For months, health officials in this socially conservative state capital have been staggered by a fast-spreading outbreak of a disease that, for nearly two decades, was considered all but extinguished.
Syphilis, the deadly sexually transmitted infection that can lead to blindness, paralysis and dementia, is returning here and around the country, another consequence of the heroin and methamphetamine epidemics, as users trade sex for drugs.
To locate possible patients and draw their blood for testing, Oklahoma’s syphilis detectives have been knocking on doors in dilapidated apartment complexes and dingy motels, driving down lonely rural roads and interviewing prison inmates. Syphilis has led them to members of 17 gangs; to drug dealers; to prostitutes, pimps and johns; and to their spouses and lovers, all caught in the disease’s undertow.
More and more people around the world are getting sick with two or more health conditions at the same time. For example, people are increasingly coping with two chronic non-infectious diseases, like hypertension and diabetes. Or they will have a chronic infectious disease like HIV and a chronic non-infectious disease like asthma.
The co-existing conditions could include diseases, disorders, illnesses or other chronic health problems. The concept of having two or more chronic health conditions at the same time is called multimorbidity.
Traditionally, developed countries have a high prevalence of non-communicable diseases – like hypertension – and due to this, a high rate of multimorbidity.
Now the tables seem to be turning. Due to the rise in the cases of non-communicable diseases in developing countries, there is an increasing emerging pattern of high levels of multimorbidity. This includes cases of hypertension which is now the most common co-morbid chronic non-communicable disease in the world.
The prevalence of non-communicable diseases is increasing at an alarming rate. In 2000, non-communicable diseases accounted for only 56% of the total disease burden. Scientists estimate that by 2020, they will account for almost 70% of the total disease burden in developing countries.
The increase has been driven by urbanisation and changing dietary and behavioural patterns with people eating more processed food and sugar and exercising less.
But alongside this, many developing nations, especially in Africa, have the additional burden of chronic infectious diseases.
Non-communicable diseases and chronic communicable diseases co-occur, and the risk factors, such as alcohol and tobacco use, associated with them are often shared. This further increases the likelihood of multimorbidity.
In Africa, the concern is that populations who are already socially and economically vulnerable also face the highest risk of multimorbidity. These include the elderly, people who have a lower socio-economic status and those who are not as educated. An intersectoral approach to address these vulnerable groups is needed. This remains challenging for developing health services in many African countries.
Affecting the patient and the system
The impact of multimorbidity is three-fold: it affects the patient, the health care provider and the health system as a whole.
Multimorbid patients have a decreased quality of life and tend to access health services more frequently. This often results in loss of potential income. And it places an extraordinary financial and psychological burden on the patient. The psychological burden often manifests as depression with mental health conditions frequently being associated with multimorbidity, which are often neglected or poorly managed.
More generally, the high self-management requirements and multiple drug prescriptions associated with multimorbidity can lead to poorer health outcomes for patients.
From the provider perspective, multimorbid patients are complex to treat. This can lead to increased workloads. In addition, they need an in-depth understanding of multiple drug and disease interactions. With each additional comorbidity consultation, time and individual patient cost increase dramatically.
But providers often find themselves in systems which are inadequately prepared to deal with this level of complexity due to their vertical nature. Vertical systems are based on the one disease model of care, which focuses on individual diseases, rather than holistic patient care.
Innovative models of integrated care are required to appropriately manage the multimorbid patient. This is a challenging task as integrated models need to be context specific. A “one size fits all” isn’t enough to address patients’ needs.
Tackling the problem
To tackle the problem, solutions need to focus on what’s causing multimorbidity. This means that policymakers must look beyond the health sector – they must engage with multiple sectors. This is necessary as most risk factors relating to multimorbidity are driven by factors that lie outside the health care system. Risk factors such as obesity, alcohol use and smoking can all be influenced by policies outside the health sector.
In South Africa, a well known example of this has been the reduction of secondary smoking as a result of a range of anti-smoking initiatives. These included using the media to run campaigns warning about the health risks of smoking, to limiting smoking areas in the hospitality industries alongside the establishment of an excise tax on tobacco products.
