The epidemic of diabetes in sub-Saharan Africa

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{***Noah***}

Coming up on Harvard Chan: This Week in Health…The growing epidemic of type 2 diabetes in sub-Saharan Africa.

{***Rifat Atun Soundbite***}

(In some countries we’ve found prevalence levels approaching almost more than 20%.)

In this week’s episode: What’s driving an alarming increase in the disease—and how can health systems respond effectively?

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{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health…It’s Thursday, August 31, 2017. I’m Noah Leavitt.

{***Amie***}

And I’m Amie Montemurro.

{***Noah***}

This week we’ll be examining what researchers are calling a rapidly expanding diabetes epidemic in sub-Saharan Africa.

{***Amie***}

We’ll speak with Rifat Atun, professor of global health systems here at the Harvard Chan School.

He’s one of the lead authors of a first of its kind Lancet Commission report examining the rise of diabetes—and possible solutions to the epidemic.

{***Noah***}

According to the report, more than 90% of diabetes cases in sub-Saharan Africa are type 2 diabetes, suggesting that modifiable risk factors are major contributors to the burden of disease.

Atun told us that the researchers were not just shocked by the scale of diabetes in the region—but also how quickly prevalence of the disease has risen.

In 1980 the average prevalence of diabetes in adults over 18 was 3.1%.

More than 30 years later—in 2014—it had jumped 150% to 7.1%

{***Amie***}

But Atun says that averages don’t tell the whole story because they can be skewed by countries where diabetes rates are much lower—or higher.

And there are sharp disparities along age and gender lines.

{***Rifat Atun Soundbite***}

(RIFAT ATUN: In some countries we’ve found prevalence levels approaching almost more than 20%. And also worrying is that, in adults, especially females who are aged 30 or 40 years, the prevalence levels reach almost 80%.

NOAH LEAVITT: What are some of the factors that are driving this increase? Because I think it’s interesting that you mentioned that there is this huge variation among gender, among age. I’m guessing it’s several factors instead of maybe a few big factors. So what is driving this increase that we’re seeing?

RIFAT ATUN: Yeah, you used the word factors. And you’re absolutely right. There’s multiple factors, all changing at the same time. So I call these contextual changes. So these transitions– for example, in demographics, so demographic transition with aging. Secondly, the transition in nutrition transition in social lifestyle or sociocultural attitudes; economic transition, which has brought increased disposable income to many.

But these funds are being used not to purchase the traditional foods but high calorie, low nutrition foods. And reduced exercise, for example, using motorbikes rather than walking to the market or to work. All of this together has happened very quickly in organization, which has diminished capacity for physical exercise. So this convergence of these transitions and their speed of change has resulted in an environment where chronic illness growth has really accelerated and has happened very rapidly.

NOAH LEAVITT: So I guess it’s a separate thing, but for example, we’re seeing the rise of high blood pressure in China. So I mean, is this a theme that we’re seeing in a lot of parts of the world where, as there’s more modernization and urbanization, we’re starting to see these chronic illnesses spike?

RIFAT ATUN: Yes. What we’re seeing is that the countries that are experiencing these rapid transitions– so the demographic change and all the other changes collectively help acceleration of the epidemiological change, which brings, A, chronic illness, and, B, disability, because of old age. So we’re seeing this in emerging economies that are growing very fast. For example the bricks in Brazil, Russia, India, as well as countries like Mexico, Turkey, that have achieved rapid growth in their economies and these transitions, only to face this rough epidemiological transition.)

{***Noah***}

This sharp increases in diabetes is particularly concerning, Atun says, because health systems in sub-Saharan Africa are not prepared to respond.

{***Amie***}

That’s because for the last several decades these countries have been focusing attention on a range of severe health issues—such as infectious diseases like malaria or HIV, and on improving maternal and child health.

But now they’re facing a wave of chronic illnesses and noncommunicable diseases.

