Tackling Noncommunicable Diseases in Africa

Abstract

Noncommunicable disease (NCD), principally cardiovascular diseases, cancer, chronic lung disease, and diabetes, constitutes the major cause of death worldwide. Evidence of a continuing increase in the global burden of these diseases has generated recent urgent calls for global action to tackle and reduce related death and disability. Because the majority of NCD deaths occur in low- and middle-income countries, increased attention has been focused on this group of countries. However, in sub-Saharan Africa, where all countries are members of the low- and middle-income grouping, NCDs are not the leading causes of death or potential life years lost. Thus, strategies to tackle NCDs in sub-Saharan Africa are best conceived and executed in alignment with existing strategies for the prevention, treatment, and control of the actual leading causes of death in this region. This commentary addresses caveats to be considered as strategies are developed to tackle NCDs in sub-Saharan Africa as part of the global effort to prevent, treat, and control NCDs.

Keywords

Africa chronic diseases demographic changes noncommunicable diseases risk factors urbanization

The rising global burden of chronic noncommunicable diseases (NCDs), especially in low- and middle-income countries, has given rise to numerous urgent calls for increased attention to coordinated efforts for their prevention, treatment, and control. In 2005, the World Health Organization (WHO) built a strong case for why the prevention of NCDs was a “vital investment” (WHO, 2005) and conducted a series of consultations that led to publication of a global status report (WHO, 2011) and the adoption of a global action plan to tackle NCDs (WHO, 2013). Additionally, heads of state and government affirmed their commitment to this endeavor in the landmark political declaration at the high-level meeting of the United Nations General Assembly in 2011 and its follow-up document in 2013 (United Nations, 2011, 2013).

The basis for these urgent calls to action was clear. The WHO global action plan stated that more than 36 million people die annually from NCDs—mostly from cardiovascular disease, cancer, chronic lung disease, and diabetes (WHO, 2013). These deaths constitute nearly two thirds of all global deaths, and more than 14 million people die prematurely between the ages of 30 and 70 (WHO, 2013). Importantly, low- and middle-income countries account for 86% of the premature deaths and are estimated to suffer related cumulative economic losses of US$7 trillion projected over 15 years (WHO, 2013). These dire disease burden data have been confirmed in recent Global Burden of Disease (GBD, 2013) Study assessments of mortality, disability, and disability-adjusted life year losses in low- and middle income countries (GBD 2013 Mortality and Causes of Death Collaborators, 2015; Global Burden of Disease 2013 Collaborators, 2015; Murray et al., 2015).

Since all countries in sub-Saharan Africa are members of the group of “low- and middle-income countries,” it is generally assumed that these dire statements of death and disability from NCDs apply equally to these countries as they do to other low- and middle-income countries. This assumption is not supported by recent data. This commentary addresses the importance of tackling NCDs in sub-Saharan Africa but also highlights crucial caveats important in planning or developing strategies for the prevention, treatment, and control of NCDs in sub-Saharan Africa as part of the global effort to tackle NCDs (WHO, 2013).

The seven caveats addressed are the following: (1) NCDs are not the leading causes of death in sub-Saharan Africa; communicable, maternal, neonatal, and nutritional causes are; (2) demographic changes, including continued population growth and aging, together with recent successes in controlling communicable diseases are contributing to the rise in NCDs; (3) changing lifestyles and patterns of NCD risk exposure call for a prominent role in health promotion and the prevention and control of risk factors; (4) transmissible agents are also important risk factors for NCDs in Africa; (5) urbanization and globalization pose additional challenges for the burden of NCDs in sub-Saharan Africa; (6) there is a crucial need to learn from and leverage service delivery models that have been successful in addressing communicable diseases such as HIV/AIDS in sub-Saharan Africa; (7) transdisciplinary global health research that cuts across and leverages expertise in communicable and noncommunicable disease prevention, treatment, and control will be necessary.

