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Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

Neurological, Psychiatric, and Developmental Disorders

Meeting the Challenge in the Developing World

Committee on Nervous System Disorders in Developing Countries

Board on Global Health

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

NATIONAL ACADEMY PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

Support for this project was provided by Centers for Disease Control and Prevention, Global Forum for Health Research, National Institute for Child Health and Human Development, National Institute for Mental Health, National Institute for Neurological Disorders and Stroke, and the Fogarty International Center of the National Institutes of Health. The views presented in this report are those of the Institute of Medicine Committee on Nervous System Disorders in Developing Countries and are not necessarily those of the funding agencies.

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Copyright 2001 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

Cover: Mbangu mask, Central Pende, Bandundu, Zaire, registered in 1959. One of the great masterworks of Pende art in Western collections, this Mbangu mask represents the bewitched him. It dances to the song, “We look on (unable to help), the sorcerers have bewitched him.” The masker wears a humpback from which an arrow extends. The arrow refers to the popular image of sorcerers “shooting” their prey with invisible arrows when they cast their spell. The metaphor communicates the perception of sudden onslaught in illness or misfortune, just as we might say, “It came out of the blue.”

Mbangu is “bewitched”; however, since the Pende worldview attributes almost all illness and personal misfortune to the malice of others, what is really at issue is chronic illness or disability and our response to it. If he does not carry a bow and arrows, the dancer usually avails himself of a cane to indicate his physical weakness. The black-and-white division of his face refers to the scars of someone who fell into the fire due to epilepsy or some other medical condition. This sculptor has also depicted traces of smallpox on the black eyelid, and the face is pulled down on one side due to a paralysis of the facial nerve. Sculptor and performer collaborate to make Mbangu a composite sign of illness and disability, of all the misfortunes that can befall someone.

What then is to be our response to Mbangu? Some sculptors render the mask comedic, but this work conveys an extraordinary delicacy and sympathy by contrasting the gentle perfection of the features on one side with the systematic distortion on the other. This sculptor responds to the widespread version of Mbangu's song: “Do not mock your neighbor, do not laugh at your brother, the sorcerers have bewitched him.” In other words, anyone can fall prey to misfortune; it could happen to you. Our brother, our neighbor, deserves our support.

Permission to use this image was kindly granted by the Royal Museum of Central Africa. ©AFRICA-MUSEUM TERVUREN(BELGIUM)

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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“Knowing is not enough; we must apply.

Willing is not enough; we must do.

—Goethe

INSTITUTE OF MEDICINE

Shaping the Future for Health

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

THE NATIONAL ACADEMIES

National Academy of Sciences

National Academy of Engineering

Institute of Medicine

National Research Council

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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COMMITTEE ON NERVOUS SYSTEM DISORDERS IN DEVELOPING COUNTRIES

ASSEN JABLENSKY (Co-chair), Professor,

Department of Psychiatry, University of Western Australia, Perth

RICHARD JOHNSON (Co-chair), Professor,

Department of Neurology,

Co-Chair of Department of Microbiology and Neurosciences,

John Hopkins University School of Medicine, Baltimore, Maryland

WILLIAM BUNNEY, JR., Professor and Della Martin Chair,

Department of Psychiatry and Human Behavior, University of California at Irvine

MARCELO CRUZ, Professor,

Neurosciences Institute, Central University of Ecuador, Quito

MAUREEN DURKIN, Professor,

Sergievsky Center, Joseph L. Mailman School of Public Health, Columbia University, New York, New York

JULIUS FAMILUSI, Professor,

Department of Pediatrics, University College Hospital, Ibadan, Nigeria

M. GOURIE-DEVI, Director-Vice Chancellor, and Professor of Neurology,

National Institute of Mental Health and Neurosciences, Bangalore, India

DEAN JAMISON, (Board on Global Health Liaison), Director,

Program on International Health, Education, and Environment, University of California at Los Angeles

RACHEL JENKINS, Director,

World Health Organization Collaborating Centre, Institute of Psychiatry, London, United Kingdom

SYLVIA KAAYA, Professor,

Department of Psychiatry, Muhimbili University College of Health Science, Dar es Salaam, Tanzania

ARTHUR KLEINMAN, Presley Professor of Anthropology and Psychiatry,

Departments of Anthropology and Social Medicine, Harvard University, Boston, Massachusetts

THOMAS MCGUIRE, Professor,

Department of Economics, Boston University, Massachusetts

R. SRINIVASA MURTHY, Dean, and Professor of Psychiatry,

National Institute of Mental Health and Neurosciences, Bangalore, India

DONALD SILBERBERG, Professor of Neurology, Director of International Medical Programs,

