Search Results for: Stroke in ICD-11

Report on the 68th Session of the WHO Regional Committee for Europe

Sept. 17-20, Rome, Italy

By Wolfgang Grisold

The World Federation of Neurology (WFN) is a global non-state actor, and has the possibility to participate in the regional WHO meetings. As with last year in Budapest, the WFN was represented this year by Wolfgang Grisold in Rome.

Opening ceremony: choir sings Italian music, ending with Verdi`s Nabucco

The meeting took place in the governmental sector of Rome (Auditorium della Tecnica, Viale Umberto Tupini 65) and was opened by high ranking Italian politicians, including the prime minister and the health minister. The WHO was represented by Tedros Adhanom Ghebreyesus, director general, and Zsuzsanna Jakab, WHO regional director for Europe.

The WFN was able to make a statement, this time on stroke. This statement can be found on the WHO website and was jointly made with the World Stroke Organization (WSO), the European Stroke Organization (ESO), and the European Academy of Neurology (EAN).

Opening speech with Zsuzsanna Jakab, WHO Regional Director for Europe.

An oral statement was also delivered by Francesca Pezzella, a representative from the ESO. It states the importance of stroke, as endorsed by four large specialist societies. This statement may be useful in the regional context for WFN member states to further emphasize the importance of stroke treatment.

The main program points were:

  • Affordability of medical services
  • Vector borne diseases and vaccination
  • Non-communicable diseases (NCDs)
  • Men’s health
  • Budget program

In this report, the topics relevant for neurology will be discussed.

“No one left behind“ is a self-explanatory motto of this year to describe that all persons in European countries should have access to health coverage. Despite the fact that Europe is one of the richest regions in the world, a large disparity of out of pocket costs for patients exists. In summary, in those countries in Europe that are the poorest, the percentage of self payment and individual payment (out of pocket) is highest.

Whether people can afford to pay for health care is a question of growing importance, and varies greatly in European regions. It is alarming that some health costs, for example, dentistry, are not covered at all in some countries.

The wish and recommendation is the move toward a European health plan, with health coverage of EU citizens. Residual and out of pocket payment need to be reduced or ideally abolished.

An action plan to improve public health preparedness and response in the WHO European Region is on the way. Turkey was specifically mentioned in this WHO meeting. This country is providing free medical care for more than 3 million Syrian refugees, which was greatly acclaimed by the delegates.

Vaccine-Preventable Diseases and Immunization: Realizing the Full Potential of the European Vaccine Action Plan

The issue of vaccination deficits in Europe has reached large dimensions. As all vaccinations need a herd immunity of 95 percent to be effective, the present trend to refuse or reduce vaccinations has a large impact. Worldwide, and in Europe in particular, individualist ideas and anti-vaccination activists have successfully undermined the vaccination strategies; subsequently, new threats from diseases that had been prevented, and seemed to have been extinguished by vaccination, reappear.

As an example, measles presents with 40,000-60,000 cases per year in Europe. Although it can be harmless, measles can be more severe, or even extremely severe as in measles encephalitis. Similar concerns can be expressed for polio, which is presently extinct in Europe.

The need for vaccination and protection needs to be on the agenda of European states. Also vaccination for personal health is an emerging issue, as non-vaccinated health professionals pose a risk for the dissemination of infectious diseases.

Non-Communicable Diseases (NCDs)

The topic of NCDs is of growing importance, as they are the most frequent cause of death and disability. In addition to high income countries, NCDs are becoming increasingly important in low income regions of the world. Lifestyle and nutrition are the most important modifiable risk factors. The issue of NCDs will be the subject of further conferences, in particular the New York meeting at the United Nations on Sept. 27. (See the report on page 5.)

From the contributions, it seems that cardiology is very active and stressing the importance of cardiovascular disease. Despite our statement on stroke and success with the new ICD 11, neurology still needs to carefully watch the final implementation of the ICD-11, which will only be in 2021.

Other neurological NCDs, such as dementia, trauma, and neuromuscular disease were not included in the discussions and will also need more advocacy from the neurological community.

Environment

The important role of the environment on diseases is increasingly attracting attention. The WFN and its Applied Research Group on the Environment (Prof. Reis, France; Prof. Wasay, Pakistan) have already devoted the WFN World Brain Day 2018 to the environment. Also the WHO statement from 2017 in Budapest clearly defines the importance of environment for the risk of stroke.

As the environment is an increasingly important factor, the WHO will organize a conference dedicated to the environment and diseases in Geneva this year.

Summary

The WFN as a non-state actor is grateful to the WHO for cooperation and also to be able to participate at this high-level meeting. Many of the issues discussed are important for neurology, not only in Europe, but also worldwide. The experience and inclusion in this meeting enhances the awareness of regional and global aspects of the WHO. •

The Third High-Level Meeting of the United Nations on Non-Communicable Diseases

By Wolfgang Grisold, MD

“Time to deliver, leaving no one behind.”

The third high-level meeting of the United Nations (U.N.) on Non-Communicable Diseases (NCDs) was held Sept. 27 at the UN in New York City. It scaled up multistakeholder and multisectoral responses for the prevention and control of NCDs in the context of the 2030 Agenda for Sustainable Development. The World Federation of Neurology (WFN), represented by Wolfgang Grisold, was able to participate in this high-level meeting through the support of the Austrian Society of Neurology and the Austrian Health ministry.

Mrs. Mandela speaking on health issues.

The meeting was attended by heads of state and government, parliamentarians, ministers of foreign affairs, finance, and health, heads or senior representatives of relevant United Nations entities, civil societies, the private sector, philanthropic foundations, academia, medical associations, indigenous leadership, and community organizations. The meeting highlighted the importance of non-communicable diseases for the WHO.

Non-communicable diseases such as stroke, dementia, other degenerative diseases, brain cancer, and neuromuscular diseases are an important part of neurology. In particular, stroke and the recent modifications of the ICD-11 classification, aim toward an improvement of the care of stroke patients worldwide. To continue this important development is a critical task of the neurological community.

WHO Secretary General Tedros Adhanom Ghebreyesus.

The meetings follow a structured pattern, with openings, plenaries, and various dedicated side meetings. There were key speakers, and following these, many speakers from states around the world illuminated the multitude of aspects of NCDs. The efforts are directed to achieve the Sustainable Development Goals, in particular Goals 3 and 4.

There were several interesting keynote speakers, such as Mr. Bloomberg, Mrs. Mandela, director general of the WHO Tedros Tedros Adhanom Ghebreyesus, and several ministers of health, who gave key speeches on the importance of preventing diseases, including the influence of modern lifestyle, the need to reduce sugar content in food, the adaptation of nutrition, excess of sodium, and the recreational abuse of tobacco and alcohol. These changes are spreading fast around the world, making the prevention of NCDs a high priority.

U.N. building, where the meeting took place.

The greatest attention was directed toward diabetes, cardiovascular diseases, and cancer, and also the issue of vaccination. The issue of dementia and other neurological diseases was mentioned by only a few speakers and countries, and it will be a mission of the neurological WFN community to act on their local and international level on behalf of the recognition of neurological disease. The worldwide need for palliative care was only mentioned by one speaker (Somalia), although it is an important issue worldwide.

However, stroke was included in the list: The heads of state and government committed to 13 new steps to tackle non-communicable diseases, including cancers, heart and lung diseases, stroke, and diabetes, and to promote mental health and well-being.

Another important side meeting was directed toward Universal Health Coverage (UHC) in emergencies. This is an important aspect and should provide help for persons in need following an emergency such as catastrophes, but also outbreaks of diseases such as ebola. The need for this was emphasized by Director General Tedros from the WHO.

“Leaving no one behind” is applicable for the prevention and treatment of NCDs and needs to be available universally in medical emergencies.

This meeting not only acknowledges the need for further care of NCDs and highlights the problems worldwide, but also clearly reveals that the advocacy for neurological diseases needs to be increased.

In all sessions, speeches were allowed from countries as well as a few organizations such as non-governmental organizations (NGOs). The meeting allowed listening to a worldwide representation of speakers who gave presentations of their local health systems and also of their efforts to take active measures against NCDs. •

Toward a More Meaningful WHO/WFN Relationship

By William Carroll
WFN President

The WFN and WHO share a number of common features and have had useful collaborations in the recent past. Both organizations have a global perspective with regional organizations, parallel mission and goals, and the development of the Atlas of Neurology and the neurology section of the 11th revision of the International Classification of Disease (ICD11) to its present stage.

