Mention neurology as an under-acknowledged and under-resourced branch of Irish medicine and some might raise their eyebrows. Neurology? What's that? Something obscure to do with the nerves? In fact neurology encompasses complaints as common as migraine (which affects 15 per cent of the population) and the after-effects of a stroke, as well as more complex diseases such as MS and motor neurone disease. We have only 11 consultant neurologists in the Republic, which is less than a third of the European average.
"One neurology consultant per 100,000 people is the acceptable European average," explains Dr Orla Hardiman, a consultant neurologist at Beaumont Hospital in Dublin. "In the Republic we have one for every 350,000 people." Dr Hardiman, under the auspices of the Irish Institute of Neurology and Neurosurgery (IINN), has organised an international conference in Dublin next weekend "to showcase Irish neurological research and to provide a forum for Irish graduates in neurology."
Of these estimated 40 Irish neurologists who are gaining expertise abroad, many would like to come home, but the positions are just not available: "Traditionally the Department of Health has not been pro-active about creating new consultant neurologists because neurology has been perceived as an academic discipline," says Dr Hardiman. "People were put off neurology because they thought that there wasn't much you could do with many neurological diseases. But the situation has changed. The 1990s was the decade of the brain in the US and there have been huge advances."
She believes that overseas experience gives Irish neurologists invaluable experience which could be harnessed back at home if more consultant positions were made available: "Ireland is small, and most people in medicine spend time abroad to flesh out their training. In Boston where I trained, there were 14 neurologists in one hospital alone." During the 1980s there was no certified specialist training in neurology in Ireland, but it is now available through the Irish Commission of Higher Medical Training.
However, the fact that there are so few consultant neurologists available here leads to a variety of problems. "It means a limited access to expert opinions. In the public system, my waiting list is a year," says Dr Hardiman. "People have to travel long distances, because most of the consultants are in Dublin and Cork and there are only a few outreach clinics. The clinics are always overbooked and people have to wait for hours. Typically, my afternoon clinic doesn't end until 8 p.m."
The consultant's input is vital, she stresses. It is very much a partnership situation with the patient's GP, but a consultant has a far greater familiarity with the diseases involved: "A GP might see one case of motor neurone disease in his whole career. New treatments for MS and Parkinson's have become available in the last 10 years. We know about them, whereas a GP might not."
Some of the "new vistas" opening up for Parkinson's include brain surgery (pallidotomy, or cutting fibres in the affected part) and deep brain stimulation to control symptoms. Diseases such as MS, motor neurone and Alzheimer's require "a multi-disciplinary approach" which a GP cannot easily co-ordinate, but can be organised by consultants working in a hospital setting: "In Beaumont we have a multi-disciplinary clinic for people with motor neurone disease. Patients come to see me every two months, and they also see an occupational therapist about their living space, a physiotherapist for management of stiffness, a speech therapist for swallowing problems, and a nutritionist."
Similarly with severe cases of epilepsy; a neurologist rather than a GP is needed "to advise on medication and other treatment" (here, too, surgery is becoming an option). As for stroke victims: "It has been shown that if you set up stroke units managed by experts, the outcomes for patients are better." Some inherited diseases are neurological, such as Huntingdon's disease and Friedreich's Ataxia. Others are what is known as "acquired", such as stroke or migraine. Motor neurone disease, Parkinson's and Alzheimer's are a combination of the two. Neurological infections include CJD, encephalitis and meningitis. MS is a neuro-immunological disease, where the inflammation of the central nervous system leads to damage and disability. There are five different forms, with relapsing remitting MS being the most common. In 40 per cent of cases, there is very little disability after five or 10 years, stresses Dr Hardiman: "The beta-interferon injection, available in Ireland for the last four years, decreases the amount of relapses by 30 per cent."
Her speciality, motor neurone disease, is a terminal condition where there is a disruption of how cells handle their toxic by-products and the sufferer becomes unable to move. Death occurs in three years or less, usually due to breathing failure. Well-known victims include David Niven and Jill Tweedy. Mao had it and Stephen Hawking has a variant of it. Ten per cent of cases are genetic, the rest are "acquired", but "there may be predisposing factors".
One of these is, ironically, if the person is athletic: "In the US it is known as Lou Gehrig disease, after a famous baseball player, who, before Babe Ruth, made the most home runs ever. The first symptom was that his batting average went down." The only medication available for motor neurone disease is Riluzole, which extends life expectancy by just three months. Otherwise there is nothing that can be done for patients beyond "palliative care and applied rehabilitation". With the pace of research, however, Dr Hardiman is convinced that the development of new forms of treatment is not far off.
Since 1995, she has been involved in "a huge population study of motor neurone disease in Ireland. Ireland is a good place to do this kind of research, because it is a confined population with very little immigration. You can start seeing disease patterns and outcomes." She stresses that "in spite of the manpower shortages, important research work is being done here".
Meanwhile, shortages continue to hold things up: "One of the best ways to of seeing what is happening in the brain is an MRI scan, but there is only one scanner in the country, in Beaumont Hospital. The waiting list can be six months."