Title: Rational management of epilepsy in developing countries: requirements and resources
1Rational management of epilepsy in developing
countries requirements and resources
- Prof. Paulo R M de Bittencourt, MD, PhD
- Co-chairman, Subcommission on Therapeutic Needs
in Emerging Countries - ILAE Commission on Therapeutic Strategies
2Epilepsy in Latin America
- Reliable health statistics, cost evaluation
studies not available - Health systems mixed, private participation
- Cost similar to average developed countries
- Investigation and therapy cheaper
- Disease-related costs higher
- Greater disability and death
3The cost of epilepsy
- Active versus inactive or remission, early costs
higher - Total in UK US 6000-8000 per year
- Direct, related to medical care
- 20-30, in UK, USA, Australia US 1000-3000 per
year - May be applicable to other countries
- Indonesia direct cost is US 1000 per year
- Indirect costs not calculated
- Beran and Pachlatko, 1995
4Population, poverty and development
5Doubling times of world population
- Developed countries 809 years
- Less developed 42 years
- Western, Middle Africa 20-30 years
- Latin America/Caribbean upper 20s-130 years
- Brazil 45 years
- Mexico 36 years
- www.prb.org
6Human Development Indexwww.undp.prg/hrdo
- Brazil 8th largest industrial nation 63rd
(1995), 74th (1998) - Barbados 30th
- Argentina, Antigua, Barbuda, Chile, Uruguay below
40th - 40-50th Caribbean, Latin American, East European
- Mexico 55th, Cuba 56th, Venezuela 65th, Colombia
68th - Brazil with Lybia, Kazakhstan, Saudi Arabia,
Thailand, Philippines, Ukraine, Georgia
7Human Development Index
- List of 174 countries
- Last 24 in Africa
- First African is Lybia at 72
- Almost all below India, at 128, are African
8Human Poverty Index (HP-1)
- 7 Latin American countries in 10 better
- Mexico 12th, Brazil 21st, with Lybia, Philippines
- Of 85 countries, 9 of 35 poorest are not African
- Most Latin American and Caribbean are in the 92
countries with Medium Human Development in the
2000 report Haiti is in Low - Of the countries listed 46 are High and 38 are
Low Human Development
9Lack of access to health care
- No data for Brazil or many Latin American and
Caribbean countries - Number extrapolated from mean of 97 is 25
without access to health care - May be a rough estimate
10Distribution of wealth - Development
- Rate of comsumption of richest over poorest 20
- Between 16-25 most countries
- 5.2 in Korea
- 3-5 in high developement
- 10 in USA and Australia
- High development nations developing at 1-3 a
year - Medium are zero or just below
- 50 of Low are negative
11What is the social pyramid like in Latin America?
(www.fao.org, 2000 report, relative to 1998)
There are 863 million undernourished in the
world, 729 million in developing and 34 million
in developed countries
- Use the undernourished to define the poor in
Latin America - 20 in Central America
- 30 in Caribbean
- 10 in South America
- Similar to 1992 (1988-90), average 13, 59
million total
12Depth of hunger (FAO, 2000) Per peson food
deficit, in kcal
- In Subsaharan Africa, in 46 of the countries
the undernourished lack gt 300kcal per day - In LA/Caribbean 8 of the countries gt300kcal,
65 between 200-300kcal 25 lt 200kcal - Some 15 of Latin Americans and Caribbeans will
be called The very poor - 15 of the total population
- Forest, mountains, seaside, riverside,
semi-urbanized - Survive on less than US 70 /month
13The poor and the wealthy in Latin America and the
Caribbean
- The poor are 25 of the total, families living
with US 70-350/ month - one sallary of US 250 or various US 100
- 50 are urban
- The wealthy are 1-15 of the total, more than US
2000 per family per month
14The middle classes
- 40-50 of the population
- US 400-2000 per month per family
- Typically US 10000 per year
- Secondary education
- industrial or service sector workers,
secretaries, drivers, receptionists, health and
public sector workers, school teachers,
university teachers, independent professional
wrokers
15Epilepsy care the very poor 15
- Similar to central Africa except for war and
famines environment far less hostile - High birth and death rates low HIV (1)
- Rare visiting physicians X-rays EEGs
- Treatment gap universal
- Phenobarbitone, irregular
- Numbers increasing or decreasing?
16Epilepsy care the poor 25
- Irregular visits to GPs in national health system
clinics - Catchment areas of universities widespread in
Costa Rica, Uruguay, Chile and Argentina - Goodwill and influence quality decreasing
- Rule is 20min EEG, plain X-ray, CT
- Epilepsy surgery in - 10 centers Mexico,
Colombia, Chile, Argentina and Brasil - Treatment gap 30-50 irregular in 90
government supplied phenobarbitone, phenytoin and
benzodiazepines
17Epilepsy care the wealthy 1-15
- Private health plans US100/ person/month 30
of Curitiba - National health rarely
- International level hospitals in Bogotá, São
Paulo, Buenos Aires, Mexico City - Epilepsy surgery and associated diagnosis
- Treatment gap 20 irregular in 50 (compliance)
18Epilepsy care the middle class 50
- Cultural adaptation to modern life private
health plans - Between US 20-100/ person/month 50 of Curitiba
- national health for major problems in cheaper
plans or in default - Very rapid evaluations, lots of exams
- Epilepsy surgery and associated diagnosis
- Treatment gap 20 irregular in 50 (psychiatric)
- benzodiazepines
19Epilepsy care in Latin America
- Epileptologists in every major city, child or
adult neurologists, neurophysiologists - Residential centers do not exist? Large
psychiatric institutions? Early death? - Surgery and diagnostic centers Mexico City,
Barranquilla, Santiago, Buenos Aires, São Paulo,
Goiânia, Porto Alegre, Curitiba, Ribeirão Preto,
Campinas - Too many in São Paulo, Curitiba, Goiânia
- New drugs all available, some through public
systems similar to HIV and MS
20What is irrational in Latin America and the
Caribbean (AED!)
- Widespread use of drugs to which tolerance
develops - Phenobarbitone, clonazepam and clobazam are cheap
and tremendously easy to start
- Slow deveelopment of knowledge in clinical
pharmacology - Generics versus similars
- Kinetics of phenytoin, carbamazepine
- Dynamics of valproate
21The new reality Health Management Organizations
- Low pay, large numbers, no time for history or
orientation, one visit per month, useless EEGs - No diagnosis of age related idiopathic epilepsies
- Potential failures
- Diagnosis of partial seizure
- kinetics
- Action
- Phenobarbitone in simple cases
- Benzos in complex, spike-wave/ absence cases
22What is irrational
- Barbiturates and benzos
- Tonic clonic seizures
- Frequent status
- Somnolonce
- Low IQ
- Depression
- New drugs
- Polytherapy
- Compliance
23Conclusions
- Region covers spectrum from Subsaharan Africa to
New York - Increasing presence of private health plans in
spite of lack of progress - Poor clinical pharmacology and therapeutics
- Treatment gap related to social and geographic
factors
24Actions ILAE and IBE
- ILAE politically correct diagnosis and treatment
guidelines CT, carbamazepine and valproate
rather than MRI and topiramate - Develop relationship with local NGOs, raising
technical awareness not related to new drugs - NGOs to relate to local manufacturers, mainstream
and of generics - Distribution of cost-effective therapies
- Local clinical pharmacology