Neurological disorders in India: past, present, and next steps
Authors: Man Mohan Mehndiratta, Vasundhara Aggarwal
Journal: The Lancet Global Health (2021)

India is a large developing country with limited resources, yet caters to approximately 18% of the total world population. Neurological disorders, both fatal and non-fatal, are among the leading contributors to the burden of non-communicable and communicable diseases in India.1GBD 2016 Neurology CollaboratorsGlobal, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Neurol. 2019; 18: 459-480Summary Full Text Full Text PDF PubMed Scopus (903) Google Scholar Disability-adjusted life years (DALYs) are an important metric for assessing the global burden of neurological disorders, and they continue to increase globally.1GBD 2016 Neurology CollaboratorsGlobal, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Neurol. 2019; 18: 459-480Summary Full Text Full Text PDF PubMed Scopus (903) Google Scholar A systematic and comprehensive data analysis of neurological disorders within the Indian population has been warranted, to provide insight regarding prevalence, disease burden, and risk factors associated with these diseases. Such information will help policymakers to plan funds: firstly, for the employment of a trained workforce in the field of neurosciences; secondly, for the creation of infrastructural facilities; and thirdly, to meet health-care needs (according to social, cultural, and ethnic variations) of communities, regions, and nationally among individuals with a variety of neurological disorders. Until this year, these data had not been readily available for various states of India.2Gourie-Devi M Epidemiology of neurological disorders in India: review of background, prevalence and incidence of epilepsy, stroke, Parkinson's disease and tremors.Neurol India. 2014; 62: 588-598Crossref PubMed Scopus (70) Google Scholar As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, the India State-Level Disease Burden Initiative Neurological Disorders Collaborators for the first time have provided a comprehensive analysis of patterns and trends in neurological diseases from 1990 to 2019,3India State-Level Disease Burden Initiative Neurological Disorders CollaboratorsThe burden of neurological disorders across the states of India: the Global Burden of Disease Study 1990–2019.Lancet Glob Health. 2021; (published online July 14.)https://doi.org/10.1016/S2214-109X(21)00164-9Google Scholar in terms of changes in prevalence or incidence and DALYs with time, in different Indian states. The Article highlights the increasing contribution of non-communicable and injury-related neurological disorders, and the decreasing contribution of communicable neurological disorders, to total DALYs in India. The contribution of non-communicable neurological disorders was 4·0% (95% UI 3·2–5·0) in 1990, doubling to 8·2% (6·6–10·2) in 2019; injury-related neurological disorders contributed 0·2% (0·2–0·3) in 1990 and 0·6% (0·5–0·7) in 2019; and communicable neurological disorders contributed to 4·1% (3·5–4·8) in 1990 and 1·1% (0·9–1·5) in 2019. In the past three decades, most studies in India have shown a high disease burden for specific diseases including stroke, epilepsy, headache, Parkinson's disease, and dementia,4Nadig R Namapally USK Sarma GRK Mathew T Outpatient burden of neurological disorders: a prospective evaluation of 1500 patients.Neurol India. 2019; 67: 708-713PubMed Google Scholar mostly reported for the urban Indian population. Despite progress in improving access to national health care, disparities persist based on socioeconomic status, age, geography, and gender.5Balarajan Y Selvaraj S Subramanian SV Health care and equity in India.Lancet. 2011; 377: 505-515Summary Full Text Full Text PDF PubMed Scopus (493) Google Scholar India has a huge target to achieve as far as equity in health and health care is concerned, as one of their guiding principles of governmental policy. The Government of India has introduced welfare programmes, such as Ayushmann Bharat—Pradhan Mantri Jan Arogya Yojna, for various diseases including neurological disorders. Sincere and targeted efforts are needed for implementation of these programmes, to provide large-scale benefits. Such efforts include employing a trained workforce and awareness drives to educate people via television, radio, and other social media platforms. However, in addition to prevailing disparities, progress in achieving health and care equity has further been impacted by the ongoing COVID-19 pandemic, due to a financial diversion to manage the complications of SARS-CoV-2 infection and a vaccination programme run by the Government of India. Under current circumstances, with social distancing in place, telemedicine might be a major way to implement clinical practice for neurological disorders, both in terms of patient safety, and logistically for patients living in regions of the country that have scarce health-care facilities.6Chirra M Marsili L Wattley L et al.Telemedicine in neurological disorders: opportunities and challenges.Telemed J E Health. 