World Congress of Neurology 2015, Santiago, Offers Access to Collaboration and Cooperation

Donald H. Silberberg

Donald H. Silberberg

As we begin to think about attending the forthcoming World Congress of Neurology in Santiago, Chile, it seems timely to consider how we might take advantage of the unique opportunity that this provides to advance our field. As WFN President Raad Shakir points out in his column in this issue of World Neurology, we neurologists everywhere attempt to address identical or very similar clinical problems, but in quite different environments. Some do so surrounded by colleagues and all of the support systems that are key to optimal care. Others of us walk alone, sometimes as the sole neurologist in a region with very few physicians. Because of differences in the local health care system, cultural and other environmental differences, the neurologist practicing in optimal circumstances thinks about epilepsy, Parkinson’s disease or stroke in quite a different way than her counterpart practicing in difficult circumstances or in conflict zone.

A major function of an international meeting such as the World Congress of Neurology is to facilitate the sharing of knowledge, and to help develop ongoing working relationships that can lead to many advances for all. Although publications and electronic communications provide essential ways to communicate, an international meeting offers unparalleled access to one’s peers whose workplace and problems are far from home, but may be extremely informative.

Both information sharing and clinical and research collaboration become very real possibilities. Clinical collaboration today often takes the form of setting up periodic video conferences, supplementing important opportunities to visit one another. Research collaboration can lead the way to developing multilateral programs supported by universities, national agencies such as the National Institutes of Health (U.S.) or Canada’s Grand Challenges Program, and foundations such as the Bill and Melinda Gates Foundation. Many of us engaged in global neurology can think back to ways in which WFN congresses and other meetings introduced us to international problems, opportunities and colleagues—let’s put WCN Santiago to work for this purpose in November.

Neurology and Psychiatry in Babylon

Babylonians described epilepsy, stroke, psychoses, depression, anxiety

By Edward H. Reynolds

James Kinnier Wilson and Edward H. Reynolds.

James Kinnier Wilson and Edward H. Reynolds.

In the last 25 years I have had the privilege of collaborating with James Kinnier Wilson (JKW) on Babylonian texts of neurological and psychiatric disorders.  JKW is a Cambridge-based assyriologist and son of the distinguished neurologist, Samuel Alexander Kinnier Wilson (1878-1937) (see World Neurology, October 2014).

It was believed that studies of disorders of the nervous system began with Greco-Roman medicine, for example, epilepsy, “the sacred disease” (Hippocrates) or “melancholia,” now called depression.  Our studies have now revealed remarkable Babylonian descriptions of common neuropsychiatric disorders a millennium earlier.

There were several Babylonian dynasties with their capital at Babylon on the River Euphrates.  Best known is the Neo-Babylonian Dynasty (626-539 BC) associated with King Nebuchadnezzar II (604-562 BC) and the capture of Jerusalem (586 BC).  But the neuropsychiatric sources we have studied nearly all derive from the Old Babylonian Dynasty of the first half of the second millennium BC, united under King Hammurabi (1792-1750 BC).

The Babylonians made important contributions to mathematics, astronomy, law and medicine conveyed in the cuneiform script, impressed into clay tablets with reeds, the earliest form of writing, which began in Mesopotamia in the late 4th millennium BC (see Figure 1, page 8).  When Babylon was absorbed into the Persian Empire cuneiform writing was replaced by Aramaic and simpler alphabetic scripts and was only revived (translated) by European scholars in the 19th century AD.

A Babylonian cuneiform text on epilepsy. Obverse of BM47753 in the British Museum.

A Babylonian cuneiform text on epilepsy. Obverse of BM47753 in the British Museum.

The Babylonians were remarkably acute and objective observers of medical disorders and human behavior. In texts located in museums in London, Paris, Berlin and Istanbul, we have studied surprisingly detailed accounts of what we recognize today as epilepsy (Figure 1), stroke, psychoses, obsessive-compulsive disorder (OCD), psychopathic behavior, depression and anxiety.  For example, they described most of the common seizure types we know today, e.g., tonic clonic, absence, focal motor, etc., as well as auras, post-ictal phenomena, provocative factors (such as sleep or emotion) and even a comprehensive account of schizophrenia-like psychoses of epilepsy. Early attempts at prognosis included a recognition that numerous seizures in one day (i.e., status epilepticus) could lead to death.

