Urban–Rural Divide in Neurocritical Care in Low- and Middle-Income Countries: The Tip of the Iceberg

Neurocritical care services are provided differently in different areas of the world. Specifically, care by specialists in dedicated units is more available in high-income countries and mainly in urban areas. Mahajan et al. [1] reviewed and analyzed the available literature on the urban–rural divide in neurocritical care in low- and middle-income countries (LMICs). This a timely comprehensive review on an important topic with significant public health implications on a large population in LMICs. The authors emphasized the disparities of care of neurocritically ill patients in rural areas in general and specifically in LMICs through a summary of the available evidence, analysis of the barriers, and the underlying factors related to the health care systems and socioeconomic situations. The implications of suboptimal care are huge considering the baseline health disadvantage of this population, the mortality and morbidity related to acute brain injury, the long-term disability, and the scarcity of rehabilitation resources. The authors also discussed in more depth specific disease entities that are more prone to this disparity in care or more prevalent in rural areas, including ischemic stroke, traumatic brain injury, tuberculous meningitis, and epilepsy. General headlines for potential solutions tailored to the situation were also suggested, although the feasibility, efficacy, and cost-effectiveness of such interventions remain to be proven individually per intervention and per setting. One controversial solution suggested by the authors was early tracheostomy to decrease intensive care unit stay and spare resources, with the limitations of lack of supportive data, potential for more unindicated invasive procedure, and potential risks of taking care of such patients on a regular ward. Other solutions focused on human resources, telemedicine, mobile stroke units, protocolized care, education, and strengthening communication and collaboration. …