Ryuji Kaji MD, PhD

In his 2010 inauguration speech as the president of World Federation of Neurology (WFN), Prof. Vladimir Hachinski conveyed a message: “Asia has more than 60 percent of the global population, yet in some areas, the education of neurology to young neurologists does not keep up with the patients’ needs of neurological care.” He organized the Asia Initiative as a part of WFN to bring attention to this region. As the chair of this initiative, I have met many Asian neurologists and have begun to realize that there are unique problems that require attention from the rest of the world.

The 14th Asian & Oceanian Congress of Neurology was held in March in Macao, China. This is an official meeting of Asian Oceanian Association of Neurology, whose history dates back almost half a century ago. Charles M. Posner, a WFN representative, toured the Asian and Oceanian countries and challenged local neurologists to form an association that would promote and foster the advancement and exchange of information within the area. In response, Shigeo Okinaka, then the executive of Japanese Society of Neurology, invited the region’s neurologists to a planning meeting in Tokyo. This gave birth to the Asian and Oceanian Association of Neurology (AOAN) on June 26, 1961. Its official meeting, Asian & Oceanian Congress of Neurology (AOCN), had been held every four years until the current 14th meeting in China, which followed the 13th meeting in Melbourne in 2012 by two years. There was uncertainty over the financial and scientific outcomes of this short-interval meeting, but thanks to the dedication of the Hong Kong Society members, it became an unprecedented meeting with the largest number of international participants ever. Its surplus funds should significantly contribute to the activities of AOAN, chaired by Dr. Man Mohan Mehndiratta from India. The next AOCN will be held in 2016 in Malaysia.

On March 4, there was a plenary session on “Special Issues in Asia,” in which three speakers spoke. Prof. Chong-Tin Tan from Malaysia gave a talk on education in Asia. He serves as the editor of Neurology Asia, the official journal of AOAN and Association of Southeast Asian nations Neurological Association (ASNA). He pointed out that Asia accounts for 60 percent of the world population, but less than 20 percent of neurologists in the world, and stressed that education is the key to development of neurology in Asia. Next, Dr. Li-Ping Liu from China emphasized rapidly advancing frontiers of neuroscience research in China. At the last of this session, I gave a talk on neurology service in Asia. Asian countries are rapidly exploding in population and economy. Some are facing unique problems not experienced in other regions¹.

Figure 1. Projected increase of the aged (>65) populations among nations.
Adapted from Current Status and Predictions for an Aging Society with Fewer Children, Japanese Ministry of Education, Sports, Culture, Science and Technology (with permission).

Figure 1 depicts the projected increase of the population over 65 years among nations. While Western countries have a linear increase of the aged over years, Asian countries (Japan, Korea and China) have S-shaped curves indicating a steep surge of the aged population during 2000-2020 (Japan) and 2020-2030 (Korea and China). India will probably join this group by the end of this century.

Japan is the first to be exposed to this surge, and medical needs for the aged people are highlighted. Among these, neurological disorders such as stroke and Alzheimer’s disease came to the forefront. For instance, the number of stroke survivors has steeply increased from 1.7 million in 2000 to 2.8 million by 2013. Stroke was the No. 2 killer in the 1970s, but it is currently the fourth, following cancer, heart disease and pneumonia. Although the number of stroke attacks is six times as frequent as heart attack, it has largely become non-fatal, although it typically leaves disabilities; two- thirds of the patients are unable to return to pre-morbid activities.

From the global point of view, stroke is the second leading cause of death after ischemic heart disease, with an estimated 5.5 million people dying from stroke every year worldwide. Two thirds of these deaths occur in countries with limited resources². Approximately 80 percent of patients survive the acute phase of stroke, but are left with varying degrees of chronic disability.

Not only the number of deaths, but also the quality of life after stroke is an important aspect. Disease-adjusted life years (DALYs) are defined as number of years of healthy life lost by disease³. They reflect the impact of a disease in the aging societies.

Figure 2. Disease-adjusted life years (DALYs) of neurological diseases with respect to nation’s income status. Data from WHO (2005).

Figure 2 shows DALYs among various neurological diseases with respect to the economic status of a nation. Stroke is more important than Alzheimer’s disease, because many Asian nations are still in the state of low-middle income by World Bank Criteria. Japan had been among those with limited resources with high mortality of stroke, but her economy grew up in a short period to high income state, and other Asian nations should follow this path.

The drop of stroke mortality in Japan is due to change in diet, western lifestyle and the efficient social health care system. However, the main factor is the control of hypertension by medication, which decreased the number of fatal massive hemorrhages³. The impact of thrombolytic therapy is limited, rather increasing those disabled by preventing stroke deaths⁴.

The expense related to caring for stroke survivors is now exceeding $25 billion (U.S. dollars) per year in Japan. Now the Japanese economy is revolving around those aged patients and their care. In fact, a major diaper maker saw sales of adult diapers outpace infant diapers. Stroke centers with staff dedicated to thrombolytic therapy are urgently needed, and we are investing effort into increasing awareness of stroke among Asian people. Educating health professionals in neurology is the Asian Initiative’s first priority.