The Babylonians recognized the unilateral nature of stroke involving limbs, face, speech and consciousness, and distinguished the facial weakness of stroke from the isolated facial paralysis we call Bell’s palsy. They did not, and perhaps could not, describe what we call transient ischemic attacks as they had no method of expressing small units of time such as seconds or minutes. The distinction between a transient ischemic event and some epileptic seizures would have been difficult, as it can be today.

The modern psychiatrist will recognize an accurate description of an agitated depression, with biological features including insomnia, anorexia, weakness, impaired concentration and memory. The obsessive behavior described by the Babylonians included such modern categories as contamination, orderliness of objects, aggression, sex and religion. Accounts of psychopathic behavior include the liar, the thief, the troublemaker, the sexual offender, the immature delinquent and social misfit, the violent and the murderer.

A bas-relief of a wounded lioness from the Palace of Ashurbanipal at Nineveh, in the British Museum.

A bas-relief of a wounded lioness from the Palace of Ashurbanipal at Nineveh, in the British Museum.

The Babylonians had only a superficial knowledge of anatomy and no knowledge of brain or psychological function. Although they had no knowledge of the spinal cord, the Babylonians and the Assyrians clearly understood that an arrow in the center of the back led to paralyzed hind legs, another important clinical observation (figure 2). They had no systematic classifications of their own and would not have understood our modern diagnostic categories. Some neuropsychiatric disorders, e.g., stroke or facial palsy, had a physical basis requiring the attention of the physician or asà», using a plant and mineral-based pharmacology.  Most disorders, such as epilepsy, psychoses and depression, were regarded as supernatural due to evil demons and spirits, or the anger of personal gods, and thus required the intervention of the priest or aÅ¡ipu.  Other disorders, such as OCD, phobias and psychopathic behavior, were viewed as a mystery, yet to be resolved, revealing a surprisingly open-minded approach.

From the perspective of a modern neurologist or psychiatrist, these ancient descriptions of neuropsychiatric phenomenology suggest that the Babylonians were observing many of the common neurological and psychiatric disorders that we recognize today.  There is nothing comparable in the ancient Egyptian medical writings and the Babylonians therefore were the first to describe the clinical foundations of modern neurology and psychiatry.

A major and intriguing omission from these entirely objective Babylonian descriptions of neuropsychiatric disorders is the absence of any account of subjective thoughts or feelings, such as obsessional thoughts or ruminations in OCD, or suicidal thoughts or sadness in depression. The latter subjective phenomena only became a relatively modern field of description and enquiry in the 17th and 18th centuries AD. This raises interesting questions about the possibly slow evolution of human self awareness, that is central to the concept of “mental illness,” which only became the province of a professional medical discipline, i.e., psychiatry, in the last 200 years.

References

Kinnier Wilson JV, Reynolds EH. Texts and documents. Translation and analysis of a cuneiform text forming part of a Babylonian treatise on epilepsy. Med Hist. 1990; 34:185-98.

Reynolds EH, Kinnier Wilson JV. Stroke in Babylonia. Arch Neurol. 2004; 61:597-601.

Reynolds EH, Kinnier Wilson JV. Neurology and Psychiatry in Babylon. Brain. 2014; 137: 2611-2619.

Edward H. Reynolds is former consultant neurologist to the Maudsley and King’s College Hospitals; former director of the Institute of Epileptology, King’s College, London and former president of the International League against Epilepsy.

Peter J. Koehler is the editor of this history column. He is neurologist at Atrium Medical Centre, Heerlen, The Netherlands. Visit his website at www.neurohistory.nl

Pediatric Neurology in Africa

Fellowship program builds skills for health practitionersAPFP_logo

By Jo Wilmshurst, MD

Doctors trained in the management of child neurology conditions are lacking in Africa1,2. Epilepsy is one of the major disease burdens in the continent and training in this area is even more scarce. EEG interpretation in children is very different to that for adults and grave errors can occur in patient management when misinterpretations occur.

