This paper was made possible by the HIV clinician’s society, whose staff and members were always ready to answer my questions. An additional thank you goes to Management Sciences for Health pharmaceutical information center in the Central Hospital that provided me with an article from The Lancet.
A vision of chronic diseases
Another year goes by and Namibia draws closer to vision 2030. But are we ready for the Tsunami? A wave of chronic, non-communicable, diseases is set to hit Namibia. Industrialized countries experienced the transition from infectious diseases, such tuberculosis, to non-communicable diseases, notably cardiovascular disease during the course of the twentieth century. Now low- and middle-income countries are experiencing this same transition, but in a shorter time frame. According to the projections World Economic Forum 2010 global health risks report, deaths from chronic diseases will rise by 71 percent, while those due communicable diseases will fall by only 3 percent by the year 2020. (Kelland, 2010). Cardiovascular diseases, which are intimately associated with high blood pressure and cholesterol, diabetes, renal failure and stroke are the second biggest killers in Sub-Saharan Africa. AIDS associated infections, unsurprisingly, still account for the largest number of deaths in Sub-Saharan Africa (Miranda et al., 2008). Given Namibia’s position as a middle-income country in Sub-Saharan Africa, the “double burden”of AIDS and chronic diseases is set to hit us as the country develops.
Cardiovascular disease accounts for the largest proportion of all deaths in low and middle income countries (Miranda et al., 2008). These diseases include heart failure, heart attack and also predispose one to stroke. Since 1990 – the year of our independence – the disease burden due to chronic diseases in low and middle income countries has grown to almost half of the total disease burden (Miranda et al., 2008). Looking at the changes in Namibia during that time frame — universal health care and education, but also rapid urbanization and the rise of consumerism — we can locate risk factors for chronic diseases.
Today, most Namibians live in an interconnected country where dependence on mass produced, refined food stuffs is the norm. Especially in urban areas, black people are opting for white bread and white rice instead of the brown bread or traditional staples such as oshifima or maize. Rural areas too are bleeding into urban settlements, such as in the Oshana region, where consumption of these refined foods is displacing traditional foods. By refined, I mean any food whose raw product has been processed to maximum. White flour and white rice, which have lost the nutrient rich, whole grains, are clear examples. But ultra fine mahangu meal that has been refined in a machine is also an example. Not only have these food lost vitamins, but they are less filling which predisposes one to overeating and obesity. In other African countries that experienced this urbanization before us, such as Ghana, the increase in consumption of refined foods was a determining factor in outbreaks of cardiovascular disease (Miranda et al., 2009).
But this does mean that eating white bread everyday will give one a heart attack! A diet rich in refined foods, and in fats, is “a cause of causes”, which together induce cardiovascular disease. Given such a diet and little exercise, one becomes obese, which in the presence of smoking can lead to heart disease by the time one hits 50. Therefore, an age of 50 or greater and an unhealthy diet predispose the body to high blood pressure and cholesterol, diabetes and obesity, which in turn increase the chance of heart attack, heart failure or stroke. (Miranda et al, 2008, Mayosi et al 2009). And then there is alcohol abuse that pushes a body on the verge of heart disease to a life-threatening condition. The path from lifestyle to heart disease is non-linear and it requires the synergistic action of multiple factors, but it is there nonetheless.
When we think of heart attacks and strokes, we think of white people. We see the logo of the heart association on tubs of unsaturated (expensive) margarine, the kind used by white people on television adverts. Indeed, those we consider as white people are often genetically predisposed to suffer from heart disease. In South Africa, for instance, it was found that 0.5% of Afrikaaners have an innate risk to coronary heart disease (Mayosi et al,2009). However, let us not delude ourselves into thinking that cardiovascular illnesses are limited to whites only. We must realize that the risk factors necessary for the development of cardiovascular diseases cut across racial lines. In fact a confluence of these risk factors occurs in the township, where people have few dietary options and live amidst substance abuse. This is supported by the finding in South Africa that between 2001 and 2006, most deaths due to cardiovascular diseases occurred in the Khayelitsha township of Cape Town, much fewer than in the wealthier southern suburbs. (Mayosi et al, 2009). It thus appears that the poorest people, who are often black, are most at risk of cardiovascular disease.
