the presence of malaria and/or
undernutrition. It is therefore advised that iron and folic acid supplementation be targeted to those
who are anaemic and at risk of iron deﬁ ciency. They should receive concurrent protection from
malaria and other infectious diseases through prevention and effective case management (25).
Zinc deﬁ ciency
There is a close connection between zinc deﬁ ciency and stunting. In addition, zinc supplementa-
tion of young children in low income countries improves their neurophysiological performance (26),
also in combination with iron supplements (27 ). Some behavioural abnormalities in adults also
seem to respond favourably to zinc supplementation, such as mood changes, emotional lability,
anorexia, irritability and depression (28).
Selenium deﬁ ciency
Selenium deﬁ ciency has been linked to adverse mood states (29). Selenium supplementation
together with other vitamins has been found beneﬁ cial in the treatment of mood lability (30).
Generally, the scientiﬁ c information about selenium and neurological disorders remains scarce.
TOXICONUTRITIONAL DISORDERS
In the 19th century, medical science successfully revealed the causation of several neurological
disorders that occurred in localized epidemics or endemic foci. There are, however, still a number
of obscure neurological disorders occurring in localized epidemics or endemic foci in tropical
countries. Most of these syndromes consist of various combinations of peripheral polyneuropathy
and signs of spinal cord involvement. The term “tropical myeloneuropathies” has been used to
group these disorders of unknown etiology; to reduce the confused clinical terminology, Román
distinguishes two clinical groups which he calls tropical ataxic neuropathy, with prominent sensory

neurological disorders: a public health approach
119
ataxia, and tropical spastic paraparesis, with predominantly spastic paraparesis with minimal
sensory deﬁ cit (31).
Syndromes of ataxic polyneuropathy
Reports on a form of ataxic polyneuropathy described by Strachan and later by Scott led to the
recognition of a tropical neurological syndrome characterized by painful polyneuropathy, orogenital
dermatitis and amblyopia, known as Strachan’s syndrome. It was linked with malnutrition and
reported from Africa. During the Second World War, prisoners of war in tropical and subtropical
regions suffered from similar syndromes with “burning feet”, numbness and loss of vision with
pallor of the temporal border of the optic disks. Spastic paraplegia was also seen in these highly
variable conditions (32). Since the Second World War, ataxic polyneuropathies have been reported
from many tropical and subtropical areas (31).
In the 1930s, Moore described, in an institution in Nigeria, a syndrome of visual loss, sore
tongue, stomatitis and eczema of the scrotum in adolescent boys. Their cassava-based diet was
suggested to be the cause, as the students improved during holidays. The cyanide-yielding capac-
ity of bitter cassava and its toxic effects were described at that time. This syndrome of painful
polyneuropathy, ataxia and blurred vision was extensively studied in Nigeria by Osuntokun (33).
The diagnostic criteria used for this tropical ataxic neuropathy were the presence of two of the
following: myelopathy, bilateral optic atrophy, bilateral sensorineural deafness, and symmetrical
peripheral polyneuropathy. Men and women were equally affected, with a peak incidence in the
ﬁ fth and sixth decades of life. The prevalence in certain areas of Nigeria ranged from 1.8% to
2.6% in the general population. When discussing the neurological syndromes resembling Nigerian
ataxic neuropathy described from different parts of the world, Osuntokun pointed out that it is
unlikely that the same speciﬁ c etiological factor is involved in all places. In Nigeria, tropical ataxic
neuropathy has been shown to persist also into this millennium (34).
Syndromes of spastic paraparesis
The second clinical group of tropical myeloneuropathies proposed by Román (31) is comprised
of syndromes with spastic paraparesis as the main feature. Besides paraparesis as a sequel of
extrinsic cord compression resulting from trauma or tuberculosis, several syndromes with spastic
paraparesis have been reported in epidemics or endemic foci throughout the world.
The classic form of locally occurring spastic paraparesis, mentioned already by Hippocrates,
is lathyrism (35), caused by excessive consumption of grass pea, Lathyrus sativus (36). The clini-
cal picture is an acute or sub-acute
onset of an isolated spastic parapa-
resis, with increased muscle tone,
Figure 3.6.3 Loss of gross domestic product (GDP) attributable
brisk reflexes, extensor plantar
to iron deﬁ ciency
responses and no sensory signs.
3.0
It has been known since ancient
times and has occurred in Europe
2.5
(37 ) and North Africa but is today
1.9
known as a public health problem
2.0
in only Bangladesh, India (38) and
1.5
Ethiopia (39). An excitotoxic amino
1.3
1.1
1.1
acid in the grass pea, beta-N-oxa-
GDP lost (%)
0.9
1.0
0.8
lylamino-L-alanine is held respon-
sible for the disease (36).
0.5
0
Bangladesh
India
Pakistan
■ cognitive losses only
■ cognitive losses + losses in manual work
Source: (24).

