Neurological, Psychiatric, and Developmental Disorders

459 Pages·2001·3.53 MB·English

by  Committee on Nervous System Disorders in Developing Countries, Board on Global Health, Institute of

i
Neurological,
Psychiatric, and
Developmental
Disorders
Meeting the Challenge in the Developing World
Committee on Nervous System Disorders in Developing Countries
Board on Global Health
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
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ii
NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the
National Research Council, whose members are drawn from the councils of the National Academy
of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of
the committee responsible for the report were chosen for their special competences and with regard
for appropriate balance.
Support for this project was provided by Centers for Disease Control and Prevention, Global Forum
for Health Research, National Institute for Child Health and Human Development, National Institute
for Mental Health, National Institute for Neurological Disorders and Stroke, and the Fogarty Interna-
tional Center of the National Institutes of Health. The views presented in this report are those of the
Institute of Medicine Committee on Nervous System Disorders in Developing Countries and are not
necessarily those of the funding agencies.
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Copyright 2001 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
Cover: Mbangu mask, Central Pende, Bandundu, Zaire, registered in 1959. One of the great
masterworks of Pende art in Western collections, this Mbangu mask represents the bewitched him.
It dances to the song, “We look on (unable to help), the sorcerers have bewitched him.” The masker
wears a humpback from which an arrow extends. The arrow refers to the popular image of sorcerers
“shooting” their prey with invisible arrows when they cast their spell. The metaphor communicates
the perception of sudden onslaught in illness or misfortune, just as we might say, “It came out of the
blue.”
Mbangu is “bewitched”; however, since the Pende worldview attributes almost all illness and
personal misfortune to the malice of others, what is really at issue is chronic illness or disability and
our response to it. If he does not carry a bow and arrows, the dancer usually avails himself of a cane
to indicate his physical weakness. The black-and-white division of his face refers to the scars of
someone who fell into the fire due to epilepsy or some other medical condition. This sculptor has
also depicted traces of smallpox on the black eyelid, and the face is pulled down on one side due to
a paralysis of the facial nerve. Sculptor and performer collaborate to make Mbangu a composite sign
of illness and disability, of all the misfortunes that can befall someone.
What then is to be our response to Mbangu? Some sculptors render the mask comedic, but this
work conveys an extraordinary delicacy and sympathy by contrasting the gentle perfection of the
features on one side with the systematic distortion on the other. This sculptor responds to the
widespread version of Mbangu's song: “Do not mock your neighbor, do not laugh at your brother,
the sorcerers have bewitched him.” In other words, anyone can fall prey to misfortune; it could hap-
pen to you. Our brother, our neighbor, deserves our support.
Permission to use this image was kindly granted by the Royal Museum of Central Africa.
©AFRICA-MUSEUM TERVUREN(BELGIUM)
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures
and religions since the beginning of recorded history. The serpent adopted as a logotype by the Insti-
tute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in
Berlin.
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iii
“Knowing is not enough; we must apply.
Willing is not enough; we must do.
—Goethe
INSTITUTE OF MEDICINE
Shaping the Future for Health
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iv
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v
COMMITTEE ON NERVOUS SYSTEM DISORDERS IN
DEVELOPING COUNTRIES
ASSEN JABLENSKY (Co-chair), Professor, Department of Psychiatry, University
of Western Australia, Perth
RICHARD JOHNSON (Co-chair), Professor, Department of Neurology, Co-Chair
of Department of Microbiology and Neurosciences, John Hopkins University
School of Medicine, Baltimore, Maryland
WILLIAM BUNNEY, JR., Professor and Della Martin Chair, Department of
Psychiatry and Human Behavior, University of California at Irvine
MARCELO CRUZ, Professor, Neurosciences Institute, Central University of
Ecuador, Quito
MAUREEN DURKIN, Professor, Sergievsky Center, Joseph L. Mailman School
of Public Health, Columbia University, New York, New York
JULIUS FAMILUSI, Professor, Department of Pediatrics, University College
Hospital, Ibadan, Nigeria
M. GOURIE-DEVI, Director-Vice Chancellor, and Professor of Neurology,
National Institute of Mental Health and Neurosciences, Bangalore, India
DEAN JAMISON, (Board on Global Health Liaison), Director, Program on
International Health, Education, and Environment, University of California at
Los Angeles
RACHEL JENKINS, Director, World Health Organization Collaborating Centre,
Institute of Psychiatry, London, United Kingdom
SYLVIA KAAYA, Professor, Department of Psychiatry, Muhimbili University
College of Health Science, Dar es Salaam, Tanzania
ARTHUR KLEINMAN, Presley Professor of Anthropology and Psychiatry,
Departments of Anthropology and Social Medicine, Harvard University,
Boston, Massachusetts
THOMAS MCGUIRE, Professor, Department of Economics, Boston University,
Massachusetts
R. SRINIVASA MURTHY, Dean, and Professor of Psychiatry, National Institute
of Mental Health and Neurosciences, Bangalore, India
DONALD SILBERBERG, Professor of Neurology, Director of International
Medical Programs, University of Pennsylvania School of Medicine, Philadelphia
BEDIRHAN ÜSTÜN, Group Leader of Assessment, Classification, and
Epidemiology Group, World Health Organization, Geneva, Switzerland
Study Staff
STACEY KNOBLER, Study Director (from February 2000 to May 2001)
JUDITH BALE, Director, Board on Global Health and Study Director
