Standing in the lobby of the Sheraton Times Square Hotel at the Clinton Global Initiative’s 10th annual meeting, Kenyan physician Dr. Allan Pamba excitedly tells me about a new initiative to train African scientists in non-communicable disease (NCD) research. This $8.1 million NCD Open Lab is the brainchild of GlaxoSmithkline (GSK), where he is now vice president of pharmaceuticals for East Africa, but I first met him when he was an intern at a rural hospital in the foothills of Mount Kenya nearly 15 years ago. He explains to me that he now thinks of non-communicable diseases with the same urgency as he did infectious diseases back then.
Like Pamba, for as long as I can remember, working as a doctor in sub-Saharan Africa, the three big catchwords were: malaria, tuberculosis, and HIV/AIDS. These diseases ravaged the sub-continent and, rightfully so, received the most funding. But while donors have poured resources into fighting infectious diseases, non-communicable, chronic diseases have quietly but rapidly ascended the morbidity and mortality ladders, especially high blood pressure, or hypertension.
Today, cardiovascular disease is the number-one cause of death in sub-Saharan Africa in adults over the age of 30. Globally, low- and middle-income countries bear 80 percent of the world’s death burden from cardiovascular disease. One of the strongest drivers is undiagnosed and untreated hypertension, which affects nearly one in two Africans over the age of 25—the highest rate of any continent in the world.
But current funding spins a different narrative. In November 2010, a Center for Global development working paper on global development assistance for health (DAH) revealed that after controlling for burden of disease, 30 times more DAH money was allocated to malaria, tuberculosis, and HIV, compared to all NCDs combined. Astonished by these numbers, I called development economist Rachel Nugent, the lead author of that study, who is now director of the Disease Control Priorities Network, funded by the Bill and Melinda Gates Foundation.
Though Nugent has not officially updated the numbers since her 2007 calculations, she has insight into current trends, and says that assistance for NCDs is increasing, but slowly. Nugent agrees with Pamba that sub-Saharan African countries recognize that hypertension and cardiovascular disease are priorities, but the lack of funding is a major barrier. “Without a doubt the perception of what causes and who gets chronic disease is a barrier to donor investment,” Nugent says. “Donors don’t say it, but I am quite convinced that in the backs of the minds of those in wealthier countries is that NCDs are for rich, fat white men. It’s not something poor children and adults get—but that’s wrong. That perception that it’s people’s own fault and that you can’t change behavior may seem believable, but that doesn’t accord with the facts.”
As Nugent insinuated, hypertension in this population is not exclusively a lifestyle issue; studies have shown that sub-Saharan Africans may be genetically predisposed as well. One hypothesis is that certain African populations may be more vulnerable to salt retention, resulting in more drug-resistant hypertension that strikes at a younger age. This idea is not new. Pamba shares a personal story from his youth: “I’m from western Kenya. My father had hypertension. He came home one day with an article showing hypertension is increased in our population because of a certain gene. When I reflect on that now, it means someone was thinking about this all the way back in the 1980s!”
Dr. Marleen Hendriks, a researcher who successfully implemented hypertension treatment within a state health insurance program in rural Nigeria, also agrees that there is a common misconception that this is the disease of the rich when it actually devastates the poor far more as an unfortunate, inevitable side effect of economic growth and Westernization. Hendriks explains to me that in Africa, “Coca-Cola is everywhere and cheap, sometimes even cheaper than water. It’s the same for all these processed foods. You can buy cheap cookies at every corner, even in the most rural areas.”
Hendriks’s initial interest was sparked when she was a clinician in Amsterdam; she recalled seeing patients from Ghana with uncontrolled blood pressure and was struck by how much younger and sicker they were compared to their Dutch counterparts. She soon realized, “Treating hypertension is a whole different story than treating one malaria episode. If you want to treat chronic diseases, you need to strengthen the entire health system. It’s a test that your health system is functioning if you’re successful. And in general most African health systems are dysfunctional.”
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One of the biggest challenges to properly treating hypertension is simply knowing that a patient has it. Currently, it remains undiagnosed in the majority of sub-Saharan Africa. For instance, less than 10 percent of those in rural Nigeria and Gabon with hypertension are even aware of it. This is particularly alarming given that the current healthcare systems of most sub-Saharan African countries are not able to provide emergency ambulance services or technological interventions like cardiac stents. If an African feels chest pain and has a heart attack, he or she will likely die, or have severe heart failure, which can quickly add up to heavy health and economic burdens. And, unlike in the U.S., where heart problems often occur at an older age, in Africa, they usually strike younger people in their prime who normally would provide for an entire household.