More recently, to address the rising burden of diabetes and associated risk factors, South Africa has proposed a tax on sugar-sweetened beverages. A similar tax was successful in reducing the consumption of sugar-sweetened beverages in Mexico.
One of the challenges in creating these policies lies in opposing powerful industry actors whose interests don’t lie with health issues, but with making profits. This requires advocacy from several key public health role players such as academics, civil society, and governmental departments.
In Africa, multimorbidity will impose increasing strain on vulnerable people and already stretched health systems.
A structured collaborative approach is needed to manage the problem. This should include developing a good understanding of Africa’s unique patterns of multimorbidity, its causes, and focus on prevention.
Tolullah Oni, Associate Professor at the School of Public Health and Family Medicine, University of Cape Town and Natacha Berkowitz, Global Health Clinical Research Fellow Imperial College London and Honorary Research Officer, University of Cape Town
Before he became defense secretary, Gen. Jim Mattis once pleaded with Congress to invest more in State Department diplomacy.
“If you don’t fund the State Department fully, then I need to buy more ammunition,” he explained. Alas, President Trump took him literally, but not seriously.
The administration plans a $54 billion increase in military spending, financed in part by a 37 percent cut in the budgets of the State Department and the U.S. Agency for International Development.
That reflects a misunderstanding about the world — that security is assured only when we’re blowing things up. It’s sometimes true that political power grows out of the barrel of a gun, as Chairman Mao said, but it also emerges from diplomacy, foreign aid and carefully cultivated good will.
Military power is especially limited when threats come from new directions. More than four times as many Americans now die each year from opioids as have died in the Iraq and Afghan wars combined, but warships can’t defeat drug traffickers. To beat traffickers, we need diplomacy and the good will of countries like Mexico and Afghanistan.
And we certainly can’t bomb Ebola or climate change.
NAIROBI, Kenya – When a visitor walks up the stony path to Catherine Mwayonga’s home in Thika, 30 minutes from the Kenyan capital, she hears their footsteps and raises her voice – bold and husky – to usher them in. She’s sitting on the sofa, knitting a sweater for a newborn baby and counting the stitches with her fingers. “Karibu sana (welcome),” she says.
Mwayonga, 62, the mother of six grown boys and two adopted daughters, is blind. She lost her eyesight when she was 7, after a cow kicked her in the head and threw her against a tree. She is also HIV-positive, which she only discovered when she overheard a doctor talking about her to his colleagues: “The patient on bed 12 is HIV-positive.”
Mwayonga remembers hearing him announce her status as she lay still on the cold bed, pretending to be asleep. “He said it in English, assuming that I did not understand,” she says. “It shocked me.”
That moment led to years of fear, denial and confusion as Mwayonga’s disability – one that had long ago become a natural part of her full life – suddenly became an impediment to coping with her illness. Everything from getting information from doctors to taking medication was a struggle. But 15 years on, Mwayonga has overcome those challenges and now devotes her time to advocating for HIV-positive people with disabilities, calling for more respect and improved resources.
The first case of HIV was discovered in Kenya in 1984, and the country’s infection rate currently stands at 5.6 percent. Figures from the Kenya National HIV and Aids Estimates shows it has the fourth highest HIV prevalence in the world, with about 1.6 million people infected with the virus.
For two years before her diagnosis, Mwayonga had pleaded with doctors to test her for HIV/AIDS. In 1996, after a decade of illness, her husband died from what Mwayonga later discovered were AIDS-related complications. She knew the risk of her having contracted HIV from him was high. “In 1999, I would have malaria today, typhoid tomorrow, but nothing specific,” she says. “I would ask why they were not testing me for HIV/AIDS. They would say the disease would not get [disabled] people like me. But I asked them: Aren’t I a human being?”
The strikes in the Nigerian health sector could end if two things were tackled: changing the way hospitals are managed and secondly, how health workers are paid.
To improve efficiency and quality of services delivered by public hospitals, the management and day-to-day running of hospitals should be done by professionals with expertise in health administration.