University of Pennsylvania School of Medicine, Philadelphia

BEDIRHAN ÜSTÜN, Group Leader of Assessment, Classification, and Epidemiology Group,

World Health Organization, Geneva, Switzerland

Study Staff

STACEY KNOBLER, Study Director (from February 2000 to May 2001)

JUDITH BALE, Director, Board on Global Health and Study Director

PAMELA MANGU, Study Director (from September 1999 to February 2000)

CHRISTINE COUSSENS, Research Associate

ALISON MACK, Consultant Writer

LAURIE SPINELLI, Project Assistant

KEVIN CROSBY,

The National Academies Christine Mirzayan Internship Program

CARLA HANASH,

The National Academies Christine Mirzayan Internship Program

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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BOARD ON GLOBAL HEALTH

DEAN JAMISON, (Chair), Director,

Program on International Health, Education, and Environment, University of California at Los Angeles

YVES BERGEVIN, Senior Health Specialist,

Canadian International Development Agency

HARVEY FINEBERG, Provost,

Harvard University, Boston, Massachusetts

EILEEN KENNEDY, Deputy Under Secretary for Research, Education, and Economics,

U. S. Department of Agriculture, Washington, D.C.

ARTHUR KLEINMAN, Presley Professor of Medical Anthropology and Psychiatry,

Harvard Medical School, Boston, Massachusetts

PATRICIA DANZON, Professor of Health Care Systems Development,

Wharton School, University of Pennsylvania, Philadelphia

NOREEN GOLDMAN, Professor,

Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, New Jersey

ALLAN ROSENFIELD, Dean,

Mailman School of Public Health, Columbia University, New York, New York

ADEL MAHMOUD, President,

Merck Vaccines, Whitehouse Station, New Jersey

SUSAN SCRIMSHAW, Dean,

School of Public Health, University of Illinois at Chicago

JOHN WYN OWEN, Secretary,

Nuffield Trust, London, United Kingdom

GERALD KEUSCH, (Liaison), Director,

Fogarty International Center, National Institutes of Health, Bethesda, Maryland

DAVID CHALLONER, (IOM Foreign Secretary), Vice President for Health Affairs,

University of Florida, Gainesville

Staff

JUDITH BALE, Director

JONATHAN DAVIS, Study Director

STACEY KNOBLER, Study Director

KATHERINE OBERHOLTZER, Project Assistant

LAURIE SPINELLI, Project Assistant

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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REVIEWERS

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Naomar Almeida-Filho, Campus Universitario-Canela, Salvador-Bahia, Brazil

Nancy Andreasen, University of Iowa Hospitals and Clinics, Iowa City

Gretchen Birbeck, Michigan State University, East Lansing

Daniel Chisholm, World Health Organization, Geneva, Switzerland

Sir David Goldberg, King's College, United Kingdom, London

Nora Groce, Yale University, New Haven, Connecticut

Vladimir Hachinski, University of Western Ontario, Canada

William Harlan, National Institutes of Health, Bethesda, Maryland

Guy Mckhann, John Hopkins University School of Medicine, Baltimore, Maryland

Alberto Minoletti, Ministry of Health, Santiago, Chile

Malik Mubbashar, WHO Collaborating Centre for Research Training in Mental Health, Rawalpindi, Pakistan

Elena Nightingale, Institute of Medicine, Washington, D.C.

Nimal Senanayake, University of Peradeniya, Sri Lanka

Rune Simeonsson, University of North Carolina, Chapel Hill

R. Thara, Schizophrenia Research Foundation, Chennai, India

Myrna Weissman, Columbia University College of Physicians and Surgeons, New York

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Arthur Asbury, University of Pennsylvania School of Medicine, Philadelphia, and Floyd Bloom, The Scripps Research Institute, La Jolla, California, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Preface

The continuing existence of gross disparities in health between affluent and poorer countries is becoming a major challenge for policy makers in the new millennium. While the link between poverty and disease is well established and has been recognized by public health leaders and social reformers for a century and a half, the complexity of this relationship has become apparent only in the last several decades as national governments and international organizations have accorded health increasing priority in development programs. It is now widely accepted that socioeconomic development and population health must advance together to be sustainable in the long term. Improvements in population health are not merely or even necessarily a by-product of economic growth. They are a prerequisite and a driving force of economic and social productivity. Reductions in maternal and infant mortality, improvements in nutrition and environmental sanitation, and control of communicable diseases have made important contributions to economic growth. Conversely, high levels of preventable morbidity and mortality, survival with chronic disability, reduced quality of life, and widespread demoralization are a drain on society's resources and impede overall development.

