African countries made huge gains in life expectancy. Now that could be deleted.
NAIROBI, Kenya – Hannah Wanjiru has been plagued by dizzy spells and headaches for years. After half a dozen costly doctor’s visits, she was finally diagnosed with high blood pressure. It was two more years – and a few fainting spells – before she started taking medication. By this point, her husband David Kimani had been going back and forth between doctors himself and ended up being diagnosed with diabetes, another condition the couple were unaware of.
They might have wished for other diseases. Not far from her small apartment in the Kenyan capital there is a public hospital where HIV and tuberculosis are treated free of charge. Posters promoting free HIV prevention services line the streets of her low-income neighborhood.
There is no such program for high blood pressure or diabetes, cancer or chronic respiratory diseases. The health systems in Kenya and much of sub-Saharan Africa – and the international donations that support them – are heavily geared towards treating communicable diseases such as HIV and malaria.
“Sometimes I get my sugar tested and I wait all day and I almost pass out, right there in the lineup,” Mr Kimani said.
Success in tackling HIV, tuberculosis and other deadly infectious diseases, and expanding essential services, have helped countries in sub-Saharan Africa achieve extraordinary gains in healthy life expectancy over the past two decades — 10 extra years, the world’s largest improvement , the World Health Organization recently reported.
“But this has been offset by the dramatic rise in high blood pressure, diabetes and other noncommunicable diseases and the lack of health services that target these diseases,” the agency said at the launch a report about health care in Africa. It warned that increases in life expectancy could be wiped out before the next decade is over.
Noncommunicable diseases now account for half of Kenya’s hospital bed occupancy and more than a third of deaths. Rates are similar in the rest of sub-Saharan Africa, and people in that region are affected affected at a young age than those in other parts of the world.
“Vaccination programs are going very well, HIV programs are going very well – but those same people will die from NCDs at a young age,” said Dr Population and Health Research Center, an independent organization in Nairobi.
The medicines and supplies Ms Wanjiru, 44, and Mr Kimani, 49, need to control their condition cost $60 each month, a large part of the earnings from their convenience store, Ms Wanjiru said over tea in their living room. Both skip their medications during the months when their four children’s school fees are due.
“I get headaches and feel weak, and then I feel stressed because I know I have to buy medicine instead of food for my family,” Mr Kimani said.
Routine screening for conditions such as hypertension is rare here, diagnosis rates are low, and care is often confined to specialized centers in urban areas. The public is unaware of the diseases – anyone can spot malaria, but few associate blurred vision or fatigue with high blood pressure – and medical professionals in primary care often don’t know what to look for, either.
as dr When Asiki’s organization set up random screenings in a low-income community in Nairobi a few years ago, researchers found that a quarter of adults had high blood pressure. But 80 percent of them didn’t know they had it. Of those who did, less than 3 percent controlled their blood pressure with medication.
A fraction of Kenya’s health budget goes to noncommunicable diseases – it was 11 percent in 2017-18, the government’s latest figures strategic plan – and these funds are mainly earmarked for expensive medical services such as radiation machines in cancer clinics and kidney dialysis centers. “But people with cancers that are as early as stage 4 have a very low chance of surviving because they can’t be diagnosed,” said Dr. Asiki.
Government ministers are happy to cut the ribbon on new cancer centers, but there is no political value in investing in a long-term screening program, said Catherine Karekezi, executive director of the Kenya chapter of an international patient advocacy organization called the Noncommunicable Disease Alliance.
“Eighty percent of NCD deaths in this country are from preventable causes,” said Dr. Karekezi. “We can prevent the causes, and if you have the condition, we can prevent you from developing complications.”
Instead, she said, younger people get sick and develop serious complications and are sometimes unable to work. “The economically active part of the population is affected,” she said.
People die in their 50s from undiagnosed heart disease or complications from diabetes, and that’s attributed to “old age.” Systems for accurately tracking causes of death are weak, meaning neither the public nor policymakers understand the true extent of the problem, said Dr. Asiki.
