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Two Physicians Work to Improve Epilepsy Care in Nicaragua

As a young physician barely into residency, Michael Funke, M.D., Ph.D., spent a year working at the Hospital Alemán-Nicaragüense (HAN) in Managua, the only public hospital on the capital city’s east side, a poor and highly populated neighborhood.

For the past 28 years, he has maintained a connection with the hospital and with Nicaraguan friends who finished their residencies and remained in Managua. Now, he and Gretchen Von Allmen, M.D., chief of pediatric epilepsy at Children’s Memorial Hermann Hospital and director of the pediatric epilepsy program at McGovern Medical School at UTHealth, are collaborating with the Universidad de Managua to bring modern pediatric epilepsy care to the city.

Limited Resources for Healthcare

Nicaragua“Nicaragua is one of many, many countries in the world with a health system with limited resources,” says Dr. Funke, medical director of Memorial Hermann Magnetic Source Imaging and an associate professor in the division of Child and Adolescent Neurology in the department of Pediatrics at McGovern Medical School. “The Hospital Alemán-Nicaragüense is part of the public health system, on which most of the population depends. There are only two EEGs in the system for children, and there is no EEG at all in the HAN, which has a service area of 700,000 people. There’s a wait to schedule diagnostic studies with the single MRI they have, an open MRI system with 0.8 Tesla field strength, designed for the whole body and not ideal for brain studies for epilepsy. There are only two pediatric neurologists at La Mascota, the country’s tertiary-care children’s hospital, and no pediatric epileptologists in the country. We’re hoping to accomplish what the World Health Organization recommends for developing countries: teach the primary care providers – in this case the pediatricians – to diagnose and treat epilepsy.

After Haiti, Nicaragua is the poorest country in Latin America. Its colonial past, history of military dictatorship, years of war and natural catastrophes have led to poverty for a large part of the population. Despite these obstacles, there are general hospitals like the HAN, which provides the basic medical specialties – internal medicine, obstetrics and gynecology, surgery and pediatrics – and specialty hospitals for other disciplines, including neurology and neurosurgery, orthopedics and cardiology.

Developing a Training Program

In May 2016, after more than a year of planning, Dr. Funke and Dr. Von Allmen made their first visit to Managua, where they met with physician leaders at the university and local hospitals to begin planning for the development of a collaborative training program with UTHealth. 

“We have a double aim – to help the people of Nicaragua improve the care they provide to children with epilepsy by training their residents, and to offer UTHealth residents an opportunity to learn about epilepsy care in Nicaragua,” Dr. Von Allmen says. “Our long-term goal is to help the Nicaraguans start a pediatric epilepsy treatment program that they can eventually run themselves.”

The two physicians made a second visit in October 2016, during which they assessed and treated 25 children over a four-day period. They returned in February 2017 to continue talks about resident education programs and community outreach, and to see patients in follow-up with Nicaraguan residents and attending physicians.

Epilepsy in Nicaragua

Of the more than 6 million inhabitants of Nicaragua, 1 in 26 will develop epilepsy in his or her lifetime, a statistic based on prevalence in the United States. “That adds up to 250,000 people with epilepsy, about a third of whom are children,” Dr. Von Allmen says. “There is no surgery for epilepsy available in Nicaragua, which means that the patients who do have access to treatment receive medication. One-third of children with epilepsy do not respond to medications taken on a daily basis to prevent seizures. Once a child fails two or three different anti-seizure medications with the proper drug and dosing, the chance of becoming seizure free with subsequent drugs is less than 2 percent. These children are placed in the intractable category. Persistent seizures, especially in early childhood, have a detrimental effect on cognitive and social development and on quality of life. The longer a child has seizures, the greater the damage to the brain.”

Epidemiological information is also lacking in Nicaragua, which precludes population-based healthcare planning and prioritization. “The healthcare system in Nicaragua is well organized and has been recognized by the World Health Organization for its success in following recommendations on how to develop a public system,” Dr. Funke says. “They’ve been extremely successful in the past 20 years in reducing infant mortality, for instance, but they don’t have much in the way of data for epilepsy. We’d like to help them gather the meaningful epidemiological data they need to develop national treatment guidelines for children with epilepsy.”

Looking to the Future

The two physicians plan to return for a weeklong visit every four months to see patients, consult with their Nicaraguan colleagues and further develop the interinstitutional collaboration. “At this point, we’ve gotten our feet wet and are pleased with the progress we’re making,” Dr. Von Allmen says. “Many of our colleagues in the American pediatric epilepsy community are working to develop programs in Latin America and the Caribbean. We hope to work with them to gather epidemiological data that will benefit the region.”

Both physicians are impressed with the knowledge base in Managua. “Despite poverty, the families are very knowledgeable about their children, extremely observant of their condition and very involved in their care. All are very grateful for the care we provide,” she says. “Even though they have limited resources, the residents are passionate about taking care of these kids and learning more about how to treat epilepsy. It’s been a very rewarding experience.”

Dr. Funke agrees. “The enthusiasm of the residents is infectious,” he says. “They’re well educated despite having much less access to educational resources than we have in the United States. Here, we have advanced imaging and other studies to rely on in making diagnoses and treatment decisions. There, they do things more in the old way, relying on their experience, observation and intuition. We have much to learn from each other.”