{***Rifat Atun Soundbite***}

(RIFAT ATUN: On the one hand, we have the current problems, so-called the remaining challenges of infection, and high levels of maternal mortality, as well as infant mortality or child mortality in these countries. Then, we see a swathe of new burdens emerging due to chronic illness. But health systems are not designed to cope with this burden or manage chronic illness. And the dangers– of course, we’ll be successful in treating children, and save lives of mothers, and improve management of infectious disease, only to find that these individuals develop chronic illness that’s not managed. That’s a huge a societal loss beyond, of course, the health burden.

NOAH LEAVITT: And what is it about a non-communicable diseases like diabetes that is so stressing for health systems? I guess, why are they not prepared to deal with this?

RIFAT ATUN: So with infectious disease, typically, there’s a very clear intervention. And the infection is treated, say from malaria. For HIV, we do not have very effective antiretroviral treatments. The difference with chronic illness is that this is lifelong. And for someone who diabetes or hypertension at the age of, say, 20 or 30, they would have this disease for 30, 40, 50 years. And it requires not just treatment but a lot of behavior change. And behavior change is very difficult.)

{***Noah***}

And the impact of this diabetes epidemic will be felt in many ways says Atun.

Of course there is the health of individuals and the complications linked to diabetes—such as damage to the eyes, kidney, and heart…and peripheral nerve damage.

{***Amie***}

This also comes with a long-term economic burden because those battling diabetes may not be able to work.

{***Rifat Atun Soundbite***}

(RIFAT ATUN: And often, these individuals have multiple morbidities. They may also have hypertension. They will develop ischemic heart disease. And they’re at high risk of having catastrophic events, such as a heart attack, or a stroke, or kidney failure, or they might have an amputation, which then prevents them– A, there’s loss of life, which leads to loss of human capital. Secondly, those individuals who are ill, they’re not able to go to work. And those who are able to go to work are not able to function properly. So there’s a loss of productivity. And there’s also a decline in productivity for those who are able to attend work. And we estimated the economy cost of this, in the African context. And we estimated, in Sub-Saharan African contexts, the economy cost currently is around $20 billion, which is huge for a continent that has some of the poorest countries in the world.)

{***Noah***}

And as Atun said a moment ago—health systems are not prepared to deal with these unique consequences.

And there are several reasons.

First: There is simply low awareness of diabetes and its impact among patients, doctors, and policymakers

There is also a lack of diagnostic capability to actually tell when people have diabetes—and there has been limited uptake of international regulations regarding diabetes treatment.

{***Amie***}

And one factor that’s particularly concerning for Atun: Because primary care systems in many sub-Saharan countries are not strong, there is a lack of continuity of care for those who have been diagnosed with diabetes.

{***Rifat Atun Soundbite***}

(RIFAT ATUN: So we looked at what happens at every step of care, from someone who might have diabetes to someone who is aware of diagnosis, those who receive advice, and those who receive medication. And we were able to use primary data from 12 countries, a very original study. We found that, for every 100 people who have diabetes, 50% are not diagnosed. So we are already missing 50% of the population with diabetes. And of those who have their glucose measured, as part of a screening program for example, a further 13% are not aware of their illness. So we’re down to 37% from that cohort. And of those who are aware of their diagnosis, a further 20% do not receive advice. So we’re down to 17%. And of that group, 6% do not receive treatment. So we’re down to 11%. So for every 100 people with diabetes, only 11% receive treatment. That’s on average. Some countries, this is as low as 8%.

NOAH LEAVITT: So in a sense, as people go through the steps of care, they’re almost falling out of care. So what are some of the factors that are driving that?

RIFAT ATUN: Yes, I think that was one of the fundamental questions we tried to address. You’re spot on. We found slightly different patterns, actually, in countries. In some countries, there would be good screening programs. For example, in the case of Seychelles, they have a good screening program. But then, there’s no follow up. In other countries, for example countries such as Liberia, where health systems are severely stressed due to Ebola and other problems, there is no screening. So only 19% of those who have diabetes have their glucose measured. Then, we see attrition. In countries such as Mozambique, again, we see a rapid decline, and then attrition. But in countries like Namibia and South Africa, we saw that, although there is a decline– or in Tanzania– once someone has their glucose measured, then there is care. But we see attrition at every step. So what we see is either very weak health systems where all of these steps are not managed effectively; or systems where screening might work; or systems where, once someone is diagnosed, there is not enough comprehensive care to enable them to receive advice and ongoing care or ongoing treatment; so multiple reasons, in terms of the health system functioning. Of course, one of the big problems is not just the supply of services, it’s also the awareness, and education, and the decrease of the population in relation to diabetes.)