William Carroll, MD

In addition, the WHO and WFN have collaborated during the Zika virus Public Health Emergency of International Concern of 2016, and the recognition of stroke as a disease of the brain and dementia and on other degenerative neurological disorders being included in the WHO non-communicable disease (NCD) initiative. The two organizations diverge only in the magnitude of the tasks confronting them.

The WFN mission is to foster quality neurology and brain health worldwide; the WHO to improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health. Arguably, the two organizations are a natural fit with the potential for beneficial cooperative activity. Both have regional organizations of similar geographic distribution pursuing the same goals as above. For the WHO, member states are grouped into six regions: African, the Americas, South-East Asian, European, Eastern Mediterranean, and Western Pacific. WFN member societies are in five regions; the American (represented by the American Academy of Neurology and the Canadian Neurological Society) and the Pan American Federation of Neurological Societies, representing Central and South American members, the European region comprising the European Academy of Neurology, the Middle East and North African region represented by the Pan Arab Union of Neurological Societies, the African region represented by the newly formed African Academy of Neurology, and the Asia Pacific region represented by the Asian and Oceanian Association of Neurology.

DRAFT AGENDA

1300–1305
Introduction and welcome to delegates by the President, Dr. William Carroll (BC)

 

1305–1320
Roll call and proxies Dr. Wolfgang Grisold (SG)

 

1320–1325
Minutes of the COD Meeting in Kyoto 2017 (BC)

 

1325-1345
Presentation of the WCN 2023 intending candidate venues (5 minutes each)
a. Canada, Montreal
b. Mexico
c. Brazil

 

1345-1355
Receipt of Annual Report 2017
President’s report (WHO, GNA, Brief Dubai, Needs Registry)

 

1355-1405
First Vice President’s report (RK)
WCN 2019 progress report

 

1405-1415
Secretary General’s report (WG)
London Office
Overview

 

1415-1425
Treasurer’s report (RST)
Receipt of the accounts of the Federation for the financial year
Dec. 31, 2017.
Appointment of auditor.

 

1425-1450
Election: Candidate statements (5 minutes each)

 

Secretary General
Wolfgang Grisold

 

Elected Trustee
Morris Freedman
Alla Guekht
Jean-Marc Leger
Daniel Truong

 

1450-1515
Election: Voting

 

Secretary General
Wolfgang Grisold

 

Trustee
First round voting
Second round voting

 

1515-1525
Education Committee Report (SL)
Continuum
Training Centres/Teaching courses
World Neurology

 

1525-1535
Membership Committee Report (MF)

 

1535-1545
Public Awareness and Advocacy Committee (WBD MW)

 

1545-1555
Publications Committee (Journals JE)

 

1555-1605
E-Communications Committee (WS)

 

1605-1615
Africa Education Report (RG)

 

1615-1620
AOB

 

1620-1625
Announcement of all voting results

 

Close

Draft agenda for the upcoming WFN council of delegates meeting in Berlin Tuesday, Oct. 9, 2018.

The WHO is the lead organization for all matters in health.Its constituency is the national health organizations representing national governments in most instances.

The WHO does interact with many non-governmental organizations termed “non state actors” but it recognizes only one type of formal relationship known as “official relations.” Other informal contact includes “working relations” which have their own set of criteria. Official relations are usually between the WHO and global organizations which share common goals as does the WFN. Further, “official relations” is conferred by the WHO for a specified period and for designated topics. The WFN has greatly appreciated having “official relations” status for its partnership in the Atlas of Neurology and with the topic advisory neurology group for ICD-11 extended to 2019. It is the seemingly arbitrary nature of this collaborative effort and that the WHO does not have the same ready access to medical specialties and their global, regional, and national organizations as does the WFN for neurology and others such as the World Heart Foundation, the International Union of Immunological Societies and the International Society of Nephrology, that the WFN believes could be reviewed and probably optimized.

In the neurological sphere, it became apparent some years ago that there might be benefit in a closer alignment between two existing groups of “neurological” organizations. One roughly represented those with more specialty-focused neurological interests such as stroke (World Stroke Organization), epilepsy (International League Against Epilepsy), dementia (Alzheimers Disease International) movement disorders (International Parkinson and Movement Disorder Society ) and multiple sclerosis (Multiple Sclerosis International Federation). The other included those with neurologically related interests such as the World Federation of Neurosurgical Societies, the World Federation of Neurorehabilitation, the World Psychiatry Association, the International Child Neurology Association and the International Brain Research Organization.

During recent in-depth discussions with the WHO over ICD11 and the classification of stroke, these two groupings worked more closely than previously to the benefit of the WHO, the WFN, and members of these two groups. Emerging from this experience was a sentiment that had first been expressed during the meeting of representatives attending the WCN 2015 in Santiago; that a more formal unified structure interacting more regularly to share information, acting concertedly and advocating more cohesively could be mutually beneficial. This organization, at present in formal development, would be known as the Global Neurological Alliance (GNA).

It should bolster many areas to do with brain health not least by providing ready access to neurological specialties and speciality perspectives. In effect, it adds a valuable third dimension for the promotion of brain health by the WFN and GNA. Recognizing the role the WFN will play as the communication hub for this new alliance, the trustees have committed to provide the personnel and resources required to ensure its success.

The WFN has also recommitted to ensure all alliance members have the opportunity to participate in the biennial World Congress of Neurology; a practice developed by the immediate WFN past President. Finally, it is hoped that the WFN will be able to offer to GNA members free advertisements in World Neurology and on its website.

The immediate benefits of establishing the GNA are recognizable and have little or no risk to it or its members. These include a more influential voice in matters of advocacy, a more rapid response to global government and non-government calls for action, the provision of specialist task forces, the promotion of brain health in general, and the continued evolution of World Brain Day (WBD) in partnership with other GNA members.

WBD themes have been epilepsy and stroke in previous years, the environment this year, and headache for next year. Indeed, the risk of not proceeding to establish the GNA are possibly a greater threat to the common goals than doing so. Most importantly among tasks suitable for the GNA is the ability of the GNA to provide greater support for the WHO in its NCD and Air Pollution and Health initiatives, its global action plan for dementia, in addition to the call by the WSO for the WHO to increase awareness, treatment access, and removal of inequities in stroke care.

From my position, it is to be hoped that the ability to interact successfully at this global level will be facilitated by the WFN retaining “official relations” status with the WHO to pursue areas of common interest mentioned above and in the other major concern for us, that of the inequities of access to health care in general and neurological care in particular.

In closing, let me remind all member societies of the WFN AGM and COD meeting to be held 1 p.m. on Tuesday, Oct. 9, 2018, in the Ulm room City Cube Messedamm 26 in Berlin. A draft agenda for this meeting is provided on page 3. We must have sufficient member society delegates to be quorate in order to elect a trustee from the four excellent candidates. •

Looking Back and Forward

William Carroll, MD

It is with much pleasure that I write this, my first “President’s Column.”

It affords an opportunity to speak directly with neurologists worldwide and to update them of the changes in the World Federation of Neurology (WFN) that naturally follow a change in leadership and to acknowledge the contributions of many.

Officers and trustees at their first Trustees meeting Feb. 12, 2018, in London, before the combined
trustees and regional presidents strategy meeting. From left to right: Morris Freedman,
elected trustee; Richard Stark, treasurer; William Carroll, president; Ryuji Kaji, vice president;
Wolfgang Grisold, secretary-general; Riadh Gouider, elected trustee. Not pictured: Steven
Lewis, elected trustee, who joined the meeting on Tuesday.

To Raad Shakir, who has stepped down at the completion of his four-year term as president, the re-election of Riadh Gouider as trustee for another three years, and to those who unsuccessfully contested elections held during the WCN Kyoto, I offer my congratulations for their effort and gratitude for their demonstration of commitment to the work of the WFN.

This time also marks the end of the two years that the WFN committee chairs and many on the committees will have served. Traditionally, there is a change in personnel in all committees every two years. To them, on behalf of the WFN, I thank you wholeheartedly. Without their unselfish involvement and valuable contributions, the WFN would not run as smoothly and as successfully as it does. As with many committees, their contribution largely goes unnoticed by the membership but certainly not by the officers and trustees.

Without a doubt, however, the contributions of Raad Shakir as president for the last four years was outstanding. Consequently, although there is much to inform you of, I intend to limit this for now and spend the bulk of this report touching on the successes of Dr. Shakir’s term.