For several decades, investments in health in the context of national and international development strategies have targeted primarily the major communicable diseases, malnutrition, and poor sanitation in low-income countries. A number of such programs have successfully lowered infant mortality rates and, as a result, increased life expectancy at birth. However, the net effect of such gains has been largely offset by the epidemiological transition from a

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

morbidity and mortality pattern dominated by acute and often fatal communicable diseases to one characterized by a rapid rise in chronic and potentially disabling diseases such as cardiovascular disorders, diabetes, and neoplasms. As a consequence, middle- and low-income countries are increasingly facing an epidemic of chronic diseases along with the unfinished agenda of infectious disease and malnutrition.

This complex epidemiological situation is further complicated by the widespread incidence of neurological, psychiatric, and developmental disorders, all involving a congenital or acquired brain dysfunction and affecting the behavior and quality of life of some 250 million people in the developing world. Their global importance was highlighted in the Global Burden of Disease study published in 1996 by the World Health Organization (WHO), the World Bank, and the Harvard School of Public Health. Although brain disorders account for only 12 percent of all deaths in these estimates, they are responsible for at least 27 percent of all years of life lived with disability, and this combined share of the total global burden of disease was estimated at nearly 15 percent in 1990 and projected to rise significantly by 2020. Negative attitudes, prejudice, and stigma are associated with many of the neurological, psychiatric, and developmental conditions. As a result, the majority of people affected by these disorders in developing countries remain virtually untreated, while for many others the conditions remain undiagnosed. Since many of these disorders run a continuous or recurrent course that is often lifelong, they profoundly affect an individual's capacity to relate to others and perform culturally expected roles, and result in significant distress and dysfunction among family members and the community. Therefore, their socioeconomic impact is likely to be greater than their prevalence would suggest.

Despite negative attitudes, prejudice, and neglect, many brain disorders can be successfully addressed: some can be prevented from occurring, and all the disabling sequelae of others can be mitigated. Treatment, prevention, and reduction of disability for this group of disorders could therefore have a major impact on the total burden of disease and disability in developing countries.

Indeed, the timeliness of initiatives to raise global public awareness of brain disorders in developing countries is underscored by major advances in scientific understanding of the neurobiology of brain development and function, epitomized by the Decade of the Brain, 1990–2000. Echoing the farsighted aphorism of one of the founders of modern psychiatry that “mental diseases are brain diseases” (Griesinger, 1845), current neuroscience research now recognizes mental disorders as arising from brain dysfunctions that interact with environmental triggers at different stages of neurodevelopment. The mapping and cloning of specific genes that contribute to vulnerability to psychiatric disorders will be greatly accelerated by the complete sequencing of the human genome and by powerful new technologies for gene tracking and functional

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

analysis. Such knowledge will inevitably provide new insights into the pathophysiology of these disorders and lead to novel treatments. Similarly, the diagnosis and treatment of many neurological disorders are likely to be revolutionized as a result of advances in molecular neuroscience. An increasing number of such disorders may become preventable in the not-too-distant future.

It is important at the same time to recognize that, regardless of the promise of future developments, many of the brain disorders accounting for a major share of the burden of disease and disability in the developing world can be treated effectively with means that are currently available and, in principle, affordable. To highlight these opportunities and the prerequisites for implementing appropriate interventions, was the principal task of the Committee on Nervous System Disorders in Developing Countries, convened by the U.S. Institute of Medicine.

This study was sponsored and supported by the U.S. Centers for Disease Control and Prevention, the Fogarty International Center of the National Institutes of Health, the Global Forum for Health Research, the National Institute of Child Health and Human Development, the National Institute of Mental Health, and the National Institute of Neurological Disease and Stroke.

The charge to the committee was first to address the broad burden of neurological, psychiatric, and developmental disorders and then to focus on six groups of conditions: developmental disabilities affecting the central nervous system in early life, epilepsy, unipolar depression, bipolar disorder, schizophrenia, and stroke. These conditions share the following characteristics:

  • highly prevalent;

  • potentially disabling;

  • often subject to stigma and neglect; and

  • amenable to interventions that are effective and relatively low cost.