120
Neurological disorders: public health challenges
A second form of spastic paraparesis, nowadays called HTLV-I associated myelopathy/tropical
spastic paraparesis, has been found in geographical isolates in different parts of the world (40).
It is now proved to be caused by the human T-lympho tro pic virus type I (HTLV–I) and is unrelated
to nutrition.
A third form of spastic paraparesis with abrupt onset has been reported in epidemic outbreaks
in Africa. Clinically and epidemiologically it is similar to lathyrism but without any association with
consumption of L. sativus. This disease is now called konzo (41). Konzo has been reported only
from poor rural communities in Africa; it is characterized by the abrupt onset of an isolated and
symmetric spastic paraparesis which is permanent but non-progressive. The name derives from
the local designation used by the Congolese population affected by the ﬁ rst reported outbreak in
1936. Konzo means “tied legs”, and is a good description of the resulting spastic gait. Outbreaks of
konzo are described from Cameroon, the Central African Republic, the Democratic Republic of the
Congo, northern Mozambique and the United Republic of Tanzania. Konzo has been associated with
exclusive consumption of insufﬁ ciently processed bitter cassava in epidemiological studies (42).
Toxic optic neuropathy
Toxic optic neuropathy, also called nutritional amblyopia, is a complex, multifactorial disease,
potentially affecting individuals of all ages, races, places and economic strata (43). It may be
precipitated by poor nutrition and toxins (especially smoking and alcohol) but genetic predisposal
is also an important factor. Most cases of nutritional amblyopia are encountered in disadvantaged
countries (9). Typically, toxic and nutritional optic neuropathy is progressive, with bilateral sym-
metrical painless visual loss causing central or cecocentral scotoma. There is no speciﬁ c treat-
ment for this disorder. Nevertheless, early detection and prompt management may ameliorate and
even prevent severe visual deﬁ cit.
Alcohol-related neurological disorders
Alcohol and other drugs play a signiﬁ cant role in the onset and course of neurological disorders.
As toxic agents, these substances directly affect nerve cells and muscles, and therefore have
an impact on the structure and functioning of both the central and peripheral nervous systems.
For example, long-term use of ethanol is associated with damage to brain structures which are
responsible for cognitive abilities (e.g. memory, problem-solving) and emotional functioning. In
people with a history of chronic alcohol consumption the following abnormalities have been ob-
served: cerebral atrophy or a reduction in the size of the cerebral cortex, reduced supply of blood
to this section of the brain which is responsible for higher functions, and disruptions in the func-
tioning of neurotransmitters or chemical messengers. These changes may account for deﬁ cits in
higher cortical functioning and other abnormalities which are often symptoms of alcohol-related
neurological disorders.
Fetal alcohol syndrome
The role of alcohol in fetal alcohol syndrome has been known for many years: the condition affects
some children born to women who drank heavily during pregnancy. The symptoms of fetal alco-
hol syndrome include facial abnormalities, neurological and cognitive impairments, and deﬁ cient
growth with a wide variation in the clinical features (44). Not much is known about the prevalence
in most countries but, in the United States, available data show that the prevalence is between
0.5 and 2 cases per 1000 births (45). Though there is little doubt about the role of alcohol in this
condition, it is not clear at what level of drinking and during what stage of pregnancy it is most
likely to occur. Hence the best advice to pregnant women or those contemplating pregnancy seems
to be to abstain from drinking, because without alcohol the disorder will not occur.

neurological disorders: a public health approach
121
Alcohol-related polyneuropathy
A typical example of a toxiconutritional disorder, alcohol-related polyneuropathy is elicited by a
combination of the direct toxicity of alcohol on the peripheral nerve and a relative deﬁ ciency of
vitamin B1 and folate. In its usual form it starts in an insidious, progressive way with signs located
at the distal ends of the lower limbs: night cramps, bizarre sensations of the feet and the sufferer is
quickly fatigued when walking. Examination reveals pain at the pressure of the muscular masses.
This polyneuropathy evolves to a complete form with permanent pain in the feet and legs. The signs
of evolution of alcoholic polyneuropathy are represented by the deﬁ cit of the leg muscles leading
to abnormal walk, exaggerated pain (compared to burning, at any contact) and skin changes. At
the latest stage, ulcers may occur (46). The onset of the peripheral neuropathy depends on the age
of the patient, the duration of the abuse and also the amount of alcohol consumed. The excessive
abuse of this substance determines the central and/or peripheral nervous lesions.
Wernicke’s encephalopathy
Wernicke’s encephalopathy is the acute consequence of a vitamin B1 deﬁ ciency in people with
severe alcohol abuse. It is due to very poor diet, intestinal malabsorption and loss of liver thiamine
stores. The onset may coincide with an abstinence period and is generally marked by somnolence
and mental confusion; which gradually worsens, together with cerebellar signs, hypertonia, pa-
ralysis and/or ocular signs. The prognosis depends on how quickly the patient is given high-dose
vitamin B1 (by intravenous route, preferably). A delay or an absence of treatment increases the risk
of psychiatric sequelae (memory disorders and/or intellectual deterioration). If the treatment is too
late, the consequences could be an evolution to a Wernicke–Korsakoff syndrome, a dementia.
Alcohol and epilepsy
Alcohol is associated with different aspects of epilepsy, ranging from the development of the
condition in chronic heavy drinkers and dependent individuals to an increased number of seizures
in people already with the condition. Alcohol aggravates seizures in people undergoing withdrawal
and seizure medicines might interfere with tolerance for alcohol, thereby increasing its effect.
Though small amounts of alcohol might be safe, people suffering from epilepsy should be advised
to abstain from consuming this agent.
After an episode of weeks of uninterrupted drinking, sudden abstinence may lead to epileptic
seizures and severe coma, “delirium tremens”. Detoxiﬁ cation should be under medical supervision
and possibly with medication to decrease the risk of this potentially life-threatening condition.
In terms of relative risk, much more is known about alcohol and epilepsy than other conditions.
There is little difference between abstainers and light drinkers in the risk for chronic harmful alco-
hol-related epilepsy. Risk is highest at levels of consumption which exceed 20 g of pure alcohol (or
two drinks) per day for women and 40 g for men. For example, the WHO project on comparative
risk assessment has shown more than a sevenfold increase in risk among those who consume
these high volumes or are dependent on alcohol when compared with abstainers for both male
and female drinkers (47 ).
PREVENTION OF NUTRITIONAL DEFICIENCIES
The neurological disorders discussed in this chapter stem from three main causes:
■ general malnutrition in childhood leading to macronutrient deﬁ ciency;
■ micronutrient deﬁ ciencies caused by insufﬁ cient supply or increased consumption (sometimes
called “hidden hunger”);
■ ingestion of toxic compounds.