Dr. Shakir has been a prominent figure in neurology in the United Kingdom for more than 20 years and was one of the key people in the organization of the successful 2001 World Congress of Neurology, which was held in London. My acquaintance and knowledge of him began at that time and has largely paralleled my own involvement with the WFN. I have been fortunate to witness first-hand the contributions he has made to our organization.

Officers, trustees, and regional presidents attending the combined strategy meeting in London. From left to right: Riadh Gouider; Franz Fazekas, president-elect, European Academy of Neurology; Yomi Ogun, president, African Academy of Neurology; Morris Freedman; Richard Stark; William Carroll, WFN president; Marco Medina, president, Pan-American Federation of Neurological Societies; Wolfgang Grisold; Ralph Sacco, president, American Academy of Neurology; Beom-Seok Jeon, president, Asian and Oceanian Association of Neurology; and Ryuji Kaji.

He has provided dedicated service over many years, aided by his multicultural education and experience, and his seemingly boundless energy and enthusiasm. With his detailed understanding of the varied cultural sensitivities in the global neurological community, he has been a successful leader.

Before being elected to the position of WFN’s Secretary-Treasurer General in 2009, he had assumed this position in 2006 on the unexpected retirement of the incumbent and he immediately displayed these skills and commitment in this new role. With then-WFN-President Johan Aarli, he was able to negotiate an understanding with the Peoples Republic of China that enabled the Chinese Neurological Society to join the WFN without fracturing the memberships of the Hong Kong and Taiwanese neurological societies. This was no easy task, as two previous presidents had been unsuccessful in the same endeavor.

His presidency of the WFN commenced in 2013 and was marked by a commitment to empower the regional organizations of the WFN. This was crowned by the establishment of the African Academy of Neurology (AFAN) in 2015 and its first Congress in 2017 in Hammamet, Tunisia. Although Dr. Shakir did not instigate the WFN African initiative in 2006, there is no doubt in my mind that it was his vigor and leadership that enabled the initiative to be transformed into AFAN as an active and independent regional affiliated WFN organization.

At the same time, Dr. Shakir has also prosecuted the African initiative plan for the WFN to develop four neurological training centers, two in Anglophone and two in Francophone Africa. A major limitation has been the funding of trainees in these centers. Through his persistence and endeavor, enduring funding is now being established that will benefit neurology in Africa. Such an outcome will both free up valuable WFN funds for additional educational projects and elevate the visibility and support for the WFN. The benefit of the increasing recognition of the WFN as a leader in neurological education in one of the most difficult yet needful areas of the world will pay dividends for many years, particularly in lifting the standard of neurological care in Africa.

The final development and the establishment of the Pan American Federation of Neurological Societies (PAFNS) also occurred in Latin America during his presidency. It is fair to say that his influence and guidance were fundamental in driving this successful outcome. As a consequence of these two initiatives, the WFN now has affiliated regional organizations in six areas, approximating those of the World Health Organization (WHO). Importantly, these afford more effective and immediate interaction between the WFN and the regions and regional member societies. It is no boast to say that the vision of regional empowerment is transforming communication within the WFN and that this in turn advances engagement at all levels of the WFN.

Dr. Shakir has displayed the same dedication and skill in guiding the WFN dealings with the WHO. Intimate involvement with WHO-related activities such as the Neurology Atlas of 2017, and in him heading the neurology Topic Advisory Group for the revision of the International Classification of Diseases (ICD-11), have required enormous effort, patience, and skill over a considerable period of time.

The WFN and the global neurological and stroke communities are indebted to Dr. Shakir for his Churchillian doggedness in dealing with the WHO, which at times has appeared out of touch with reality and driven by internal bureaucratic imperatives. The interaction between the WFN and the WHO is leading to a fundamental change in the way the WHO views stroke (as a disease of the brain), and this should be reflected in ICD-11. Both will be advantageous to the advancement of neurological care worldwide.

The outbreak of the Zika virus in early 2015 afforded another example of Dr. Shakir’s ability to mobilize rapidly the required WFN response. Within weeks of it becoming recognized as a major threat to health, particularly to fetal health and a potential risk for children and adults of an acute paralytic illness resembling Guillain-Barre syndrome, the WFN had in place an international committee of experts headed by Prof. John England.

The WFN Zika experience, particularly the need to act rapidly with other organizations in developing a multiskilled response, gave direction to the role of the WFN as a natural lead point for like organizations. Both the World Brain Alliance and the Global Neurology Network, which commenced life under President Hachinski and Vice President Hacke, respectively, are natural partners for the WFN. Dr. Shakir has recognized this “natural fit” and has emphasized the important role all three may need to play in the future. To assist this relationship, he made special provision for all to be involved in the biennial WCN scientific program.

It is fitting that Dr. Shakir’s presidency should terminate with arguably one of our most successful World Congresses of Neurology, in Kyoto. By numbers of delegates (more than 8,500), number of participating countries (110), number of bursaries offered to young neurologists from low- and low-middle-income countries (200), and our most profitable despite the highest dollar value support for the faculty to make them feel appreciated, it was a success. As the chair of the Congress committee for 2017, I can attest to both the efforts of the Japanese Society of Neurology and Dr. Shakir’s guiding influence in the success of this WCN1.

Dr. Shakir will be missed, but as is his nature, he has offered his advice and service should they be needed in the future. We all wish him and his wife, Nada, the best of futures and more quality time for each other and their extended family.

New Developments

I will now briefly summarize some of the other developments since Jan. 1, which will be dealt with in more detail in my next reports.

1. The trustees and officers of the WFN met in London in mid-February for a strategic planning meeting and were joined by the presidents of the six regional organizations. The full complement of attendees met over two consecutive days of intense discussions, preceded and succeeded by more specific and focused topical meetings which all lasted four days.

2. The outcomes were a thorough review of WFN education and related programs, including the annual research Grant Program, Department Visits, regional teaching courses in Africa, regional training Centers in Africa, plans to ensure the successful continuation of the AFAN, interaction with the West African Academy of Medicine, and the goals, financing, and outcome measures of all training centers before they are established, and a review of support for trainees in these programs. All in all, once implemented, these measures should ensure their successful continuation.

3. Review and revamp of website, social media platforms, and publications (mainly World Neurology) with uniform external branding.

4. Preliminary work on the needs registry to be developed by the regional organizations with their member societies.

5. A review of each committee and its role, activity, and constituents.

6. An agreement to hold this same strategic review biennially.

7. A review of the AAN/WFN Continuum program developed new criteria for its continuation, which will be instituted gradually and involve an appeal process to minimize any inadvertent hardship.

8. Importantly, it was agreed to hold the following meetings during 2018.

8.1 Congress Committee incorporating the 2019 Scientific Program, Teaching Course Committee, and Tournament Committee meeting  in April during the Los Angeles AAN meeting — dates to be confirmed.

8.2 Finance Committee and other WFN Committee meetings during the EAN meeting in June in Lisbon — dates to be confirmed.

8.3 The Council of Delegates and AGM of the WFN including the election of a Secretary-General and an elected Trustee, in October during the Berlin ECTRIMS meeting — dates to be confirmed.

All 2016 constituted committees will be advised in the near future whether they will continue to operate into 2018, join with the newly constituted 2018 committees for a variable period, or disband.

It was clear to all who attended the strategy meeting that it was informative and empowering, and the inclusivity was team-building, which bodes well for the progress of the WFN through 2018.

Finally, in closing and in the interests of openness and transparency, the executive of the WFN would be pleased to engage in dialogue at any level on these and any other matters. Until next time, I wish all a successful and productive 2018.

Reference
1. Carroll W M (2017). The need for a Global  Neurological Alliance, JNeuroSci. 379;321-323.

Evolution

The WFN has grown more financially stable and made credible contributions to the mission and the members

By Raad Shakir

Prof. Shakir in front of a map showing where neurology trainees came from, displayed at the Groote Schuur Hospital in Cape Town, South Africa. This is one of the four WFN training centers in Africa.

Successful organizations evolve and grow. Harmonious and uninterrupted processes of sound administration and guidance accelerate this natural progression. The World Federation of Neurology (WFN) is 60 years old. It has been through periods of upheaval and difficulties, but over the years, the success in fulfilling its aims and goals is unquestionable. This is undoubtedly due to the dedication and vision of its leaders.

