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Interview | Stroke prevention in Nepal: An urgent call for awareness and policy action

Nepal's neurologists are skilled but they need more resources. How can 36 neurologists treat 30 million people: Dr Amit Kandel

Dr Amit Kandel had two options to choose from—medicine or engineering. He mentions that he felt somewhat “influenced” and followed the crowd in choosing medicine as his profession. Later, he was inspired by neurologists in India who saved his father’s life when the latter suffered from severe meningitis. This incident made a huge impact on his life, leading him to decide to become a neurologist.

Currently, Dr Kandel is a clinical associate professor in the Department of Neurology at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo in the US. He is board-certified in neurology, stroke, and traumatic brain injury medicine by the American Board of Psychiatry and Neurology (ABPN). He is also an expert in stroke clinical care, stroke center management, neurology education, and population-based studies. He describes himself as a hardworking person who does not enjoy his work unless he is solving problems and is a skeptical person who always has a ‘why’ in his mind. In conversation with Dr Kandel, DMN News’ Monica Lohani talks about his profession and his journey in the medical field, among other issues.

Excerpts:

What grabbed your interest in stroke among other departments of neurology?

When I was working in the Emergency Department at Patan Hospital, my experiences at Nepalgunj Medical School made it easier for me to handle neurological emergencies. In Nepalgunj, we treated many patients with Japanese encephalitis, which sparked my interest in pursuing a career in neurology. However, there was no neurology training available in Nepal at that time, so I went to the US in 2007 to study neurology. I completed a year of preliminary internal medicine residency at the University at Buffalo, followed by four years of neurology residency and a year-long fellowship in vascular neurology.

I was drawn to the fast pace and problem-solving nature of emergency medicine. General neurology and other fields were much slower in comparison, so I found my niche in stroke neurology, also known as vascular neurology.

What is the current stroke scenario in Nepal?

The stroke situation in Nepal is dire and unacceptable. Each year, around 35,000 people in Nepal suffer from a stroke. Stroke is one of the top three causes of death in the country and is the leading cause of disability. Despite the increasing number of cases, there is a severe lack of awareness and access to advanced treatments. Standard treatment and post-treatment services for stroke are almost non-existent.

Stroke in Nepal is not just a medical issue; it is a social and political one. Improving domestic politics and establishing stroke treatment centers with advanced technologies could significantly improve stroke care. With better facilities, doctors could potentially save nine out of ten stroke patients, drastically reducing the death rate.

While stroke is a preventable condition, awareness and preventive measures in Nepal are still in their infancy. Greater awareness and improved medical infrastructure are crucial to combating this growing crisis.

So, what are the symptoms and treatment for stroke?

Ninety percent of strokes are preventable, and with appropriate treatment, stroke is a curable condition, and disability can be minimized. It is crucial to recognize the six major symptoms of a stroke. First is weakness of the face or weakness on one side of the body. Second, speech changes or confusion. Third, a new type of headache or severe headache. Fourth, numbness on one side of the body. Fifth, changes in vision, such as loss of vision in one eye or loss of peripheral vision in both eyes. And finally, dizziness or loss of balance while walking. 

Often, patients and their families fail to recognize these symptoms and the urgency of seeking medical attention, which is vital for improving health outcomes.

Another area needing improvement is the system and culture of ambulance services. In neurology, the saying “Time is Brain” emphasizes the importance of timely stroke treatment. A person suffering from a stroke loses 1.9 million brain cells every minute the stroke goes untreated. Every hour of delayed care ages the brain by 3.6 years. This highlights the critical need for immediate medical attention for stroke symptoms in the stroke center.

What are the risk factors?

Stroke risk factors include high blood pressure, high glucose levels, air pollution, high cholesterol, body weight, poor diet (particularly one high in fatty foods, salt, and sugar and low in fiber), and heart disease. Controlling blood pressure alone can reduce stroke risk by 50 percent. Achieving this requires a multi-faceted approach, including medication, exercise, salt restriction, improved diet, and weight reduction. The target blood pressure for long-term control is 130/80. Consistently high blood pressure above this level increases the risk of both clotting and bleeding strokes.

