The weighty burden of NCDs in Nigeria: Time to Act

Editor’s Note: This week’s Thought Leadership Piece comes from Dr. Mamsallah Faal-Omisore, a primary-health physician with qualifications in global health policy, infectious diseases and maternal and child health. This week the third United Nations High-level Meeting on Non-Communicable Diseases (NCDs) holds in New York, to help set the stage for global health conversations about tackling these group of killer diseases. Faal-Omisore argues the case for an Agency in Nigeria dedicated to Non-Communicable Diseases given the burden in Nigeria.

A child was born; life in the womb was tough, not enough nutrients came through to encourage good growth and Naya emerged into the world underweight and possibly underdeveloped. Feeble cries were a hallmark of her childhood and food was neither sufficient; nor of the right quality. Naya just made it to school age, suffering several bouts of malaria along the way. Sadly, Naya lost her mum at 13 from a stroke and she had to move with her brothers to the city to live with their uncle.

The next few years were spent at school, helping in the family shop and caring for her siblings and cousins. On reaching 21, she left home to live with Isaiah – a 25-year-old mechanic, popularly called a ‘vulcaniser,’ who eventually became her common-law husband and father of her two children. Both her pregnancies were difficult; she had high blood pressure and had to be induced. Fortunately, she had good care at the Federal Medical Centre and both children were born healthy. By the time she was 27, Naya was a mother of a 5 and 4-year-old, had started her own business and was doing quite well. She was happy to provide well for herself and her children who went to good schools and lived in a self-contained apartment. Naya made up for her early years of food deprivation, eating plentifully and well. She ballooned to 107 kilograms, quite a lot of weight for her 160cm height. Over the years, she struggled to get about easily and increasingly relied on her assistants to run the business. At 41 years old, whilst making her way to the shop, she collapsed and died from a stroke.

Image credit: Nigeria Health Watch

The impact of Non-Communicable Diseases (NCDs) on Nigerians

Naya’s untimely death is unfortunately a daily occurrence in Nigeria. People diagnosed with any of the four major non-communicable diseases; cardiovascular diseases (stroke and heart disease), diabetes mellitus, cancer and chronic lung diseases are on the rise. WHO estimates that deaths from noncommunicable diseases (NCDs) are likely to increase globally by 17% over the next 10 years, and the African region will experience a 27% increase, that is 28 million additional deaths from these conditions which are projected to exceed deaths due to communicable, maternal, perinatal and nutritional diseases combined by 2030. The costs on society will therefore be staggering; the burden on the health system will be increasingly unsustainable, the loss from the workforce of adults in their prime will have profound effects on the fiscus and families and communities will struggle to make ends meet. All this of course likely to be made worse by a rising population projected to be the third highest in the world by 2050.

Reversal of this trend is possible and existential. Eighty percent of the risk of developing an NCD is related to lifestyle choices; WHO has identified four areas that if addressed will reduce the number of NCD sufferers. These include focusing on physical inactivity, unhealthy diets, harmful use of alcohol and tobacco consumption.  In addition, WHO has also been able to quantify through return on investment analyses, the best value-for-money approaches that governments can take to reduce NCDs in the population.  So, clearly there are remedies that can be taken but what, when and how these should happen in a coherent way remain elusive and unnecessarily so.

In fact, the wide-ranging determinants and outcomes involved suggest that adequately tackling NCDs is imperative, if we are to face this challenge and win. Currently, we have an NCD division within the Federal Ministry of Health which has developed a national strategic plan of action on prevention and control of NCDs – a good start, but more is needed, desperately more, to avoid a catastrophic situation.

What could more robust anti-NCDs action look like?