The African Paediatric Fellowship Program (APFP) is a project developed by the Department of Paediatrics and Child Health at the Red Cross War Memorial Children’s Hospital, under the University of Cape Town in South Africa, to build skills capacity of health practitioners from Africa. The center is the largest dedicated children’s hospital in sub-Saharan Africa. Children are managed across primary to quaternary levels of care with the spectrum of diseases prevalent in Africa.

Figure 1. some of the 2014 apfp fellows attending the end-of-year discussion group. dr. kija, child neurology trainee from tanzania, is fourth from the left. represented in the group are doctors training in areas from pediatric urology to pediatric rheumatology from areas in africa inclusive of uganda, zambia, kenya, ghana, zimbabwe and malawi. the group remains as a cohesive support network and stay in contact after completion and following their return home.

Figure 1. Some of the 2014 APFP fellows attending the end-of-year discussion group. Dr. Kija, child neurology trainee from Tanzania, is fourth from the left. Represented in the group are doctors training in areas from pediatric urology to pediatric rheumatology from areas in Africa inclusive of Uganda, Zambia, Kenya, Ghana, Zimbabwe and Malawi. The group remains as a cohesive support network and stay in contact after completion and following their return home.

The APFP formed collaborations with tertiary centers across Africa and has assisted their identification of strategic training requirements based on their countries’ key health care needs. Structured training occurs at the pediatric units through the University of Cape Town. More than 65 specialists have completed, or are completing in 2015, the training program in diverse pediatric areas, referred from 33 centers in 12 different African countries. There has been a 98 percent retention rate of trainees returning to work in their home country since 2008. The program is evolving with training arms supporting nursing and ancillary services. The trainee becomes the trainer in his or her home center, and a key opinion leader equipped to lobby for changes to health care policy (Figure 1).

The grant provided by the WFN to support neurology training in 2013 has enabled the focused training for six general pediatricians from different centers in Nigeria, and three further trainees from Zimbabwe, who manage large caseloads of children with neurodisabilities and epilepsy. The University of Cape Town rolled out in 2015 a post-graduate diploma in “basic electrophysiology interpretation and the management of children with epilepsy.” This requires one-on-one training with a focus on areas relevant to the African context. The aim of the post-graduate diploma is to establish safe practice and not to train accredited epileptologists. In Africa, most child health practitioners who manage children with neurologic disorders must address the comprehensive needs of the child inclusive of the other health issues, such as co-infections, nutritional deficits, and social challenges (Figures 2 a, b).

At the current time in most African settings, it is not viable to work as an epileptologist without addressing these other health care issues (Figures 3 a, b). However as a result of more cost-effective neurophysiology equipment, and through equipment donations, there are an increasing number of EEG machines that are potentially being operated and interpreted by health practitioners with no pediatric training. This training program was devised out of the needs that this situation created. The audit of the preliminary findings of a pilot study on the impact of the training course while it was being established is in press. The audit confirmed that access to a basic handbook improved EEG interpretation skills, but that the optimal outcomes were seen in those doctors who had additional one-on-one training.

a.) Children attending the neurology clinic at Red Cross War Memorial Children's Hospital, enjoying a donation of new reading books. b.) One of the neurology patients occupied in puzzle play in the waiting area.

a.) Children attending the neurology clinic at Red Cross War Memorial Children’s Hospital, enjoying a donation of new reading books. b.) One of the neurology patients occupied in puzzle play in the waiting area.

