Saturday, 19 May 2012

PETER LAMPTEY


THINK AFRICA’S DISEASE BURDEN IS HIV?  THINK AGAIN

PETER LAMPTEY

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Women with depression, men with heart disease: Africa has acquired the so-called diseases of the wealthy, but without the wealth.
Chronic, non-communicable diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the world’s leading cause of mortality, representing 60 percent of all deaths, according to the World Health Organization (WHO). Of the 35 million people who died from chronic diseases in 2005, half were younger than 70. WHO projects that, globally, non-communicable disease-related deaths will increase by 17 percent over the next 10 years and even more severely in Africa, where up to a 27 percent increase is projected.
However, international health aid to Africa has largely been limited to communicable diseases, reproductive health and disaster relief. While we must continue to address these issues, African health systems also deserve attention, as they are systematically failing to address chronic disease epidemics. The reasons are many: overburdened health-care systems that are unable to meet the needs of chronic diseases and acute communicable diseases; a lack of donor attention (there is no Millennium Development Goal related to chronic disease epidemics); poor infrastructure; and poor governance. As a result, deaths from cardiovascular disease, depression and cancers may soon overwhelm the fragile health infrastructure of developing countries. Africa’s “double disease burden” of acute communicable disease and chronic disease demands an enhanced response.

AFRICA HERE AND NOW

The most common form of cardiovascular disease, hypertension, is strongly associated with urbanization, and as African nations race to develop, people are moving to cities in droves. The lifestyle changes – including Westernized diets, lower physical activity, and increased consumption of alcohol and cigarettes – associated with urban migration are so extreme that one study in Ghana found that urban dwellers have nearly a twofold increase in hypertension compared to their rural counterparts.
Because cardiovascular disease in developing countries strikes younger working age populations at higher rates than in high-income countries, the economic impact is more severe in terms of lost productivity from illness and premature death. A study of patients attending a cardiac service in Nigeria found that 57 percent suffered from hypertension and 12 percent suffered from some other form of cardiovascular disease. These and other studies make it clear we are missing vital opportunities to slow this epidemic.
© FHIHowever, a lack of epidemiological data on cardiovascular disease in Africa is creating a deadly Catch-22: without reliable data on the disease burden, resources will not be devoted to the problem; without resources, African countries will not be able to make cardiovascular or other chronic diseases a priority.
Mental illness, including depression, is among the most stigmatized of chronic diseases, and also has a shockingly high prevalence, according to some studies. For example, South Africa’s 2003-2004 Stress and Health Survey indicated that 16.6 percent of participants experienced some form of mental disorder in the past 12 month period, and less than a third of those with a diagnosed mental disorder are in treatment. The relationship between mental health and other disease is cyclical: poor mental health increases likelihood of other diseases, and other diseases can fuel mental health disorders. This interrelationship suggests we need to increase attention to mental illness and to treatment integration.
Incidence of cancer worldwide is projected to double over the next two decades, with roughly 26.4 million new cases and 17 million deaths annually by 2030. WHO data shows that in most developed countries, cancer is the second largest cause of death after cardiovascular disease, and epidemiological evidence suggests this trend is emerging in the developing world. Women in developing countries are disproportionately affected: according to the WHO, more than 270,000 women died of cervical cancer in 2007. Human papillomavirus (HPV) is considered the primary cause of this chronic disease. Worldwide it is estimated that one in 10 women are infected with HPV, with rates of almost one in four in Africa. Cases of breast cancer in these countries are growing at up to 10 times the global average.