The constitution and bylaws of the WFN provide a wonderful document that has stood the test of time and is fully adaptable to all situations. It has been the backbone of our federation. It is clear that the trustees govern the WFN. All decisions are made by consensus, and this has been closely followed. This governance structure is a major reason for sound and informed decisions.

If we look at the past decade or so, the WFN has been led by a variety officers and trustees who have come from all regions of the world. It is important that various neurological associations are represented in the leadership. This is assured by the method of nomination and the electoral process we follow.

Over the last decade, the WFN has become more financially sound and able to fulfill its mission in promoting and funding neurological training, education, and research. It is important to say that our financial status has not been affected by the downturn in the world economy 10 years ago. Our financial advice and prudence meant that we continued to increase our assets throughout the past two decades. This has been enormously helped by successful World Congresses.

Neurology Training

It is clear that efforts should be targeted at low- and low-middle-income countries with limited resources and in many non-existing neurology training programs. The facts were made starkly clear by the publication of the Neurology Atlas in 2004. This joint publication of the WFN/WHO remains a major resource for the status of neurology globally. The second edition was published in 2017. It makes interesting reading to look at what has been achieved in over a decade. The differences are glaringly obvious. The status in Sub-Saharan Africa, parts of Latin America and Southeast Asia are dire, to say the least. This was immediately recognized by the WFN leadership during the presidency of Jun Kimura, and the process was started to rectify the situation as much as possible.

Following the success of the Sydney World Congress in 2005 and the establishment of the Task Force for Africa in December 2006, it became clear that a coherent program of training young neurologists in their own regions was the way forward. The decision by the trustees during Johan Aarli’s presidency was to explore the establishment of WFN training centers in Africa as a start. An exploratory visit by Ragnar Stein (Norway) to Rabat and Cairo was positive.

The process of training Africans, by Africans, in Africa, took hold. The last of the quadrennial congresses was held in Bangkok in 2009. Following this, the WFN moved to biennial congresses, further improving the financial status. The foundation of regional organizations for Africa, Asia, and Latin America took hold. This was helped in no small measure by the success of congresses in the regions. The first was the congress in Marrakesh held in 2011 with the banner of  “With Africa, For Africa.” The trustees, during the presidency of Valdimir Hachinski, proceeded with the negotiations to establish the first WFN approved training center in Rabat, Morocco. The finances came through a grant from the Moroccan neurology society and the WFN.

Training Centers

The WFN continued with its plans to establish the African Academy of Neurology, and this was finally established during a special meeting in August 2015 in Dakar. This was a momentous event for African neurology. The establishment of three more training centers progressed further. Dakar and Cairo were visited and accredited; the last to be accredited is Cape Town.

Now, the WFN has four centers in Africa, two Francophone and two Anglophone. The fifth one is in Mexico City for Central and South America. The plans for a sixth center in Asia are in hand and should happen in 2018. If we think about Africa, the needs are enormous, as was shown in the second edition of the Neurology Atlas published jointly by the WHO and WFN in September 2017. The WFN is grateful for several funders who have come to partner with the WFN in financially supporting the training centers. As an example, the Societe Francaise de Neurologie (SFN) is supporting the centers in Rabat and Dakar, while the Association of British Neurologists is supporting the training in Cairo. Other societies and regional organizations have pledged financial support, which makes the WFN confident that as an example in Africa we can be assured of producing five trained neurologists a year in due course.

This is most beneficial evidence of the WFN training neurologists in the developing parts of the world. Although arranging teaching courses, traveling fellowships, and bursaries to attend and present scientific work in international meetings are all important activities, I think that the training centers are the most practical and tangible way for young trainees to return to their home countries at the end of training. This will hopefully reduce brain drain to a minimum. Thus far, trained neurologists from our first center in Rabat have returned to their home countries, and the program is functioning exceptionally well. As can be imagined, the most important issue is the dedication of the trainers and the welcoming attitude of all the administrations of training centers. The WFN has seen this in abundance.

Moving Forward

This is my last president’s column during my tenure, having served eight years as Secretary-Treasurer General and four years as President. The final year has seen two other pivotal events for neurology. The first is the classification of stroke as a disease of the nervous system following the WHO’s change of opinion. After 62 years in exile, the WHO has finally agreed to place cerebrovascular disease under the nervous system diseases section of ICD-11. This will ensure that future statistics will clearly show that neurological diseases are the first cause of disability adjusted life years (DALYs) and the second commonest cause of mortality.

The benefits to neurological patients are enormous, as funding should follow, and governments will finally recognize that nervous system diseases are a funding priority. I am most grateful for the WFN trustees and my fellow members of the ICD-11 Topic Advisory Group for their advice and continued support.

The second event is the huge success of the largest World Neurology Congress in Kyoto. The final number of attendees exceeded 8,500, and the Japanese Society of Neurology has been an effective, wonderful host and partner. The scientific and financial reverberation will continue to enrich the WFN is various ways.

I wish the newly elected officers and trustee the best for their continued hard work with the other trustees to move the WFN further forward. With the election this year of Bill Carroll, Ryuji Kaji, and Riadh Gouider, I am confident that the trustees will forge ahead to evolve our activities for a better future for world neurology. I wish them all the best and will always be available for any task whenever required.

Regional WHO Meeting Update

By Wolfgang Grisold

The World Federation of Neurology (WFN) was invited to participate in the World Health Organization (WHO) meeting that took place Sept. 11-14 in Budapest.

Regional Director Zsuzsanna Jakab (left) speaks with WFN Professor Wolfgang Grisold, WFN secretary general.

The agenda included a review of the current work of the WHO, presented by the regional director, Zsuzsanna Jakab. Statements came from the Hungarian government (Prime Minister Viktor Orban) and individual European countries. WHO Director General Dr. Tedros Adhanom Ghebreyesus explained his ideas on the future development of the WHO.

The WFN was invited as a permanent member. Several non-governmental organizations (NGOs) and non-state actors participated, including the World Stroke Organization (WSO), represented by Professor Patrik Michel.

WHO Director General Dr. Tedros Adhanom Ghebreyesus outlines his vision of the WHO during its regional meeting for Europe.

The WFN was invited to provide a statement, which it chose from agenda item 5b referring to the environment and neurology. This statement was developed by using the work done by a WFN applied research group on neurology and the environment. This research group met in 2016 in Strasbourg and emphasized the importance of the environment and its effect on neurologic diseases. The final version of the report as accepted is posted at who.int/en/. The written statement has been posted at euro.who.int/en/about-us/governance/regional-committee-for-europe/67th-session/statements-from-non-state-actors.

Crown Princess Mary of Denmark, the patron of WHO European region, speaks at the WHO Regional Committee for Europe.

Also present were the WSO and several other NGOs with overlapping fields in neurology, such as palliative care, occupational therapy, and student representation (IFSMA).

The cooperation of the WFN with the WHO is important and has included several successful projects, such as the Atlas of Neurology, the ICD-11 classification, and future work on non-communicable diseases.

The WFN participating with the WHO in regional meetings is extremely important as it gives neurology a local voice in the important regional aspects of WHO work. 

From the Editors

By Steven L. Lewis, MD, Editor
and Walter Struhal, MD, Co-Editor

Walter Struhal

Steven L. Lewis

We are pleased to introduce the May/June 2017 issue of World Neurology. The issue begins with the important news from WFN President Raad Shakir, who reports on the momentous and exciting decision by the World Health Organization to classify Stroke under the Central Nervous System chapter of the International Classification of Diseases (ICD-11). On the topic of stroke, Dr. Wolfgang Grisold, secretary-general of the WFN, and Dr. Mohammed Wasay, remind us that the topic of World Brain Day 2017 is devoted to stroke awareness, prevention, and management. Dr. William (Bill) Carroll, first vice president of the WFN, and the convener of the Global Neurology Network, provides the background and analysis underlying the need for a global neurology alliance to address the global burden of neurological disease.

Dr. Grisold and Riadh Goulder, MD, provide their report on the recent and highly successful first African Academy of Neurology (AFAN) Conference & 15th Pan Arab Union of Neurological Societies (PAUNS) meeting that was just held in March in Yasmine-Hammamet, Tunisia. Marina Alpaidze, MD, PhD, and Alexander Razumovsky, PhD, FAHA, report on the third WFN neurosonology teaching course that took place in October 2016 in Tbilisi, Georgia.

Dr. Mohammad Bassam Hayek, a neurologist in Aleppo, Syria, and the vice president of the Syrian Society for Neuroscience, provides us with an important on-the-scene update on the recent and current state of neurology and neurological care in Syria.