Other risk-taking behaviors, such as smoking, alcohol consumption and lack of exercise also increase stroke risk and should be addressed on time. Stroke prevention strategies should begin at the primary school level to instill healthy habits before any disease develops.

Certain heart conditions, like atrial fibrillation, significantly increase stroke risk by five times. Early detection and treatment of atrial fibrillation can prevent strokes. Quitting smoking can reduce stroke risk by half. Additionally, conditions like carotid artery narrowing can be detected and treated to prevent strokes if a regular surveillance system is established. 

Awareness and timely action on these risk factors can prevent 90 percent of strokes. One-third of strokes are recurrent, so patients with a history of stroke need to control these risk factors with medication, diet, and exercise to prevent another stroke.

Transient Ischemic Attacks (TIA) have similar symptoms to strokes but last less than 24 hours. However, 12 percent of patients with TIA can experience a stroke within the next five years. It is crucial to seek medical attention even if TIA symptoms resolve, as future events can be prevented with risk factor control and modifications.

By understanding and addressing these risk factors, we can significantly reduce the incidence of stroke and improve overall health outcomes.

What are the strategies for dealing with the stroke burden in Nepal?

There are several key strategies we need to implement to effectively manage the stroke burden in Nepal. Let me mention a few here. First, establishing Stroke Centers in every city. Each city should have at least one advanced stroke center supported by multiple essential or basic centers. Advanced centers can provide thrombectomy care, while essential and basic centers can administer thrombolysis treatment. Second, there should be free Thrombolysis and Thrombectomy therapy. To ensure accessibility and affordability, these treatments should be made free for all stroke patients in Nepal.  Third, we need national guidelines for stroke care.  Implementing national guidelines will standardize treatment and improve patient outcomes across the country. Fourth is related to curriculum changes in medical and nursing schools. Introducing neurology training early in medical and nursing school curricula will better prepare healthcare professionals to handle neurological emergencies. Fifth, we need improved prehospital care. Enhancing prehospital care, including reliable ambulance services, is crucial. Time is critical in stroke treatment—every minute counts. A patient loses 1.9 million brain cells every minute a stroke goes untreated, and every hour of delay ages the brain by 3.6 years. And sixth, we need to launch a national brain health campaign. A national campaign can raise awareness about stroke prevention and the importance of early treatment, educating the public and healthcare providers alike.

Could you elaborate on the importance of immediate action and the role of politics and policy in this context?

Certainly. When someone suffers a stroke, they must be rushed to the nearest hospital immediately. A reliable ambulance service is vital for this. Patients need to be screened and treated with clot-busting medication within 4.5 hours of symptom onset. Delays can lead to severe consequences, as this medication is only effective within that time frame. Currently, it’s available in only a few hospitals in Kathmandu, with none in rural areas.

For severe strokes, a procedure called thrombectomy can remove clots and restore blood flow, potentially bringing patients back to normal if treated in time. Unfortunately, this service is unavailable in many major hospitals, including Tribhuvan University Teaching Hospital and Bir Hospital. Every major city in Nepal needs a hospital capable of providing advanced stroke care, accessible within an hour by ambulance. Given the country’s terrain, helicopter ambulances are an effective solution.

What about the solutions for rural areas and the cost-effectiveness of treatments?

In a mountainous country like Nepal, it’s challenging for rural residents to reach a hospital within 4.5 hours for stroke treatment. Establishing major stroke centers in every region and smaller centers within those regions is essential. Helicopter ambulances can transport patients quickly, and motor ambulances can take them to the nearest helipad. This method, proven in other countries, can ensure timely treatment with guideline-based acute stroke treatments like thrombolysis and thrombectomy.