Recreational facilities which provide much needed cardiovascular exercise are few and far between for those most at risk in Namibia. While learners and students partake in recreation, in the form of sport and dance at their institutions of learning, adults have limited options. The parks in towns do not allow any ball games and so people are forced to look elsewhere to play soccer, for instance. For this reason, we often see makeshift soccer fields in car parkings and open areas in Namibia. However, these spaces of recreation are prone to disappear, as is the case with a soccer field in the Mondessa suburb of Swakopmund. In spite of the community’s appeal against the building of a business complex on the ground, the Swakopmund municipality affirmed that the soccer playing on the area was “illegal” and “never intended” for that purpose. The Municipality is building a new soccer field, but community members will have to pay to make use of it (NBC news, 15 January 2010). Recreation, it seems, is an increasingly expensive activity in urban areas, where access to sports ground incurs a cost to the user. Invariably, this makes recreation inaccessible to the poor people in urban areas.
Even though poor people rarely access recreation, their lifestyles are generally more physically active than those of wealthier people. Blue collar workers abound Windhoek, often performing physically strenuous tasks such as gardening and building, while women living in informal settlements pound mahungu in order to produce their staple Oshifima, as they cannot afford to do otherwise. Then of course, there is the undeniable reality of hunger for about 400 000 Namibians according to the World Food Programme, for whom obesity is not a problem. Given these socio-economic structures, one may speculate that chronic diseases are not a major health problem for the poorest section of society. However, in absence of research on this matter, this can only remain speculation. We must bear in mind that Namibians are highly socially mobile and more people are expected to become employed as Namibia develops economically towards Vision 2030. Consequently, it is important to assess whether socially emancipated, middle age, Namibians will still place value in physical activity that used to be done out of necessity. To what extent do people continue physical pursuits when they can afford to drive around in cars and hire domestic workers? The fact that the nearly all the cyclists on the road are workers in uniform suggests that the prevailing culture places little value in physical activity for its own sake. And it is precisely in such a culture context that heart disease can become a major problem.
When addressing chronic diseases, the Ministry of Health uses billboards. The ones I have seen show two profiles —one of a person smoking and the other one eating an apple. There is also cautionary message “Prevent unwanted illness stop smoking” on accompanying this message. Apart from two billboards I have seen at Windhoek Central hospital, I have not come across other media or public discourse that raises awareness about non-communicable diseases. Perhaps the intense focus on HIV and AIDS and repeated outbreaks of communicable diseases, such as measles, sequesters mental and financial resources, such that there is little room left for fighting chronic diseases. The AIDS pandemic, however, aggravates the burgeoning chronic disease epidemic in Sub-Saharan Africa, because HIV infection increases the body’s susceptibility to chronic diseases, both before and after a patient begins antiretroviral treatment (ART).
However, the association between these two public health problems is often neglected, even in countries where research on chronic diseases is being done. In South Africa, for example, a report on the cause of death and premature mortality in Cape Town from 2001-2006 completely ignored the possibility that people who died of chronic disease, such as diabetes, may have also been HIV positive. Through a regular collection of death certificates, the Cape Town Health Department is capable of detecting a combination of diseases in any given patient. But when determining the cause of death, International Case Definition (ICD-10) guidelines did group chronic disease deaths due to AIDS. Instead, the department sought to ascertain which tuberculosis (TB) deaths were attributed to AIDS (Groenewald et al., 2008). A more open school of thought, however, is rising. This is evidenced by a 2009 medical review in South Africa that emphasized the association between AIDS and cardiovascular disease in that country (Mayosi et al, 2009).