Giordani Rodrigues dos Passos, MD, reports on his recent eye-opening and successful participation in the Canadian/WFN Department Visit Program, where he visited the Montreal Neurological Institute in March. In another successful report from the Rabat/WFN Teaching Visit Program, Dr. Boubacar Maiga reports on his experience from his one-year fellowship in clinical neurophysiology at University Mohamed-V in Rabat, Morocco.

Drs. Jon Stone, Ingrid Hoeritzauer, and Mark Hallett provide us with a brief, up-to-date, and authoritative review of the current thinking with regard to the classification, pathophysiology, diagnosis, and management of functional neurologic disorders, including an invitation to learn and share more at the third International Conference on Functional Neurological Disorders to be held in September in Edinburgh. In this issue’s history column, Dr. M.J. Eadie provides us with a historical view of the emergence of clinical neurology in Australia, and the key neurologic figures who contributed to this rich history.

You also will find the nice reports and descriptions from each of the four candidate city venues for World Congress of Neurology 2021. Each city also will be presenting (for voting by
the Council of Delegates) at the upcoming World Congress of Neurology in Kyoto, Japan. Also in this issue is the announcement from the WFN Nominating Committee with regard to the listing of the candidates for WFN leadership and trustee positions to be voted on by the Council of Delegates in Kyoto. (Note: The statements from the candidates for president and vice president will appear in the upcoming [July/August] issue.)

Tissa Wijeratne, MD, provides an intriguing biographical sketch of his pathway and journey from the “jungle” of Sri Lanka to becoming a neurologist. Finally, Dr. Grisold and Robert Schmidhammer, MD, provide a heartfelt obituary for Dr. Hanno Millesi, a renowned peripheral nerve surgeon.

We sincerely hope that you will enjoy the many and varied contributions in this issue for and about neurology and neurologists around the globe.

The Need for a Global Neurology Alliance

By W. (Bill) M. Carroll, MB, BS, MD, FRACP, FRCP(E)

W. (Bill) M. Carroll, MB, BS, MD, FRACP, FRCP(E)

Recently, there has been an explosion of health awareness recognized by individuals, nations, and the global community. The decade of the brain was followed by the human genome project, accompanied by the near eradication of malaria and polio. Yet, we now stand at the threshold of even more rapid advances on many fronts.

3-D printing of the human heart is being used in planning cardiac surgery. Next-genome sequencing is revolutionizing old concepts of disease. Gene therapy shows success in some inherited neuropathies (spinal muscular atrophy) and myopathies (Duchenne muscular dystrophy). Precision medicine is no longer an aspiration in some diseases and countries, and the ability to use publicly accessible data via expanding cloud technologies is yielding unexpected information and the repurposing of medications. Conversely, the cost of drug development, especially in bringing them to market, is becoming prohibitive, exacerbating the accessibility of therapies in many countries.

For the thoughtful and the less fortunate, it is obvious that the developing progress, while exciting and to be celebrated, is creating problems that need to be addressed. The increasing burden of non-communicable diseases (NCD) adds up to what can only be viewed as a potential tsunami for the economies of the world. These NCDs include mental (neurological) and substance-abuse disorders; musculoskeletal disorders; neurodegenerative conditions such as dementia, stroke and Parkinson’s disease; poor lifestyle choices in diet and exercise; and the effects of unhealthy environments1 together with the changing demographic of aging populations in so-called developed countries.

Those people and countries least able to afford the advances and/or mobilize services to adjust to them will see a widening gap, not only in these areas of disease but also in their ability to respond to the periodic recrudescence of infectious disease. This was seen with the outbreaks of Ebola, MERS, SARS, and, most recently, the Zika emergency. It is not by chance that the recent waves of mass migration have occurred as much because people seek better lifestyles (and health services) as fleeing armed conflict.

It is in this environment that those in the neurological fraternity need to mobilize and prepare measures at a number of levels that will mitigate the consequences of these changes. To begin, we must look at the magnitude of the problems facing us. Then, we will evaluate the resources we have available. Finally, we will view three illustrations of how those resources can be optimized to provide the organizational readiness for rapid and effective action as well as long-term planning on a national, regional, and global scale.

The Problem

The global burden of neurological disease figures as a relatively small fraction of the global burden of all disease (GBD) for a range of reasons2. Although not included in the WHO 2014 global status report on NCDs3, stroke and dementia are of major concern to clinicians and national health systems.

The annual stroke toll is approximately 15 million, with one-third being fatal and another third permanently disabling. Indeed, stroke mortality is double that of HIV/AIDS, malaria, and tuberculosis combined, emphasizing the rising burden of brain NCDs. With rates of dementia estimated to triple from 47.5 million to 115 million worldwide by 20504, it is clear that the world faces a rising impost on resources.

Currently, the total burden of mental, neurological, and substance abuse (MNS) is now reckoned to be 258 million disability-adjusted life years — a measure of overall disease burden expressed as the number of years lost due to ill health, disability, or early death. That is up from 182 million in 1990, which has been equated to a $8.5 trillion (U.S.) loss of economic value now, and which will increase again by a factor of two by 20305.

With the addition of other NCDs to stroke and dementia, it is clear that the world neurological fraternity must act in concert and alert governments. Those other NCDs include age-related Parkinson’s disease and other chronic neurodegenerative disease, perinatal injury largely due to asphyxia, childhood developmental and degenerative disease, schizophrenia, high levels of traumatic brain disease, all causes of epilepsy, substance and alcohol abuse, and rising neuroinflammatory disease of the brain and spinal cord.

While world neurological expertise has been steadily advancing partly in parallel with the recognition of the increasing challenges on the horizon and partly with the advances in medical science, it is far from equitably distributed. When the widening gap between well-developed countries with comprehensive health care and those less developed populations and health care systems is appreciated, the likelihood for an emergency is evident6.

Resources

There are a number of valuable resources available. These include measures of the GBD and specific problem areas, such as the NCDs, BNCDs, and MNSs, as well as WHO monitoring for more acute challenges to health through national health departments and WHO’s regional structural organization. (The WHO regional organization mirrors approximately that of the WFN). The periodic assessments of the GBD by the WHO and the Atlas of Neurology (a joint WHO-WFN project) provide the broad sweep, big picture view of resources and needs.

The WFN itself plays an important and growing role in the equalization of access to neurological care both through regional organization support and neurological education. The establishment of the African Academy of Neurology (AFAN) and its first meeting in Tunis this year are illustrative. It joins the expanding roles of other WFN regional organizations, including the Pan American Federation of Neurological Societies (PAFNS), the Australasian and Oceanian Association of Neurology (AOAN), the Pan Arab Union of Neurological Societies (PAUNS), the American Academy of Neurology (AAN), and the European Academy of Neurology (EAN).

Neurological training, the improvement in access to neurological care, and an increasing awareness of the importance of brain health in the general population are furthered by World Brain Day (WBD)7 and the biennial World Congress of Neurology (WCN). The WFN, in partnership with AFAN, has followed the World Federation of Neurosurgical Societies (WFNS) program to train young African specialists. The WFN plans to have four regional training centers in Africa — two each for the Francophone and Anglophone regions. Additional emphasis of WFN involvement at a global level was given by WFN President Raad Shakir as chair of the Neurosciences Topic Advisory Group for the WHO-sponsored International Classification of Disease (ICD-11), due for release in 2018.

More generally, other areas are developing, which will enhance the ability to respond to challenges. Increasingly rapid communication through electronic media, including social media, draws attention to emerging problems. The maturation and expanding expertise of neurological subspecialties and their involvement in wider educational activities (e.g. the International League Against Epilepsy, the World Stroke Organization, and the Movement Disorders Society) as well as the added interest of the larger regional neurological organizations, such as the AAN and EAN, provide a rich resource of intellectual and monetary capital.

