African countries have made huge gains in life expectancy. Now it could be erased.
NAIROBI, Kenya — Hannah Wanjiru has been plagued with dizziness and headaches for years. After half a dozen costly visits to the doctor, he was finally diagnosed with high blood pressure. It took two more years – and some fainting spells – before she finally started taking medication. By then, her husband, David Kimani, was shuttling between doctors himself and ended up with a diagnosis of diabetes, another disease the couple knew nothing about.
They could have wished for different diseases. Not far from their small apartment in the Kenyan capital, there is a public hospital where free treatment for HIV and tuberculosis is provided. Posters of free HIV prevention services line the streets of their low-income neighborhood.
There is no such program for hypertension or diabetes, or for cancer or chronic respiratory disease. Health systems in Kenya and much of sub-Saharan Africa – and the international donations that support them – are heavily stretched to treat infectious diseases such as HIV and malaria.
“Sometimes I’ll go get my sugars tested and wait all day and almost pass out right there in the queue,” Mr Kimani said.
Success in the fight against HIV, malaria and other deadly infectious diseases, along with an expansion of essential services, has helped countries in sub-Saharan Africa make extraordinary gains in healthy life expectancy. health over the past two decades – 10 more years, the biggest improvement in the world, the World Health Organization recently reported.
“But this has been offset by the dramatic increase in hypertension, diabetes and other non-communicable diseases and the lack of health services targeting these diseases,” the agency said, launching a report on health care in Africa. He warned that the increase in life expectancy could be wiped out before the end of the next decade.
Non-communicable diseases now account for half of hospital bed occupancy in Kenya and more than a third of deaths. Rates are similar in the rest of sub-Saharan Africa, and people in this region are affected at a younger age than those in other parts of the world.
“Immunization programs work very well, HIV programs work very well – but these same people will die of non-communicable diseases when they are young,” said Dr Gershim Asiki, a researcher specializing in the management and prevention of these conditions at the African Population and Health Research Center, an independent organization in Nairobi.
The drugs and supplies that Ms. Wanjiru, 44, and Mr. Kimani, 49, need to control their conditions cost $60 a month, a huge chunk of their small convenience store’s income, Ms. Wanjiru said around a tea in their living room. Both skip their meds in the months when school fees are due for their four children.
“I have headaches and I feel weak, then I feel stressed knowing that I have to buy medicine instead of eating for my family,” Mr Kimani said.
Routine screening for conditions such as high blood pressure is rare here, diagnosis rates are low, and care is often only available at specialist centers in urban areas. The public is unaware of the diseases – everyone can recognize malaria, but few associate blurred vision or exhaustion with high blood pressure – and primary health care workers often don’t know what to check for either.
When Dr. 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% of them didn’t know they had it. Of those who did, less than 3% controlled their blood pressure with medication.
A fraction of Kenya’s health budget is spent on non-communicable diseases – it was 11% in 2017-2018, according to the latest figures released by the government strategic plan – and these funds are mainly for expensive curative services such as radiation machines in cancer clinics and kidney dialysis centers. “But people come in with cancers that are already at stage 4, with very little chance of survival, because they can’t be diagnosed,” Dr Asiki said.
Government ministers like to cut the ribbon on new cancer centres, but there is no perceived political value in investing in a long-term screening program, said Catherine Karekezi, executive director of the Kenyan chapter of a international patient advocacy organization called the Noncommunicable Disease Alliance.
“Eighty percent of non-communicable disease deaths in this country are from preventable causes,” Dr Karekezi said. “We can prevent the causes, and if you have the disease, we could prevent you from progressing to complications.”
Instead, she says, young people get sick and develop serious complications, and are sometimes unable to work. “It is the economically active segment of the population that is affected,” she said.
People die of undiagnosed heart disease or diabetes complications in their 50s and this is blamed on ‘old age’. THE systems to accurately track causes of death are weakmeaning neither the public nor policymakers understand the true scale of the problem, Dr Asiki said.