NCDs Are Not Yet the Leading Causes of Death in Sub-Saharan Africa

Noncommunicable diseases are increasingly becoming an important cause of death, especially among adults in sub-Saharan Africa. However, at present, they are not the leading causes of death or years of life lost (YLL) in this region (GBD 2013 Mortality and Causes of Death Collaborators, 2015). Although patterns of mortality vary across sub-Saharan Africa, the major leading causes of death and largest contributors to YLL throughout the region include malaria, HIV/AIDS, tuberculosis, other communicable diseases, nutritional deficiencies, and maternal and perinatal complications (GBD 2013 Mortality and Causes of Death Collaborators, 2015). Together, this group of communicable, maternal, neonatal, and nutritional diseases accounted for 63% of all deaths in sub-Saharan Africa in 2013 while all NCDs accounted for 30% of deaths (GBD 2013 Mortality and Causes of Death Collaborators, 2015). Figure 1 shows the leading causes of YLL per 100,000 population for all ages and for both sexes in sub-Saharan Africa for 1990 and 2013. Ideally, strategies to tackle NCDs in this region are best conceived and executed in alignment with existing strategies for the prevention, treatment, and control of the actual leading causes of death in this region.

Figure 1.

Leading causes of years of life lost (YLL) per 100,000 population for all ages, both sexes, sub-Saharan Africa, 1990 and 2013.

Although NCDs are not the leading cause of death in sub-Saharan Africa, they are nevertheless important and merit the increased attention proposed. For example, in 2013 alone, stroke and heart diseases caused nearly one million deaths in sub-Saharan Africa—about 11.3% of deaths from all causes in that region (Mensah et al., 2015). These deaths represented 5.5% of global cardiovascular disease deaths (Mensah et al., 2015). There were more deaths from stroke (409,840) than ischemic heart disease (258,939) and more deaths in women (512,269) than in men (445,445; Mensah et al., 2015). In nearly all countries in sub-Saharan Africa, stroke and other cardiovascular diseases contributed significantly to the probability of death in middle age (age 50 to 75 years; GBD 2013 Mortality and Causes of Death Collaborators, 2015). Together with hemoglobinopathies (in particular sickle cell disease), mental disorders, violence and injuries, oral and eye diseases, the major NCDs contribute especially to adult mortality and represent important developmental challenges.

Importance of Demographic Changes

Demographic changes, especially population growth and ageing, and other health transitions are important drivers of NCD burden (Roth et al., 2015). In sub-Saharan Africa, the age-standardized cardiovascular mortality rate (per 100,000) in 1990 was 327.6 and 330.2 in 2013, representing a 1% increase in more than two decades. However, compared to 1990, the number of cardiovascular disease deaths in sub-Saharan Africa increased 81% in 2013—reflecting an important contribution of population growth and ageing (GBD 2013 Mortality and Causes of Death Collaborators, 2014; Roth et al., 2015; World Health Organization Regional Office for Africa, 2011).

In addition, recent successes in controlling HIV/AIDS and other communicable diseases are also contributing to the rise in the proportion of deaths attributable to NCDs. This is consistent with the epidemiologic transition, although some have recently argued that our current concepts and frameworks of demographic, epidemiological, and health transitions are “incomplete or irrelevant” for documenting or describing the population and health experiences in the African context (Kuate, 2014). Nevertheless, there is increasing evidence that in many sub-Saharan African countries, mortality rates from many infectious, parasitic, and neonatal diseases are declining (Oosthuizen, Jinabhai, Terblanche, & Becker, 2008). For example, in the GBD 2013 all-cause and cause-specific mortality data, significant reductions in diarrhea, lower respiratory infections, and neonatal disorders led to large gains in life expectancy in sub-Saharan Africa (GBD 2013 Mortality and Causes of Death Collaborators, 2015). With population growth and aging, coupled with changing patterns of diseases and related risk factors typically seen with health transitions, the prevention and control of risk factors takes on even greater prominence.

Changing Lifestyles and Major NCD Risk Factor Trends

Modifiable behavioral and lifestyle-related risk factors play a critical role in the major acquired NCDs. For example, in the INTERHEART Africa Study, five modifiable risk factors (cigarette smoking, diabetes, hypertension, abdominal obesity, and ratio of apolipoprotein B to apolipoprotein A-1) contributed a population-attributable risk of nearly 90% for acute myocardial infarction in that study (Steyn et al., 2005). Changing lifestyles that lead to adverse risk factor profiles are associated with an increasing burden of NCDs. Current evidence suggests that changing lifestyles in sub-Saharan Africa are leading to adverse increases in hypertension prevalence, obesity and other cardiometabolic risk factors, physical inactivity, poor nutrition, and tobacco use in many countries (Mensah, 2013).

