In this report, aspects of epilepsy that differ in developing and in developed countries are reviewed. This is inevitably an incomplete and impressionistic survey, because data on many aspects in developing countries are scarce, and because it is difficult to generalise meaningfully about the enormous diversity of countries and populations that make up the developing world. Epidemiological studies of prevalence and incidence are reviewed with an emphasis on the problems inherent in work in this area in developing countries. Data concerning seizure type, aetiology, and severity of seizures in the Third World are contrasted with those from developed countries. Sociocultural aspects of epilepsy have been poorly studied, and yet are fundamental to effective medical management. The social effects of epilepsy and the local perceptions of cause and of treatment are discussed from work in Africa, Asia, and South America. The principles and success of treatment in the Third World may differ considerably in developing and developed countries. In the Third World, medical manpower is scarce, and epilepsy is managed essentially by primary care resources, without specialised investigations or personnel. The principles of drug therapy may not be understood by patients, and the supply of drugs is often erratic; and these are major reasons for poor compliance with treatment. World Health Organisation (WHO) initiatives have stressed the extensive use of paramedical personnel and of an essential drugs list, but this emphasis may be misdirected, and in practice neither proposal has achieved much success. The recommendation that phenobarbital be extensively used in the Third World, because of its cheapness and efficacy, is also of doubtful merit, as there are well-known and major drawbacks to the widespread use of this drug. Computations of treatment gap figures in three developing countries suggest that between 80-94% of patients with active epilepsy are not receiving anticonvulsant therapy, and cost is only one of a number of reasons for this. The key to improvements in medical treatment lie with a better understanding of the patients' cultural concepts of epilepsy and its treatment, improved drug supply and availability, and efforts to improve education amongst general practitioners and other primary care medical personnel.

As part of a population-based study of epilepsy in northern Ecuador, 215 patients with epilepsy and 125 controls were given a questionnaire designed to elicit the degree of stigma associated with epilepsy. Evidence for stigma was also sought from local medical personnel. 144 patients and 98 controls were questioned again 12 months later at study completion to see whether their perceptions had changed. Both intellectual and physical abilities of people with epilepsy were regarded as low by controls, and this opinion did not change over the study period. Observations by medical personnel also suggested stigmatizing attitudes in the community. The number of patients reporting problems with their marriage or childbearing as a result of their epilepsy did not alter over the 12-month period, unlike their estimates of their own intellectual and physical capacities which had significantly improved. Conversely, although their expectations of employment outside the home had diminished, the reasons stated for this related to continuing epilepsy and not to the objections of fellow workers and employers.

No abstract

215 patients with epilepsy and 125 healthy controls were questioned on the effects of epilepsy on social functioning as part of a population-based study of epilepsy in Northern Ecuador. 144 of these patients and 98 of the controls were followed, over a period of 1 year during an intervention study and then-response to treatment assessed. Economic, intellectual and social functioning were examined. In the patient group, function was affected in important areas, most clearly, work. The low opinion the community had of the intellectual and physical abilities of patients might affect a patient''s own view of themselves and sometimes diminish their opportunity for development. At 12 months, as a result of treatment, a significantly lower level of patients reported effects on function in some areas, though control individuals'' views of their functional impairment had not shifted to any extent. Moreover, despite improvement, more patients at 12 months acknowledged fear of seizures, especially their unpredictability, as a handicapping factor, particularly in working outside or away from home. This seems to indicate that even when seizures are controlled, for many patients, the uncertainties of the condition remain and continue to affect their view of their capabilities.