Reflections on the Age of Limits in Healthcare Resources

The academic new year at Mekelle University for residents (doctors who have graduated from medical school and now will undertake several years of specialty training) is just a few weeks away. They will transform from the theoretical and observing from the sideline to actually being involved in medical care to improve the quality and longevity of their patients. A part of the new experience will be their discovery that there is a limit of resources even in the richest countries and of course more severe in the developing countries. This same thing is happening not just in Mekelle, not just in Ethiopia, but around the world in all the teaching hospitals.

Although we like to pretend otherwise there is no escaping the inevitable fact that we are mortal and will at some point suffer significant illness followed by death. An Ethiopian diaspora calculated based upon the year 2000 that the per capita lifetime medical expenses where $316,000 in the state of Michigan (USA). Most of the cost occurs in the first year of life and after age 50. Women were more than men because they live longer. About one third occurs in middle age and about one half in the senior year of life.
It is hard to put a measure on the value of human life.

When discussions occurred about the use of dialysis as to whether should be payed for by government, analysts determined that spending $50,000 to give an additional year of quality life was worthwhile. This same measure was applied by several governments world wide. The actuarial value of a human life in developed countries is put somewhere between $ 500,000 and ten million dollars by actuarial experts. It is much less in developing countries where the economic output of an individual is much lower often less than a few hundred dollars a year.

The most recent budget for healthcare in Ethiopia was 1.4 billion dollar equivalents which cames out to about $14 per person for the approximately 100 million Ethiopian population. If you count out of pocket expenses it increases to about $24 per capita. This is of course much less than than the $4000-$5000 you see in European countries and the almost $10,000 in the United States. Yet even in these rich countries there are cries that funding is insufficient.

This means that physicians and the policy makers whom they advise have to learn to do more with less. They have to spend resources where they will have most impact. How are these decisions made? Medical ethicists talk about years of productive life as a reasonable way to compare, for example, spending money to help newborns versus the elderly. But not all cultures would agree with this concept totally. There is often a belief that older citizens should be rewarded for their service to society. Note the creation of Medicare and Social Security and its equivalents in the United States and many other developed countries.

Good medical care even in this age of limits is possible. It requires a sound knowledge of likely outcomes, compassion, and realistic communications with the patients and the community at large in both developing and developed countries. The inevitable consequences of our mortality and economic reality of limits leaves no room for anything other than truthful sincerity.

Recommendation for Valproic Acid Restricted Use in Ethiopia

prenatal ultrasound of myelomeningocoel
Prenatal ultrasound showing fetus with lumbar myelomeningocoel

Given the already highest incidence of neural tube defects measured globally present in Ethiopia it would seem exceedingly urgent to immediately call for the cessation of use of Valproic acid, which has been shown to cause neural tube defects,  in women of child bearing age in Ethiopia except for special circumstances.

History of Valproic Acid

Valproic acid was first produced in 1882. At that time its discoverer did not imagine that would be any therapeutic use because it was thought to have no pharmacological value. Then in the 1960s it was begun to be used in France and then in the late 1970s was approved for use in the United States as a primary drug for first epilepsy and then also for migraine headaches as well as mood disorders.

Over the next thirty years, however, concerns began to be raised about the potential relationship of the drug and birth defects.  Both a joint European study and a separate French study showed that women of child bearing age taking appropriate therapeutic doses of 1000 mg a day or more had a high incidence of neural tube defects and other malformations up to seven times higher than the control population.

Valproic Acid Use in Ethiopia

The use of Valproic acid is relatively new in Ethiopia in just the last few years. A review of the treatment of epilepsy from Gondar University showed that 4.84 % of patients were using it. In addition it is being used to treat mood disorders and migraine headache to an unknown extent. The prescription of this medicine is relatively unrestricted and can be done by general practitioners and even non-physician health care providers. Unfortunately the official formulary for Ethiopia briefly mentions that pregnancy is a contraindication and suggests consideration for folic acid supplementation should be given to reduce the risks of birth defects. However a recent animal model study using chick embryos showed that supplemental folic acid for neural tube defects caused by valproic acid was not effective in prevention.

Neural Tube Defects in Ethiopia

Our research at Mekelle University looking at the incidence of neural tube defects in the Tigray region of Northern Ethiopia suggested an over all incidence of at least 130 per 10,000 births but with some locals reporting close to 300 per 10,000 births. We know from studies done by the Ethiopian Institute of Public Health that 28% of women of children bearing age throughout Ethiopia have a significant folic acid deficiency which is likely the strongest contributing factor to the high incidence of neural tube defects

Recommendations for Valproic Acid Restriction in Ethiopia

1.Given the already highest incidence of neural tube defects measured globally present in Ethiopia it would seem exceedingly urgent to call for the immediate cessation of use of Valproic acid in women of child bearing age except for situations where no other drug can be used and the patient is receiving implantable or injectable forms of birth control.

2. Prescription of Valproic acid should only be done by physician sub-specialists in neurology, neurosurgery, or psychiatry and should require extensive counseling to the patient.

3.The formulary of Ethiopia should be modified and vigorously amended to warn of the risks. Although consideration for folic supplementation is appropriate it should be clearly stated that such supplementation may not be effective in preventing birth defects.