122
Neurological disorders: public health challenges
The prevention of neurological complications attributable to the ﬁ rst two causes is, in theory,
very simple: achieve Millennium Development Goal No. 1 by eradicating extreme poverty and
hunger. Most people encountering a nutritional deﬁ ciency do so because of poverty. Acknowledg-
ing that eradicating poverty is easier said than done, there are some strategies that can be used
to prevent some of the micronutrient deﬁ ciencies. There are three principal ways of approaching
a potentially micronutrient-deﬁ cient diet:
■ Diversiﬁ cation — include other micronutrient-rich food items in the diet.
■ Supplementation — add a supplement of the micronutrient, for instance as a pill. This method
is used with vitamin A in a large number of low income countries, linked to the immunization
programme.
■ Fortiﬁ cation — add more of the micronutrient to a common food commodity. Universal salt
iodization is an example where this strategy has been used.
Worldwide efforts to cope with the most appalling micronutrient deﬁ ciencies are ongoing.
Adding iodine to all salt has been a very successful way of preventing neurological complications
caused by iodine deﬁ ciency. Supplementation of vitamin A for children under ﬁ ve years of age is
another successful strategy to prevent blindness as a result of vitamin A deﬁ ciency. In societies
with more resources and more centralized food distribution, fortiﬁ cation of ﬂ our with folate has
been shown to decrease the occurrence of neural tube defects. In populations with restricted food
choice, such as refugee populations in camps surviving on food rations, surveillance is needed to
detect and correct vitamin deﬁ ciencies.
The toxic exposures need different approaches. For L. sativus, supplementation of cereals
during acute food shortages in lathyrism-endemic areas can reduce its consumption. Another pos-
sibility is the development of a genetically modiﬁ ed atoxic variety that could prevent the problem.
In the case of insufﬁ ciently processed toxic cassava, this solution does not seem so attractive,
as low-toxic varieties are not as reliable in producing food for the family; the approach should
concentrate on the proper processing of cassava. For alcohol, the focus needs to be on restricting
alcohol consumption, at least during pregnancy.
The large majority of the malnutrition-related neurological disorders can be avoided by simple
measures, such as the following recommended actions for policy-makers.
■ Support efforts towards universal salt iodization.
■ Support vitamin A supplementation among children under ﬁ ve years of age, if judged neces-
sary.
■ Consider strategies to decrease childhood malnutrition.
■ Consider folate fortiﬁ cation of ﬂ our, if affordable and possible.
■ Oversee the distribution of food rations to refugee populations, in order to detect and correct
vitamin deﬁ ciencies.
■ Promote the proper processing of toxic cassava.
■ Restrict alcohol consumption, especially during pregnancy.
A preventive approach should include adapted communication with the aim of changing be-
haviour, strengthening capacities and reducing the incidence of some chronic diseases such as
frequent neurological complications. The following activities are possible examples:
■ speciﬁ c nutritional programmes for children and pregnant and nursing women;
■ rapid diagnosis of nutritional deﬁ ciencies in vitamins and minerals that could have a severe
impact on mother and child and alter their mental and physical status and development;
■ nationwide measures such as those for the prevention of iodine deﬁ ciency and its conse-
quences.

neurological disorders: a public health approach
123
Early interventions could reverse the deleterious tendencies. In many countries, the mass
interventions against iron, vitamin A and iodine deﬁ ciencies among children (those under ﬁ ve years
of age and older ones as well) and pregnant and nursing women, must be reinforced. At the other
end of the scale, much remains to be done for adults and elderly people.
A PUBLIC HEALTH FRAMEWORK
Political aspects
Within the context of the ﬁ ght against poverty, malnutrition would beneﬁ t from strong political
commitment to improve and develop an integrated approach of various ministries. Improving the
dialogue between public and private sectors should be an important approach to emphasize in
every country. Efforts remain to be made for a comprehensive salt iodization as recommended
by international organizations. This implicates obligatory reinforcement of policies for legislation,
standards, application and control. Regulations on the advertising of beers, wines, other alcoholic
drinks and tobacco must be reinforced, especially during sports and cultural events. Nigerian
President Olusegun Obasanjo has lent his support to the goal of reducing death from chronic dis-
ease: “Governments have a responsibility to support their citizens in their pursuit of a healthy, long
life. It is not enough to say: ‘we have told them not to smoke, we have told them to eat fruit and
vegetables, we have told them to take regular exercise’. We must create communities, schools,
workplaces and markets that make these healthy choices possible.”
Management and provision of care
The management of neurological disorders related to malnutrition — attributable to direct causes
or secondary induced effects of metabolic diseases — is a challenge that requires a pragmatic
approach in order to be effective. Setting up pilot interventions that are feasible and realistic
would be a useful demonstration to WHO Member States concerned by this public health problem.
Lessons learnt from other integrated programmes (for both noncommunicable and communicable
diseases) could serve as a model for neurological disorders associated with malnutrition.
It is essential to set up a multidisciplinary task force surrounding neurologists and nutritionists.
This team should be supplemented by clinicians who are concerned with the secondary causes of
neurological diseases related to nutrition, i.e. cardiologists, endocrinologists, specialists in internal
medicine and paediatricians. Social scientists would also have an important role, for a better
understanding of knowledge, attitudes and practices. Specialists in communication would be
involved in the initiative, so as to reach, educate and sensitize the population. Other sectors such
as education, private and public sectors, civil society, community leaders and nongovernmental
organizations will all have a part to play to contribute to the concretization and reinforcement of
the strategies and interventions.

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Neurological disorders: public health challenges
CONCLUSIONS AND RECOMMENDATIONS
1
Malnutrition, micronutrient deﬁ ciencies and ingestion of toxic compounds continue to be
priority public health problems. Most of the neurological disorders associated with them
are preventable.
2
Priorities need to be identiﬁ ed for the actions needed to deal with neurological disorders
associated with malnutrition, micronutrient deﬁ ciencies, or the ingestion of toxic
compounds.
3
The strategy of communication should use appropriate and diversiﬁ ed channels for
better sensitization and social mobilization. It should target the general population,
health professionals and social workers. Schools constitute a favourable environment
because they provide access to teachers and pupils who can carry the message home at
household level.
4
The interrelationship between neurological disorders and nutrition must be stressed in the
training of general practitioners, paramedical staff and social workers. The capacities of
nongovernmental organizations, community organizations and the education sector must
be reinforced and developed so as to target the prevention of nutritional problems.
5
Development and review of training manuals, counselling guidelines and training curricula
is a necessary part of capacity-strengthening whose contents need to be centred on
speciﬁ c subjects in accordance with needs assessment, the gaps to be ﬁ lled and the
interventions to be implemented in the community.
6
Educative support to the health services must be elaborated to develop tools of education
and counselling for primary and secondary prevention and to develop guidelines and
support to facilitate management of the targeted diseases and secondary complications,
including disabilities and rehabilitation.

neurological disorders: a public health approach
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15. Oakley GP Jr et al. Scientiﬁ c evidence supporting folic acid fortiﬁ cation of ﬂ our in Australia and New
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16. Dietrich M et al. The effect of folate fortiﬁ cation of cereal-grain products on blood folate status, dietary
folate intake, and dietary folate sources among adult non-supplement users in the United States. Journal of
the American College of Nutrition, 2005, 24:266–274.