The specific focus on six groups of disorders does not imply future exclusion from consideration of other conditions that meet the same criteria, fully or in part. Peripheral neuropathies, alcohol and drug dependence, dementia, and disorders resulting from trauma and interpersonal violence are examples of conditions that merit commensurate attention and it is hoped that they will be the subject of future studies.

The membership of the committee reflects both the multidisciplinary nature of the problems to be addressed and the need for first-hand familiarity with and expertise in their socioeconomic and cultural context in various regions of the world. Thus, the committee comprised 15 members with expertise in fields as diverse as clinical neurology and psychiatry, developmental neuroscience, epidemiology, cultural anthropology, and health economics. In addition, the committee had the benefit of access to consultants and advisers with expertise in primary health care, health statistics, and public policy. A complete list of contributors is included in Appendix A. Invaluable technical and administrative

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

support throughout the study, including compilation of an extensive bibliography, literature research, technical writing, and editing, was provided by the staff of the Institute of Medicine. We thank each of these individuals and organizations for their assistance and support over the course of this study.

Assen Jablensky, M.D. Richard Johnson, M.D.

Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Acknowledgments

The breadth and scope of the issues considered within this report are extensive. The committee is grateful for the many individuals who contributed their time and expertise toward the committee's understanding of these complex issues and the development of the report. Particular thanks are in order to the authors of the background papers, whose efforts provided important information bearing on the topic of this report and the development of draft chapters: Eduardo Castilla, Eclamc/Genetica, Fiocruz, Brazil; Oyewusi Gureje, University College Hospital, Nigeria; Nalia Khan, Bangladesh Institute of Child Health; Kwame McKenzie, Institute of Psychiatry, University College, London; Vikram Patel, London School of Tropical Hygiene and Sangath Centre, Goa, India; Gregory Powell, University of Zimbabwe; and Marigold (Molly) Thorburn, 3D Projects of Jamaica and the Jamaica Coalition on Disabilities.

The committee thanks Marcelo Cruz, Maureen Durkin, Assen Jablensky, Rachel Jenkins, Tom McGuire, and Donald Silberberg for their chapter drafts; and William Bunney, Julius Familusi, M. Gourie-Devi, Dean Jamison, Dick Johnson, Sylvia Kaaya, Arthur Kleinman, Srinivasa Murthy, and Bedirhan Üstün for their substantive contributions to the committee deliberations and draft chapter reviews.

Special thanks is expressed to the following workshop participants for advising and informing the committee's efforts: Alex Cohen, Harvard Medical School; Beugre Kouassi, University of Abidjan-Cocody, Ivory Coast; Thomas Langfitt, University of Pennsylvania; Jessie Mbwambo, Muhimbili University College of Health Science, Tanzania; Norman Sartorius, University of Geneva,

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

Switzerland; Peter Schantz, Centers for Disease Control and Prevention; and Harvey Whiteford, the World Bank.

The committee is particularly grateful for those who provided technical review of and substantive contributions to draft chapters: Gretchen Birbeck of Michigan State University, East Lansing; Jose Biller of Indiana University School of Medicine; Ellis D'Arrigo Busnello of the Universidade Federal do Rio Grande do Sul, Brazil; Robert Edgerton and Jerome Engel of University of California, Los Angeles; Joop T. V. M. de Jong of the Transcultural Psychosocial Organisation, Amsterdam; Matthew Menken of the World Federation of Neurology Research Group on Medical Education; Pierre-Marie Preux and Michel Dumas of the Institut de Neurologic Tropicale, Limoges, France; Leonid Prilipko of the Department of Mental Health and Substance Dependence, World Health Organization; Niphon Poungvarin of Mahidol University, Thailand; Ralph Sacco of Columbia University; Josemir W. A. S. Sander and Robert Scott of the Institute of Neurology, University College, London; and Rune Simeonsson of the University of North Carolina, Chapel Hill.

The committee gratefully acknowledges those who provided data, information, and guidance critical to the committee's deliberations: Gallo Diop of the Centre Hospitalier Universitaire De Fam, Dakar, Senegal; Ronald Kessler of Harvard Medical School; Robert Kohn of Brown University; Itzhak Levav, Charles Godue, and Felix Rigoli of the Pan American Health Organization; Beverly Long of the World Federation for Mental Health; Ronald Manderscheid of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services; Benedetto Saraceno of the World Health Organization; Hisao Sato of the Japan College of Social Work; Koon Sik Min of the Sam Yook Rehabilitation Center, Korea; B.S. Singhal of the Bombay Hospital Institute of Medical Sciences, India; James Toole of the Wake Forest University School of Medicine and the World Federation of Neurology; and the African Medical and Research Foundation.