At health centers in the U.S., workers routinely check vital signs, including blood pressure. In most facilities in sub-Saharan Africa, this is not common practice. The lack of primary-care infrastructure is one big reason why. Another reason is the traditional focus on infectious diseases that has now become customary. As Pamba explains to me, African clinicians are still relatively inexperienced in caring for hypertension and other chronic diseases.
Furthermore, true to its nickname as “the silent killer,” hypertension often doesn’t show symptoms until it’s too late. It can be hard to justify spending precious resources on hypertension when people are visibly suffering from infectious diseases. Inevitably, doctors have to ask themselves whether they want to go searching for patients with high blood pressure, who then will likely have to be on lifelong medications to prevent heart attacks or strokes, when they could spend that money on a patient who is clearly coughing from tuberculosis and could be cured with nine months’ worth of drugs. It is yet another manifestation of the prevention-versus-treatment conundrum faced by resource-limited countries, and the challenge is even greater with hypertension because patients usually have to stay on treatment forever, which can be cost-prohibitive. But as Nugent reminds me, “We crossed all those hurdles with AIDS.”
In fact, global health experts do compare hypertension to HIV/AIDS. Individuals with HIV need to stay on life-long, daily medications, as do individuals with hypertension. Both are often relatively symptom-free when they need to start treatment. HIV-positive patients are at higher risk for many other illnesses and need vigilant follow-up; the same is true for those with chronic hypertension. Now, many people with HIV who adhere to their medicines are able to live long lives and do end up with NCDs—and are actually at increased risk for certain diseases like hypertension compared to their HIV-negative peers. In the same way that HIV testing became universal, blood-pressure screening could follow that same path. As Hendriks tells me, one of the first to recognize the huge burden of hypertension in sub-Saharan Africa was her mentor Dr. Joep Lange—a leading pioneer in HIV research, who recently died aboard Malaysia Airlines Flight 17. Lange identified the high prevalence of cardiovascular disease in the region because he frequently saw it in his African HIV patients.
One strategy to fix this would be to stop asking “Which disease to target?” and instead work on strengthening overall health systems. Currently, in many health centers, resources exist to care for HIV patients, but those very same resources are not used for hypertensive patients, who have similar needs. UNAIDS, the joint United Nations Program on HIV/AIDS, recommends transitioning from vertical HIV programs to more harmonized programs integrating NCDs.
AMPATH, which stands for Academic Model Providing Access to Health Care, is an organization that was originally created to fight HIV/AIDS and has now expanded into improving longitudinal care for patients with hypertension by building on their extant expertise in HIV care. Dr. Rajesh Vedanthan, a young cardiologist at Mount Sinai School of Medicine, calls me from Kenya, where he is implementing the first phase of a clinical trial to link and retain hypertensive patients in an effective clinical management program. As Vedanthan explains, “The programs aims to leverage principles borrowed from AMPATH’s HIV experience to geographically decentralize clinical services to literally bring screening and community health education to people’s homes by going door-to-door, task-distribute care from doctors and nurses to community health workers, and strategically use smart phones to help task-distribute.”
Despite innovative initiatives like AMPATH’s, the funding gap is still there. “While more traditional donors are catching up,” Nugent states, “private sectors like pharmaceutical foundations are stepping up to the plate and out there implementing projects.” But even they struggle with long-term funding and programming. As Dr. Evan Lee, who directs Eli Lilly’s $30 million NCD Partnership, reveals, “Internally, the challenge is: How do we move beyond just a philanthropic or charitable function?”
Several experts have expressed to me that successfully targeting NCDs largely remains an issue of governance. As Pamba explains, “In 2001, African governments made a commitment that 15 percent of their national budgets will go to health. This is a promise that was never kept—most are still in single figures. We need to push governments. I think Africa will need to pay its way out this time.”
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Last month, I had a patient in the emergency department who recently emigrated here from Africa. He was 75 years old and looked robust and healthy, despite having lived with HIV for many years. As we’re talking, he interrupted the conversation to proudly show me his pillbox with all of his HIV pills neatly slotted in each day-of-the-week compartment. He repeatedly asked me during his stay if he could take his pills—he wanted to make sure he didn’t miss a single dose. But he wasn’t here for HIV complications—he was in for a blood pressure double what is considered normal, numbers that could easily be fatal. He ran out of his blood-pressure medications two weeks ago, but unlike his HIV drugs, he never saw them as essential.