Why the number of people with more than one chronic condition is rising in Africa: The Conversation Africa


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Scientists estimate that by 2020, non-communicable disease will account for almost 70% of the total disease burden.

Tolullah Oni, University of Cape Town and Natacha Berkowitz, University of Cape Town

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.

Next steps

In Africa, multimorbidity will impose increasing strain on vulnerable people and already stretched health systems.

The ConversationA 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

This article was originally published on The Conversation. Read the original article.


EXCLUSIVE: Interview with Steve Davis, PATH President

I got a rare chance in November last year when I met the Head of PATH during one of his visit to Nairobi. We shared about health, development and his work. Here is the interview:  

“I don’t like being sick, because my health enables me to do my work”

This is the mantra that Steve Davis, 55, has held close to his heart. And sure enough he lives by it. He is the Head of an organization that seeks to solve health concerns through innovations.

Mr Davis is the president of the Program for Applied Technologies in Health (PATH).

Steve Davis

He is a lawyer by profession and a specialist in civil rights and intellectual property. But this is tip of his global experience and he shares his thoughts on innovation and health.

Q. Prior to joining PATH in 2012, you served as a strategist and business leader for a range of private, nonprofit companies and international organizations such as Corbis, a global digital media firm; interim CEO of Infectious Disease Research Institute among others.  How did you move from all that, into health?

It is actually a complicated journey; I started my career right after college. I was involved in refugee and human rights work. I spent my earlier days in South East Asia and China working on development issues. As a lawyer I got involved in the social sector. Actually coming to PATH was a combination of many things because at PATH its core social justice and addressing incredible inequities in health. These inequities in health trigger poverty and further issues. Therefore, the previous positions enrich my position at PATH which is a global organization thus I bring a lot of global experience in the health sector.

Q. So far how has it been?

It’s been busy but it’s been great. We have seen some big wins in global health this year such as the roll out of the Meningitis aid vaccine Project across Africa as well good results in the rotavirus vaccine research, Malaria control and HIV/Aids management.

Q. PATH is involved in maters innovation, Could you offer your definition of what you consider ‘innovation’?

Innovation is doing something new in order to make a difference. It can be financial, social and also in health. But I also believe that innovation has to get to the people who need it the most. It’s great to have all these new technologies but it is vital to have these ideas reach to those who need them the most. It however doesn’t always mean doing something brand new; there are things that we have which are effective but sometimes it take new approaches to make them even more effective.

For instance, we have been doing work around malaria control where a lot of the tools we have used include bed nets, spraying but we have to look at new approaches to reinforce them such as use of bed nets which have insecticides; not mere spraying of homes but specifically targeting mosquito reservoirs in order to be fully effective.

Q. You mention you work in malaria and PATH has a malaria vaccine in the works. What have you done in this light so far?

We have comprehensive malaria portfolio as we look at the disease wholistically.  We work on the malaria vaccine; we have a large malaria control program, diagnostic and care, malaria in pregnancy, advocacy in malaria. We are committed to the elimination of malaria.

Notably, PATH’s Malaria Vaccine Initiative (MVI) and partner GlaxoSmithKline Vaccines is on the late-stage trial of the most advanced malaria vaccine which helps protect infants and young children against malaria for up to 18 months. Three clinical trial sites are based in Kenya—Kilifi, in the coastal region, and Kombewa and Siaya, both in western Kenya.

Also, with the support of partners, PATH has created a new, stable supply of artemisinin- powerful medicine that reduces the number of Plasmodium (Malaria causing parasites) in the blood of patients.

Utility on Malaria:

  • It is stated that 30,000 people died from Malaria in Kenya last year.
  • 20% of child mortality is caused by malaria annually. 
  • In 2012 one in every 20 deaths worldwide caused by Malaria occurred in Kenya.
  • 28 million Kenyans live in areas where they are at risk of contracting malaria.
  • Malaria costs Kenya up to 10 billion shillings annually. 
  • 108,127 pregnant women were diagnosed with malaria in 2012.

Q. Any challenges in this pursuit?

Developing vaccines is a complex, time consuming and an expensive affair. Secondly, it is delivering vaccines where they are needed the most. Also we still hear of cases that a child taken to a clinic with a fever and immediately it is assumed that they have malaria. Sadly, we end up losing a lot of these children and even mothers because we did not treat them with the right medicines.

Q. Recently, PATH released 10 innovations geared on addressing maternal mortality and the lives of children. They seek to address issues of post-delivery bleeding, high blood pressure, infections in new born as well as contraceptives. What prompted this move?

Our commitment is to contribute directly to maternal and infant health by reducing morbidity and deaths as spelled out in the Millennium Development Goals five and four. Therefore these 10 innovations are our approaches to address these concerns. However, we have not done enough as an organization in this compared to children health but we are striving to make a difference. As we know that mothers take care of their children and not themselves.

Children die from diseases such as pneumonia, diarrhea and rotavirus. The ten innovations will have an immediate impact on these leading killers of women and children particular in developing nations.

For instance one of the innovations is the Non-pneumatic anti shock garment which will slow excessive bleeding after childbirth and stabilize the mother.

The innovations have already available and used in Zambia, Malawi and Tanzania in Africa and in India in Asia. They are not yet available on scale the scale we need but the East Africa region is in the plans.

Q. Recently Save the Children, the independent organisation for children, released a report on maternal health dubbed Surviving the First Day: State of the World’s Mothers 2013”. It ranked Finland, Sweden and Norway champions of maternal and infant health while Sierra Leone, Somalia and the Democratic Republic of the Congo at the rear. What can we learn from this discrepancy?

One, these findings show there is a close link between health and poverty. Place in DRC getting basic requirement is an issue as there lacks institutional grounding for matters of health due to years of conflict, this disable the ability to reach to people who need health services. Finland is a rich country with a solid social integrated system on health coverage. Also, it has a relatively ‘small’ and uniformed population. In fact a vaccine campaign in Norway will be more successful than one in India where it is a mixed populace.

Utility on Maternal and Child Mortality:

  • Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth.
  • 99% of all maternal deaths occur in developing countries.
  • Maternal mortality is higher in women living in rural areas and among poorer communities.
  • Young adolescents face a higher risk of complications and death as a result of pregnancy than older women.
  • More than one million babies around the world die on the day they are born each year. Nearly 3 million die within the first month.
  • Between 1990 and 2010, maternal mortality worldwide dropped by almost 50%

Q. Parting word to young innovators in Kenya?

Your country needs your creativity, your ideas and your fresh outlook to life. If you have an idea, say in health, go for it and do not give up. We can learn from you as there are more opportunities not than in the past. However, know about your Intellectual Property rights to protect your innovation.

Q. Other than the pursuit for health equity what else do you enjoy doing?

I like to travel, hanging out with my son, reading, playing the piano, participate in marathons, skiing, and writing.

Q. Memorable event in your work?

One that comes to mind, it was recently actually, I was in Congo for a week where we had set up night-time HIV/Aids testing in a part of Lubumbashi, (southeastern part of DRC) on a seedy slum, frequented by commercial sex workers and whose HIV infections are pretty high. So there were a lot of people who preferred this cover of darkness to get tested and counseled instead of walking into a similar facility during the day for fear of stigma. So this woman comes to get tested and I am a few meters from the tent she goes for the test. Minutes later she comes out rejoicing and she finds me there and she is jumping up and down and hugging me.

She is elated as her partner has the HIV virus (but have been having protected sex) and she had been too scared to get tested, but when she did on that day, she found out she was HIV negative. She promised to kill a white chicken in thanksgiving for narrowly escaping ’death’.

Thank you Steve Davis for the time and great insight.