As mentioned earlier, acquiring an NCD relates to lifestyle choices which in turn are influenced by social norms, the policy environment and poverty challenges. For example, our sociocultural constructs promote weight gain and unhealthy diets in individuals as a sign of affluence, as was the case with Naya. There is very little public health education on the right dietary choices to make nor the importance of physical activity to counter some of these beliefs. Commercial interests rather than health concerns dictate trade and food/agricultural policy, and food safety standards are inconsistently enforced. And, with growing poverty rates, affordability and accessibility to the right quality of food will become unachievable.

Image credit: Nigeria Health Watch

This clearly illustrates that NCD action extends beyond the health sector because of the diversity of influential factors and consequences and as such innovate and sustainable solutions are necessary. In fact, an operation that is so influential it leads to a paradigm shift in our national NCD discourse should be the aim; making real and tangible differences to Nigerian lives daily. Such an entity can be a parastatal mandated by government as is the case with the NCD commissions in Caribbean countries or part of the remit of an existing public health body like in India or the UK. Regardless of its structure, fulfilling the assignment of changing the trajectory on NCDs will be pivotal to its success. It should be defined by being empowered and enabled to perform independent and oversight functions that are built on the following pillars:

• Policy:

Fulfill a governance role by informing as well as assessing the impact of government policy formulation on NCD risk; making an investment case for prioritising NCDs across all sectors; pushing for regulation that promote policies for instance with food and beverages which reduce NCD risk; and ensuring that national strategies emphasise intersectoral collaboration in alignment with international discourse on the best methods to tackle NCDs.

• Health system design:

Mandated to understand the population effect of NCDs through data collection of disease and risk factor burden; set local and national targets that endorse standards for improvement in NCD care delivery; and stimulate robust health system design that has integrated people-centred care at its heart.

• Advocacy:

Calling for adequate and accessible health financing to prevent and avoid the catastrophic costs associated with an NCD diagnosis will be instrumental. Backing behaviour change campaigns built on a strong health literacy, prevention and promotion ethos will be the game-changer and potentially lead to sustainable changes in lifestyle across the lifetime of every individual.

• Knowledge:

The generation and dissemination of organisational outputs publicly through exemplary monitoring and evaluation activities is central to embedding social trust. This will encourage all stakeholders to have a sense of ownership in performance and emphasise its worth as an entity with a powerful social capital philosophy.

Image credit: Nigeria Health Watch

Tomorrow is built today

Would more visible national NCD activity have made a difference to Naya? Probably. There were missed opportunities for change throughout her life; a healthier mother, a healthier lifestyle, regular health checks, a healthier environment for physical activity and so on.  Ultimately, Naya’s chance for a longer, healthier life boiled down to being better informed and being empowered to make the right choices.

As a growing nation, we can no longer leave our most prized assets – our human capital – to the whims and vagaries of luck and chance for survival. To tackle NCDS, a ‘whole-of-society’ plus a ‘whole-of-government’ approach is fundamental. Negotiating these changes starts with recognising that we do need to urgently and effectively coordinate a multi-pronged and targeted approach encompassing socio-economic, cultural and political influencers thereby assuring a sustainable reversal in outcomes. It must also set us on the path to join global efforts of meeting a substantial proportion of the SDGs especially SDG 3.4: Reducing by a third the number of premature deaths from NCDs by 2030… There are only 12 more years to go!

Guest Columnist Bio: Mamsallah Faal-Omisore is a primary-health physician with qualifications in global health policy, infectious diseases and maternal and child health. She has a diverse portfolio of activity centred around the promotion of quality health care in resource-limited settings. Mamsallah is also a clinical team member of Primary Care International – an NGO that provides strategic and capacity building support to governments and institutions in LMICs to strengthen health systems particularly in NCD care. In addition, she is a member of the working group on citizens, parents and children of the NGO: Health Information for All as well as a member of the special interest group on NCDs for the global family doctor organisation – WONCA. Her activities in the policy development space have included developing NCD strategies for pharmaceutical companies, advising organisations on employee health risk assessments for NCDs and supporting initiatives such as the development of a health literacy foundation targeted at children as change agents for NCD prevention action in communities.