In an interview with The Global Journal at the Economist Conferences NCD Summit held in Geneva on 29 October 2012, Ama de-Graft Aikins discusses NCDs in emerging markets and the need for coordinated action. Ama de-Graft Aikins is Visiting Fellow at LSE Health and Associate Professor of Social Psychology at the University of Ghana.
Developing countries are facing a double burden of infectious and chronic diseases. Prevention there seems to focus much more on infectious diseases such as HIV or tuberculosis than on NCDs. Do you see new initiatives focusing on the prevention of NCDs in African countries?
There are at least four countries that have done something about prevention and have published their research: Cameroon, Ghana, South Africa and Tanzania. A lot of what is done in other countries as far as prevention is concerned focuses on educating the population, for example using the mass media. But chronic diseases are complex lifestyle diseases as well as diseases of social conditions, such as poverty. So education is a good start but it is not enough. Communities need to be involved in understanding what their health problem is and how they can contribute to the development of relevant solutions. That's where I think South Africa has led in terms of an early coronary heart disease intervention project that mixed education, community-level activities, mass media and so on. Community-based approaches are considered best practice because they tend to have longer term impact.
A few years ago, then President Thabo Mbeki's AIDS denialism caused some uproar in South Africa and among the international community. Did you notice differences and specificities with regards to representations of chronic diseases in African countries?
A lot of the work in Africa has been epidemiological. A number of surveys provide numbers in terms of prevalence of risk and complications, but very few studies try to explore how people make sense of these conditions. Take diabetes for instance, qualitative research on experiences has been conducted in about six countries: Botswana, Cameroon, Ghana, South Africa, Tanzania, Uganda. What has emerged out of these studies is that in almost all these countries people see diabetes as a 'sugar disease'. But people also attribute diabetes to supernatural causes. In between, there are other ideas that relate to what doctors tell their patients, about physical inactivity or smoking or alcohol overconsumption, but those are few and far between. Overall, people either attribute diabetes to their diet or they draw on traditional belief systems about health and illness to make sense of diabetes. A similar thinking process exists for hypertension, in some of these countries, although the dominant belief is that hypertension is stress-related or linked to daily hassles of poverty.
What is the response from the healthcare sector?
NCD research, intervention and policy is far advanced in high income countries. In contrast, very few African countries have managed to develop responses that address the needs of ordinary people. Many basic things that are routine in high income countries, such as taking blood pressure, are not done at health centre level. Doctors and senior nurses might be knowledgeable about general aspects of common NCDs, but health workers with lower levels of training struggle to understand NCDs. This group is often no more knowledgeable about NCDs than lay communities.
That is where the shifting of competencies from highly skilled healthcare professionals to community health workers you mentioned comes in. Can you elaborate on this?
It is a very simple idea. There are many basic things that can be done in NCD care which do not involve complex knowledge and technical skills. For instance, you can teach an educated health worker to be able to take someone's blood pressure or to know that there are three or four types of drugs that work for hypertension in a particular locality. You can teach them to teach somebody with hypertension what to eat, what to avoid eating, how much exercise and what kind they can do. The task-shifting strategy has worked for the care of some neglected tropical diseases and common mental disorders in Asia, Latin America and Africa, and has now been piloted in Africa for diabetes and hypertension. As a matter of fact, highly skilled health professionals in Africa are scarce so you need to figure out how to devolve healthcare for a vast range of healthcare services in order to make healthcare accessible and effective.
Can you tell us more about the West African Health Organisation?
WAHO has been around since 1987 and is based in Bobo-Dioulasso, Burkina Faso. It is a Specialised Agency of ECOWAS and works with West African governments at the health level. They have the power to convene meetings with member states and to mediate the relationship between the global health community and national policymakers. However, there is not much communication between the organization and researchers and they have only just recently developed a programme on NCDs when NCDs have been a public health problem in Africa for a long time. These are some of the things we need to consider if we want important ideas discussed in Geneva or New York to get operationalised in a rural village in Ghana or an urban slum in Kenya. Usually governments will sign up to agreements at the global stage, but somebody has to make sure governments actually do what they pledged they were going to do for their citizens. I think organisations like WAHO have that power to push policymakers to action. So it is really about how researchers, policy makers and regional organisations work together so that everybody gets plugged into the global system. But global ideas only work if they are implemented locally. It has to be a two-way system, top-down and bottom-up. Communities must be at the centre.
(Photo © DR)