Making thrombolysis and thrombectomy free for all stroke patients in Nepal is cost-effective for patients, families, society, and the country. Thrombolysis costs around 60,000 to 90,000 NPR, improving disability outcomes so that 30 percent more patients can return to work within three months. This reduces costs related to productivity loss, medication, hospital stays, and caregiver needs. The government can break even on costs in six to nine months. Thrombectomy, costing 400,000 to 1,100,000 NPR, is also cost-effective, with a break-even point in around two years.

How can we advance stroke care and enhance training and resources?

Government-sponsored free thrombolysis and thrombectomy programs will accelerate advancements in stroke care and resource development. As the prohibitive cost of these treatments is the biggest bottleneck, a free program will encourage every hospital to become a stroke center, thereby improving prehospital care, acute stroke care, post-stroke care, and community outreach.

While Nepal’s neurologists are skilled, they need more resources. How can 36 neurologists treat 30 million people? All medical students and trainees must receive basic neurology training. Internal medicine and emergency doctors, ambulance drivers, and the public also need training. A new, pragmatic curriculum in medical, nursing, and health assistant schools is essential to address the neurological burden.

Photo: Dhulikhel Hospital

What role does a brain health campaign play in this?

A brain health campaign is crucial in Nepal to address these critical issues for population health and to educate healthcare providers and policymakers. By understanding and addressing these risk factors and improving stroke care, we can significantly reduce the incidence of stroke and improve overall health outcomes in Nepal.

You have been recently awarded with the prestigious Clerkship Director Innovation Award 2024 by the American Academy of Neurology (AAN). Could you tell us more about the same?

Neurologists face a global challenge: the traditional, dogmatic approach to teaching neurology. This outdated method is not time-efficient and lacks value, which is particularly problematic for treating stroke—a time-critical condition. We cannot afford to waste 20 minutes just examining patients. To address this, we introduced a new simulation curriculum. Although simulations existed, they were never organized specifically for medical students at the medical school level.

My colleagues, residents, and I developed a curriculum divided into two parallel parts: education and research. The response from students was overwhelmingly positive, with many reporting it as one of their best educational experiences. We taught them the best practices of neurological examination and then engaged them in problem-solving in a simulation setting. By focusing on symptoms, students learned to evaluate stroke without relying solely on tests.

The curriculum is engaging, interactive, and practice-based, adding significant value to the teaching process. This innovative approach earned me an award in April. In July 2024, we plan to bring this approach to Nepal. Dhulikhel Hospital, which has a simulation lab and well-trained human resources, is poised to benefit greatly. I will return to Dhulikhel Hospital to discuss further advancements.

For a developing country like Nepal, Dhulikhel Hospital can become a role model in stroke treatment if progress continues at this pace. If successful, this system could be expanded to other hospitals in Nepal within two years. Moreover, this model could be applied across South Asia. This is my vision for the future of neurology education and stroke treatment in the region.

Finally, what is your message to our readers?

Stroke care is a human right. It is deeply ironic and tragic that so many deaths and disabilities occur despite strokes being preventable and treatable diseases. The lack of care due to insufficient resources is unacceptable, especially for those living in villages or non-urban areas. This is sheer discrimination and a glaring indicator of inequality. Stroke care is both a political and social issue, and we must address it as such.

Increasing the number of neurologists is essential. The indifference from politicians and policymakers toward patients with neurological disorders cannot be tolerated. Access to healthcare must be available to everyone across the country. A comprehensive strategic plan encompassing the health system, health economics, and the education system is urgently needed. As time passes, the harm caused by inadequate care increases. Brain health must be prioritized. Surveillance, prevention, treatment, and rehabilitation are the four pillars that need immediate action.

I urge you to ask your leaders at local and federal levels about their understanding and plans to address the neurological burden in Nepal. Your advocacy can make a difference in ensuring better stroke care and brain health for everyone.