Lao People's Democratic Republic
- Correspondence to Dr F J Mateen, Fellow, Departments of International Health and Neurology, The Johns Hopkins University, 615 N Wolfe Street, Room 8527E, Baltimore, MD 21205, USA;
Any important celebration of medical doctors in Laos begins with the medical director and the assistant director singing a favourite song at the microphone. I was warned; when visiting Laos, it's always good to have a couple of numbers up your sleeve. I was privy to the recent graduation ceremony of nine internal medicine residents in the country's capital, Vientiane. It was a grand occasion with spicy minced meats, traditional Lao dancing, karaoke music and a high percentage of the country's skilled medical personnel in a single room.
Laos has only one fully trained neurologist and nearly 6 million inhabitants. To remark that there is a shortage of neurologists here is beyond obvious. This land of clandestine war, dinosaur fossils, embroidered silks and golden stupas is tropical and ancient. Neurological care is, by comparison, very new. Knowledge of common neurological disorders among both the Lao people and medical trainees is only beginning to be formalised.
Laos remains one of the poorest countries in southeast Asia. It ranks as a least developed country, landlocked by Thailand, Vietnam, Cambodia, Burma and China. On health indicators, it often fares worse than its neighbours. Laos still reports cholera, neonatal tetanus, measles and leprosy, and is heavily burdened by malaria, tuberculosis and dengue fever.1 The children's index ranks Laos 19th of all of the least developed countries on important indicators of child health, placing it below Zambia, Rwanda and Bangladesh.1 Sixty per cent of the population has access to basic sanitation and clean water. Hospital care is public and largely centralised in the capital while approximately 85% of the population live in rural areas. The WHO reports that the Lao government contributes 21% of all expenditures made on health in the country.2
Depending on the disease, neurological care in Laos is delegated to a variety of non-neurologist physicians. During my visit, I was surprised—as I often am in Asian intensive care units (ICU)—by the high burden of critically ill neurological patients that filled the general ICU wards. The 12 bed ICU at Mittaphab Hospital had 11 patients with neurological injury: intracerebral haemorrhage (n=3), epidural haematoma (n=1), ischaemic stroke (n= 1), status epilepticus (n=1) and traumatic brain injury, most often due to motorcycle crashes (n=5). One patient on the medical teaching unit had fulminant meningitis with pustulent CSF but did not survive long after the transfer to the ICU. He presented very late to the hospital and aggressive treatment was unsuccessful.
The rainy season (surprisingly short of rain in 2010) brought with it drenched walks along the Mekong River and a wave of patients with dengue infection. Fever, achy bones and muscles, pancytopenia and rash were part of daily life. Dengue virus can be confirmed in the laboratory but clinicians in Laos know dengue like neurologists in high income settings know stroke. Tropical infections accounted for at least half of the admissions on the medical teaching unit during my visit. Foreign funding allowed the hospital and outpatient clinics to employ diagnostic tests to increase laboratory based surveillance. But in Laos I was just as likely to see stroke or seizures as I was to see dengue, schistosomiasis or other tropical infections. Stroke care is under the auspices of the cardiologists and emergency room physicians. Epilepsy is treated by psychiatrists. Whereas aspirin and antihypertensives were not always available to stroke patients because of cost, drug companies are making an impact in Vientiane by advertising lipid lowering agents and dubious intravenous stroke remedies from overseas. If it looks like urine, I recall thinking to myself, it may not be a cure.
The prevalence of epilepsy in rural Laos has been estimated to be 7.7 cases per 1000 people, making it an underrecognised burden of disease in the country.3 A country-wide estimate of the number of people living with epilepsy ranges from 5883 to 11 8774. The case fatality of epilepsy is reported to be higher than in high income countries, especially among the disabled5. The Institut de la Francophonie pour la Médecine Tropicale continues to do important work on the understanding of epilepsy throughout the country. They have reported that the epilepsy treatment gap in Laos reaches 90%, exacerbated by low disease awareness, difficult transportation conditions and an inconsistent supply of phenobarbital4 5 (ie, only 10% of patients with epilepsy receive antiepileptic drugs). For this reason, having trained professionals in neurology is not necessarily the first step forward but just one stride. Currently, the country has no functioning electroencephalogram or electromyogram equipment. The supply of phenobarbital from a local manufacturing company is uncertain. Patients who need an MRI study are forced to pay out of pocket in neighbouring Thailand. More importantly, basic texts on the nervous system are not available in Lao, making reference materials scant for non-English or French speaking students.
Each year, approximately 450 students enter medicine in Vientiane, making the potential workforce in medicine high for the country. However, retention, medical education and recruitment into the needed specialties are harder tasks. Because there is no training programme for neurology in Laos, interested students are offered an opportunity to study in Malaysia for up to 3 years. However, this scholarship opportunity is not taken up by the students. Anecdotally, they told me the study of neurology was difficult, a statement with which we can all easily agree!
The challenges for Laos in neurological care are many but worth addressing. The country is peaceful, developing and open. An initial goal for neurology is the provision of baseline knowledge of neurological disorders and the nervous system to existing medical trainees. Simple measures such as funding for translated books, access to the internet and better remuneration for the country's one neurologist may begin this task. In the community, new ways to reach villagers by teaching that diseases such as epilepsy and hypertension are treatable and avoidable will also be part of the leap forwards. Finally, more consistent support by foreign trained professionals in a coordinated way would help alleviate the burden of neurological disease in the longer term.
My experience was overwhelming marked by hospitality, generosity, enthusiasm and appreciation for the consultants' clinical acumen. “We are one big family in Laos,” I was told. “Every patient, the nurses, the doctors are all like family.” “Even if they can't sing?” I asked. “Yes,” replied my hosts, “there is time for you to practice”.
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.