17. Eichholzer M, Tonz O, Zimmerman R. Folic acid: a public health challenge. Lancet, 2006, 367:1352–1361.

18. Malouf R, Areosa Sastre A. Vitamin B12 for cognition. Cochrane Database of Systematic Reviews, 2003, 3:
CD004326.
19. The state of the world’s children. New York, United Nations Children’s Fund, 1995.
20. Assessment of iodine deﬁ ciency disorders and monitoring their elimination. A guide for programme managers.
Geneva, World Health Organization, 2001.

21. Andraca I de et al. Psychomotor development and behavior in iron-deﬁ cient anemic infants. Nutrition
Reviews, 1997, 55:125–132.

22. Lozoff B, Wachs T. Functional correlates of nutritional anemias in infancy and childhood – child development
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23. Hunt JM. Reversing productivity losses from iron deﬁ ciency: the economic case. Journal of Nutrition, 2002,
132(Suppl. 4):794S–801S.

24. Horton S. Opportunities for investment in nutrition in low-income Asia. Asian Development Review, 1999,
17:246–273.

25. WHO Global Malaria Programme. Geneva, World Health Organization (http://malaria.who.int/).

26. Bentley ME et al. Zinc supplementation affects the activity patterns of rural Guatemalan infants. Journal of
Nutrition, 1997, 127:1333–1338.

27. Black MM et al. Iron and zinc supplementation promote motor development and exploratory behavior among
Bangladeshi infants. American Journal of Clinical Nutrition, 2004, 80:903–910.

28. Aggett P. Severe zinc deﬁ ciency. In: Mills C, ed. Zinc in human biology. London, Springer, 1989:259–280.

29. Rayman MP. The importance of selenium to human health. Lancet, 2000, 356:233–241.
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33. Osuntokun BO. Cassava diet, chronic cyanide intoxication and neuropathy in Nigerian Africans. World Review
of Nutrition and Dietetics, 1981, 36:141–173.

34. Oluwole O et al. Persistence of tropical ataxic neuropathy in a Nigerian community. Journal of Neurology,
Neurosurgery and Psychiatry, 2000, 69:96–101.

35. Acton H. An investigation into the causation of lathyrism in man. Indian Medical Gazette, 1922, 57:241–247.

36. Spencer PS et al. Lathyrism: evidence for role of the neuroexcitatory aminoacid BOAA. Lancet, 1986,
2(8515):1066–1067.

37. Gardner A, Sakiewicz N. A review of neurolathyrism including the Russian and Polish literature. Experimental
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38. Dwivedi MP, Prasad BG. An epidemiological study of lathyrism in the district of Rewa, Madhya Pradesh.
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39. Haimanot R et al. Lathyrism in rural northwestern Ethiopia: a highly prevalent neurotoxic disorder.
International Journal of Epidemiology, 1990, 19:664–672.

40. Proietti FA et al. Global epidemiology of HTLV-I infection and associated diseases. Oncogene, 2005,
24:6058–6068.

41. Konzo, a distinct type of upper motoneuron disease. Weekly Epidemiological Record, 1996, 71:225–232.

42. Tylleskär T et al. Cassava cyanogens and konzo, an upper motoneuron disease found in Africa. Lancet, 1992,
339:208–211.

43. Kesler A, Pianka P. Toxic optic neuropathy. Current Neurology and Neuroscience Reports, 2003, 3:410–414.

44. Chaudhuri JD. Alcohol and the developing fetus – a review. Medical Science Monitor, 2000, 6:1031–1041.

45. Chang G. Screening and brief intervention in prenatal care settings. Alcohol Research and Health, 2005,
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46. Agelink M et al. Alcoholism, peripheral neuropathy (PNP) and cardiovascular autonomic neuropathy (CAN).
Journal of the Neurological Sciences, 1998, 161:135–142.

47. Rehm J et al. Alcohol use. In: Ezzati M et al., eds. Comparative quantiﬁ cation of health risks. Global and
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RECOMMENDED READING
■ Reilly C. The nutritional trace metals. Oxford, Blackwell Publishing, 2004.
■ Assessment of iodine deﬁ ciency disorders and monitoring their elimination. A guide for programme manag-
ers. Geneva, World Health Organization, 2001.
■ Physical status: the use and interpretation of anthropometry. Geneva, World Health Organization, 1995.
■ The Micronutrient Initiative web site (http://www.micronutrient.org/) includes links to the most important
Internet sites regarding the individual micronutrients discussed in this chapter.

neurological disorders: a public health approach
127
3.7 Pain associated with
neurological disorders
128 Types of pain associated with neurological
disorders
130 Assessment of pain
131 Public health aspects of pain disorders
133 Disability and burden
Pain can be a direct or an indirect consequence of a
neurological disorder, with physical and psychological
133 Treatment and care
dimensions that are both essential for its correct diag-
136 Research
nosis and treatment. Pain — acute and chronic — is a
136 Training
major public health problem that poses signiﬁ cant chal-
137 Conclusions and recommendations
lenges to health professionals involved in its treatment.
Chronic pain may persist long after initial tissue damage
has healed: in such cases, it becomes a speciﬁ c health-care problem and a recog-
nized disease. Adequate pain treatment is a human right, and it is the duty of any
health-care system to provide it.
The current and most widely used deﬁ nition of pain was published by the International Associa-
tion for the Study of Pain (IASP) in 1979, which states that pain is “an unpleasant sensory and
emotional experience associated with actual or potential tissue damage or, is described in terms
of such damage” (1). This deﬁ nition was qualiﬁ ed by the Taxonomy Task Force of the association
in 1994 (2): “Pain is always subjective. Each individual learns the applications of the word through
experiences relating to injuries in early life”.
The physiological effect of pain is to warn of tissue damage and so to protect life. Pain is
classiﬁ ed as nociceptive if it is caused by the activation of nociceptors (primary sensory neurons
for pain). Nociceptive pain can be somatic (pain originating from the skin or musculoskeletal
system) or visceral (pain originating from visceral organs). The sensory system itself can be dam-
aged and become the source of continuous pain. This type of pain is classiﬁ ed as neuropathic.
Chronic neuropathic pain has no physical protective role as it continues without obvious ongoing
tissue damage. Pain without any recognizable tissue or nerve damage has its cause classiﬁ ed
as idiopathic pain. Any individual pain state may be a combination of different pains. A clinician’s
duty is to diagnose, treat and support pain patients, which means the identiﬁ cation of pain type(s)
and their causative disease(s). It is also to provide adequate treatment aimed at the cause of the
pain and symptomatic relief which should include psychosocial support. As the deﬁ nition of pain
reveals, pain has both a physical and a psychological element. The latter plays an important part
in chronic pain disorders and their management. Adequate pain treatment is a human right and
organization of it involving all its dimensions is the ethical and legal duty of society, health-care
professionals and health-care policy-makers.