PAMELA MANGU, Study Director (from September 1999 to February 2000)
CHRISTINE COUSSENS, Research Associate
ALISON MACK, Consultant Writer
LAURIE SPINELLI, Project Assistant
KEVIN CROSBY, The National Academies Christine Mirzayan Internship Program
CARLA HANASH, The National Academies Christine Mirzayan Internship Program
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vi
BOARD ON GLOBAL HEALTH
DEAN JAMISON, (Chair), Director, Program on International Health, Education,
and Environment, University of California at Los Angeles
YVES BERGEVIN, Senior Health Specialist, Canadian International Development
Agency
HARVEY FINEBERG, Provost, Harvard University, Boston, Massachusetts
EILEEN KENNEDY, Deputy Under Secretary for Research, Education, and
Economics, U. S. Department of Agriculture, Washington, D.C.
ARTHUR KLEINMAN, Presley Professor of Medical Anthropology and
Psychiatry, Harvard Medical School, Boston, Massachusetts
PATRICIA DANZON, Professor of Health Care Systems Development, Wharton
School, University of Pennsylvania, Philadelphia
NOREEN GOLDMAN, Professor, Woodrow Wilson School of Public and
International Affairs, Princeton University, Princeton, New Jersey
ALLAN ROSENFIELD, Dean, Mailman School of Public Health, Columbia
University, New York, New York
ADEL MAHMOUD, President, Merck Vaccines, Whitehouse Station, New Jersey
SUSAN SCRIMSHAW, Dean, School of Public Health, University of Illinois at
Chicago
JOHN WYN OWEN, Secretary, Nuffield Trust, London, United Kingdom
GERALD KEUSCH, (Liaison), Director, Fogarty International Center, National
Institutes of Health, Bethesda, Maryland
DAVID CHALLONER, (IOM Foreign Secretary), Vice President for Health
Affairs, University of Florida, Gainesville
Staff
JUDITH BALE, Director
JONATHAN DAVIS, Study Director
STACEY KNOBLER, Study Director
KATHERINE OBERHOLTZER, Project Assistant
LAURIE SPINELLI, Project Assistant
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REVIEWERS vii
REVIEWERS
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures
approved by the National Research Council's Report Review Committee. The
purpose of this independent review is to provide candid and critical comments that
will assist the institution in making the published report as sound as possible and to
ensure that the report meets institutional standards for objectivity, evidence, and
responsiveness to the study charge. The review comments and the draft manuscript
remain confidential to protect the integrity of the deliberative process. We wish to
thank the following individuals for their review of this report:
Naomar Almeida-Filho, Campus Universitario-Canela, Salvador-Bahia, Brazil
Nancy Andreasen, University of Iowa Hospitals and Clinics, Iowa City
Gretchen Birbeck, Michigan State University, East Lansing
Daniel Chisholm, World Health Organization, Geneva, Switzerland
Sir David Goldberg, King's College, United Kingdom, London
Nora Groce, Yale University, New Haven, Connecticut
Vladimir Hachinski, University of Western Ontario, Canada
William Harlan, National Institutes of Health, Bethesda, Maryland
Guy Mckhann, John Hopkins University School of Medicine, Baltimore,
Maryland
Alberto Minoletti, Ministry of Health, Santiago, Chile
Malik Mubbashar, WHO Collaborating Centre for Research Training in
Mental Health, Rawalpindi, Pakistan
Elena Nightingale, Institute of Medicine, Washington, D.C.
Nimal Senanayake, University of Peradeniya, Sri Lanka
Rune Simeonsson, University of North Carolina, Chapel Hill
R. Thara, Schizophrenia Research Foundation, Chennai, India
Myrna Weissman, Columbia University College of Physicians and Surgeons,
New York
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions or
recommendations nor did they see the final draft of the report before its release. The
review of this report was overseen by Arthur Asbury, University of Pennsylvania
School of Medicine, Philadelphia, and Floyd Bloom, The Scripps Research Institute,
La Jolla, California, who were responsible for making certain that an independent
examination of this report was carried out in accordance with institutional
procedures and that all review comments were carefully considered. Responsibility
for the final content of this report rests entirely with the authoring committee and
the institution.
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REVIEWERS viii
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PREFACE ix
Preface
The continuing existence of gross disparities in health between affluent and
poorer countries is becoming a major challenge for policy makers in the new
millennium. While the link between poverty and disease is well established and has
been recognized by public health leaders and social reformers for a century and a
half, the complexity of this relationship has become apparent only in the last several
decades as national governments and international organizations have accorded
health increasing priority in development programs. It is now widely accepted that
socioeconomic development and population health must advance together to be
sustainable in the long term. Improvements in population health are not merely or
even necessarily a by-product of economic growth. They are a prerequisite and a
driving force of economic and social productivity. Reductions in maternal and infant
mortality, improvements in nutrition and environmental sanitation, and control of
communicable diseases have made important contributions to economic growth.
Conversely, high levels of preventable morbidity and mortality, survival with
chronic disability, reduced quality of life, and widespread demoralization are a drain
on society's resources and impede overall development.
For several decades, investments in health in the context of national and
international development strategies have targeted primarily the major
communicable diseases, malnutrition, and poor sanitation in low-income countries.
A number of such programs have successfully lowered infant mortality rates and, as
a result, increased life expectancy at birth. However, the net effect of such gains has
been largely offset by the epidemiological transition from a
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