2019; 25: 541-550Crossref PubMed Scopus (31) Google Scholar It could replace facility-based evaluations, and improve on virtual consulations and visits (eg, by video call). Telemedicine could also serve as a platform for experts in tertiary care centres to educate, train, and interact with primary care physicians. Most of the Indian population lives in villages, and therefore a new method of care delivery based around telemedicine needs to be made user-friendly and cost-effective for both the patients and health-care providers, and safe in terms of patients receiving adequate care. The concept of telestroke is becoming established for stroke patients, whereby a team of doctors at a distant site, including neurologists, neurosurgeons, and radiologists, provide neurological expertise to emergency medicine doctors and other staff at the originating site. It has been successfully implemented in the state of Himachal Pradesh through use of innovative approaches such as smartphones.7Padma MV "Telestroke": an Indian approach to telemedicine.Pract Cardiovasc Sci. 2017; 3: 2-4Crossref Google Scholar In Himachal Pradesh, telestroke has improved the rate of administration of intravenous thrombolysis and decisions for performing endovascular therapy, and has helped in the early detection and management of transient ischemic attacks and lacunar strokes.7Padma MV "Telestroke": an Indian approach to telemedicine.Pract Cardiovasc Sci. 2017; 3: 2-4Crossref Google Scholar Other states including Uttar Pradesh, Punjab, Haryana, Rajasthan, and Telangana have initiated telestroke and started training doctors in their state public health-care centres. Telemedicine can be used for other diseases including headache disorders and Parkinson's disease (in both instances, with monitoring of treatment response and progression of the disorder, and providing referral for deep brain stimulation interventions if required). Another important non-communicable neurological disorder that needs the attention of policymakers is epilepsy. Globally, around 50 million people have epilepsy, among whom 10–12 million live in India.8Garg D Specific considerations for epilepsy in India.Curr Med Issues. 2020; 18: 105-110Crossref Google Scholar The prevalence estimates in India for 2019 range from 3·0 to 11·9 per 1000 of the population and incidence from 0·2 to 0·6 per 1000 of the population per year, with a major contribution from the rural population.3India State-Level Disease Burden Initiative Neurological Disorders CollaboratorsThe burden of neurological disorders across the states of India: the Global Burden of Disease Study 1990–2019.Lancet Glob Health. 2021; (published online July 14.)https://doi.org/10.1016/S2214-109X(21)00164-9Google Scholar, 8Garg D Specific considerations for epilepsy in India.Curr Med Issues. 2020; 18: 105-110Crossref Google Scholar Due to substantial gaps in various domains of knowledge, attitude, and practice, the majority of people with epilepsy in India do not receive adequate treatment, leading to a treatment gap.9Rathore C Radhakrishnan K Epidemiology of epilepsy surgery in India.Neurol India. 2017; 65: S52-S59PubMed Google Scholar Nearly one-third of people with epilepsy have drug-resistant epilepsy9Rathore C Radhakrishnan K Epidemiology of epilepsy surgery in India.Neurol India. 2017; 65: S52-S59PubMed Google Scholar and require presurgical evaluation in the form of MRI, single-photon emission computerised tomography, PET, and magnetoencephalography, in addition to standard intervention from a trained neuroscience team consisting of neurologists, neurosurgeons, neuroradiologists, and psychiatrists. Few centres in India cater for the surgical needs of people with drug-resistant epilepsy, and they are mainly concentrated in urban cities. According to the recommendations of Rathore and Radhakrishnan,9Rathore C Radhakrishnan K Epidemiology of epilepsy surgery in India.Neurol India. 2017; 65: S52-S59PubMed Google Scholar India needs at least 60 state-level epilepsy surgery centres (with each undertaking at least 50 surgeries per year) and six national centres of excellence to address the treatment gap. The Government of India has showed momentum in developing epilepsy surgery centres, however needs a sense of enthusiasm, determination, and desire to make them available in both urban and rural parts of India. In several other countries, new treatments such as monoclonal antibodies are being introduced and applied for particular neurological disorders, including migraine, multiple sclerosis, and other demyelinating conditions, but in India, the use of these costly medicines needs government funding, to provide for people in the low-income group at affordable cost. We should continually learn from the past and incorporate ideas in the present to see benefits in the future. The burden of non-communicable neurological disorders is reaching a substantial proportion of the total DALYs in India, with a growing percentage in the ageing population.1GBD 2016 Neurology CollaboratorsGlobal, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Neurol. 2019; 18: 459-480Summary Full Text Full Text PDF PubMed Scopus (903) Google Scholar The burden of diseases such as stroke and epilepsy affect resource-poor countries like India. The effects on human wellbeing and financial costs of non-communicable neurological disorders in India are also increasing considerably. The scientific and clinical care costs will soon become unmanageable for all tiers of Indian society. This challenging burden requires a suitable pragmatic approach, with the establishment of newer, realistic, and feasible pilot interventions. Reinforcement and concretisation of government policies and medical interventions require a multidisciplinary task force involving various actors, including educational bodies to prepare trained health-care workers, community leaders, the private and public sectors, and other non-governmental organisations. We declare no competing interests. The burden of neurological disorders across the states of India: the Global Burden of Disease Study 1990–2019The increasing contribution of non-communicable and injury-related neurological disorders to the overall disease burden in India, and the substantial state-level variation in the burden of many neurological disorders highlight the need for state-specific health system responses to address the gaps in neurology services related to awareness, early identification, treatment, and rehabilitation. Full-Text PDF Open Access