For example, prevalence data in adult overweight and obesity (Stevens et al., 2012) and systolic blood pressure (Danaei et al., 2011) generally show adverse trends for sub-Saharan Africa. Between 1980 and 2008, the age-standardized body mass index increased in all geographic subregions of sub-Saharan Africa except in central Africa (Finucane et al., 2011). In women, Southern Africa was among the subregions with the highest body mass index in 2008 (Finucane et al., 2011). In fact, in 2008, the age-standardized prevalence of female obesity was highest in southern African women at 36.4% (Stevens et al., 2012). Although systolic blood pressure declined at the global level by 1.0 mmHg per decade in women and 0.8 mmHg per decade in men between 1980 and 2008, it increased in East Africa for both sexes and in West Africa for women (Danaei et al., 2011). Consistent with these trends, the highest systolic blood pressure levels in women were found in some East and West African countries (Danaei et al., 2011). These observations call for a prominent role in health promotion and especially risk factor prevention and control.

Transmissible Agents Are Also Important Risk Factors for NCDs in Africa

The global effort to address NCDs have focused, understandably, on the major NCD risk factors including high blood pressure, tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity (WHO, 2005). These risk factors are also important in sub-Saharan Africa, especially in light of recent surveillance evidence of rising prevalence of high blood pressure and cardiometabolic risk in sub-Saharan Africa (Mensah, 2013). In sub-Saharan Africa, however, the list of important risk factors for NCDs do not stop at these traditional risk factors but also include transmissible agents that underlie the burden of neglected NCDs in sub-Saharan Africa (Mensah & Mayosi, 2012).

For example, the role of Group A beta-hemolytic streptococcus in the etiology of rheumatic heart disease is well established. This is a highly preventable NCD; nevertheless, the prevalence in sub-Saharan Africa remains as high as 15 to 30 per 1,000 asymptomatic schoolchildren (Beaton et al., 2012; Marijon et al., 2007). One of the greatest concerns is the high morbidity and mortality associated with rheumatic heart disease, especially in pregnancy where it is associated with a maternal mortality as high as 34% and a high rate of fetal loss among survivors (Mayosi, Gamra, Dangou, & Kasonde, 2014). Other transmissible agents associated with NCDs include Helicobacter pylori, hepatitis viruses, Epstein–Barr virus, human papillomavirus, Chlamydia trachomatis, Onchocerca volvulus, Mycobacterium tuberculosis, and HIV (Bridson, Govan, Norton, Schofield, & Ketheesan, 2014; Ogoina & Onyemelukwe, 2009). Not surprisingly, the Ministers of Health and Heads of Delegation of the WHO African Region called attention to infectious etiologies as part of the “common risk factors” that must be addressed in the sub-Saharan African setting (World Health Organization Regional Office for Africa, 2011).

Urbanization and Globalization Portend Future Challenges

Urbanization and globalization have both desirable and adverse impacts on population health. The African Development Bank Group recently stated that urbanization in Africa “has largely been translated into rising slum establishments, increasing poverty and inequality” (African Development Bank Group, 2012). The adverse impact of rapid urbanization in sub-Saharan African settings and the relation to NCDs have been well recognized (Barrett, 2010; Mbanya, Assah, Saji, & Atanga, 2014; Schram, Labonte, & Sanders, 2013; Siervo, Grey, Nyan, & Prentice, 2006). Together with trade liberalization and investment liberalization, rapid urbanization in sub-Saharan Africa has generally resulted in a net adverse risk exposure to NCD risk factors such as unhealthy diet, physical inactivity, diabetes, harmful use of alcohol, and a greater prevalence of hypertension, especially for the urban poor (Schram et al., 2013). In South Africa, for example, Temple and Steyn (2011) have shown that a healthier diet is about 69% more expensive than an unhealthy one, making it unaffordable for nearly 80% of the urban poor. Although urban dwellers accounted for approximately 36% of the population in 2010, current projections suggest the proportion will grow to 50% and 60% by 2030 and 2050, respectively (African Development Bank Group, 2012). Such rapid urbanization associated with adverse NCD risk factors is likely to contribute to the rising burden of NCDs.

