Pre-Collegiate Global Health Review
Epilepsy’s Dark Prevalence in Poverty-Stricken Regions
By Vamsi Nandamuri, Downingtown STEM Academy, Downingtown, Pennsylvania, USA
As 4.6 million people annually add onto the world’s 51.7 million active cases, epilepsy has crowned itself as an internationally prevalent and devastating neurological disorder (Vaughan et al., 2018). While 40% of epilepsy diagnoses are idiopathic, the majority are caused by head trauma, infections striking the central nervous system (CNS), brain tumors, and neurodegenerative conditions (Sirven, 2015). Nearly 500 new cases are diagnosed daily, and quality of life is substantially diminished for patients, with premature death and psychiatric disorder rates higher for epileptics than the general population (WHO, 2019a; Sirven, 2015; WHO, 2019b). Although treatments for this chronic disorder have been refined substantially, there is no cure on the horizon.
Figure 1. This diagram illustrates the fluctuation of sodium and potassium ions within the axon of the neuron during abnormal seizure activity (“Seizures and Epilepsy”, 2021).
Normally, the CNS rapidly transmits signals throughout the body via neurons generating action potentials. Once neurotransmitters attach to receptors on its surface, the neuron depolarizes and the action potential begins to move ions into and out of ion-gated channels. Following the closure of these channels, the cell hyperpolarizes and cannot transmit action potentials until resting potentials are achieved. Yet, in abnormal neurons, defective ion-gated channels allow dangerous quantities of sodium ions to enter the cell while potassium ions slowly leave, thus leading to recurrent action potentials without attaining resting potentials. This generates seizures - therefore, epilepsy is characterized as “recurrent seizures due to abnormal excessive and synchronous neuronal activity in the brain” (Serrano & Kanner, 2015). Epilepsy can be classified as focal or generalized seizures. Though they can be further grouped into simple or complex, all focal seizures disrupt CNS activity in one hemisphere of the brain and can target motor, sensory, autonomic, and psychic structures. Some lead to spontaneous jolts from muscles, instantaneous anxiety, or elevated heart rate activity, while others develop automatisms, like incessant blinking (“Simple Focal Seizures”, 2021; “Childhood Epilepsy”, 2021). Focal seizures can develop into generalized seizures, seizures that strike both hemispheres of the brain (“Simple Focal Seizures”, 2021). Absence generalized seizures bring about staring spells that can be misunderstood as daydreaming, while tonic-clonic seizures suddenly stiffen the body before uncontrolled muscle contractions follow (“Childhood Epilepsy”, 2021; Kiriakopoulos, 2019).
While epilepsy incidence rates and deaths are decreasing in some countries, with mortalities and disability-adjusted life years (DALYs) between 1990 and 2016 decreasing by 24.5% and 19.4%, respectively in higher-income countries, such results unfortunately do not translate to patients in impoverished nations (ILAE, 2019). Such regions host 80% of all epilepsy cases globally (WHO, 2019a; ILAE, 2019). Multiple factors generate this drastic statistical difference, but the primary issue is the lack of access to essential healthcare for low-income patients, as 75% of them do not receive necessary treatment, an issue even worse in rural regions of the world with 90% of low-income rural patients lacking treatment (WHO, 2019a; ILAE, 2019). Additionally, the shortage of anticonvulsants maintains the number of active cases, as the average availability of first-line medications is less than 50% in deprived areas (WHO, 2019a). For instance, phenobarbital was obtainable in only 36.3% of pharmacies in Madagascar, while phenytoin was inaccessible in all supply chains (Jost et al., 2016). Furthermore, trained professionals with the knowledge to treat epilepsy are also meager. Only four African countries reported having over ten medical physicists and the neurologist-to-population ratio in Africa is 0.3 per 1,000,000 (IAEA, 2016; Sarfo et al., 2017).
Figure 2. This chart provides a unique insight into the number of medical physicists in individual African countries. African nations not listed in the above chart have no medical physicists (IAEA, 2016).
Stigma associated with epilepsy proves to be a pivotal factor for destitute patients when deciding to seek treatment. It results from “misunderstanding[s] about the medical facts”, and with these inaccurate interpretations, patients fear discrimination from the ‘norm’ - either through bullying, unemployment, or isolation from peers (Wyllie & Tilahun, 2019). They are also deprived of certain human rights such as the ability to drive and get married, thus people think twice before pursuing professional help (WHO, 2019b).
While surgical solutions are being improved and various therapeutics are trickling into the market, focuses should now be directed to providing these treatments in impoverished regions while simultaneously developing cures. Increasing the accessibility of anticonvulsants for lower-income regions can significantly decrease active cases, as 70% of epileptic patients can achieve seizure-free life if medications are supplied and used accordingly (WHO, 2019b). Furthermore, the World Health Organization (WHO) works alongside countries to develop legislation incorporating the improvement of neurological disorders into their primary health care systems, and their Mental Health Gap Action Programme (mhGAP) provides first-line support for neurological disorders through non-specialist administrators (WHO, 2019b). Amplifying medical counselors that calm patients’ worries and fears, as well as clarify certain facts of epilepsy diagnoses, can increase treatment rates and ease worries (Wyllie & Tilahun, 2019). Over a period of time, by addressing these issues poverty-stricken countries face and launching initiatives to support them, there is hope in lowering the prevalence of epilepsy and containing this global health crisis.
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