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TYPES OF PAIN ASSOCIATED WITH NEUROLOGICAL
DISORDERS
Pain can be a direct or an indirect consequence of a neurological disorder. The former is seen
in neurological conditions where there has been a lesion or disease of pathways that normally
transmit information about painful stimuli either in the peripheral or in the central nervous system
(CNS). These types of pain are termed neuropathic pains. Pain can also be an indirect conse-
quence of a nervous disease when it causes secondary activation of pain pathways. Examples of
these types of pain include musculoskeletal pain in extrapyramidal diseases such as Parkinson’s
disease, or deformity of joints and limbs due to neuropathies or infections.
It is useful to distinguish between acute and chronic pain. Pain begins frequently as an acute
experience but, for a variety of reasons — some physical and often some psychological — it
becomes a long-term or chronic problem. According to the IASP classiﬁ cation of chronic pain,
this term refers to any pain exceeding three months in duration.
Pain directly caused by diseases or abnormalities
of the nervous system
Neuropathic pain
In contrast to nociceptive pain which is the result of stimulation of primary sensory nerves for pain,
neuropathic pain results when a lesion or disruption of function occurs in the nervous system.
Neuropathic pain is often associated with marked emotional changes, especially depression, and
disability in activities of daily life. If the cause is located in the peripheral nervous system, it gives
rise to peripheral neuropathic pain and if it is located in the CNS (brain or spinal cord) it gives rise
to central neuropathic pain.
Peripheral neuropathic pain. Painful diabetic neuropathy and the neuralgia that develops after
herpes zoster are the most frequently studied peripheral neuropathic pain conditions. Diabetic
neuropathy has been estimated to afﬂ ict 45–75% of patients with diabetes mellitus. About 10%
of these develop painful diabetic neuropathy, in particular when the function of small nerve ﬁ bres
is impaired. Pain is a normal symptom of acute herpes zoster, but disappears in most cases with
the healing of the rash. In 9–14% of patients, pain persists chronically beyond the healing process
(postherpetic neuralgia). Neuropathic pain may develop also after peripheral nerve trauma as in
the condition of chemotherapy-induced neuropathy.
The frequencies of many types of peripheral neuropathic pain are not known in detail but vary
considerably because of differences in the frequency of underlying diseases in different parts
of the world. While pain caused by leprosy is common in Brazil and parts of Asia, such pains
are exceedingly rare in Western parts of the world. Because of an explosion in the frequency of
diabetes as a result of obesity in many industrialized countries and in South-East Asia, the likely
result of this will be an increase in painful diabetic neuropathy within the next decade.
Central neuropathic pain, including pain associated with diseases of the spinal cord. Central
post-stroke pain is the most frequently studied central neuropathic pain condition. It occurs in
about 8% of patients who suffer an infarction of the brain. The incidence is higher for infarctions
of the brainstem. Two thirds of patients with multiple sclerosis have chronic pain, half of which is
central neuropathic pain (3).
Damage to tissues of the spinal cord and, at times, nerve roots, carries an even higher risk
of leading to central neuropathic pain (myelopathic pain). The cause may lie within the cord and
be intrinsic, or alternatively, be extrinsic outside the cord. Intrinsic causes include multiple scle-
rosis and acute transverse myelitis, both of which may result in paraplegia and pain. In certain
developing countries, for example in sub-Saharan Africa, intrinsic damage may be attributable
to neurotoxins — as in the case of incorrectly prepared cassava, which leads to tropical spastic

neurological disorders: a public health approach
129
paresis. Lathyrism resulting from consumption of the grass pea (Lathyrus sativus) may cause a
spinal disorder and, in both cases, pain is a signiﬁ cant symptom (see also Chapter 3.6).
Extrinsic causes of cord damage and pain are numerous. Spinal cord injuries result in pain in
about two thirds of all patients (4). Other causes include compressive lesions, for example tumours
and infections, especially tuberculosis and brucellosis. The former group comprises both primary
CNS tumours (e.g. neuroﬁ broma and meningioma) and secondary tumours from breast, lung,
prostate and other organs, together with lymphomas and leukaemias.
Pain indirectly caused by diseases or abnormalities of the nervous
system
Pain arises as a result of several distinct abnormalities of the musculoskeletal system, secondary
to neurological disorders. These can be grouped into the following categories:
■ musculoskeletal pain resulting from spasticity of muscles;
■ musculoskeletal pain caused by muscle rigidity;
■ joint deformities and other abnormalities secondary to altered musculoskeletal function and
their effects on peripheral nerves.
Pain caused by spasticity
Pain caused by spasticity is characterized by phasic increases in muscle tone with an easy pre-
disposition to contractures and disuse atrophy if unrelieved or improperly managed. In developed
countries, the main causes of painful spasticity are strokes, demyelinating diseases such as
multiple sclerosis, and spinal cord injuries. With an ageing population, especially in the industrial-
ized countries, and rising numbers of road trafﬁ c accidents, an increase in these conditions, and
therefore pain, is to be expected in the future.
Strokes and spinal cord disease are also major causes of spasticity in developing countries, for
example stroke is the most common cause of neurological admissions in Nigeria.
Pain caused by muscle rigidity
Pain can be one of the ﬁ rst manifestations of rigidity and is typically seen in Parkinson’s disease,
dystonia and tetanus. Apart from muscle pain in the early stages of Parkinson’s disease, it may
also occur after a long period of treatment and the use of high doses of L-Dopa causing painful
dystonia and freezing episodes. Poverty of movement and tremors may also contribute to the
pain in this disorder.
Tetanus infection, common in developing countries, is characterized by intense and painful
muscle spasms and the development of generalized muscle rigidity, which is extremely painful.
During intense spasm, fractures of spinal vertebrae may occur, adding further pain.
Pain caused by joint deformities
A range of neurological disorders give rise to abnormal stresses on joints and, at times, cause
deformity, subluxation or even dislocation. For example “frozen shoulder” or pericapsulitis occurs
in 5–8% of stroke patients. Disuse results in the atrophy of muscles around joints and various
abnormalities giving rise to pain, the source of which are the tissues lining the joint. In addition,
deformities may result in damage to nerves in close proximity resulting in neuropathic pain of the
“evoked” or spontaneous type.
The literature does not give data for the prevalence and incidence of the pain associated with
the disorders mentioned.
Complex painful disorders
Complex regional pain syndrome (CRPS) refers to several painful disorders associated with dam-
age to the nervous system including the autonomic nervous system. CRPS Type I was previously