Over the last few years, the WFN has provided a focal point for those involved in the medical care of neurological disease through two similar, though importantly different, groups. The first is the World Brain Alliance (WBA). Originally chaired by Vladimir Hachinski, MD, when he was WFN president, it is now chaired by Dr. Shakir. The WBA members include, in addition to the WFN, global organizations that usually do not include neurologists, such as the WFNS, the International Brain Research Organization (IBRO), the World Psychiatric Association (WPA), the International Child Neurology Association (ICNA), and the World Federation of Neurorehabilitation (WFNR). The second group is the Global Neurology Network (GNN) for which the WFN is the current convener and whose members mainly include neurological disease-specific organizations from around the world. Many were originally part of the WFN but have grown to be independent organizations. They include the World Stroke Organization (WSO), the International League Against Epilepsy (ILAE), the Multiple Sclerosis International Federation (MSIF), the Treatment and Research in Multiple Sclerosis (TRIMS) Group, Alzheimer’s Disease International, the Movement Disorder Society, the International Headache Society, the International Society for Clinical Neurophysiology, the Peripheral Nerve Society, and the Tropical Disease Group. Closely associated with this category of disease-specific organizations are both large regional organizations supporting all neurological subspecialties, such as the AAN and the EAN, and the smaller WFN-affiliated regional organizations, such as the AOAN, PAUNS, PAFNS, and AFAN.

Together, these two groups create an impressive global alliance of neurological expertise. It is an alliance appropriately suited to provide global disease-specific advice to international organizations, such as the WHO and the U.N., and to advocate with these organizations and national governments. It is an alliance worthy of the term Global Neurology Alliance.

Recent Examples of United Action

The most critical function of a global alliance of neurological organizations is the ability to formulate, organize, and execute rapid and effective policy or reaction. A powerful advocacy initiative that can mobilize governments and NGOs is of enormous value to those under threat, and it is the rapidity of communication and the common understanding of the advocating group that empower these initiatives as a force for good.

Underlying this ability are two fundamentals. The first is an intimate understanding by the subspecialty organization in the national, regional, and global spheres of all matters affecting practitioners and patients. The second is the intercommunication among the various subspecialty organizations facilitated by the GNN. Regular meetings, updates on activities, and a common understanding of the means to reach their constituencies contribute to the effectiveness of the network.

Recent examples of where this alliance has been called to mobilize and has proven its worth are the 2015 Zika virus outbreak, the WHO initiative on NCDs, and the crisis over the WHO classification of stroke as a circulatory rather than neurological disease.

The outbreak of the arthropod-borne (Aedes aegypti) Flavivirus crisis, known as Zika virus, in April 2015 in Brazil, was designated by the WHO in February 2016 as a public health emergency of international concern (PHEIC)8.

Zika was first found in Uganda in 1947, and the first outbreak of disease occurred in Micronesia in 2007. The South American outbreak was much worse. The primary infection was often asymptomatic or relatively banal, comprising arthromyalgia, a light rash, or a low-grade fever. The major secondary effects were of brain neuronal migration injuries to the fetuses of pregnant women manifesting often, but not solely, as microcephaly, and a postinfectious neuropathy resembling Guillain-Barré syndrome.

Given the unknowns with this outbreak and the urgency to gather information, a committee, headed by John England, MD, was constituted, assisting the global investigation of the outbreak. The committee was supported by WFN resources through the regional organization in South America, the expertise within the organization, and the rapidity with which the WFN could respond to assist. PHEIC status was ceased in November 2016.

The NCD initiative, launched in 2011 by the WHO following the GBD report highlighting the impact of NCDs9, concentrated on cardiovascular disease, cancer, diabetes, and respiratory disease. Omitted were major illnesses central to brain health, such as dementia and stroke. The omission was questioned by the global neurological fraternity. The WFN, through its role as WBA convener and led by Dr. Shakir, waged a campaign to have brain NCDs included in the initiative5.

How did such a situation arise? It seems that because the WHO viewed stroke and dementia not to be brain diseases but rather as circulatory and mental disorders, respectively, they were not included as risks to brain health. There are historical reasons for this view, which were defended by the WHO, but ICD-11 brought this matter to a head. In doing so, it also provides an illustration of the value of a global neurological alliance.

The ICD is revised every decade. ICD-10 was adopted in 1990, and in 2007 the revision ICD-11 was commenced under the supervision of the Revision Steering Group, which took advice from a number of Topic Advisory Groups (TAGs). The ICD-11 Neurology TAG was constituted in 2011 under the leadership of Dr. Shakir. Soon after this process commenced, stroke was apparently accepted as a disease of the brain. When the beta version of ICD-11 was published in 2016, the neurological and stroke fraternities were astounded to find that stroke had been changed to a circulatory disease.

Clarity as to the reason stroke had been omitted from the NCD initiative had arrived. Stroke was not a brain disease. The decision galvanized the neurological and stroke communities. After considerable effort, it was determined that the powerful statistics group within the WHO had been at the forefront of the opposition to the change initiated by the Neurology TAG. While the grounds for such opposition were reasonable and based on a desire to obtain the best longitudinal epidemiological data, it effectively “hid” the impact of stroke in the global community and paid little heed to the growing evidence of the contribution of cerebrovascular disease to dementia and NCDs in general.

There followed initial correspondence to Lancet10 by the WFN and WSO, and the formation of an ad hoc advisory group through the recruitment of national departments of health to voice opposition to the way stroke was handled by the WHO. A number of important face-to-face and telephone meetings took place, as well as a review of the evidence, from the WSO perspective, of why stroke should not be classified as only a circulatory disease. Through an innovation introduced in ICD-11, multiple parenting was possible. This, together with the weight of argument, has seen stroke, as of April 2017, classified as a cerebrovascular disease in the current beta version of ICD-11—an event described by many as momentous. (See the President’s Column.)

Conclusion

It is no accident that these external initiatives of the WFN and partners have been successful. The ability to respond rapidly, to gather expertise, and to plan and implement the agreed approach, while maintaining the flexibility to adapt to developments, are the prime reasons. That there has been an immediate sense of shared purpose, and the acknowledgement that together we are better able to present the arguments firmly and authoritatively, has no doubt assisted. The foresight of the originators of these two groups has to be praised, as does the leadership of the current WFN president and the members of the WBA and GNN.

With the world facing continuing uncertainties, it is likely we shall see more reasons to be grateful for the contributions made by these groupings and to possibly have periodic joint meetings. In practice, these groups and their membership represent a truly global neurological alliance. •

W. (Bill) M. Carroll, MB, BS, MD, FRACP, FRCP(E), is first vice president of the WFN and is the WFN convener for the Global Neurology Network.

References:

  1. Vos T et al Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163–96.
  2. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015; 386: 743–800.
  3. Global Status Report on Noncommunicable Diseases 2014. WHO ISBN 978 92 4 156485 4.
  4. Prince M et al. The global prevalence of dementia: a systematic review and meta-analysis. Alzheimer’s and Dementia. 2013; 9: 65-75.
  5. Shakir R Brain health: widening the scope of NCDs. Lancet 2016,387: 518-519).
  6. Income inequality: The gap between  rich and poor. OECD insights 2015.
  7. Wasay M et al. World Brain Day 2016 celebrating brain health in an ageing population. Lancet neurology 2016;15:1008.
  8. Zika virus and complications: 2016 Public Health Emergency of International Concern. WHO Int on line.
  9. Bloom D E et al. 2011 The global economic burden of non-communicable diseases. Geneva: World Economic Forum.
  10. Shakir R et al. Revising the ICD: stroke is a brain disease. Lancet 2016, 388: 2475-2476.

PRESIDENT’S COLUMN: Long Established WHO, WFN Relationship Continues to Prosper

Raad Shakir

Raad Shakir, MD

The WFN is a non-governmental organization (NGO) in official relationship with the WHO. The relationship is symbiotic and solid. It started back in the 1960s during the first term of the presidency of MacDonald Critchley from 1965 to 1969. Initially, it was small and dealt with special problems related to tropical neurology. The association continued following the establishment of the mental health section during Sigvald Refsum’s presidency from 1973 to 1981. Diana Bolis was a major contributor at the time. The relationship continued when the WHO contacted the WFN regarding the revision of the neurological section of the International Classification of Diseases (ICD)-10. At the time, the WHO included stroke in the section of cardiovascular disease, in spite of WFN objections. Walter Bradley and Jean-Marc Orgogozo gave expert advice.