A Need to Leverage Successful Models of Communicable Disease Care

There is a crucial need to learn from and leverage service delivery models that have been successful in addressing communicable diseases such as HIV/AIDS in sub-Saharan Africa. For example, in a provocative article on the subject, Rabkin and El-Sadr (2011) pose the question “Why reinvent the wheel?” They emphasize that many of the implementation strategies developed for HIV programs in these low-resource settings have a strong potential to contribute to the “continuity care framework” necessary for tackling NCDs (Rabkin & El-Sadr, 2011). Given the fiscal constraints of the present era, adopting, adapting, and leveraging these delivery models originally developed for communicable disease care may be exactly what is needed to stimulate NCD care services in sub-Saharan Africa.

In fact, it can be argued that the time has come to abandon the traditional dichotomy between communicable and noncommunicable diseases and explore integrated models that place the patient and all comorbid diseases and risk factors, not the type of disease, at the center of disease control priorities in sub-Saharan Africa. Oni and Unwin (2015) have demonstrated that this dichotomy is problematic for public health control strategies because of the “complexity, bidirectionality, and heterogeneity” of interactions between established communicable diseases such as HIV, tuberculosis, and malaria and emerging NCDs such as diabetes, cardiovascular disease, chronic obstructive lung disease, chronic kidney disease, epilepsy, and mental disorders (Figure 2).

Figure 2.

Interaction between tuberculosis, malaria, and HIV, and risk factors/disease precursors and noncommunicable diseases.

Leveraging successful models of communicable disease care in sub-Saharan Africa for the prevention and control of NCDs deserves emphasis and support. As shown in Figure 3, the investigators of the Academic Model Providing Access to Healthcare Partnership (AMPATH), funded by the United States Agency for International Development and in partnership with the Government of Kenya, are exploring how to successfully expand its clinical scope of work to include hypertension and other NCDs (Bloomfield et al., 2011). Similarly, the Government of Rwanda is exploring the feasibility of leveraging the investments made and successes in the treatment and control of HIV/AIDS to tackle broader health system strengthening efforts and the emerging challenges of NCDs including major mental illness (Binagwaho et al., 2013).

Figure 3.

NCD—The AMPATH model.

Transdisciplinary Health Research and Research Training Are Needed

Transdisciplinary research approaches that cut across and leverage expertise in communicable and noncommunicable disease prevention, treatment, and control will be necessary. Nearly a decade-and-half ago, the Institute of Medicine highlighted the importance of the transdisciplinary approach that involves the active engagement of “teams of researchers that work across disciplines in the development of the research questions to be addressed” in an effort to keep the public healthy (Gebbie, Rosenstock, & Hernandez, 2003). For tackling NCDs in sub-Saharan Africa, such a team could include physicians, physician assistants, nurses, social workers, community health workers, health promotion specialists, health educators, teachers, communication specialists, biostatisticians, epidemiologists, behavioral scientists, health planners, policy analysts, health care administrators, and research grant managers. Building and nurturing these transdisciplinary teams for health research takes time, require resources, and deserve appropriate planning in preparing research grant applications.

Conclusions

Although NCDs are not currently the leading cause of death and years of life lost in sub-Saharan Africa, they already contribute significantly to adult mortality and represent an important developmental challenge for the region. Coordinated and sustained strategies are needed for effective prevention, treatment, and control of NCDs in this region. However, these strategies are best conceived and executed in alignment with existing strategies for the prevention, treatment, and control of the actual leading causes of death in this region. Recognizing the crucial role that communicable, maternal, neonatal, and nutritional diseases currently play in death and disability in sub-Saharan Africa is an important first step. Additionally, the important role that demographic changes and health transitions play in the changing patterns of disease and risk exposure is crucial. More so in sub-Saharan Africa than elsewhere, the role of transmissible agents as important NCD risk factors should be recognized. Scaling up service delivery models that have successfully leveraged existing infrastructure and expertise for HIV/AIDS and other communicable disease care will be important. Finally, investments made in building and nurturing transdisciplinary research teams and support for research training are likely to pay big dividends in the global effort to prevent, treat, and control NCDs.

Footnotes

Author’s Note

The views expressed in this article are those of the author and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; National Institutes of Health; or the U.S. Department of Health and Human Services.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Supplement Issue Note

This article is part of a Health Education & Behavior supplement, “Noncommunicable Diseases in Africa and the Global South,” which was supported by SAGE Publishing, with additional support from the National Heart, Lung, and Blood Institute Contract No. HHSN268201500073P. The entire supplemental issue is available open access for one year at .

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