THE PITFALLS OF MODERNIZATION

A small set of common risk factors are responsible for the majority of chronic disease worldwide: smoking, poor diet, and lack of exercise. Tobacco use is growing fastest in low-income countries as a result of steady population growth and aggressive marketing by the tobacco industry. Poor diet and lack of exercise contribute to the alarming escalation of obesity, hypertension and diabetes. Most of the rise in cancers can also be explained by these common risk factors and infectious diseases, such as sexually transmitted human papillomavirus infection, Helicobacter pylori bacterium infection, and occupational carcinogens. Lessons learned from high-income countries prove that most of the risks associated with chronic diseases are preventable. According to WHO, “if major risk factors were eliminated, it is estimated that 80 percent of heart disease, stroke and type 2 diabetes, and 40 percent of cancer [in Europe] could be avoided.”
© FHIThe nutrition transition in developing countries from home-grown to packaged and processed foods has resulted in increasing rates of adult obesity, a major risk factor for chronic diseases. Recent trends show a shift in obesity prevalence from the rich to the poor. There is increasing evidence that early nutrition can biologically program later cardiovascular health. For example, studies have established that low birth weight followed by fast weight gain increases cardiovascular risk and disease in adulthood. This association of early under-nutrition with CVD risk factors such as obesity has critical implications for developing countries.
The increase in cardiovascular disease in Africa reflects a major epidemiological transition as a result of industrialization, urbanization, economic development, globalization and aging populations. With increased access to antiretroviral medicines, people are living longer, and HIV is now a chronic disease. The disease and the treatment are, however, causing other risks. According to a joint report by the American Heart Association and the American Academy of HIV Medicine, people living with HIV have an increased risk of CVD.  The risk of heart attack is 70 to 80 percent higher among this population as compared to their HIV-negative counter-parts.

WEAK POLICY FORMATION AND IMPLEMENTATION

There are several examples of policies in Africa aimed at addressing the causes of chronic disease. However, in most instances, implementation is lacking. Lack of stakeholder engagement contributes to this failed implementation and is a major barrier to the advancement of chronic disease-prevention legislation. An example of an effective policy may be South Africa’s Tobacco Products Control Act of 1993, which some consider responsible, in part, for the observed decrease in the number of deaths due to smoking-related diseases (including heart disease, cancer and respiratory illnesses). South Africa also has less well-known policies that address mental health and chronic disease generally; however, their implementation is weak.
At the policy formation stage, factors beyond public health must be considered, or policies may not be implementable. For example, anti-tobacco advocacy groups in Nigeria are trying to pass legislation to restrict tobacco sales and keep cigarettes from minors. The bill is being contested by the tobacco lobby, and by farmers and workers who fear they will lose their jobs. Without effectively addressing these competing priorities – in this case, public health, the business sector, and the need for jobs – bills like Nigeria’s will be in jeopardy.

WE MUST RESPOND WITH URGENCY

© FHIWe must act now to address chronic disease in Africa. HIV – an emerging chronic disease and an international priority – provides an opportunity to engage international agencies and donors in strengthening health systems and workforce development, initiatives that benefit a broader array of health needs. It would not be enough, however, to simply piggyback chronic disease efforts on HIV-focused care. Chronic diseases demand their own international movement. A strong first step would be to develop a Millennium Development Goal that speaks to this issue, one that also supports the integration of global health initiatives to improve efficiency and increase likelihood of sustainability.
As with HIV, prevention is always the best medicine. We call on national governments to step up efforts to reduce smoking, improve nutrition, promote exercise, and start chipping away at the root causes of chronic diseases. African governments must play the primary role in reducing rates of chronic disease in their countries. As we are seeing in Nigeria, however, this cannot be achieved without the engagement of communities and other stakeholders.
There is a large knowledge gap on the prevalence and impact of chronic diseases in African countries. Research is needed to assess the extent of these epidemics, including behavioral, vocational and other factors that fuel them. With this information, efforts to fight chronic disease can be accurately targeted for greater impact. There may be some lessons from high-income countries that have succeeded in reducing the burden of many of these diseases.
In many African nations, the public is unaware of the long-term risks of poor diet, smoking, pollutants or infectious agents. They are not educated about warning signs and symptoms. Mass education will require mobilization of local and international government and advocacy groups to highlight the importance of chronic disease and promote healthy diet and lifestyles. Ultimately, the people affected must be empowered to make decisions and take responsibility for their own health and well-being.
Dr. Peter Lamptey is president of public health programs of Family Health International, a global public health and development organization that builds capacities of health systems to address infectious and chronic diseases and other health needs in more than 100 countries in the developing world.


