Report on neurological burden in Hargeisa, Somaliland between 2019
and 2020: A cross-sectional study

A. University of Hargeisa Medical School, Hargeisa, Somaliland
B. Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
C. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
D. The Chester M. Pierce, MD Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
e Department of Neurology, Massachusetts General Hospital, Boston, MA, USA

Neurological diseases are the leading causes of mortality and morbidity worldwide, giving rise to a significant burden on patients, families, communities, and nations. Globally, neurological diseases are the largest contributors to disability-adjusted life-years (DALYs; 276 million or 11.6% of DALYs for all global diseases) and the second leading cause of death (9 million or 9.1% of global deaths).

Strokes are the largest contributor of neurologic DALYs (42.2%), followed by headaches (16.3%), dementias, including Alzheimer’s Disease and Parkinson’s Disease (10.4%), and meningitis (7.9%). Over the past three decades, these numbers have continued to rise. While the agestandardized mortality rate has stabilized, absolute deaths due to
neurological diseases have increased by 39%, with a 15% increase in DALYs .

In low-income and middle-income countries (LIMC), this rise has been especially problematic. With increasing population sizes, stalling economies, and stifled care delivery, LMICs are unable to keep up with the rising need for neurological care.

In sub-Saharan Africa (SSA) and East Africa, both neurologic care resources and available epidemiological data are particularly scant. This region also experiences a disproportionate burden of
neurological disease compared to higher-income countries (HICs).

Stroke, which is the leading cause of neurologic death worldwide, has
increased by an alarming 100% in SSA in recent decades, with a younger average age of onset than in HICs . 80% of people living with strokes live in LMICs. Epilepsy has also experienced a rise of nearly 70% in SSA in just the past two decades. Both stroke and epilepsy—whose etiologies in SSA differ slightly from that of LIMCs—could be largely prevented or have treatments available to address this rising burden.

Malnutrition, the rise in infectious diseases, stigma centered around
neurological disease, and lack of access to care contribute directly and indirectly to disease burden . Further, a lack of attention to neurologic disease in SSA, which is evidenced by the scant epidemiological literature on the matter, is a significant contributor to the lack of
progress and continued rise of these diseases in the region. Together, the
increase in neurological disease burden and the lack of measures to mitigate this rise exacerbate the socioeconomic health of the region, stifle developmental advances, and hinder the livelihood of those livingbin SSA.

Of the sparse literature on neurological disease burden and prevalence in East Africa that does exist, many studies have focused on disease-specific prevalence as opposed to carrying out a holistic investigation of all neurological diseases within a particular country or subSaharan region . The Global Burden of Diseases, Injuries, and Risk Factors Study published in the Lancet remains one of the only
studies to provide comprehensive epidemiological data on the prevalence of neurologic disease around the world, including SSA-specific regions. However, these estimates on GBD are largely based on freely accessible data where most of the SSA countries had scarce or no patient data readily available when the data for this study was collected,requiring the authors to estimate prevalence similarity based on
“geographical proximity” to the country in question.

This major limitation underscores the importance of and need for high quality
studies in countries that are poorly represented in large-scale studies like
this. In that vein, we set up a dual neurology-psychiatry residency program in partnership with the University of Hargeisa (UoH) as a starting
point to address the growing needs of brain disorder care delivery in SSA
and to investigate the neurologic patient population in this particular city, which stands as the capital of Somaliland.

Somaliland, which only recently gained independence from Somalia in 1991, is situated in the Horn of Africa . It shares boundaries with the Gulf of Aden in the north, Somalia in the east, the Federal Republic of Ethiopia in the south-west, and the Republic of Djibouti in the northwest. It covers a total surface area of 176,119.2 km2, with a 850 km long coastline . It houses approximately 3.8 million inhabitants, 52.8% of which are urban, 33.8% nomadic, 11% rural, and 2.4%
internally displaced persons.

The health infrastructure of Somaliland is severely underdeveloped. The country ranks 161 out of 163 least developed countries in the world and has a healthy life expectancy of 45 years compared to the regional average of 58 years. This comes to no surprise, as there are only 4 physicians per 100,000 people, and 22
hospitals for its 3.8 million inhabitants, three of which are in Hargeisa.

More alarming is the fact that there are only 3 neurologists in all of Somaliland, 2 of which are in Hargeisa. The lack of
neuroimaging equipment in Somaliland further compounds this care capacity deficit, with recent reports indicating the presence of as few as four CT scanners and two MRI scanners for the nation’s 3.8 million citizens. Furthermore, these modalities are not available to the
public due to the paucity of health insurance in the region, forcing
people to pay out of pocket for life-saving imaging.

Fortunately, CSF diagnostics and EEG/EMG units are more available, with larger cities
such as Hargeisa and Berbera harboring up-to-date and sophisticated
neurophysiology units.

In this study, we collected de-identified health data from patients in all three of Hargeisa’s hospitals, which included demographic and descriptive data on the neurologic diagnoses, services, and care delivery.rendered by three neuropsychiatry trainees. All three trainees are residents at the dual neurology-psychiatry residency program established by the Chester M. Pierce, M.D. Division of Global Psychiatry at the Massachusetts General Hospital in partnership with the University of Hargeisa Medical and Nursing schools, with the goal of creating a sustainable training pipeline to increase the scarce levels of brain care delivery in the region.

To date, no study has investigated the prevalence of neurological diseases in Somaliland, which stands as one of SSAs most underdeveloped countries. Therefore, the objective of this study was to determine the prevalence of neurological disease in Somaliland and to use this data to provide the country with the standards from which to provide neurologic services and clinical guidelines. Moreover, we intend for this paper to set the stage for future investigations into the immense gaps in neurological epidemiology in Eastern Africa and SSA. Lastly, this study could in part inform policymakers and clinicians in Somaliland to translate this data into policy driving preventative care.

In Conclusion the study characterizes the prevalence of neurological disease in Hargeisa, Somaliland. Our findings corroborate previous study findings 
examining similar country profiles while also shedding light on important differences that demonstrate a dire need for updated clinical guidelines and policy intervention aimed at improving brain health and minimizing morbidity, mortality, and overall disease burden in Somaliland. Lastly, it is of utmost importance for the scientific and medical community to continue to add to the sparse literature on neurologic epidemiology in African countries, as this will uncover unique patterns and etiologies critical to disease prevention and mitigation.