Between 2013 and 2014, three doctors from Nigeria, Tanzania and Ghana entered the APFP for formal training to become accredited child neurologists. Tanzania has no accredited child neurologists and Ghana has two. These trainees, in addition to completing the full post-graduate clinical master’s degree in child neurology, also are completing research in areas relevant to the context they work in. The doctor from Tanzania is heading a prospective study to review the effects on bone mineral density in children on antiepileptic drugs in the African setting. Vitamin D supplementation is not part of standard care of these patients and it is hoped that the findings from this study will lead to data to support lobbying for this intervention to be part of standard practice. The doctor from Ghana will complete a study assessing the neurobehavioral influences on children from antiretroviral therapy. The doctor from Nigeria has completed a large prospective study assessing the efficacy of attaining sleep EEGs in children using melatonin.

In the next training cycle it is hoped that there will be funding to support applicants from Sierra Leone, Zimbabwe, Uganda, Kenya, Sudan and Zambia.

The training curriculum, while in line with international templates, also accommodates approaches novel to Africa, such as the neurological care for children with tuberculous meningitis, HIV, malaria and neurocysticercosis. The perinatal complication rates remain high in Africa with significant numbers of neonates suffering hypoxic ischaemic encephalopathy. Other neuroinsults are seen from the effects of central nervous system infections and motor vehicle accidents. The training must accommodate these areas in depth as well. The returning trainee must often function in all areas from social welfare to rehabilitation, the training is adjusted for this.

a.) Mothers attending the Queen Elizabeth Hospital, Blantyre, in Malawi, taken during an APFP site visit in 2013. This is the main teaching hospital in the country, which has one pediatric neurologist for the total population. b.) Child-care workshop for children with motor disabilities at the Child Rehabilitation Unit, Harare Hospital, Zimbabwe, taken during the APFP site visit to the referring units in the country in 2014.

a.) Mothers attending the Queen Elizabeth Hospital, Blantyre, in Malawi, taken during an APFP site visit in 2013. This is the main teaching hospital in the country, which has one pediatric neurologist for the total population. b.)
Child-care workshop for children with motor disabilities at the Child Rehabilitation Unit, Harare Hospital, Zimbabwe, taken during the APFP site visit to the referring units in the country in 2014.

Prevention and early intervention is one of the major aims for this project and all trainees in the program are facilitated in the knowledge gained during their training and assess its relevance to their home setting, how to introduce these skills to the optimal benefit to child health care and how these interventions can extend across all levels of health care—from primary to tertiary.

On the trainee’s return to their home center they maintain contact with their supervisor, and site visits are scheduled as needed to provide local input into service development and local training (Figure 3 a, b). Research collaborations also continue. These trainees are having a real impact in their home centers and are becoming voices in Africa lobbying to promote child health. One of the child neurology trainees who completed training in 2009 and returned to Kenya now sits on the national Kenyan pediatric body, assists selection of ongoing APFP trainees referred from the country, and is also on the Pediatric Commission for the International League Against Epilepsy. This trainee is part of a team developing its own subspecialty training program for East African doctors. This is viewed as a major future aim of the APFP. In order to grow and to fulfill the health care needs for the continent, more training sites are needed. It is important these remain within Africa with training relevant to the diseases of the region. There is much to learn from the approaches many innovative African centers undertake to cope with the challenges of scare resources.

While training experience in overseas centers offers obvious gains in skills development, the local relevance of the training may be questionable and the risk of the “brain drain” is high. A number of overseas specialists have opted to spend time working, training and lecturing in African centers. This is a superb way to assist skills development in African centers. Building on these relationships with regular visits develops sustained skills where often none existed before.

References

  1. Wilmshurst JM, Badoe E, Wammanda RD, Mallewa M, Kakooza-Mwesige A, Venter A, Newton CR. Child neurology services in Africa. J Child Neurol. 2011 Dec; 26(12):1555-63.
  2. Wilmshurst JM, Cross JH, Newton C, Kakooza AM, Wammanda RD, Mallewa M, Samia P, Venter A, Hirtz D, Chugani H. Children With Epilepsy in Africa: Recommendations From the International Child Neurology Association/African Child Neurology Association Workshop. J Child Neurol. 2013; 28 633-644
Dr. Wilmshurst is the head of paediatric neurology, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa, and the director of the APFP.
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