In the following sections, I elaborate on how chronic diseases can be overlooked in AIDS patients and how ART comes with a certain vulnerability to chronic diseases.
The chronic AIDS
The WHO announced that chronic, non-communicable diseases, are surpassing AIDS as the biggest killers in developing countries in its most recent report on global health risks (Kelland 2010). This statement seems to caution public health programs in the developing world against focusing solely on AIDS while populations are increasingly at risk of death from chronic illnesses. However, it also perpetuates a contentious point view on the “double burden” of AIDS and chronic diseases — that there is a dichotomy of chronic diseases and AIDS in developing countries, one which necessitates fighting a public health battle on two different fronts. It overlooks that possibility that AIDS patients can suffer from chronic diseases in as much as they can suffer from tuberculosis or other opportunistic infections. The physician at the ART clinic in a Windhoek hospital best explains this through her anecdote:
“ I worked at a district hospital before I came here. People are so focused on HIV and TB that they really miss out on non-communicable diseases. I remember a [HIV positive] patient who was loosing weight very rapidly. The patient was wasting away, but the CD4 count was very high. People were wondering what is wrong with the patient and I don’t know how many sputums were collected, but there was no TB. Then someone did a blood sugar test and it was really high at 34 micromoles”
AIDS patients who waste away are immediately suspected of having TB, owing the high frequency of TB and HIV co-infection. Consequently diabetes was not initially suspected in the patient at a district hospital. Indeed, it is either “TB, cryptococcal meningitis or those opportunistic infections you see in the [ART care] book”. AIDS patients often do suffer from opportunistic infects which are formally associated —canonized as AIDS symptoms — in the ART care book used to record the patient’s medical history. Thus, to what extent does the existence of a sort of official list of AIDS diseases impinge upon the inclusion of chronic disease as major threats for those with AIDS? Clearly, the physician at the ART clinic lamented the fact that diabetes is overshadowed by TB in the AIDS treatment spheres. She was indeed appreciative of the research I was doing and expressed interest in reading the final article. Her comments echoed those of an internal medicine specialist I spoke to who told me that “there is already a high incidence of diabetes in the general population and HIV positive people are not spared from it.” This specialist treats patients in state and private facilities, which give her a broad perspective of disease trends. Her remarks therefore signal the existence of a diabetes epidemic that cuts across sex, race and notably HIV status.
The dilapidating effects of HIV on the immune system, however, render HIV positive people more susceptible to suffering from chronic diseases. From the same internal medicine specialist I learnt that the risk of developing chronic cardiovascular disease is redefining what it means to transition from HIV to AIDS:
Before we used to start treating patients when the CD4 [immune cell] count dropped to about 250. Then we found out that patients with a CD4 count between 200 and 400 have an increased risk of vascopathy [a risk factor for cardiovascular disease]. Now we begin [ART] treatment at a CD4 count of 350, which is now the recommended WHO count for beginning treatment. The ART reverses this risk factor, since incidence of vascopathy falls with ART.
The point when an HIV positive patient acquires the immune deficiency syndrome coincides with the drop in the number of CD4 cells such that the patient struggles to recover from the most mundane sicknesses. It is at this point that ART therapy enters to protect the fragile immune system. Now, this conception of AIDS has been recast to include when the body becomes vulnerable to a chronic,(cardiovascular) disease due the underlying HIV. The implications of this do not only affect the timing of the start of ART, but also overhaul the definition of a healthy HIV patient as one who is free of an opportunistic infection. Indeed, the advent of ART in Namibia necessitated that HIV becomes a lifelong, chronic condition. And as the universal ART rollout continues to expand to cover more and more people who need it, the incidence of opportunistic infections will diminish allowing the life expectancy of the patients to increase. But a longer life on ART in a fast paced, globalised world does come with its share of chronic diseases (Mayosi et al, 2008).
