Indian Write- Ups
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| Epilepsy: Changing Attitudes and Enabling Treatment Dr Veena Kalra, Head-Neurology Division, Dept of Pediatrics, AIIMS, New Delhi |
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As is well known, management of epilepsy depends greatly upon improved maternal and child health services, specifically aimed at the avoidance of adverse perinatal events. The identification and treatment of childhood meningitis, among other entities, should see a fall in the prevalence of epilepsy. Hib vaccination is an effective approach toward this end. Neurocysticercosis is the cause of seizures in about 37% of otherwise healthy children >3 years old³. Physicians need to be aware of this possibility when viewing a case of abrupt-onset seizures. Neurocysticercosis and other treatable secondary causes of epilepsy mandate neuroimaging before a case is finally diagnosed as one of idiopathic epilepsy.
Besides the improvement of diagnostic and therapeutic options, patient education and involvement are a must. In fact, lack of awareness among the afflicted and their families is the limiting factor to the efficacy of any infrastructural measures. The Indian Epilepsy Association was formed in 1971 and now has 20 national chapters, with 46% of members belonging to non-medical professions. There is much work to be done in educating patients and the general public about epilepsy. Indian law equates epilepsy with insanity; the presence of recurrent seizures at the time of marriage was considered as a ground for annulment. This placed a terrible sociocultural burden on patients4. The Indian Epilepsy Association went to work to remove this law. Children with epilepsy are discriminated against by peers and also to an extent by our educational system, inspite of legislations to the contrary. Such attitudes are detrimental to the progress of the society as a whole. India also needs a law, such as the Americans with Disability Act in the United States5, to protect patients with epilepsy against discrimination. WHO proposal on control of epilepsy in rural areas The WHO proposal on control of epilepsy in rural areas envisages a continuous free supply of phenobarbitone (PB) through the primary health centers (PHCs) after case identification by the medical staff. The need for such a project cannot be objected to in principle. But it has received considerable flak in recent years6 on the choice of PB and the primary role assigned to PHCs. This requires some comment. The Rural Mental Health Project, from the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, has been quietly expanding its services and is offering practical epileptology consultancy and monitoring services, thanks to their training in epilepsy in earlier years. This is to be welcomed vis-à-vis the fears expressed earlier6. In view of the marginal difference in price between PB and diphenylhydatoin (DPH), comparative pilot studies on the use of DPH are worthy of consideration with careful clinical observation, especially at higher dosage schedules. Whatever the ethical objections toward a hierarchial approach6, irregularity in drug supply is finally in the hands of the pharmaceutical industry and the government. The impact of WHO efforts is already significant and visible. Countries are beginning to act and move forward innovatively. WHO can catalyze this new energy to improve the mental health situation around the world. Private enterprise on the lines of the Sarvodaya Shramdana Movement in Sri Lanka7,8 still operates through the PHCs. Impediments and human frailties in the system need to be corrected with patience and tact. There appears to be no other workable alternative to the PHC approach on the horizon, but other strategies have to be explored. In all discussions, the crux of the problem, namely, primary healthcare and epilepsy, brooks no delay. We cannot afford to throw the baby out with the bath water. Into the Light It is important to understand the ethos of the villagers9,10. "Irrational" sociocultural practices may have to be accepted, so long, as they are not harmful. If well-planned and tactful endeavors bear fruit, that is a major step forward. The impact of WHO efforts is already significant and visible. Countries are beginning to act and move forward innovatively. WHO can catalyze this new energy to improve the mental health situation around the world. Through the Mental Health Global Action Programme, and the efforts of the Indian healthcare system, there is the opportunity to advance the momentum generated into intensive action, so that the tide on the neglect of mental health is ultimately turned. The role of the general practitioner whether in the private or the public health setup shall be central to the progress in the eradication of epilepsy, the hidden menace. Reference
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