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Neurological disease on the global agenda.

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Neurological Disease on the Global Agenda
Neurological disease impacts people living all over the globe.
This is obvious but easy to forget when you review the literature. Most manuscripts published in wide-distribution journals come from high-income countries in Europe and North
America. The Annals of Neurology is no exception: we published 685 manuscripts in the last three years, and 91% had
a corresponding author in either North America or Europe
(Figure 1A). Broken out by national income according to
World Bank classification,1 the problem appears even worse,
with 97% of manuscripts produced in high-income countries (Figure 1B), where only 15% of the population resides.
Furthermore, the vast majority of clinical studies of neurological disease describe people in high-income countries. In the
Annals, for example, we could find only four manuscripts describing populations in Africa during the last three years.
This focus on neurological disease in high-income countries may be responsible for neglect in recognizing that these
diseases are important elsewhere. Taking a step back and
looking at estimates of the global impact of neurological disease, the numbers are startling and underline the extent of
current neglect.
The best estimates of disease burden come from the
World Health Organization's (WHO) Global Burden of Disease program, which systematically combines evidence from
the literature and from governmental programs, such as death
registries.2,3 The disability-adjusted life-years (DALY) is a
well established metric of disease burden, tracked by the
WHO, that is equivalent to one year of life without disability or a greater number of years with lesser disability (e.g.,
one DALY also equals two years of life with 50% of normal
function). It is a nice metric that better reflects the impact of
disease on both early mortality and on disability, which is
very important for neurological diseases.
Applying the DALY metric to diseases worldwide, it is
apparent that the global burden of neurological disease is extremely high and that it is actually greater in lower income
countries than in the developed world (Figure 2). Neurological disease accounts for a loss of over 20 disability-free years
of life per 1,000 person-years in a low-income country compared to 14 DALYs lost per 1,000 person-years in high-income countries. It is not surprising, of course, that certain
neurological diseases that tend to impact the elderly, such as
Parkinson's disease and dementia, are less common in countries where the life expectancy is substantially lower. However, other diseases more than make up for the difference, in
particular stroke and birth asphyxia/trauma.
Thus, the burden of neurological disease is actually
skewed towards lower income countries while our attention
is diverted elsewhere. Although the broader issues of lower
income countries are often ignored, or at least under-appreciated in the global stage, it is curious and disconcerting that,
unlike neurological diseases, other diseases that differentially
impact the developing world have gained wide attention and
broad support. For example, HIV/AIDS, tuberculosis, and
malaria are diseases that disproportionately affect lower income countries, and several very large organizations have rec-
Figure 1. Source of manuscripts published in the Annals of
Neurology April 2005 – June 2008 by continent (A) and by
World Bank national income level (B).
© 2008 American Neurological Association A11
Published by Wiley-Liss, Inc., through Wiley Subscription Services
likely to be distinctly different in lower income countries
where frequent visits with physicians, not to mention neurologists, may be impossible.5 We need to train a cadre of
bright young investigators who can make the case for the importance of global issues in neurology, who can propose and
carry out useful research in this area, and who will be at the
table when decisions about allocation of dollars for global
projects are made.
We must remember that neurological diseases are diseases
of the developing world. We at the Annals of Neurology have
been trying to work more closely with authors from these
countries to increase our acceptance rates, primarily by assisting with editing and watching closely for signs of biased
reviewing. Perhaps the word will get out that we want these
manuscripts and the number of submissions from lower income countries will increase, the real source of under-representation. Of course, the number of these submissions will
never increase if studies from these countries are not funded.
Is it time to create a Global Fund for Neurological Diseases?
Figure 2. Burden of neurological diseases in loss disability-adjusted life-years (DALYs) per 1,000 person-years by World
Bank national income level. The burden of neurological diseases is greater in lower income countries.
ognized the pressing needs created by these disorders and
brought substantial resources to bear.
The WHO, the US Agency for International Development, the UK Department of International Development,
the Global Fund to Fight AIDS, Tuberculosis and Malaria,
and the Gates Foundation each spend hundreds of millions
of dollars each year to improve health in the developing
world, and the vast majority of this supports infectious disease research and treatment. Where are the large funders for
neurological disease in lower income countries?
One could argue that the NIH and the pharmaceutical
and device industries are major sponsors of neurological disease research, and the numbers demonstrate a strong commitment.4 But this seems to only further emphasize the need
for focus on neurological disease in resource-poor countries,
where the distribution of neurological disease is different and
where many treatments developed elsewhere cannot be used,
such as many patented drugs and even some generics that require monitoring, such as warfarin and anticonvulsants.
Strategies for implementation of proven interventions are also
Annals of Neurology
Vol 64
No 1
July 2008
S. Claiborne Johnston, MD, PhD and Stephen L. Hauser, MD
1. World Bank. Data and Statistics: Quick Reference Tables. Accessed May 24,
2. World Health Organization. Burden of Disease Statistics. Accessed
May 2, 2008.
3. Mathers CD, Bernard C, Iburg K, et al. The Global Burden of
Disease in 2002: data sources, methods and results (GPE Discussion paper 54). In: Lopez AD, Mathers CD, Ezzati M et al.,
eds. Global Burden of Disease and Risk Factors. Oxford: Oxford University Press; 2006:45-240.
4. Dorsey ER, Vitticore P, de Roulet J, et al. Financial anatomy of
neuroscience research. Ann Neurol 2006;60:652-659.
5. Patoine B. Nervecenter: How to stem a global health crisis.
Ann Neurol 2007;62:A8-11.
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