130
Neurological disorders: public health challenges
known as reﬂ ex sympathetic dystrophy, with the cause or preceding event being a minor injury
or limb fracture. CRPS II, formerly known as causalgia, develops after injury to a major peripheral
nerve. The symptoms exceed both in magnitude and duration those which might be expected
clinically given the nature of the causative event. Also, patients often experience a signiﬁ cant
reduction in motor function. The pain is spontaneous in type with allodynia and hyperalgesia. Other
features of the syndrome include local oedema or swelling of tissues, abnormalities of local blood
ﬂ ow, sweating (autonomic changes) and local trophic changes. Both conditions tend to become
chronic. They are a cause of signiﬁ cant psychological and psychiatric disturbance, and treatment
is a major problem.
Headache and facial pain
Any discussion of pain arising from disorders of the nervous system must include headache
and facial pains: these conditions are discussed in Chapter 3.3. They have been the subject
of considerable research and been carefully classiﬁ ed by the International Headache Society.
Epidemiological studies have focused primarily on migraine and tension-type headaches (primary
headache disorders). Secondary headache disorders are also described (see Box 3.3.1).
ASSESSMENT OF PAIN
Pain has physical and psychological dimensions, both of which may be measured; they form an
important aspect of the diagnosis of painful disorders and are essential for the correct applica-
tion of treatment and its assessment. Pain is a subjective experience but physiological changes
that accompany it may be measured: they include changes in heart rate, muscle tension, skin
conductivity and electrical and metabolic activity in the brain. These measures are most consistent
in acute rather than chronic pain and they are used primarily in laboratory studies. Clinically, pain
assessment includes a full history of the development, nature, intensity, location and duration of
pain. In addition to clinical examination, self-report measures of pain are often used.
The use of words as descriptors of pain have permitted the development of graded descriptions
of pain severity. For example, mild pain, moderate pain, severe pain and very severe pain, to which
numerical values may be attached (1–4), may be graded on a numerical scale from 0 to 4 indicat-
ing the level of pain being experienced. In clinical practice, however, there is widespread use of a
0–10 scale, a visual analogue scale, which is easy to understand and use and is not affected by
differences in language. Such measures are often repeated at intervals to gain information about
the levels of pain throughout the day, after a given procedure or as a consequence of treatment.
More sophisticated verbal measures use groups of words to describe the three dimensions of
pain, namely its sensory component, the mood-related dimension and its evaluative aspect. This
technique was devised by Melzack and others and is best seen in the Short-Form McGill Pain
Questionnaire (5). The questionnaire requires the patient to be well acquainted with the words
used. Often because of age, not having English as a ﬁ rst language or as a result of some form
of mental impairment, the scale cannot be used. In its place it is possible to use a “faces scale”
in which recognizable facial images representing a range of pain experiences from no pain to
very severe pain are readily understood. Such scales are often used with children. In the case of
patients with pain generated as a result of a lesion within the nervous system (neuropathic pain)
speciﬁ c measures have been devised to distinguish between that type of pain and pain arising
outside the nervous system (6). In the assessment of a patient with neuropathic pain, the evalua-
tion of sensory function is crucial and can be carried out at the bedside with simple equipment.
Another technique used in clinical assessment includes pain drawings, which allow the patient to
mark the location of pain and its qualities using a code on a diagram of the body. A pain diary is used
by patients to record levels of pain throughout the day, using a visual analogue scale. This reveals
the pattern of pain severity in relation to drug therapy and activity levels. Finally, pain behaviour is

neurological disorders: a public health approach
131
often used to aid diagnosis. It is especially useful for determining the extent to which psychological
factors inﬂ uence pain. For example, a wide discrepancy between the behaviour exhibited in the
clinic and what might be expected, given the nature of the disorder, is a valuable clue to a person’s
emotional state, ability to cope with pain and conscious or unconscious desire to communicate
distress non-verbally to the clinician. Pain assessment should take account of the patient’s sex and
ethnic and cultural background, all of which tend to inﬂ uence the clinical presentation.
PUBLIC HEALTH ASPECTS OF PAIN DISORDERS
Pain — acute and chronic — is a ubiquitous experience and it is also a major public health problem
that poses signiﬁ cant challenges to health professionals involved in its treatment. Reliable data
about the prevalence and incidence of pain, however, are limited, with available studies being based
on either regional surveys of a broad spectrum of painful disorders, or speciﬁ c pain states.
In a collaborative study of pain in a primary care setting, WHO revealed that persistent pain
afﬂ icted between 5.3% and 33% of individuals resident in both developing and developed coun-
tries. The lowest frequency was reported in Nigeria and the highest in Santiago, Chile. The study
revealed that persistent pain was associated with depression, which affected the quality of life
and reduced the level of daily activity of the sufferers (7 ). It was concluded that the essential
need to work and to earn income might be a reason why many people in developing countries
tolerate pain rather than reporting to doctors or hospitals. Therefore, lack of an adequate social
and health-care support network, cost implications and job security must inﬂ uence the extent to
which people living in developing countries and suffer pain fail to seek help.
A detailed study of the prevalence, severity, treatment and social impact of chronic pain in 15
European countries was carried out recently (8). The prevalence of chronic pain ranged between
12% and 30%, ﬁ gures similar to those in the WHO study. The most common sites for pain were the
head and neck, knees and lower back. Of the respondents, 25% had head or neck pains (migraine
headaches, 4%; nerve injury from whiplash injuries, 4%). Although back pain may have a neuro-
logical cause, the likelihood was that in the great majority pain was the result of musculoskeletal
disorders or back strain. The authors concluded that one in ﬁ ve Europeans suffer from chronic pain
which is of moderate severity in two thirds and severe in the remainder. The study also reveals
that, in the opinion of 40% of the respondents, their pain had not been treated satisfactorily and
20% reported that they were depressed. In economic terms, 61% were less able or unable to work
outside their homes, 19% had lost their jobs because of pain and another 13% had changed their
jobs for the same reason.
A large-scale survey in Australia (9) of just over 17 000 adults with pain daily for at least three
months (chronic pain) yielded a prevalence rate of 18.5%; in a comparable survey in Denmark,
a prevalence rate of 19% was obtained (10). It is therefore evident from the three surveys that
a prevalence rate for chronic pain of 18–20% is to be expected in adult populations selected at
random from developed countries. Unfortunately, these ﬁ gures do not give any detail about pain
arising from the nervous system, except for the information about head and neck pain in the
European survey.
Certain neurological disorders causing pain have been examined in terms of the incidence of
pain. For example Kurtzke (11) estimated that the annual incidence of herpes zoster infection in
the United States was 400 per 100 000 of the population. A study of the incidence of post-herpetic
neuralgia in 1982 revealed a ﬁ gure of 40 per 100 000 (12). Further information from Bowsher (13)
indicated that the number of individuals with post-herpetic neuralgia increases with age so that
40% of people over 80 years of age who acquire acute herpes zoster will suffer from chronic post-
herpetic neuralgia. In populations in which ever greater numbers are living to 80 years and more,
there is likely to be a signiﬁ cant increase in individuals suffering from post-herpetic neuralgia.

