Everyday at work, I see patients with stereotypical infectious diseases such as typhoid fever, malaria and tuberculosis. However, practicing medicine in Sub-Saharan Africa today requires more than just managing tropical infections. On a daily basis, I also see many patients with non-communicable diseases such as diabetes, heart failure and high blood pressure.
These chronic diseases are often referred to as ‘diseases of the rich’, but in recent years have become increasingly common and problematic in developing countries.
Health-care systems in Sub-Saharan Africa are focused towards managing acute infection and trauma. Money from foreign aid and charities tend to focus around the ‘sexy’ tropical diseases like Tuberculosis or Malaria. As a result, the infrastructure needed to manage chronic diseases is lacking. This means that the high blood pressures are crazily high, the heart failure epic and the diabetic complications spectacular.
There is a large and growing burden of diabetes in developing countries. The WHO estimates that about 347 million people worldwide have diabetes. Diabetes is set to become the seventh leading cause of death in the world by 2030. Yet St Francis Hospital does not stock glucose sticks for measuring blood sugar levels, let alone HbA1c tests, making good diabetic control near impossible.
Most doctors and medical students bring their own glucose machines and a supply of sticks for their machine, but a pack of 50 sticks runs out very quickly. Each machine uses slightly different sticks; it is not a one size fits all. As a result, there are drawers full of glucometers of different brands (6 glucometers on my ward alone), which can’t be used because there are no sticks.
Without sticks, the only option we have is to use urine glucose as a proxy. Finding glucose in urine means that the blood sugar level is greater than approximately 8-10 mmol/L (therefore too high). Patients are asked to bring in four urine samples (with one taken before breakfast, before lunch, before dinner and before bed) to give an idea of their blood sugar levels during that day. My patients commonly produce the samples at the wrong times of day or into wrongly labelled bottles, making the result impossible to interpret.
Patients can live more than 200km away from the hospital in small villages with a communal water pump, a shared toilet and subsistence crops. Coming for review is difficult, time consuming and expensive. A chronic disease like diabetes or hypertension may be asymptomatic, causing very little impact on day-to-day life. It is easy to see why patients might not prioritise their diabetes.
I saw an elderly lady last week in Outpatient Clinic who had Type 2 Diabetes. She had run out of medications and had failed to attend for review since February 2012. I enquired why she had not come for review as instructed, explaining the importance of good diabetic control to avoid complications such as kidney failure or foot amputations. After many nods and smiles and not much progress, I changed approach and asked instead why she had decided to come today. I established that she was a widower who had outlived all of her five children. Another person from her village was also travelling to the hospital that day, giving her someone to make the journey with.
By the time she goes on to develop the later complications of diabetes that I tried to warn her about, the irreversible damage will already have been done. But is it really in her best interests to be travelling long distances to the hospital every two months when we can’t even accurately measure her blood glucose?
I don’t pretend to know what the solutions are for chronic disease management in Sub-Saharan Africa. However, I do know that a country such as Zambia has climbing rates of chronic diseases, insufficient infrastructure to manage them properly, and patients that have bigger problems to worry about than the possibility of a foot ulcer in a few years. It seems likely that the burden of chronic disease is going to get worse before it gets better.