Unlike HIV medication and care, which is usually free and subsidized by international donors, treating diabetes or blood pressure is usually an out-of-pocket expense for families and often cripplingly expensive, said Dr. Jean-Marie Dangou, who coordinates the noncommunicable diseases program of the WHO Regional Office for Africa.
“In the Democratic Republic of the Congo, treating high blood pressure accounts for two-thirds of typical household income each month,” he said. “It’s absurd for this family. But it’s not uncommon.”
Annah Mutindi, 42, used all her life savings from her day job as a clerk at a Nairobi clothing store on doctor visits and tests before a painful lump in her breast was diagnosed as cancer in January 2021. She was prescribed a course of 12 bi-weekly sessions of chemotherapy. In theory, she could have gotten it from a large public hospital in the center of town for minimal cost, but the drug was constantly out of stock.
Instead, she had to wait for her family and friends to scrape together $360 every few weeks so she could pay for treatments individually, spread over the next nine months.
“I was shocked when they told me it was cancer because I never touch alcohol and eat healthily,” Ms Mutindi recalled of her diagnosis. “They said it might be environmental factors.”
The proportion of deaths from noncommunicable diseases is increasing across the Region, most rapidly in the continent’s most populous countries, said Dr. dangou In Ethiopia, for example, mortality from these diseases rose from 30 percent in 2015 to 43 percent of deaths last year, and made a similar jump in the Democratic Republic of the Congo
It is clear that rapid urbanization and an increase in sedentary lifestyles are driving some of the increase in these conditions. Tobacco and alcohol consumption is also growing, as is the consumption of processed foods.
The Kenyan government has been slow to update policies to prevent this. And all three industries have powerful lobbying organizations focused on stopping legislation like a sugar-sweetened beverage tax. Kenya is a major tobacco producer and the industry is reminding the government of the jobs it creates, said Dr. Asiki
Add to that the simple fact that people are living longer because of advances in fighting infectious diseases. But other causes, such as possible genetic factors and a correlation with exposure to infectious diseases, are less well understood.
There is little public investment in unraveling the mystery of why NCD rates are rising so rapidly in this region, and among comparatively younger people.
The experience of high-income countries is of limited relevance to the situation in a country like Kenya, said Dr. Asiki. The lack of nutritious food in childhood seems to prepare people metabolically for obesity in adulthood. There is some evidence of this Malaria infections predispose people to cardiovascular disease; Hepatitis infections put them at risk of cancer.
Years of use of antiretroviral drugs that control HIV can put you at greater risk of heart disease. City dwellers also face increased air pollution and environmental toxins, and some the stress of living in areas of high violence and insecurity. All of these are contributing factors, said Dr. Asiki, but their combined effect is not well understood.
dr Andrew Mulwa, who leads preventive and health promotion programs for the Kenya Ministry of Health, said the government is concerned about rising rates of noncommunicable diseases, but it is a slow process to roll out diagnosis and treatment at the primary care level in rural areas.
“When I was working as a clinician in a rural area 10 years ago, you saw 50 patients a day with these conditions, and now it’s 500 to 1,000 in the same facility,” he said.
Poor diet affects the rise in noncommunicable diseases in a variety of ways – which Dr. Asiki referred to as a “double burden of malnutrition”. This region is home to the world’s largest number of underdeveloped children and the fastest growing obesity rate.
In low-income households, it’s common to find both malnourished children, who lack the proteins and nutrients essential for growth, and adults who are obese because they depend on cheap, greasy, high-energy street food – often one more affordable option than paying for vegetables and cooking gas to prepare food at home.
“You can have enough of the bad food but lack of the food you need,” said Dr. Asiki. “The body stores excess energy as fat – but in the end it’s still deficiency.”
He speculated that the government has been slow to roll out screening programs because it cannot respond to the scale of the problem.
“That’s when you suddenly realize I don’t have enough meds for high blood pressure, I don’t have enough meds to treat people with cancer,” said Dr. Asiki. “When you screen, you will select cases that are treatable. But do we have the resources to treat them?”
https://www.nytimes.com/2023/03/09/health/africa-diabetes-hypertension-cancer.html African countries made huge gains in life expectancy. Now that could be deleted.