The relationship between the WFN and the WHO has not always been smooth and straightforward. When Richard Masland took over as president in 1981, one of his challenges was to define mental health. Later, during John Walton’s presidency from 1989 to 1997, Norman Sartorius, who was the director of the WHO Division of Mental Health, invited the leaders of the NGOs in neurosciences to an annual meeting at the end of the year. Walton, James Toole, and Andre Lowenthal met with Sartorius. The relationship continued during subsequent years. During Jun Kimura’s presidency, Johan Aarli chaired the Public Relations Committee and subsequently became first vice president and was appointed as the liaison officer between the WFN and the WHO. The relationship flourished during Aalri’s presidency from 2005 to 2009. Under the WHO leadership of Assistant Director General Ala Alwan, succeeded by Oleg Chestnov, head of section Benedetto Saraceno, and his successor Shekhar Saxena, the relationship moved full steam ahead. This was strongly cemented by the appointment of Tarun Dua, coordinator of the WHO’s Evidence, Research and Action on Mental and Brain Disorders Unit, and a pediatric neurologist who took the role as the officer responsible for neurology in the mental health section. The WFN provided several grants to joint activities, which were most rewarding. The publications of the first Neurology Atlas in 2004 and Neurological Disorders: Public Health Challenges are excellent examples.

The WHO activities in our field are crucial for the specialty. If neurology and brain health is to find its rightful place in the agenda of governments across the world, the only way is to go through the WHO. There were, over the last 40 years, several collaborative efforts and, in all, the relationship proved enduring and productive. If we look at the present time and evolving issues, neurologists are at the heart of the WHO activities.

ICD-11

RAAD SHAKIR (LEFT) AND WALTER BRADLEY CHAIR THE TOPIC ADVISORY GROUPS FOR ICD-11 AND ICD-10.

Raad Shakir (left) and Walter Bradley chair the topic advisory groups for ICD-11 and ICD-10.

There are four areas which I would like to highlight. The first is the ICD-11 project, which has now matured and is coming to publication. We have to remember that the ICD is a WHO and not a WFN process, as neurological diagnoses only form a small part of the whole ICD revision program. The ICD-11 will have short definitions for all entities, and it is crucial that the WHO secretariat, represented in our case by Dua, has the support to discuss the issues with the central classification team at the WHO. The common version to be presented in October 2016 is the Joint Linearization for Mortality and Morbidity Statistics (JLMMS) and not the neurology specialty version, which will come later. This is a crucial step to the WHO, as member states will follow this classification. It is most important to point out that, with the help of the WHO team, stroke is now part of the neurology section, which is most important for brain health future statistics. We still have some fine-tuning to do until the end of June 2016. It is inevitable that some neurology specialists, patient organizations, and others may find some of the ICD layout and content not to their liking. All of us have made efforts to reconcile the opinions and needs of neurological and neurosurgical associations and interest groups, at the same time satisfying public health needs and clinical utility, as well as other medical and surgical specialties.

I would like to use this opportunity to thank all my fellow neurologists and neurosurgeons who contributed their time and expertise over the past seven years in making the neurology ICD-11 a viable and meaningful project. The support of the WHO is vital to us in our work and continues to be so. The comments made by the central classification team were taken and acted upon. My fellow members of the Topic Advisory Group (TAG) have been wonderful in their advice and work over the years, and I had the honor to chair the neurology TAG.

WHO Non-Communicable Diseases

LEFT TO RIGHT: OLEG CHESTNOV, WHO ASSISTANT DIRECTOR GENERAL; BENTE MIKKELSEN, GCM NCDS CHAIR; AND RAAD SHAKIR, WFN PRESIDENT.

Left to right: Oleg Chestnov, WHO assistant director general; Bente Mikkelsen, GCM NCDs chair; and Raad Shakir, WFN president.

The second issue is that of the WHO non-communicable diseases (NCD) project. The NCDs launch did not initially include neurological diseases. However, since 2013, it has become clear that the neurological, mental, developmental, and substance use (NMDS) group surpasses, in numbers and in Disability Adjusted Life Years (DALYs), the cancer and cardiac disease group. Moreover, prevention is now clearly possible in many such conditions. This has led to the involvement of the WFN in the global coordinating mechanism for NCDs (GCM/NCD), headed by Dr. Bente Mikkelsen. The WFN is an official member and attended meetings for the NCD project. This is very important as the G8 London declaration on dementia states, “the G8 has an ambition to identify a cure or a disease-modifying therapy for dementia by 2025 and to increase collectively and significantly the amount of funding for dementia research to reach that goal.” The WFN has declared that there is “No health without brain health.” This has been met with approval by those involved in health provision from various parts of the world.

In the WHO structure, neurology falls under the administrative charge of the assistant director general for non-communicable diseases and mental health. The WFN has long argued to replace mental health with brain health. This, in our opinion, is more descriptive and inclusive. However, we all appreciate that there are many administrative issues and channels to convince at the WHO, as well as those involved in all aspects of brain health.

Neurology Atlas 2015

The third project nearing finalization is that of the second edition of the Neurology Atlas 2015. The first atlas was published in 2004 and was a WHO best seller. The second edition is coming this year, and we await the final publication. The countries’ resources will be detailed, and again the policies on neurological care and provisions for management will be presented. One can say, even with the preliminary data, that the provisions in low- and low, middle-income countries remain abysmal compared to high-income economies. It is also possibly true to say that the situation regarding the number of health care professionals has improved over the past 10 years. This will have to await final statistical analysis. As for WHO regions, the deficiencies remain in Africa, South Asia, Latin America, and parts of the Eastern Mediterranean region. The atlas, when published, will be of a huge benefit and impact on neurological care provision and training across the world. The WFN would like to thank the WHO secretariat, in particular Tarun Dua and her team, for all their hard work in this endeavor. The WFN is also proud to have contributed to the project financially, as well as with experts helping in the process.

World Health Assembly

RAAD SHAKIR (LEFT) AND TARUN DUA, COORDINATOR OF THE WHO'S EVIDENCE, RESEARCH AND ACTION ON MENTAL AND BRAIN DISORDERS UNIT.

Raad Shakir (left) and Tarun Dua, coordinator of the WHO’s Evidence, Research and Action on Mental and Brain Disorders Unit.

The fourth issue is representing the interests of neurology during the World Health Assembly (WHA). The WHA is the decision-making body of the WHO. It is attended by delegations from all WHO member states and focuses on a specific health agenda prepared by the Executive Board. The WHA meets annually at the end of May. NGOs, like us, can apply to make a statement through a request, and we need to influence the secretariat well in advance to have resolutions adopted by some member states to be presented. The best example of this is the resolution on epilepsy during the 68th WHA meeting in 2015. The delegates endorsed a resolution urging member states to strengthen their ongoing efforts in providing care for people with epilepsy. Although affordable treatment for epilepsy exists, up to 90 percent of people with the condition may not be properly diagnosed or treated in resource-poor settings. The resolution highlights the need for governments to formulate, strengthen, and implement national policies and legislation to promote and protect the rights of people with epilepsy. It also stresses the need to reinforce health information and surveillance systems to get a clearer picture of the burden of disease and to measure progress in improving access to care.

Such declarations need years to achieve and the WFN congratulates the International League Against Epilepsy for its diligent work in bringing this to a conclusion. This can only help the 50 million epilepsy sufferers across the world.

For all these and many other issues, the collaboration between the WHO and the WFN will continue to flourish.

Broadening Our Horizons
WFN: 2010-2013

By Vladimir Hachinski

Vladimir Hachinski

Vladimir Hachinski

Missions set goals and guide actions.  The greatest change that took place in the past four years was an expansion of the WFN mission to “foster quality neurology and brain health worldwide.”   To accomplish this required partners, so we invited representatives from all of the major brain organizations for a meeting in Geneva on March 30, 2011, that resulted in the World Brain Alliance composed of:

  • European Brain Council (EBC)
  • International Brain Research Organization (IBRO)
  • World Federation of Neurology (WFN)
  • World Federation of Neurosurgeons (WFNS)
  • World Federation of Neurorehabilitation (WFNR)
  • World Psychiatry Association (WPA)
  • International Child Neurology Association (ICNA)
  • International League Against Epilepsy (ILAE)
  • World Stroke Organization (WSO)
  • Alzheimer’s Disease International (ADI)

The World Brain Alliance activities can be summarized as an ABC.

A = Advocacy
B = Brain Year
C = Cooperation

I took part in a high ministerial meeting in Moscow in April 2011, then  a consultation with the president of the United Nations General Assembly in June in New York and then a session of the General Assembly that adopted the Non-Communicable Diseases resolution in September 2011.  Subsequently, I continued to be involved with the WHO, including participating in meetings of the Executive Committee.

In addition to my own activities with the WHO, Raad Shakir has chaired and Donna Bergen has participated in the expert panel advising on the revision of the International Classification of Diseases 10 (ICD10) regarding brain disorders.   A major achievement has been the acceptance by the WHO of the recommendation of the subcommittee on cerebrovascular disorders chaired by Bo Norrving, of which I was a part, that stroke cease to be part of cardiovascular disorders and be classified under brain disorders in the ICD-11.