Unlike drugs and HIV care, which are usually free and subsidized by international donors, treatment for diabetes or high blood pressure are usually out-of-pocket expenses for families, and often crippling in cost, said Dr Jean-Marie Dangou, who coordinates the disease control program of the WHO Regional Office for Africa.
“In the Democratic Republic of Congo, treatment for hypertension accounts for two-thirds of the average household income each month,” he said. “It’s absurd, for this family. But that’s not unusual. »
Annah Mutindi, 42, used all her savings from her job as a clerk in 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 biweekly sessions of chemotherapy. She could have had them for minimal cost, in theory, at a major public hospital downtown, but the treatment was continually out of stock.
Instead, she had to wait for her family and friends to raise $360 every few weeks so she could pay for the treatments one by one, spread over the next nine months.
“I was in shock when they told me it was cancer, because I never drink alcohol and I eat healthy,” Ms Mutindi said, recalling her diagnosis. “They said maybe it was environmental factors.”
The share of deaths caused by non-communicable diseases is increasing across the region, fastest in the continent’s most populous states, Dr Dangou said. In Ethiopia, for example, mortality from these conditions soared to 43% of deaths last year, from 30% in 2015, and made a similar jump in the DRC.
It is clear that rapid urbanization and increased sedentary lifestyles are driving some of the increase in these conditions. The same goes for the increasing consumption of tobacco and alcohol, and the consumption of processed foods.
Kenya’s government has been slow to update policies to discourage them. And all three industries have powerful lobbying organizations focused on blocking legislation, such as a tax on sugary drinks. Kenya is a major tobacco producer and the industry reminds the government of the jobs it creates, Dr Asiki said.
There is also the simple fact that people are living longer thanks to advances in the fight against infectious diseases. But other causes, such as possible genetic factors and a correlation with exposure to infectious diseases, are less understood.
There is little public investment in finding the mystery of why rates of non-communicable diseases are rising so rapidly, and among comparatively younger people, in this region.
The experience of high-income countries is of limited relevance to the situation in a country like Kenya, Dr Asiki said. Scarcity of nutritious foods in childhood appears to metabolically prepare people for obesity in adulthood. There is evidence that malarial infections predispose people to cardiovascular disease; hepatitis infections put them at risk of cancer.
Taking antiretroviral drugs that control HIV for years can lead to an increased risk of heart disease. City dwellers are also exposed to increased rates of air pollution and environmental toxins, and some to the stress of living in areas with high rates of violence and insecurity. All of these are contributing factors, Dr. Asiki said, but their combined effect is not yet well understood.
Dr Andrew Mulwa, who heads prevention and health promotion programs for the Kenyan Ministry of Health, said the government was concerned about soaring rates of non-communicable diseases, but the roll-out of diagnostics and treatment at primary care level in rural areas was slow. areas.
“When I was working as a clinician in a rural area 10 years ago, you would see 50 patients a day with these conditions, and now it’s 500 to 1,000 at the same facility,” he said.
Poor nutrition influences the rise in non-communicable diseases in multiple ways – what Dr Asiki calls “a double burden of undernutrition”. This region is home to both the highest number of stunted children in the world and the fastest rising rate of obesity.
It is common in low-income households to find both malnourished children, who lack protein and nutrients essential for growth, and obese adults, who depend on cheap, fatty and fatty street foods. energy-rich – often a more affordable option. than paying for vegetables and cooking gas to make food at home.
“You can get tired of the wrong food but the scarcity of necessary food,” Dr. Asiki said. “The body stores excess energy as fat – but in the end it’s always a shortage.”
He speculated that the government had been slow to roll out testing programs because there was no way to address the scale of the problem.
“That’s when you suddenly realize that I don’t have enough medicine for high blood pressure, I don’t have enough medicine to treat people with cancer,” Dr Asiki said. “If you screen, you will choose cases that are treatable. But do we have the resources to treat them?