132
Neurological disorders: public health challenges
The earlier study by Ragozzino et al. (12) gave ﬁ gures for the anatomical distribution of the
neuralgia that was present in 56% in the thoracic region, 13% in the face and 13% in the lumbar
regions; 11% had pain in the cervical region. One third of patients with multiple sclerosis develop
neuropathic pain states, of whom trigeminal neuralgia occurs in 5%, and another one third develop
other forms of chronic pain (3). There is an increase in the incidence of trigeminal neuralgia in
patients with cancer and other diseases that impair the immunological systems.
It is signiﬁ cant that one third of cancer patients have a neuropathic component to their pain as
do a similar proportion of patients with prolonged low back pain (14).
It should be noted that stump pain arises from a severed nerve in the limb and may be caused
by a local neuroma or by tethering of the severed nerve to local tissues. In either case the pain
is of the peripheral neuropathic type. In contrast, phantom limb pain is central neuropathic pain
and more difﬁ cult to treat.
Central stroke pain is deﬁ ned as neuropathic pain that follows an unequivocal episode of
stroke. It is associated with partial sensory loss in all but a few cases. A prospective study by
Andersen et al. (15 ) revealed a one-year incidence of 8%, with symptoms being severe in 5%
and mild in 3%. For most patients the pain develops gradually during the ﬁ rst month but delays
of many months have been recorded. The pain is incapacitating, distressing and often even more
so than other symptoms.
Headache disorders have also been the subject of intensive epidemiological research (see
Chapter 3.3).
Poor relief of acute pain is a recognized risk factor for the development of chronic pain after
various forms of surgery, for example herniotomy, mastectomy, thoracotomy, dental surgery and
other forms of trauma. In part, this is the result of nerve injury which presents as acute neuro-
pathic pain in 1–3% of patients. The majority of such patients experience persistent pain one year
after the causative event, indicating that acute neuropathic pain is a very deﬁ nite risk factor for
chronic pain. Prompt treatment of early nerve pain is therefore important (16).
Hernia repair is followed by moderate to severe pain in 12% of patients one year postoperatively
and is of the somatic or neuropathic type (17 ). Breast surgery of various types gives rise to the
experience of phantom breast and pain with or without a phantom.
Information about the incidence and prevalence of pain generally, and neurologically related
pain in particular, is almost totally lacking for developing countries, although there is no reason
to believe that conditions that give rise to pain such as stroke, multiple sclerosis, various forms of
headache and other disorders vary in nature. There may well be differences, however, in the extent
to which some disorders are present, for example multiple sclerosis is less common in developing
countries, whereas others are not encountered in the Western world, such as certain forms of
poisoning by neurotoxins from foods, and leprosy which is a cause of neuropathic pain.
HIV/AIDS is a major cause of neuropathic pain in the later stages of the disease: 70% of
AIDS sufferers develop this form of pain, which is severe and comparable with the severe pain
experienced in cases of advanced cancer. The incidence of severe pain must, therefore, be high
in countries where AIDS is a major health problem.
Box 3.7.1 Signs and symptoms of chronic pain
■ Immobility and consequent wasting of muscle, joints,
■ Overdependence on family and other caregivers
etc.
■ Overuse and inappropriate use of health-care providers
■ Depression of the immune system causing increased
and systems
susceptibility to disease
■ Poor performance on the job, or disability
■ Disturbed sleep
■ Isolation from society and family
■ Poor appetite and nutrition
■ Anxiety and fear
■ Dependence on medication
■ Bitterness, frustration, depression and suicide

neurological disorders: a public health approach
133
The ﬁ gures quoted in this section show that a signiﬁ cant number of individuals suffer from
chronic and incapacitating pain as a result of diseases of the nervous system, or as a result of
damage to peripheral nerves at the time of surgery and other forms of trauma. The nature of the
pain, which is often neuropathic in type, means that the sufferer has a disabling condition that in
time may be primarily the result of pain, which is difﬁ cult to relieve. As such, it poses a signiﬁ cant
health problem in terms of its personal, social and economic consequences.
DISABILITY AND BURDEN
Anyone involved primarily in the management of chronic pain is aware that it may persist long
after the initial tissue damage has healed. Pain reﬂ ects pathophysiological changes in the nervous
system and they, together with changes that usually occur in patients’ emotions and behaviour,
have led to the conclusion that, in such cases, chronic pain is a speciﬁ c health-care problem and
a disease in its own right. This diagnostic category is not fully accepted among clinicians because
many continue to believe that pain must be a symptom of an ongoing disease or injury. Current
research reveals, however, that the pathophysiological changes mentioned persist when signs of
the original cause for pain have disappeared. The signs and symptoms of chronic pain, once it has
evolved into a disease, are listed in Box 3.7.1. The combination of these features of the condition
reveal the potential for physical impairment, disability and handicap which collectively form the
basis of signiﬁ cant degrees of burden for both the patient and the family.
TREATMENT AND CARE
Barriers to effective pain relief
Educational barriers
Despite the wide availability of teaching aids for educating professional groups who are heav-
ily engaged in pain management (18), relatively little attention has been given to their use in
developed countries. They are used to an even lesser extent in developing countries. Therefore
many doctors, nurses and others dealing with patients in pain enter their professional careers
inadequately equipped to deal with the most common symptom and cause of considerable suf-
fering worldwide.
Politicoeconomic barriers
The availability of drugs for the treatment of pain is a problem in over 150 countries. Frequently,
pain management has a low priority, because the chief focus of attention is infectious diseases
and, often, there are exaggerated fears of dependence with very restrictive drug control policies.
In addition, in developing countries, the cost of medicines generally and therefore problems in their
procurement, manufacture and distribution, add further barriers to their use.
A treatment gap
In many countries, therefore, there is a treatment gap, meaning that there is a difference between
what could be done to relieve pain and what is being done. That gap exists in a number of devel-
oped countries, primarily because of poor pain education and the often limited and patchy nature
of specialized facilities for pain treatment. Additionally, in developing countries these problems
are far greater and the gap is far wider because of the lack of education, access to appropriate
drugs for pain relief and facilities for pain management.
The treatment gap can be reduced worldwide by improving pain education, increasing facilities
for pain treatment and access to pain-relieving drugs. In the case of opioid analgesics, an increase
in their availability and the employment of correct protocols is a matter of urgency. Improvements
of this kind are possible if use is made of the guidelines published by WHO, together with the