Eating, recovery and risk
Obesity is taking its toll on patients on ART and thus puts them at high risk of developing diabetes and cardiovascular disease. “Patients on ART put on a lot of weight” said the internal medicine specialist without hesitating when I asked about the veracity of this common belief. But AIDS patients that do not have access to antiretroviral drugs are prone to loose weight. Sores in the mouth, nausea and depression can make eating unmanageable, while repeat bouts of diarrhea inhibit the absorption of food by intestines. The result is a frighteningly thin and weak individual, what is referred to as a “wasted” patient. However, with the onset of ART and treatments for opportunistic infections, the biological obstacles to weight gain—given the availability of food—are removed
Indeed, multivitamins and are initially prescribed to rehabilitate the wasted body and stimulate the appetite. The effects of antiretrovirals on the appetite, however, are unclear though the specialist suspects they have a long term effect: “Family members of a patient [on ART] always tell me that since they [the patient] started ART, they are eating everything in sight’. With a rehabilitated body —one that is protected from wasting—the patient’s physical appearance is now unassuming, allowing the patient to be a regular person in society. However, I wonder whether the fear of being identified as HIV positive—with all the baggage of stigma—maintains that voracious appetite? What is at stake for men and women who fail to maintain the socioculturally constructed image of a health (non-AIDS) body? If patients on ART are compelled to eat by a neurotic fear of stigmatization, to what extent are they suffering from an eating disorder, no different—yet opposite in nature—to anorexia nervosa?
In my research on the nutrition of HIV positive people, I stumbled upon a booklet by the Food and Agricultural Organisation (FAO) of the UN, titled “A manual on nutrition care and support for people living with HIV/AIDS, 2002. Though this manual provides adequate information on the consumption of staple foods, proteins, fruits and vegetables—including appetizing recipes—it encourages increased consumption of fats and sugars: “fats and sugars are good sources of energy and can help one gain weight, which can be particularly important for those living with HIV/AIDS.” The authors appear preoccupied with weight loss experienced by AIDS patients, but it shocking they advise a higher intake of fat and sugar as a solution, as this puts one at risk of developing chronic diseases. As I read on, I expected to find a cautionary message about eating fats and sugars. But all I found was that apparently “even in small amounts [fats and sugars] can provide a lot of energy.” It remained unclear how much fat an HIV positive person should eat, right up to the last paragraph of the nutrition section that read “Although [fats and sugars] are good sources of energy, they should be eaten in addition to other foods and not in place of them.” This document exemplifies a manual intended for AIDS patients. It is of concern that it fails to address the tension between eating enough to regain a healthy weight and preventing life threatening diseases, while spreading information under the auspices of the UN. I wonder to what extent HIV clinicians—nurses, physicians and nutrionists—address this tension with their patients.
Side effects of ART
In a simpler world, perhaps the risk of chronic disease amongst patients on ART could be mitigated merely by reducing the prevalence of obesity. However, the biomedical reality is that documented side effects of antiretroviral drugs represent an additional risk factor for the promotion of chronic disease. Take the protease inhibitors, for instance, which increase the risk of diabetes. The specialist informed me that “when a patient has a family history of diabetes, the protease inhibitor unmasks it” Currently, protease inhibitors are part of the second line regimen of ART that are still rarely prescribed in Namibia, as most patients are on the first line regimens. But given that HIV constantly mutates, allowing its genes to elude the antiretroviral therapy, it is only a matter of time before the second line regimens become the commonly used. Hence, the race against time for the onset of widespread HIV resistance is also a race against time for a potential epidemic of diabetes and associated chronic diseases. And there is another factor driving the move to second line ART regimens—the limited pool of acceptable first line antiretrovirals. There are first line antiretrovirals whose side effects are unacceptable to patients. A physician’s only recourse is to then move the patient to another antiretroviral. A notable unacceptable side effect is lypodystrophy, whereby adipose tissue (fat under the skin)accumulates in specific regions of the body, such as trunk. “Self image is important to the patients, especially to young people and so we shift away from drugs that cause lypodystrophy” explains the specialist. Far from being a magic bullet that that restores health to dying AIDS patients, ART reduces the risk of infectious disease, while increasing the risk of chronic disease.
