Rational management of epilepsy in developing countries: requirements and resources

1
Rational 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

2
Epilepsy 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

3
The 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

4
Population, poverty and development
5
Doubling 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

6
Human 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

7
Human Development Index

• List of 174 countries
• Last 24 in Africa
• First African is Lybia at 72
• Almost all below India, at 128, are African

8
Human 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

9
Lack 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

10
Distribution 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

11
What 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

12
Depth 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

13
The 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

14
The 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

15
Epilepsy 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?

16
Epilepsy 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

17
Epilepsy 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)

18
Epilepsy 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

19
Epilepsy 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

20
What 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

21
The 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

22
What is irrational

• Barbiturates and benzos
• Tonic clonic seizures
• Frequent status
• Somnolonce
• Low IQ
• Depression

• New drugs
• Polytherapy
• Compliance

23
Conclusions

• 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

24
Actions 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