Finally, and in particular, the committee would like to express its deep appreciation of the Institute of Medicine (IOM) staff who facilitated the work of this committee. We especially thank Judith Bale, Stacey Knobler, and Alison Mack for translating and transforming the discussions and draft chapters of the committee and technical review comments into final prose; Laurie Spinelli for her tireless efforts in research verification and preparation of the manuscript for publication; and Christine Coussens, Stephanie Baxter-Parrott, Kevin Crosby, Carla Hanash, Amber Johnson, Witney McKiernan, Katherine Oberholtzer, and Tara Rao for their valuable research and logistical support of the committee's efforts. The committee is grateful for the contributions of Pamela Mangu during the initial stages of the project. Others within the IOM and the National Academies who were instrumental in seeing the project to completion were Paige Baldwin, Clyde Behney, Andrea Cohen, Mike Edington, Janice Mehler,

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Jennifer Otten, Sarah Schlosser, and Curt Taylor. Thanks are also due to editorial consultants Rona Briere, Phillip Sawicki, and Beth Gyorgy.

This project was funded by the Centers for Disease Control and Prevention (CDC), Global Forum for Health Research (GFHR), Fogarty International Center of the National Institutes of Health (FIC), National Institute of Child Health and Human Development (NICHD), National Institute of Mental Health (NIMH), and the National Institute of Neurological Disorders and Stroke (NINDS). The committee is appreciative of their support and of the commitment and productive efforts of Duane Alexander (NICHD), Coleen Boyle (CDC), Robert Eiss (FIC), Gerald Fischbach (NINDS), Walter Gulbinat (GFHR), Gray Handley (NICHD), Steven Hyman (NIMH), Gerald Keusch (FIC), Grayson Norquist (NIMH), Mary Lou Oster-Granite (NICHD), Darrel Regier (NIMH), Joana Rosario (NINDS), and Agnes Rupp (NIMH).

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Page xviii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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 Lost Productivity,

 

33

   

 Stigma and Discrimination,

 

33

   

 The Roles of Poverty and Gender Inequality,

 

34

   

 The Role of Poverty,

 

34

   

 Poverty-Associated Risk Factors for Brain Disorders,

 

35

   

 The Role of Gender Inequality,

 

37

   

 Capacity to Address Brain Disorders,

 

41

 3

 

INTEGRATING CARE OF BRAIN DISORDERS INTO HEALTH CARE SYSTEMS

 

57

   

 The Role of Primary Care in Addressing Brain Disorders,

 

57

   

 Developing a System of Care,

 

61

   

 Primary Care,

 

61

   

 The Role of Secondary and Tertiary Care,

 

64

   

 Building Capacity Through Training,

 

65

   

 Collaboration with Other Health and Nonhealth Sectors,

 

67

   

 Private Physicians,

 

67

   

 Schools and Educators,

 

68

   

 Community-Based Rehabilitation Programs,

 

68

   

 Community Organizations,

 

70

   

 Traditional Healers,

 

70

   

 The Cost of Integrating Services,

 

71

   

 Building Research Capacity Through Collaboration,

 

73

   

 Policy Implications,

 

75

   

 National Policy,

 

75

   

 Local Policy,

 

78

   

 International Support for Systems of Primary Care,

 

79

   

 The Role of Professional Societies and International Organizations,

 

80

   

 Provision of Essential Drugs,

 

83

   

 National Centers for Training and Research,

 

85

 4

 

FINDINGS AND FUTURE STRATEGIES

 

97

   

 Reducing the Disease Burden Now,

 

98

   

 Increasing Awareness,

 

98

   

 Utilizing Existing Health Systems,

 

99

   

 Expanding Use of Cost-Effective Interventions,

 

100

   

 Creating Options for the Future,

 

103

   

 Applied Research,

 

103

   

 Capacity Strengthening,

 

103

   

 The Role of International Aid,

 

106

 5

 

DEVELOPMENTAL DISABILITIES

 

113

   

 Definition,

 

113

   

 Cognitive Disabilities,

 

114

   

 Motor Disabilities,

 

115

   

 Vision, Hearing and Speech Disabilities,

 

115

   

 Behavioral Disorders,

 

116

   

 Scope of the Problem,

 

116

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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 Prevalence and Incidence,

 

118

   

 Prevalence of Cognitive Disabilities,

 

119

   

 Prevalence of Motor Disabilities,

 

121

   

 Prevalence of Vision Disabilities,

 

121

   

