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Commentary: Epilepsy is a Global Problem

response. Epilepsy is ubiquitous; it affects people of any age, gender, ethnicity, and social background, irrespective of geographic location. Its epidemiologic dimension is staggering: >50 million people are affected; it is the most common chronic serious neurologic disease. Particularly when seizures are severe and not controlled, epilepsy devastates people’s lives. In the recent Global Burden of Disease Study, the disability weight associated with severe epilepsy ranked fourth among 220 health states surveyed, irrespective of geographic boundaries. Differences in epilepsy rates relate not to specific continents but, rather, to the income status of individual countries and related quality of health care. Thus, the incidence of epilepsy is twice as high in lowand middle-income countries as it is in highincome countries, largely due to differences in the impact of specific etiologies such as infection, antenatal insults, and head trauma. The prevalence of epilepsy is also higher in lowand middle-income countries, where the frequency of active disease is on the order of 10 per 1,000 (or even higher in rural areas), compared with 5–8 per 1,000 in high-income countries. In view of the well recognized dimension of epilepsy as a global problem, the Asia versus Africa controversy in this issue of Epilepsia seems to have originated from a sentence interpreted out of context. When addressing the cultural context of epilepsy in the African continent, a World Health Organization (WHO) African Region Report published 10 years ago noted that epilepsy is perceived as an “African” ailment, a manifestation of supernatural forces, traditionally looked upon as caused by ancestral spirits or attributed to possession by evil spirits. That statement was meant to indicate that in most parts of Africa the perception of epilepsy is strongly imprinted in local culture and spiritual beliefs. Some communities in Asia, Latin America, and other continents also have epilepsy embedded in their ancestral religions or beliefs, and therefore perceive epilepsy as specific to their local cultural context. Major geographic differences, however, do exist in the magnitude of the treatment gap, which for epilepsy typically parallels the pervasiveness and severity of stigma. There is emerging evidence that stigma is an important cause of health inequalities. Moreover, stigma-related differentials in the power of individuals within society create obstacles that make the reduction of health disparities especially challenging. Again, the treatment gap relates not to a specific continent, but to income level and quality of health care in individual countries. On average, low-income countries have 0.3 neurologists per million inhabitants, compared with close to 30 neurologists per million inhabitants for high-income countries (Figs. 1 and 2). A crossnational analysis of epilepsy treatment gap determinants found that even among resource-limited regions, people with epilepsy in countries with fewer economic, health care, neurology, and epilepsy-specific resources are more likely to have untreated epilepsy. Countries with a relatively high treatment gap do exist in all continents. In low-income countries, more than three fourths of people with epilepsy do not receive regular Emilio Perucca, ILAE President, Department of Internal Medicine and Therapeutics, University of Pavia and C. Mondino National Neurological Institute, Pavia, Italy. Tarun Dua, Medical Officer, Department of Mental Health and Substance Abuse, World Health Organization (WHO), Geneva, Switzerland. Athanasios Covanis, IBE President, Department of Neurology, Childrens Hospital Agia Sophia, Athens, Greece.