134
Neurological disorders: public health challenges
International Narcotics Control Board, on achieving balance in a national opioids control policy,
which are available in 22 languages on the web site of the WHO Collaborating Centre for Policy
and Communications in Cancer Care (19). Also, no stricter measures should be enacted than those
requested by the international drug conventions and international recommendations (20) on the
use of opioid medicines. WHO is developing a programme to assist countries in improving access
to medications controlled under the drug conventions (see Box 3.7.2) (19).
Management of pain of neurological origin
The range of treatments available for pain directly caused by diseases of the nervous system
includes pharmacological, physical, interventional (nerve blocks, etc.) and psychological therapies.
Treatments for pain are used in association with other forms of treatment for the primary condi-
tion, unless of course pain is itself the primary disorder. IASP deﬁ nitions of pain treatment facilities
and services are given in Box 3.7.3.
There are many studies of the medical treatment of peripheral neuropathic pain (21). There are
far fewer studies published on the treatment of central neuropathic pain, for example post-stroke
pain. Neuropathic pain does not respond well to non-opioid analgesics such as paracetamol, ace-
tylsalicylic acid and ibuprofen — a non-steroidal anti-inﬂ ammatory drug. Opioids have been shown
to have some efﬁ cacy in neuropathic pain but there are speciﬁ c contraindications for their use.
Topical agents may give local relief with relatively little toxicity; they include lidocaine and, to a
lesser extent, capsaicin cream, particularly in the treatment of post-herpetic neuralgia. In selected
cases, electrical stimulation techniques such as transcutaneous electrical stimulation or dorsal
column stimulation may be used, but the latter in particular is expensive which clearly limits its use.
Pain associated with spasticity and rigidity is treated with muscle relaxants. In the case of baclofen,
it can be administered systemically or intrathecally. However, the latter route requires administra-
tion by a trained specialist and therefore is unlikely to be freely available in developing countries.
Pain arising from joints secondarily damaged by the effects of neurological disorders is usually
controlled using simple analgesics, for example paracetamol or a non-steroidal anti-inﬂ ammatory
drug (NSAID).
Box 3.7.2 Access to Control ed Medications Programme
In many parts of the world, patients suffering severe pain
abuse, which led to too strict rules in many countries that
face immense challenges in obtaining pain relief, because
do not allow medical use. In relation to that, prejudice has
the opioids that could provide such relief have been cat-
developed consisting of an unjustiﬁ ed fear of psychological
egorized as “controlled substances”. They are therefore
dependence of patients on opioid medication and an unjus-
subject to stringent international control and rendered
tiﬁ ed fear of death caused by opioids. Many countries have
inaccessible.
neglected their obligation to provide sufﬁ cient analgesia
Severe under-treatment is reported in more than 150
given in the United Nations drug conventions and as called
countries, both developing and industrialized. They ac-
for by many international bodies (the International Narcot-
count for about 80% of the world population. Annually, up
ics Control Board, the United Nations Economic and Social
to 10 million people suffer from lack of access to controlled
Council, the World Health Assembly, etc.)
medications. Nearly one billion of the people living today
The programme, as proposed, will focus on regulatory
will encounter this problem sooner or later. Most of them
barriers, the functioning of the estimate system for import-
are pain patients.
ing/exporting by the countries, and the education of health-
The future Access to Controlled Medications Programme,
care professionals and others involved. It will organize re-
initiated by WHO, will address the main causes for impaired
gional workshops where health-care providers, legislators
access. These causes stem essentially from an imbalance
and law enforcers will exchange their views and the prob-
between the prevention of abuse of controlled substanc-
lems they encounter. It will train civil servants responsible
es and the use of such substances for legitimate medical
for submitting estimates and, in doing so, train health-care
purposes.
providers in the rational use of opioids. Furthermore, it will
For almost 50 years the focus was on the prevention of
develop other activities, including advocacy.

neurological disorders: a public health approach
135
Psychological techniques — and cognitive/behaviour therapy in particular — are used to help
patients cope with pain and maximize their social, family and occupational activities. Research
reveals that such therapies are effective in the reduction of chronic pain and absenteeism from
work (22).
Physical therapy carried out by physiotherapists and nurses is an important part of the man-
agement of many patients with neurological diseases, painful or not, including strokes, multiple
sclerosis and Parkinson’s disease, to name but a few. Relaxation techniques, hydrotherapy and
exercise are helpful in the management of painful conditions that have a musculoskeletal com-
ponent. In fact, in the case of CRPS type I and II they form the ﬁ rst line of treatment when used
together with analgesics. There is good evidence that multimodal treatment and rehabilitation
programmes are effective in the treatment of chronic pain (23, 24).
All health-care workers who treat pain, especially chronic pain, whatever its cause, can expect
about 20% of patients to develop symptoms of a depressive disorder. Among patients attending
pain clinics, 18% have moderate to severe depression when pain is chronic and persistent. It
is known that the presence of depression is associated with an increased experience of pain
whatever its origin and also reduced tolerance for pain. Therefore the quality of life of the patient
is signiﬁ cantly reduced, and active treatment for depression is an important aspect of the manage-
ment of the chronic pain disorder.
Service delivery
The management of neurological diseases is primarily a matter for specialist medical and nursing
staff, both in developed and developing countries. In contrast, speciﬁ c facilities for pain man-
agement, espec