The lack of attention to treatable chronic illnesses is a real gap in international public health. Today is International Stroke Prevention day, a good day to consider doing more to prevent strokes and to control htn, DM and treat depression.
— Mary Lou Fisher on 2009-10-29
Dr Lamptey provides compelling arguments for increased attention to prevention and better management of chronic disease in the developing world.
— John Engels on 2009-10-29
There is an epidemic of untreated chronic diseases in the developing world. Global health advocates need to provide more attention and resources to this growing problem. My organization, ICHA (http://www.ichaonline.org) was created to prevent chronic cardiovascular disease in developing nations. Dr. Lamptey makes a terrific case for more resources to be devoted to this growing problem.
— Sujatha Sankaran MD on 2009-10-29
Dr Lamptey makes a terrific argument for preventive medicine and public health and primary care medicine, but there is a wrong misconception towards personal super-specialty medicine and health care in Nigeria, Africa’s most populous nation. How do we re-direct attention, even from the training programs in the medical schools, towards more emphasis in community medicine and prevetion?
If primary prevention is not strengthened then all efforts to reverse the epidemic transition from communicable diseses to a mixture of both communicable and non-ccummuincable diseases in Africa will be difficult.
— Emmanuel Monjok MD, MPH on 2009-11-02
Previous strategies and approaches to control Sub-Saharan Africa diseases burden failed to recognize contribution of indigenous/traditional resources, as vital ingredients to a lasting solution for this devastating global health challenges.
— linus ndonga on 2009-11-10
I am highly delighted to note that the public health providers and the health-care providers are now observing the chronic disease epidemics in Africa most especially the West Africa sub-region. It is high time to alert the governments of these nations to put more resources in to chronic disease prevention than to invest in sophisticated chronic disease treatment which is counter productive and much more expensive than prevention.
Kadri Ajileye MD, MPH
— Kadri Ajileye on 2009-11-10
There should be an effort to build/establish an intergrated form of service provision that addresses all views of stake holders;
-The needy sick and carers
-local indigenous knowledge (about wellness & sickness)
-Medical and mental health services
-Schools to educate and promote
-National focus on preventative activities than curative.
There is a need to re-think about how to institutionalise good governance in health services, I suggest we educate health care professionals in project management so that they could hold budgets as oppossed from politicians..
The problem in Africa is not lack of resources, no, not at all , but lack of political capital commited to good cause of good health of the states.
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— William Masembe-Nkata on 2009-11-10
This is an incredible whistle-blowing attempt for a neglected but preventable aspect of our health burden. One major challenge contributing to morbidity and mortality in this area is the issue of fake drugs. Hopefully programmes addressing chronic diseases will also take a critical look at this.
— DR. BELLO FATAI on 2009-12-13
A very interesting article and more so because it highlights the fact that this important issue of funding for chronic diseases is low.  The implication is that donor countries have not addressed the matter fully and need more sensitization. As a person with depression I was startled to discover that it headed the chart, I did not know however that it could lead to death. Is is possible to find out how?
— Marietta Juko on 2010-02-09
Life never seems to be the way we want it but we have to live it the best way we can!
There is no perfect life, but we can fill it with PERFECT MOMENTS.Lets stand as one for a better tomorrow.
Nice article.
— Decampus Magazine on 2010-05-15
this is great.keep it up
— oyerinde opeyemi on 2011-06-25
it’s very dangerous problem for african people….so west & other developed country must concern about it
— faisalquayum on 2011-07-02
I very much appreciate the sensitization against weight related conditions.
I am a Cameroonian Graduate Nurse who will appreciate any form of encouragement to do more sensitization for the good of mankind.
Remain blessed as I wait to hear or read from you.
— Boniface Takwe N on 2012-01-20
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