 Prevalence of Hearing and Speech Disabilities,

 

121

   

 Prevalence of Behavioral Disabilities,

 

124

   

 Risk Factors,

 

125

   

 Genetic,

 

125

   

 Nutritional Deficiencies,

 

126

   

 Infection,

 

129

   

 Environmental Toxins,

 

131

   

 Perinatal and Neonatal,

 

132

   

 Poverty and Trauma,

 

133

   

 Interventions,

 

133

   

 Primary and Secondary Prevention,

 

133

   

 Rehabilitation,

 

141

   

 Cost Analysis,

 

153

   

 Capacity,

 

154

 6

 

EPILEPSY

 

179

   

 Definition,

 

179

   

 Scope of the Problem,

 

181

   

 Stigma and Discrimination,

 

181

   

 Treatment Gap,

 

182

   

 Infectious Diseases,

 

183

   

 Prevalence and Incidence,

 

183

   

 Mortality Rates,

 

186

   

 Risk Factors,

 

186

   

 Genetic,

 

187

   

 Pre-,Peri- and Post-Natal,

 

187

   

 Parasitic Infections,

 

188

   

 Bacterial Infections,

 

189

   

 Viral Infections,

 

189

   

 Head Injuries,

 

189

   

 Febrile Seizures,

 

190

   

 Interventions,

 

190

   

 Prevention,

 

190

   

 Treatment,

 

191

   

 Capacity,

 

195

   

 Training,

 

195

   

 Research,

 

198

   

 Neurocysticercosis,

 

201

   

 Biological Cycle,

 

201

   

 Epidemiology,

 

202

   

 Prevention,

 

204

   

 Treatment,

 

204

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

 7

 

SCHIZOPHRENIA

 

217

   

 Definition,

 

217

   

 Scope of the Problem,

 

221

   

 Mortality,

 

221

   

 Social and Economic Costs,

 

222

   

 Prevalence and Incidence,

 

225

   

 Prevalence,

 

225

   

 Incidence,

 

226

   

 Risk Factors,

 

227

   

 Genetic,

 

227

   

 Environmental,

 

227

   

 Brain Pathology,

 

230

   

 Neurochemistry,

 

230

   

 Functioning Neuroimaging and Cognitive Deficits,

 

231

   

 Neurodevelopmental,

 

231

   

 Associations with Age and Gender,

 

231

   

 Substance Abuse Comorbidity,

 

233

   

 Factors Affecting Course and Outcome,

 

233

   

 Interventions,

 

235

   

 Prevention,

 

236

   

 Treatment,

 

236

   

 Capacity,

 

243

 8

 

BIPOLAR DISORDER

 

257

   

 Definition,

 

257

   

 Scope of the Problem,

 

258

   

 Mortality,

 

258

   

 Social and Economic Costs,

 

258

   

 Prevalence and Incidence,

 

261

   

 Risk Factors,

 

263

   

 Genetic,

 

263

   

 Substance Abuse,

 

263

   

 Environmental,

 

264

   

 Associations with Age and Gender,

 

264

   

 Factors Affecting Course and Outcome,

 

264

   

 Interventions,

 

266

   

 Prevention,

 

266

   

 Treatment,

 

266

   

 Capacity,

 

272

 9

 

DEPRESSION

 

283

   

 Definition,

 

283

   

 Scope of the Problem,

 

286

   

 Mortality,

 

287

   

 Social and Economic Costs,

 

289

   

 Prevalence and Incidence,

 

291

   

 Risk Factors,

 

294

Suggested Citation:"Front Matter." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×
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Neurological, Psychiatric, And Developmental Disorders

Meeting the Challenge in the Developing World

Part I

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Brain disorders—neurological, psychiatric, and developmental—now affect at least 250 million people in the developing world, and this number is expected to rise as life expectancy increases. Yet public and private health systems in developing countries have paid relatively little attention to brain disorders. The negative attitudes, prejudice, and stigma that often surround many of these disorders have contributed to this neglect.

Lacking proper diagnosis and treatment, millions of individual lives are lost to disability and death. Such conditions exact both personal and economic costs on families, communities, and nations. The report describes the causes and risk factors associated with brain disorders. It focuses on six representative brain disorders that are prevalent in developing countries: developmental disabilities, epilepsy, schizophrenia, bipolar disorder, depression, and stroke.

The report makes detailed recommendations of ways to reduce the toll exacted by these six disorders. In broader strokes, the report also proposes six major strategies toward reducing the overall burden of brain disorders in the developing world.

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