The roots of neurology lie in Europe and this specialty matured in the U.S. Asia has its own priorities in coping with neurological diseases. In this regard, I propose “autonomy” as a key word for activating regional neurological organizations. We need a forum to discuss the problems in each region, and to provide unique educational opportunities for neurologists, general practitioners, allied health professionals and the patients. With these aims in mind, the WFN has decided to make the best use of the existing regional neurological organizations such as AOAN to fulfill its mission.

Another key for success would be “synergy”. Symposia and workshops were held in collaboration with international organizations such as the Movement Disorder Society (MDS) and the International Federation of Clinical Neurophysiology (IFCN). These joint activities provided the financial support for the meeting and increased the attendance. The event also helped the supporting organizations increase their visibility. I hope that the March 2014 meeting in Macao becomes a model for the future meetings in Asia, and the meeting will serve as an equivalent to EFNS, ENS or American Academy of Neurology meetings.

Alzheimer’s disease is a little harder to tackle. Traditionally, Asian people had a large family, three generations living together. The aged people lived with younger family members. In my childhood in 1950s, the aged are naturally thought to have memory loss to some degree. It is still a virtue that children respect and take care of the parents by Asian standard. Re-appraisal of this system in the face of increasing Alzheimer’s disease might be a solution for countries with limited resources. For the aged, it would be appropriate to prepare for the intellectual decline.

Steve Jobs, the former CEO of Apple Computer, gave a speech at the commencement at Stanford in 2005. Facing the recurrence of cancer, his message on coping with imminent death might be a hint: in the morning he thought about his life as if ending in the evening. Whenever he thought the activities of the day were not what he really wanted to do, he changed his life. These were actually the words of the old Chinese philosopher, Confucius (551–479 BC), which he probably was familiar with. Alzheimer’s disease is still unpreventable and incurable probably for the next decades to come. “Think Oriental” might be the key for the societies and the neurological community in the world.

References

1. Kaji R Asian Neurology and Stroke (Perspectives) Neurology, in press

2. WHO, W. Neurology Atlas, (2003).

3. Murray, C.J. et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2197-223 (2012).

4. Kubo, M. et al. Secular trends in the incidence of and risk factors for ischemic stroke and Its subtypes in Japanese population. Circulation 118, 2672-8 (2008).

Wolfgang Grisold

By Wolfgang Grisold

Earlier this year, the first Joint Congress of European Neurology took place in Istanbul. This was the final stage in the process of merging the two European neurological societies — the European Neurological Society (ENS) and the European Federation of Neurological Societies (EFNS) — into the European Academy of Neurology (EAN). The first elections of the new society were held during the congress, naming G. Deuschl, Germany, as the first president of the EAN, and F. Fazekas, Austria, as its first vice president. The merger of the two societies was a logical step and now that it has occurred, it seems to be a natural development, but it took a huge effort and the engagement of many individuals to make it possible.

The ENS was the first European neurological society, founded in 1986. It held its first congress in Nice in 1989. That congress was organized by G. Said.

Said along with his co-founders, P. K. Thomas and Anita Harding, were the heart of the ENS at its founding. Their idea was to create a European society based on individual membership, with a strong emphasis on science and a structure similar to that of the American Academy of Neurology (AAN). As a consequence of this philosophy, the ENS traditionally has been less engaged in political aspects of neurology, fostering individual rather than national representation. The ENS, apart from holding excellent congresses, increasingly engaged in education through teaching, scholarships and internationalsupport for countries in need. Its major publication was the Journal of Neurology, which was supplemented by informative newsletter that appeared regularly.

The EFNS was founded in Vienna in 1991 by Prof. Gerstenbrand who had a vision of creating a large European society based on prior activities in Eastern Europe, such as the International Danube Symposia and the proposed Pan-European Society of Neurology. The philosophy of the EFNS was federal in constitution and structure, where individual European countries were the constitutional members. This construction was effective. Since its founding, the EFNS has contributed greatly to European neurology. The EFNS sponsored a number of activities, many of which were originally conceived within the EFNS, promoting education, CME accreditation and supporting neurology in the former Eastern European countries, by teaching courses, holding lectures and helping in the establishment of national neurological organizations. The primary publication of the EFNS is the European Journal of Neurology, which will become the official journal of the EAN. Neuropennews is an online publication serving the purpose of a newsletter.

Due to differences in their philosophies, the two societies were effectively in competition, resulting in what many European neurologists concluded was an unnecessary duplication of effort. The initial event of their coming together was the creation of the European Board Examination in Neurology, where the examination’s creator, the UEMS – European Board of Neurology (UEMS/EBN) invited both societies to participate in its development. The presidents of the two organizations at that time — De Reuck of the EFNS and Moonen of the ENS — were both from Belgium. That facilitated the process of initiating a proposal for the creation of a joint EAN.

There were many additional steps necessary for the eventual merger. One major step was the agreement of the European delegates of the EFNS to this proposal in Florence 2009 and the subsequent agreement of ENS members. A joint task force was then formed that meticulously prepared the details for the merger and also created a new constitution and voting system.

The EAN combines the best of the developments of both societies. It is expected to foster neurology within Europe for the best of patient care, and to support and encourage science, teaching and education, as well as to be a transparent, open-minded and member-oriented society that provides an essential service for its members.

The WFN acknowledges this development toward a strong European society, and we hope to cooperate in further projects, especially where those involve furthering neurological education in countries in need of additional resources.