Public health efforts in Africa have focused on infectious diseases such as HIV, but chronic diseases are also big killers.
Few people know more about the fight against non-communicable diseases (NCDs) in Africa than Professor Ama de-Graft Aikins. An LSE African Initiative Fellow at LSE Health and associate professor of social psychology at the Regional Institute for Population Studies, University of Ghana, it has been the main focus of her work since 2004. During which time public health efforts in Africa have only had eyes for infectious diseases and the received wisdom has been that obesity, heart disease and diabetes are Western problems.
“It has become a universal phenomenon”, says de-Graft Aikins, speaking to Guardian Sustainable Business shortly before flying from London to the Ghanaian capital Accra – the two cities between which she divides her time. “The way that Africa has been portrayed in global media when public health issues are discussed, infectious disease gets flagged up very quickly and in a dominant way. Everything is filtered through HIV, tuberculosis and malaria – the ‘big three’. And so it becomes a self-fulfilling prophecy in a way. HIV, tuberculosis and malaria are the big hitters in Africa so that’s what we need to look at.
“Yet if you actually look at the trends over the last ten years of published research, you begin to see that chronic disease is close behind. Everyone knows that HIV-Aids is the biggest cause of death in South Africa – but the second biggest is cardiovascular disease. The challenge is to make NCDs visible in a way that captures the attention not just of local policy makers but also their development partners. How do we shift the perception to say we also have an NCD problem and it is just as big and problematic as it is in rich northern countries?”
The research projects led by de-Graft Aikins have been designed with this question in mind. In 2006 she received a British Academy grant to establish the UK-Africa Academic Partnership on Chronic Disease, and is a regular on World Health Organisation (WHO) panels on chronic NCDs and health systems policy. Yet raising the profile of NCDs in the developing world remains slow progress.
“Even though Ghana has a very low HIV rate – 1.8% – in contrast, hypertension prevalence is 35%. So you can see how disparate the figures are… when you actually analyse the data, there has always been a co-existence of infectious and chronic disease.”
There is also a misconception that NCDs are more prevalent among the wealthy. “The burden is polarised across social economic status and you do have wealthy communities having a high burden of chronic diseases”, says de-Graft Aikins. “But poor communities have a high burden of both infectious and chronic diseases. Across Africa, Latin America and Asia… we are actually beginning to see that poor communities have a double burden. That creates huge problems in terms of health equity and poverty reduction – if you have a chronic disease it drives you and your family further down into poverty.”
One of de-Graft Aikin’s most extensive studies, published in 2010, looked at over 100 years of public health records in Accra, going back to 1877. From colonialism though to independence and finally globalisation, the environmental influences on health could be clearly traced. In 1952 and 1966 infectious and parasitic disease were the number one cause of death in Accra. By 1991 and 2001, ‘circulatory’ (heart disease and hypertension) was the number one cause – it hadn’t even appeared in the top ten of those previous decades.
“If we’re trying to understand what happened in Accra in the 60s, 70s and 80s, what we need to be looking at are the risk factors of major chronic diseases. WHO for instance talks about five risk factors: poor eating habits, obesity, smoking, physical inactivity and alcohol over-consumption. And one finds from the research conducted by anthropologists, social historians or geographers, that these problems were becoming prevalent. Sedentary lifestyles were fast becoming the norm by the time of the 1970s… people became drawn to processed, “Western” foods. There is a story that the first [military] coup arose because people were upset over not having access to milk and sugar, corned beef and rice.”
In today’s Accra, a city of some two million inhabitants, de-Graft Aikins sees lifestyles much like any other part of the world, where “people are working 9-10 hours a day, are likely to eat lunch and breakfast at work, and even grab a takeaway on the way home. Those sorts of trends are also occurring in many African cities.”
Her current research project aims to better understand these causes within their societal contexts. While some of the factors may be global, the solutions – particularly from the point of view of wellbeing – need to be tailored locally. For example, “The ideal Ghanaian body size for a young woman is not so much overweight, but a kind of buxomness”, says de-Graft Aikins. “Thinness is really stigmatised in Ghana and much of Africa… People who are on the thin side do all kinds of things to gain weight. In Kumasi there are particular herbal supplements that people will take, or they might drink malt and milk, because there is an idea that that can make you gain weight. Or they decide not to exercise.”
Through a major multi-site study looking at obesity and diabetes amongst Ghanaians living in Ghana, Netherlands, the UK and Germany, de-Graft Aikins is examining obesity, diabetes, blood pressure, and also asking questions related to body image and wellbeing, in order to better understand how culture and environment influence NCD prevalence. Ghanaian policy makers were involved from the start, and will also be co-authors of the research when published later this year. “What we’re trying to do by this is show that NCDs are a big problem, but also that we need to address this through partnerships… between researchers, policy makers, and to some degree politicians. It comes back to why the NCD problem has not been made as prominent as the infectious disease problem. We can only do that by working with people who set the agenda.”
She believes this is starting to happen not just through her work, but across Africa. “WHO/AFRO, the West Africa Health Organisation has recently set up an NCD department. The Commonwealth Secretariat is tackling NCDs now. The bodies that matter are beginning to put NCDs on the agenda in Africa, and this creates a space to facilitate partnerships, gather evidence and research.” Before ending the interview to leave for her flight she adds, optimistically, “I am hopeful that things might change in the next five to six years.”
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The piece was amended on 10 April 2013 to change Ama de-Graft Aikins’ title from Dr to Professor, to add that she is an LSE African Initiative Fellow and not a visiting fellow and to change senior lecturer to associate professor of social psychology.