The Brain Year is a project of the European Brain Council, led ably by Mary Baker.  The intent is to proclaim a World Brain Year Europe 2014 at the European Parliament in Brussels. It is hoped that it will be followed by the World Brain Year Americas 2015, World Brain Year Asia 2016, and so on.

In terms of cooperation, the major initiative has been in the neurospecialty network founded and led by Werner Hacke, and now headed by William Carroll.  This aims to bring together all of the specialties related to the brain.  This complements the work done by Donna Bergen, chair of the Applied Research Committee, rationalizing research groups within the WFN whereby some have become largely irrelevant and have been dissolved while others have grown to become major organizations that now are reconnecting with the WFN.

A tangible proof of the new cooperative spirit is that several of the sessions of the World Congress of Neurology were co-sponsored by the Movement Disorders Society, the World Stroke Organization, the International League Against Epilepsy, the International Child Neurology and a session with the WHO.

Grassroots

We initiated a process whereby we offer modest amounts of money to individual neurologists who had ideas for projects that meet the criteria of value, viability, synergy and evaluation.  The first year all of the projects were funded by the WFN.  The second year, we asked leaders of other brain organizations to be part of the review process.  This resulted in leadership of the different organizations learning about what each was doing, allowing for cooperation and avoiding overlap.  Last year, there were 10 Grants-in-Aid, half of them were co-funded and half of them were in Africa.  This year, the total value of the 11 grants was $419,000, five co-funded and seven in Africa.

The geographic location of the Grants-in-Aid was based on the criteria alone so that it is encouraging that the largest number ended up being in the area of the greatest need, namely in Africa. The high quality of the projects makes it likely that some of them will produce enough pilot data to allow for applications to larger funding agencies such as the Fogarty Foundation.

Public Awareness  and Action Committee

The Public Awareness and Action Committee headed by Mohamed Wasay is trying to establish a World Brain Day inspired by the highly successful World Stroke Day, that I proclaimed when I was vice president of the WFN in Cape Town on Oct. 29, 2006, along with a World Stroke Agenda to which all of the major organizations dealing with stroke contributed.

Publications

During this administration at the recommendation of the Publications Committee, chaired by Christopher Kennard, a new editor was selected for the Journal of Neurological Sciences.  Robert Lisak who served as editor for 15 years steadily increased the journal’s impact factor and circulation for which the WFN is immensely grateful.  He was succeeded by John England who has co-opted highly capable associate editors in the areas of global neurology, translation research, outcomes research and practice standards that will give the journal a distinctive personality and a higher profile.

World Neurology is now totally digital, being capably edited by Donald Silberberg.  World Neurology is in dynamic interaction with the website that has been modernized, updated and made more useful under the editorship of Pete Engel and with the gifted technical capabilities of Chu Man.  Wolfgang Grisold has been  active in the website in close coordination with the activities of the Education Committee.

World Neurology Congresses:  Accelerating the Cycle

As vice president, I initiated the process that resulted in moving the World Congresses from a four-year cycle to a two-year cycle.  This has allowed for neurology to go where it is most needed.  The main aim of congresses is to take neurology to parts of the world where it becomes accessible to neurologists and others interested in the nervous system who have no means of traveling internationally.  The more frequent congresses also have allowed continuity in organization and the scientific program committee and have brought in more frequent income in an era of shrinking resources.

Finance

Our finances are sound, thanks to our able Secretary-General Raad Shakir and proceeds from a combination of successful congresses and sound investments. Our expanded activities also have required that we revamp the budgeting process, and we have implemented management accounting, whereby it is possible to monitor our income and expenditures on an ongoing basis that will allow for easier planning in the future.

The Standards  and Evaluation Committee

As part of our expanded mission, we established standards, so that anything endorsed by the WFN stands for quality and value.  This began as a working group headed by Aksel Siva, aided by Sarosh Katrak, and initially by Charles Warlow and later by Werner Hacke and has now been established as a new committee of the WFN.  The higher standards have made the WFN’s endorsements more valuable.

Continental Initiatives

WFN_Table1Africa: My predecessor, President Johan Aarli made it his mission to do more with Africa, the continent in the greatest need of neurology.

It was at his behest that the first congress on the African continent took place in Marrakesh in 2011.  Our Moroccan colleagues, led by Moustafa El Aloui, not only hosted an exemplary congress, but used the proceeds from the congress to establish a foundation to further neurological endeavors.  Similarly, the WFN devoted part of its income to be used in Africa.

The WFN has been a participant of the annual neurology courses in Africa along with European Federation of Neurological Societies (EFNS), International Brain Research Organization and others.  The training neurology center in Rabat has now been approved by the WFN, and discussions are under way with colleagues in Ghana and Tanzania for the possibility of setting up a training program in an English-speaking African country.

At the initiative and with funding from the Turkish Neurological Society, a program for visiting trainees has been established between Turkey and East Africa.

The high proportion of grassroots grants funded in Africa reflects both the great need and great opportunities to advance neurology in Africa.

Asia: We began the Asia Initiative led by Ryuji Kaji with modest help from the WFN, helping organize an infrastructure for the now thriving Asian Oceanian Association of Neurology.

Latin America: The formation of a Latin American initiative led by Gustavo Roman resulted in the Latin American Federation of Neurological Societies and in the democratic election of a regional director: Marco Medina.

Regarding the established continental regional neurological societies, namely the North American region (Canada and the United States) and the European Federation of Neurological Societies, our administration made a point of having good and direct relationships with them.  Specifically, we initiated an annual meeting of the leaders of the WFN and the AAN (Berch Griggs, Bruce Sigsbee, Timothy Pedley and Cathy Rydell) that has fostered better understanding and greater cooperation between the two organizations.  Similarly, it has been a pleasure to deal with the president of the EFNS, Richard Hughes, who was most cooperative in co-sponsoring the World Congress of Neurology in Vienna and in dealing with matters of mutual interest.

Education Committee

The single largest activity of the WFN is directed by the Education Committee.  It has been led in an exemplary, complementary way by Stephen Sergay and Wolfgang Grisold who have organized, rationalized and focused the efforts of the Education Committee. Some of their achievements include the accreditation visits to training programs such as the one in Trujillo, Peru, and the activities reported under the Africa Initiative.

The WFN: An Organization  for All Ages and Career Stages

As vice president, I facilitated the incorporation of a young neurologists group led by Walter Struhal with the aim of making the WFN an organization for all ages and career stages.  I am happy to report that there has been a considerable expansion in the participation of younger neurologists, particularly in regard to the website and using modern technology for communication and education.  We also introduced a discount on the congress registration for senior neurologists in an attempt to make the World Congress of Neurology attractive and affordable throughout a full career span.

Leadership Training

Although the administration was elected for a four-year term, we divided it into two halves.  For the initial two years, the committees and initiatives were kept small so that the member could get to know each other and learn to work together.  For the second two years, the committees and initiatives were expanded and a number of vice chairs were appointed, typically younger individuals, more women and more individuals from different parts of the world.  The two-year cycle gives opportunities for promotion to the most active individuals and the possibility of being involved in different committees and initiatives in sequence.

Conclusion

It is not for me to judge what we have achieved, except that it resulted from a collective effort.

I would like to thank Vice President Hacke, Secretary-General Raad Shakir, and fellow Trustees, Donna Bergen, Wolfgang Grisold, Ryuji Kaji, Gustavo Roman and Stephen Sergay, in the central office, Keith Newton, Laura Druce and Helen Gallagher and in my office, Rebecca Clarke and the many around the world who know that they have made a difference.

I am particularly grateful to our Austrian colleagues under the leadership of the World Congress of Neurology, Eduard Auff who hosted a magnificent event. It would be hard to imagine a more splendid congress to culminate my presidency.  I was especially privileged to have my Dream Waltz (orchestrated by Jason Stanford) premiered at the Musikverein as part of the Gala Concert.  It is not too often that one can say that one’s presidency ended literally on a high note.

I congratulate President-Elect Raad Shakir, Vice President-Elect William Carroll, Secretary-General-Elect Wolfgang Grisold, elected Trustee Gallo Diop and continuing elected Trustee Gustavo Roman and wish them every success in fulfilling the mission of the WFN to “foster quality neurology and brain health worldwide.”

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