Systems of Surveillance (or lack of thereof)
The discussion on burgeoning chronic disease problem in Namibia would be incomplete without close scrutiny of the current levels of these diseases in the population. While the “prevalence of HIV in Namibia”, as it is so referred to in Namibia, is widely publicized by the media, I have yet to come across figures that describe the chronic disease situation. Indeed, unlike in the case of infectious diseases, notably TB, the state appears silent about chronic disease levels.
I remember the launch of the TB awareness week at the start of October 2009. The launch was attended by the Minister of Health and representatives from one of its biggest donors – the USAID. Sitting in my seat, in the yellow and red “Stop TB” shirt, I listened to speakers who praised the gains made in the fight against TB, while cautioning the audience against complacency. I remember how stress was placed on how HIV positive people are especially vulnerable to TB infection, which can go undetected, compromising efforts to beat HIV and TB. Thinking back on this experience, I wonder whether “a chronic disease week” would do equally well to raise awareness about the burden of chronic diseases in Sub-Saharan Africa and the vulnerability HIV patients have towards them.
But where are all the statistics on cardiovascular disease, diabetes and renal failure for instance? “These indicators are not recorded”, said the physician at the ART clinic who I interviewed. Yet, if any of her patients on ART have a chronic disease, she records it in their patient booklet. However, since chronic disease problems, are not part of the list of “new opportunistic infections” provided for in the booklet, they fall under “other” problems: “If a patient has congestive cardiac failure or renal failure, for example, I put it under “other” and then I elaborate on the following pages. They are only a few codes for diseases given in the booklet and they are very limited” explained the physician. The process of relegating a chronic disease symptom to “other” renders it effectively invisible to the data clerks who keep a computerized record of patient diagnoses: “I have never seen them enter it [the “other”], they usually just enter opportunistic infections in the book”. The omission of the “other” is not surprising, because the “other” is difficult to account for when the diagnosis must fit a category. Indeed, the “other” complicates simplistic categorizations. Perhaps the “other” field was meant to capture rare diagnoses in patients on ART. But without surveillance of chronic disease, how can anyone know if chronic diseases are rare in AIDS patients or in anyone else? The physician told me that she currently has no patients on cholesterol medication, which suggest cholesterol associated cardiovascular disease is rare, but then she spoke about renal and congestive cardiac failure with concern. Hence, the state of chronic heart disease in Namibia remains unclear, because data on these diseases it is not in the public domain.
Ultimately, we must remember that chronic diseases, especially cardiovascular disease, are problems for a particular demographic group. In a South African community whose health is monitored by researchers, deaths due to heart disease and stroke are major killers for men and women older than 50 years of age (Mayosi et al, 2009). Moreover, a larger proportion of the women died due these diseases – double the proportion of the men. I found a similar trend for deaths due cardiomyopathy in Namibia—heart enlargement—in the records of the Central Hospital, Windhoek: 59% of the dead were women. Hence, chronic diseases have a target population. What is therefore at stake in fighting chronic diseases, given that the aging segment of society has a lower economic return in terms of working years? In addition, how does a gender bias in chronic disease affect the public health policy decisions? I wonder whether the vulnerable position of women can be channeled into the movement for the emancipation of women and thus draw a sense of urgency to this public health problem. In any case Vision 2030, with its political and patriotic underpinnings, can be used to motivate action against chronic diseases. After all, most of the people who are currently engaged in making this vision a reality will become particularly vulnerable to chronic disease by the year 2030. Then will they live to see their children and grandchildren reap the rewards of their labour?
I carried out this “amateur” research as just a post grad interested in medical anthropology after reading Will To Live and after sitting in on two lecturers organized by the HIV clinicians society in Namibia.
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