Africa’s new killers. The scourge of diabetes and hypertension in SubSaharan Africa.

The major drivers of the disease burden in Africa have always been communicable diseases like malaria, diarrhea, tuberculosis, and a surge in HIV/AIDS at the turn of 1990. Largely due to the collective efforts of the international community, diagnosis of new HIV infections dropped steeply in 2000 and this trend has continued. Since mid-2000s, the number of deaths from the disease has continued to decline as well (Fig.1).




While the continent struggle with HIV, the incidents of diabetes and hypertension grow. Mainly driven by these 2 diagnoses and their associated complications, cardiovascular disease became the leading cause of death for the first time in 2014 (fig.2). It should also be pointed out that diabetes as a co-morbidity increases the morbidity and mortality of the communicable diseases therefore, it is a multiplier of the disease burden in the continent.

It is estimated that the total economic cost of diabetes and hypertension (direct and indirect) in Africa in 2000 was more than USD100 billion. Diabetes alone was USD67.03 billion (Kiriga et al. 2009).




True estimation is limited because of under-diagnosis, poor or lack of data collection and reporting. Complications like stroke, renal failure, coronary artery disease, lost of sight and limbs are seen as de novo rather than the sequelae of untreated diabetes and hypertension.

Many sub-saharan nations are rich in resources and yet spend very little per capita on healthcare infrastructures and services hence, funding for disease education and prevention, early detection and treatment are lacking. It is incumbent on communities to assume these functions through grass root co-operations and the support of both international and national organizations.

Available education materials on diabetes and hypertension lack crucial information in local languages, foods and cultural practices - a major problem that will only be solved through direct involvement of the locals.

  

Diabetes Mellitus

 

“Disease of sugar” as it is referred to in many African languages. In 1901 Uganda, a British medical missionary noted that “diabetes is rather uncommon and very fatal” (Cook, 1901). Fast forward to today’s Africa, various studies estimate the prevalence of the disease as between 3-10%. A World Health Organization (WHO) document refers to the rising burden of diabetes and hypertension as a “slow motion disaster”, and diabetes has been declared a global emergency of the 21st century.

Diabetes is a chronic and debilitating disease that primarily affects how the body metabolizes carbohydrates. Because of this disturbance in handling the body’s primary source of fuel, fat and protein metabolism are imparted by the disease. Chronically high blood sugar lead to damage in all the body organs like the eyes, kidneys, nerves, heart and the blood vessels (fig.3). In an environment where the choice of food is limited by poverty, carbohydrates may be the only source of food available or affordable. This reality shows the challenges of any intervention proposed.

The rise in diabetes prevalence over the last two to three decades have been linked to urbanization (higher prevalence in urban than rural areas), lack of exercise with resulting weight gain and high Body Mass Index(BMI) , and increased consumption of processed foods. These changes are all happening amidst the highest population growth rate in the world and underfunded healthcare systems.

 

Typer 1 diabetes mellitus:

 

This disease results from the destruction of the insulin producing cells in the pancreas by the body’s immune system. Usually seen in children or young adults, it is less common than the Type 2 disease. Treatment is with multiple daily insulin injections, a huge burden considering the cost and storage needs.

 

Type 2 diabetes mellitus:

 

By far the commonest type of diabetes. It is characterized by under secretion and or resistance to insulin. Specific cause is unknown but obesity is a risk factor. Because it is usually asymptomatic, its is often discovered when patients present with one of the complications or during a routine health check. This can largely be managed with hypoglycemic tablets.

 

Gestational diabetes mellitus:

 

Seen for the first time during pregnancy. This diagnosis can affect pregnancy and the baby’s health. The blood sugar usually returns to normal following birth but there is a future risk of developing type 2 diabetes.

 

Secondary diabetes:

 

This is very rare and may result from infections, certain medications, other diseases of the pancreas, and genetic disorders.

 

Hypertension

 

According to the American Heart Association (AHA), high blood pressure is a pressure of 130 systolic or higher, or 80 diastolic or higher, that stays over time. The few studies available on the prevalence of the disease in sub-saharan Africa do not use consistent method of measurement or definition. It is considered the most important modifiable risk factor for cardiovascular morbidity and mortality. It should be noted that stroke is classified a cardiovascular disease, and almost all the organs in the body are affected by uncontrolled high blood pressure.

Like diabetes, the sub-continent is experiencing a growth in prevalence of hypertension. The geographic distribution mirrors that of diabetes. A systematic literature review shows that the prevalence in urban areas in Nigeria ranges between 17.5-51.6% and 4.6-43% in rural areas (Akinlua et al. 2015). Same lifestyle factors mentioned above are suspected.

Since hypertension is usually asymptomatic, it can go undiagnosed for years while it continues to cause damage to the body organs. In most studies, less than 40% of people with blood pressure above 140/90 mmHg had been previously diagnosed as hypertensive. This number will be significantly lower if the AHA numbers are used. Most of the diagnosed patients can not afford the medications and are commonly exposed to fake drugs. The latter problem has plagued the sub-continent’s pharmaceutical supply chains for decades.

Hand in hand, by targeting same organs, diabetes and hypertension have pushed cardiovascular disease to the top of the cause of death in Africa. They are top 2 on the list of the risk factors of death aged 50-69 and top 5 aged 15-49 (fig 4 and 5). A worrisome state when you notice that the other high ranking conditions are social or economic issues that will make it difficult to get a handle on the challenges pose by these two killers. 








 

Diabetes and Hypertension Co-op Society




Everyday people solving their health problems.

Doctors Charity. 2019.

 

Co-operative society outline:

 

  • Membership:

 

Individuals (30-50). Minimum to start. Max number is 50 per chapter.

Voluntary.

No restrictions.

 

  • Requirement:

 

Monthly levy or membership fee.

Co-payments at visits.

Minimum follow-up appointments threshold.

 

  • Administration:

 

Members appointed leadership.

Liaise with state co-ordinator.

 

  • Geography:

 

Members in the same quarter/area of town or village.

Designated medical home preferably in the same area.

“Power member(s)” from same area.

 

  • Operations:

 

Monthly meetings.

Society rules by members from this outline.

Levy collections.

Activities and community awareness.

 

  • Finance:

 

Monthly membership fee (350-1000 Naira).

Donations and local drives.

 

  • Medical home:

 

Clinic or hospital with a supervising doctor.

Preferably same area as the society.

 

  • Resources by doctors charity:

 

Diabetes starter kit: Glucometer, test strips, lancets, alcohol swabs.

Medications: Oral hypoglycemics, anti-hypertensives.

Education pamphlets/brochures and blood sugar record booklet.

Training.

Test equipments/lab referral: Creatinine, HbA1C, Pregnancy test kit. (Fasting lipids).

EMR.

Telemedicine.

 

  • Medications:

 

Diabetes: Metformin. Glimepiride. (Insulin).

Hypertension: Lisinopril, Norvasc. Triamterene-HCTZ, Hyrochlorothiazide, Lasix.

Hyperlipidemia: Simvastatin.