Preventive Screening of Non-Communicable Diseases in sub-Saharan Africa
One of the recent major public health concerns in low and middle-income countries, especially in sub-Saharan Africa, is the escalating burden on non-communicable diseases (NCDs). It is predicted that by the year 2020, non-communicable diseases, of greatest interest being cardiovascular diseases, diabetes and cancer, will cause seven out of every ten deaths in developing countries (Boutayeb, 2006).
This trend is particularly concerning for low and middle-income countries because a majority of these countries are still battling with infectious diseases such as malaria, AIDS, and TB. The resulting ‘double burden’ of disease would be too high especially for low income countries that are already struggling economically and are characterized by suboptimal health systems.
Another alarming aspect of non-communicable diseases in developing nations is that the majority of suffers from the increased cases are expected to be relatively young i.e. the working population (WHO, 2009). This is concerning because most African countries are experiencing a demographic transition where the majority of its people fall within the working-age population, and there’s thus a great potential for these countries to experience a demographic dividend. Demographic dividend is the accelerated economic growth that can result from improved reproductive health, a rapid decline in fertility, and the subsequent shift in population age structure (Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health; Population Reference Bureau, 2017). I therefore believe that timely and effective interventions to reverse the trend of non-communicable diseases will not only save the countries from a high burden of disease, but will also be of great economic benefit.
Borrowing lessons from developed countries, it is clear that the treatment and management of non-communicable diseases is extremely costly. In addition to the high economic burden of treating and managing NCDs at the country level, a heavy financial burden would also be experienced at the household level. Given the limited insurance coverage for NCDs, families would have to spend money on medicine, as well as deal with costs related to loss of income-generating opportunities because of the decreased productivity of ill family members. The best strategy for developing nations is prevention, before the situation becomes unmanageable. One way to achieve this is through preventive screening.
With the increased technological advances in diagnostics and preventive screening, we now have available cost-effective, rapid and easy to use tools and techniques for the diagnosis of a number of diseases. Examples include rapid blood glucoses tests (for risk of type 2 diabetes), Lipid and Blood Pressure tests (for risk of hypertension), PSA tests for the screening of prostate cancer and Clinical Breast Exams for breast cancer screening (a technique, not tool).
Most of the rapid diagnostic tools are portable, use replaceable batteries and are easy to operate; therefore, screening services can even be provided in remote and otherwise difficult to reach places on the continent. The diagnostic tools have to be purchased, and health care providers have to be trained to use them, both of which are costs to be incurred. I, however, believe that if the governments and relevant stakeholders invest in this, given the current state and performance of our health systems, in the long run, the cost of prevention would be much less than that of treatment and management of NCDs. Also, we cannot screen for every single non-communicable disease.
Priority should be given to diseases with the highest DALYs or highest prevalence, which in most African countries would be cardiovascular diseases, diabetes and cancer. Another advantage of preventive screening is that it provides us with data and evidence for which diseases are most prevalent and where; and what the differences are in prevalence between sub populations e.g. men vs women, urban vs rural dwellers, young vs older people. With this data, policy makers can make informed decisions on best ways to intervene and thus ensure the best use of resources.
One way that preventing screening can be done is through incorporating it into primary care, like the way it is done in developed countries such as the United States. However, within the African context, there would be two major challenges to this strategy. First, culturally, most people do not attend the clinic or go to the hospital unless they are sick. Therefore, screening at hospitals will miss a significant number of people who may be at risk for NCDs. Also, the screening results may give us a false sense of disease prevalence because considering the people who attend the clinics are already unwell, albeit, from other diseases, they may also be at greater risks of diseases for which we are screening given their compromised immunities. Secondly, screening at hospitals may not be feasible given the shortage of healthcare providers and the overwhelmingly large number of patients in these settings.
I, therefore, think that the best action plan would be through mass screening campaigns in communities using trained community health workers. Mass screening in communities, say by setting mobile clinics, will ensure that the population at risk is reached, which would most likely not be achieved by screening at the hospitals. Community health workers address two challenges; first they are a solution to the shortage of healthcare providers to do the screening, and secondly, since they are usually known and trusted members of the community, they are in the best position to persuade community members to participate in the screening campaigns.
Lessons can be drawn from the successes and failures of HIV screening, one important lesson being the understanding of the community’s perception of the diseases (or if they have any knowledge of it), perceived susceptibility, severity and benefits of screening. It is very crucial that education campaigns are done first because if people do not understand the benefits of the screening, i.e. they do not think that they are susceptible or they are unaware of the severity of the conditions, they will not participate. Another strategy to be borrowed from successful HIV screening campaigns is that to ensure high participation, the tests should be offered at no cost to the community. Again, this is another cost to be incurred by the government and stakeholders, but the long terms benefits would outweigh the costs.
As we proceed with preventive screening, we have to be wary of over diagnosis. There have to be clear guidelines for which conditions we are screening for, who should be screened (who is really at risk of the disease), and who should be referred to treatment. We have to ensure that treatment is available and affordable for those who will need it as a result of screening, so as to avoid unnecessary psychological stress on the participants. Therefore, counselling services should also be an important component of the screening campaigns.
Screening is only the first step to prevention. Following it, there will be cases that need treatment and should be referred to the clinic, but most importantly, the population at risk would require either behavioural or systemic interventions. Effective interventions for NCDs are not discussed in this article, as the topic deserves its own entry.
Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health; Population Reference Bureau. (2017, November 16). Retrieved from Demographic Dividend - Investing in Human Capital : http://www.demographicdividend.org/
Boutayeb, A. (2006). The double burden of communicable and non-communicable diseases in developing countries. Transactions of the Royal Society of Tropical Medicine and Hygiene , 191-199.
WHO. (2009). Noncommunicable Diseases, Poverty and the Development Agenda. ECOSOC High-level Segment 2009 .
Kwinoja Kapiteni, from Tanzania, is a first-year MPH student at the University of California, Berkeley. Kwinojas research interests in chronic diseases were influenced by her experiences working at a Health and Demographic Surveillance Site in Dar es Salaam, where NCDs were the focus area.