By Patricia Vermeulen*
Communicable diseases like HIV, malaria and tuberculosis are still responsible for high death tolls today. During its highpoint in the late 1990’s, the HIV/AIDS epidemic had a huge impact on daily life and was socially and economically devastating for much of Africa. Health systems across the region were overwhelmed by the disease, and international resources were slow to be mobilised. Much has changed since then.
Although HIV still makes many victims every year, a decade of regional and international efforts have reduced its impact. Malaria, a disease that killed more than a million Africans a year in the 1990s, also saw a significant decrease in the number of victims, due to a focus on prevention and treatment. For decades, the African continent struggled with these communicable diseases. Nowadays, African healthcare systems face the risk of being overwhelmed again: this time the lack of attention for the increase in non-communicable diseases (NCDs) can form a great threat to Africa’s health systems.
The increase in non-communicable diseases is arguably the consequence of the continent’s rapid economic growth and the changes that go with it. High GDP growth rates, urbanisation and development of a new middle class in sub-Saharan Africa created a climate that attracts all kinds of investors. By 2030, half of all Africans will live in cities. It is estimated that Africa already has a consuming class of around 300 million people. Global fast-food companies are expanding to markets in several African countries, markets that once would never be a part of their business strategy. Burger King is due to open in Angola and Zimbabwe, KFC in the Democratic Republic of Congo and Ethiopia. Moreover, Africa is increasingly a profit centre for global brewers like Heineken, SABMiller and Diageo, and one of the few markets where cigarette sales are increasing in a world that is giving up on tobacco.
This new, high-consumption lifestyle, combined with greater life expectancy, has led to a wave of non-communicable diseases. The prevalence of these kind of diseases has already increased significantly, but is estimated to continue to increase rapidly in the near future. Non-communicable diseases are also known as chronic diseases and, as the name suggests, these diseases cannot be transmitted from one person to another. Non-communicable diseases are for example different types of cancer, respiratory illnesses, cardiovascular diseases, diabetes and other diseases associated with urban living. Currently this category is responsible for around 35% of mortality in Africa; however, the World Health Organisation forecasts this will rise to 65% by 2020. Non-communicable diseases kill 38 million people worldwide each year, but disproportionately affect low- and middle-income countries. In these countries almost three quarters of the deaths occur, roughly 28 million. Many of which are so called “premature” deaths because they occur under the age of 70. Once again this is distributed disproportionately; 82% of these “premature” deaths occurred in low- and middle-income countries. These countries generally have lower capacity for the prevention and control of non-communicable diseases. In these countries the diseases are driven by forces that include ageing and the globalisation of unhealthy lifestyles as mentioned before, and by the rapid unplanned urbanization and pollution.
Skip those pages
Dr. Allan Pamba is the vice president for East Africa at GlaxoSmithKline (GSK ). He qualified as a physician at the peak of the HIV/AIDS epidemic in East Africa, he says that this formed his education to a great extent. “Nowadays, I’m hearing a lot more about cancer, strokes and long-term diabetes. Those were pages in my medical school textbook that we were told: if you skip those pages, it’ll be fine. You’ll never see that in your lifetime,” Pamba says. “We were told to read about malaria, read about tuberculosis, read about the communicable diseases. My training in the area of non-communicable diseases was deficient, as it was for many other physicians that are practicing now, because we didn’t foresee this happening in our lifetime. But they are becoming a problem. We do not have the capability to deal with it. We do not have the manpower trained in sufficient numbers. We don’t have the medicines to treat the diseases when we fail to prevent, and we don’t have the healthcare infrastructure.” Together with GSK, Amref Health Africa launched a programme to train health workers on management of non-communicable diseases. The three-year programme will train 2,500 health workers including nurses, clinical officers, laboratory technicians, nutritionists, pharmaceutical technicians, community health volunteers and community health extension workers on prevention screening, diagnosis, treatment and ongoing care for diabetes and childhood asthma. This is an important step in order to improve and strengthen the health systems in Africa.
