Editor’s Note: On October 29 the World will mark Stroke Day. Strokes are one of the highest causes of death in Sub-Saharan Africa. This week’s guest contributor reflects on the harrowing experience many families go through when one person suffers a stroke in Nigeria. He highlights the urgent need for better stroke care in Nigeria and how a newly formulated Stroke Reference Group could be a part of the solution.
By Ibrahim Imam
Secretary, Medical Association of Nigerians Across Great Britain (MANSAG)
Like a thunderbolt it strikes out of the blue, its victim caught unawares, in deep sleep or actively engaged in some mundane activity. Respecting no age or gender, disregarding poverty or wealth, it indiscriminately chooses its target. Sending no warning, it attacks in a single raid, leaving devastation in its track. It bequeaths a powerless and helpless father or mother, child or grandparent. A dazed family looks on an unfamiliar person, often conscious but unable to express themselves, regardless of what they hear. If it doesn’t kill, locks the victim away in a place unrecognisable to loved ones.
In Nigeria, one person is affected by a stroke every 80 minutes. Nigeria sees about 168,000 new stroke cases every year
One of the many debilitating diseases in today’s society, a stroke happens when a major blood vessel (artery) which supplies nourishment and oxygen to the brain ruptures or is suddenly blocked. Disrupting this vital supply line to one half of the brain results in paralysis on the opposite side of the body. Stroke affects one in six people worldwide and is the second highest cause of death in sub-Saharan Africa.
In Nigeria, as in other developing countries, strokes disproportionately affect the young and economically active members of society with serious consequences for family members and careers.
The world comes to a halt when stroke strikes. Limp and lifeless, the face sagging, the speech slurred, the arm hanging uselessly by the side, the leg unable to support the weight of its owner. Knowing that there are no ambulances they can rely on, the panicked family bundle the victim into the back of the cramped jalopy or the luxury car as the case may be. On to the potholed road, praying and wailing in equal measure, the journey to hospital seems to last forever. Clinging to hope, they half-lift and half-drag the victim into the emergency room. The long queue over, a quick examination, and they are given… the bad news:
‘He has had a stroke’. ‘He will need a CT head scan but we don’t have this in our hospital’.
‘There is a clot-busting medicine that helps if he gets it within four and a half hours but it is not available in Nigeria’
Often the family and friends have never heard of stroke or its causes. There is no public education programme on this disease, even though it is so common. Everyone knows someone who has had a stroke but many believe it is the handwork of witches or divine punishment for the real and imagined sins of the wicked. Stroke however is a medical condition with a diagnosable origin.
The stroke victim is given Aspirin, admitted to the ward, given the best nursing and medical treatment available. It is often at this time that the patient and family discover that the origin of the disease was undiagnosed hypertension. Only then is it discovered that the victim harboured diabetes. Only then will the family say ‘we knew he or she should not have been smoking recklessly, eating undeterred, drinking to stupor’.
Here lies the paradox of a stroke-it is a mostly preventable disease. The commonest risk factors for stroke are hypertension, diabetes, smoking and poor diet; these are all remediable or controllable.
After a couple of weeks in hospital the family see there is no improvement. They ask the medical team if anything more can be done. ‘If he is lucky he will recover some power and speech but there is not much more we can do for him now’, they are told. ‘We have no facilities or personnel for rehabilitation. Please take him home,’. Their hopes are crushed. Thus begins a difficult journey for the family. Gone are the dreams for a better life, the breadwinner often struck in their prime. Without any support the victim is left to a miserable existence. They walk abnormally, one arm held stiffly across the chest, the foot scraping the floor as it makes a rigid circular motion to propel the body forward. In worse cases, the victim is bed or chair bound, a burden on the family, a stigma to society, a figure of pity.
An urgent call for better stroke services in Nigeria
The provision of stroke services in Nigeria is sadly, acutely inadequate. Public awareness and understanding of stroke is deficient and this results in citizens falling victim to this largely preventable disease. In Nigeria, almost all patients in the early, potentially reversible stage of stroke do not get to the hospital, or arrive too late for any intervention. Many advanced stroke treatments like thrombolysis (clot busting medicines) are not available in our hospitals. Furthermore, survivors of the stroke often do not fulfil their potential for recovery because stroke rehabilitation services are poorly developed.
Inadequate funding for stroke care is one of the factors underlying deficient stroke services in Nigeria. The cost of treating and caring for stroke victims is prohibitive and there is currently no organised funding for stroke care in Nigeria. There are very few well-managed stroke care facilities and medical personnel are generally poorly trained to manage stroke patients. The accurate diagnosis and comprehensive treatment and rehabilitation of stroke victims are therefore compromised; as a consequence stroke outcomes are poor in Nigeria. This is in addition to poor research into the size of the problem and how best to address it in our context.
What is the government doing about this, family and friends ask themselves. Where are the stroke prevention and treatment programmes that would have staved off this disaster? Where are the stroke units and stroke experts? Where is the stroke budget? These are questions still without answers in Nigeria.
The overall management of strokes across the country needs a comprehensive strategy. There is an urgent need for better evidence of the prevalence of stroke in Nigeria. Stroke services need urgent and significant funding. Funding is also required to improve the education and training of health professionals in stroke care. Stroke will however not be well-controlled unless there is sufficient public awareness of the causes and prevention of the disease.
A step in the right direction… forward
Stroke care in Nigeria took a big step forward on the September 15, 2015when the Nigeria Stroke Reference Group (NSRG) was inaugurated. The NSRG is a multidisciplinary body set up to chart a way forward for stroke care across Nigeria. The Group is made up of specialists with varied backgrounds in stroke-related care, such as neurology, neurosurgery, neuro-rehabilitation, nursing, physiotherapy, and speech therapy. It also includes health administrators and stroke patients.
The road to the creation of NSRG started when Mrs Rita Melifonwu, a Nurse in the United Kingdom realised the huge challenges of caring for stroke patients, and established a Charity, Stroke Action. This led to great improvement in the management of stroke in the part of London where she practiced. She proceeded to extend this approach to stroke care to her home country, Nigeria. This led to the establishment of Stroke Action Nigeria (SAN) which actively engages in stroke community outreach programmes and campaigns in Nigeria. SAN collaborated with Medical Association of Nigerians Across Great Britain (MANSAG)to enhance stroke care in Nigeria through skills and technology transfer, policy development, annual training weeks, and public private partnerships (PPP). MANSAG also raised funds for Stroke Action through its Run/Walk for Stroke and a Charity Ball in May 2015.
Members of the NSRG are drawn from Nigeria, the United Kingdom, and the United States. NSRG Chairman is Prof. Sunday Bwala, Chief Consultant Neurologist at the National Hospital, Abuja and its Secretary isMrs Rita Melifonwu, Chief Executive Officer of SAN and a trained Nurse. The main objectives of the NSRG are development of a National Stroke Strategy, establishment of a National Stroke Registry, facilitation of stroke education and training for healthcare professionals, and serving as an advisory body to the FMOH on stroke services.
The current state of stroke care in Nigeria is inadequate and improving it requires a comprehensive strategy, adequate funding, skilful training, and heightened public awareness. The NSRG has been set up to implement these measures but it will need the support and cooperation of the government, funding agencies, health institutions, healthcare practitioners, and the public to succeed. We must all work together to find effective, common solutions to fight this common disease that plagues our country.