{***Amie***}

So what can be done to prepare health systems to deal with this rising challenge of diabetes?

{***Noah***}

It’s a difficult balance, because countries don’t want to cede the progress they’ve made against HIV, or improving the health of mothers and children.

{***Amie***}

Instead, Atun says the focus should be on improving primary care systems –which can benefit everyone—and identifying opportunities to use existing health system platforms to address diabetes and other chronic illnesses.

{***Rifat Atun Soundbite***}

(RIFAT ATUN: This is something that we really try to explore, what platforms we can use that are existing to enable health systems to effectively respond. For example, platforms for delivering antenatal care or interventions for children can be used for education purposes. Or mothers who are attending clinics can be screened appropriately for diabetes and provided appropriate advice. And if the pregnancy is well-managed, then the children who are born have less propensity to develop diabetes. So-called, the first 1,000 days are critically important to manage that. And the interventions begin actually during pregnancy or even before. One can use platforms for HIV. Those individuals who are an antiretroviral treatment are being managed effectively. Many of them will develop diabetes or hypertension. So one could introduce a program to manage these chronic conditions. There’s strong association between tuberculosis and diabetes. So one could manage these conditions jointly. So rather than creating a separate vertical program, one could try and use existing platforms. But most importantly, you must strengthen primary health care systems and develop an approach that enables us to focus on the individual, rather than on individual diseases. This is which leads to fragmentation and inefficiency.

NOAH LEAVITT: It’s not like the health systems have to start from scratch. It’s more about leveraging existing things that are already in place using those to address diabetes or other chronic illnesses.

RIFAT ATUN: Yes. And I think the timing is also right. International institutions, countries, and worldwide, there was a huge effort to address the high burden of HIV/AIDS, malaria, TB, and maternal and child health. And many of these targeted programs were developed. But there’s not time to integrate these, and integrate them in such a way that we develop strong primary health care systems and well-functioning health systems. Otherwise, that cascade of care that is so dysfunctional is going to continue. And the economy the consequences– we projected that, with the current scenario, if we don’t intervene, the economic burden to 2030– and that’s only 15 years– will triple to almost $60 billion.

NOAH LEAVITT: So I mean, I think, as you pointed on the report, this need for urgent action.

RIFAT ATUN: Absolutely. And we should not make the same mistake as we did with HIV and AIDS. There is an opportunity now, given that one of the Sustainable Development Goals– the third Sustainable Development Goal– is ensuring healthy lives and promoting well-being for all at all ages. And one of the targets within that is to achieve universal health coverage. And another one is to reduce, by one third, premature mortality from non-communicable diseases through prevention, promotion, and treatment. So one should use this strong momentum globally to really target diabetes and other chronic illnesses.)

{***Amie***}

As we mentioned at the beginning of the episode, this Lancet Commission report is the first study to really examine this diabetes epidemic in sub-Saharan Africa.

{***Noah***}

But Atun says identifying the problem is only the first step—now it’s time to identify solutions.

The next step is getting policymakers in affected countries—and leaders in so-called donor countries—nations that provide foreign aid—to support diabetes interventions.

{***Amie***}

That means researchers will be looking to document the approaches that work.

And also highlight the return on investment if diabetes and other chronic illnesses are managed effectively.

{***Noah***}

If you want to read more about this Lancet Commission report, you can visit our website, hsph.me/thisweekinhealth.

{***Amie***}

That’s all for this week’s episode. A reminder that you can listen any time on Soundcloud, iTunes, or Stitcher.