Crisis-orientated health systems
The health systems in African countries are not well equipped to deal with non-communicable diseases. Even regional hubs, such as Nigeria’s commercial capital, Lagos, and Kenya’s capital, Nairobi, lack the sophisticated oncology and cardio-vascular facilities required to treat current patients. Many, if they can afford it, travel abroad for treatment, for example to countries like India, Singapore or countries in the Middle East. The legacy of decades of international investment into tackling communicable diseases is that most of Africa’s medical infrastructure is arranged in silos, created to treat individual crises. The current model is designed to respond to situations only after something goes wrong, that requires a lot of expensive interventions. Non-communicable diseases require an entirely new approach to building healthcare systems. Public health has to move away from “crisis mode” and into a broader understanding of a patient’s lifestyle, wellbeing and ongoing needs. Healthcare infrastructure will need to focus as heavily on prevention and lifestyle as it does on curing those who are already sick. We have to learn lessons from the HIV/AIDS epidemic, where initially too little emphasis was put on prevention.
How technology can help
Mobile healthcare or mHealth is seen as a potential solution for a whole range of public health problems by many, since the African telecom boom began a decade ago. Today, mobile-phone coverage is still rapidly expanding , and smartphone usage is rising as phones become cheaper and data services are rolled out throughout Africa. This has already revolutionized financial services. In more than a dozen African countries, mobile wallets outnumber traditional bank accounts. Medical professionals are hoping that mobile phones will allow them to remotely treat patients and build the datasets that will help them deal with future health problems. mHealth can play a significant role in the prevention and treatment of non-communicable diseases.
Most of Africa’s 2,000 plus languages have no word for cancer. The common perception in both developing and developed countries is that it is a disease of the wealthy world. The capacities to detect, diagnose, and effectively treat cancer in Africa have been traditionally weak, as public health authorities focus on managing and suppressing infectious diseases. Surveys by the Atomic Energy Agency through middle and low income countries show that more than 20 African countries don’t have even a single facility with working radiotherapy machines. For example Uganda only has one radiotherapy treatment unit, Tanzania has two. There are 385 radiotherapy machines on the African continent distributed over 54 countries and 1 billion people. About 60% of the machines are found in just three countries: South Africa, Egypt and Morocco. The next 20% are also located in only three countries: Tunisia, Nigeria and Algeria. Given the poor state of treatment facilities, Africa has the highest death rate among cancer patients, even though it still registers a lower number of cases compared than most parts of the world. Data from the World Health Organisation, shows that 71% of the people diagnosed with cancer in Africa die. The number of cancer cases is only going to increase in the years to come. It is estimated that one fifth of the deaths from non-communicable diseases are going to be from cancer.
The case of Carol Atuhirwe
In Uganda, the poor state of the cancer treatment facilities became painfully clear this year. The case of the 29-year-old Carol Atuhirwe led to public outrage throughout Uganda. She was diagnosed with throat cancer around five years ago and received aggressive treatments ever since. Atuhirwe was treated in Uganda’s only cancer-treatment facility. Her treatment existed of multiple radiation treatments and no less than 26 surgeries. However, the radiation machine was very old and in poor state and it caused severe burnings on her right shoulder and neck. After the radiation, Atuhirwe needed reconstructive surgery to treat the burns. During one of those surgeries her trachea was displaced, now she can no longer speak and has to eat through a tube. An inspection in 2013 reported that the machine exposed patients to direct radiation and should already have been replaced much earlier. The radiation machine was installed in 2002 and has a durability of ten years. The Ugandan Cancer Institute did not respond to this report however, and continued to use the machine. That was before the machine broke down completely in April that year. Unfortunately, the state of the cancer treatment facilities in Uganda is not a unique story in Africa. It is an example of a broader, continent wide problem.
Following these events, Atuhirwe’s friends circulated a video on social media. They asked for funds so Atuhirwe could continue her treatment in the United States. People in Uganda were outraged about her story and responded en masse. Multiple crowdfunding initiatives were started. People sent contributions via their mobile phones. Supermarkets placed ‘Save Carol’ baskets at entrances for shoppers to drop contributions and charity car washes were held. Selfies behind a pink frame with hashtags #SaveCarol and #FightCancer flooded Ugandan social media timelines. A total of $98,600 was raised by all the initiatives combined. But, it all may have come too late for Atuhirwe. Her doctors in Uganda and the United States agreed that Atuhirwe was too ill to travel. She is back to receiving indefinite palliative care at the Uganda Cancer Institute. She is one of the many cancer patients in Africa who are stuck in a malfunctioning system.
*Patricia Vermeulen is the CEO of Amref Flying Doctors in the Netherlands