My gut reaction when asked to go to Africa for diabetes work was that this would resemble the earlier stages of what I had seen progressing in the Middle East, Americas, or most likely Asia. I was shocked by how wrong I was. Nairobi presented to me a reminder of how varied the needs in diabetes are among regions, communities, and lifestyles globally. Africa is developing a different breed of diabetes I have seen in other regions, largely due to significant differences in diet and cultural perceptions than the rest of the world. The rates for diabetes, especially Type 2, were much higher than I had anticipated and growing quite rapidly with little education and healthcare infrastructure to treat non-infectious diseases.
About 3.5% of Kenya’s population has diabetes – totaling about 520,000 patients in 2010. While the needs for Type 1 patients in Africa did resemble that noted in many other countries, although with much fewer resources, the largest surprise in Africa was the demographic of the typical Type 2 patient. Many Type 2 patients are triggered by familiar issues: adoption of Western lifestyles, poor diet, and lack of exercise.
However, many Type 2 patients in Kenya are NOT overweight, but underweight and simultaneously malnourished. The first clinic that cited this finding literally made me almost fall off of my chair in both shock and fear. This will require (1) significant locally-based research into why this is the case (there has been none to date due to lack of funding) and (2) custom programs in awareness and screening efforts that will be dramatically different from other regions globally. I dedicated myself to try and understand the medical perceptions for why this is the case, despite the lack of research, and have outlined a few hypotheses below based on the interviews.
HIV/AIDS and Africa
It is difficult to relate to health development in Africa without recognizing the role HIV/AIDS development work and efforts have had on individual communities and the larger region. The first thing that was apparent is the disproportionate amount of healthcare funding devoted to HIV in Africa. Tents for testing and ongoing treatment were evident at nearly every hospital and many community centers. Many interviews I conducted discussed the “overfunding” of HIV in the region and sometimes unethical use of funds or programs to use up assigned budgets. This was indeed surprising, but important to hear reiterated from varied government, corporate, and non-profit voices. Based on population alone, Africa receives significantly more health development funding than any other region. It is imperative that the purpose and use of these funds are re-evaluated to maximize impact to the community and its health.
While many HIV/AIDS programs have been very successful in terms of increasing awareness and diagnosis rates, it has not addressed a lot of the personal/family embarrassment issues, not to mention the need to balance both privacy and community openness. Everyone is aware of the “signs” for someone who has HIV and it seems on the lookout for family, friends, neighbors. For example, weight loss is typically a flag for the diagnosis of HIV or use of antiretrovirals. Historically, weight has been a sign of wealth, status and stability in most regions in Africa. This has significant implications for individuals with both Type 1 and Type 2 diabetes: Type 1 showing loss of weight at the onset of diabetes and Type 2 losing weight to control his/her symptoms, both of which could be perceived by onlookers as HIV. Therefore, many resist losing weight under any circumstances and ingest low-cost, high-calorie diets that are often very low in nutrients.
Additionally, many of the HIV efforts having succeeded in their purpose fail to dis-incentivize individuals from contracting HIV/AIDS. Although extensive prevention and educational programs exist, management is the main focus of HIV efforts. In Africa, HIV/AIDS is addressed essentially like a chronic disease. What was hopeful to me, is there could be a million “lessons learned” from HIV programs in Africa over the years that could be translated to traditional chronic diseases – like diabetes. Despite a number of models that have worked well (community diagnosis/monitoring, local women initiatives, country-wide annual testing campaigns), programs have not quite figured out the prevention side, where the long-term return-on-investment lies. One of the largest challenges results from lack of financial incentives: if you contract HIV in much of Africa, there are virtually no financial consequences. This is contrasted with the now growing diabetes rates – causing significant trauma on family and household economics. One of the very common quotes to hear from newly diagnosed patients is “I’d rather have HIV than have diabetes” referring to the lack of diabetes support in comparison to plentiful HIV relief efforts that make it easy to cope with the disease.
“I’d rather have HIV than have diabetes” – a common patient perspective in Kenya
Finally, there is a growing intersection of diabetes, HIV, and TB in Africa. The co-morbidity of HIV and Type 2 diabetes is seen as a long-term side-effect of many of the antiretroviral treatments. Wearing down the metabolic system over time, antiretroviral regimens are hypothesized to contribute to increased rates of diabetes regardless of weight, diet, and exercise lifestyle considerations. TB/diabetes co-morbidities are also noticed in Africa where TB has shown to put patients at higher risk for developing Type 2 diabetes. I believe that the large majority of development funds focused on diabetes in Africa will begin in the next 2-3 years with joint HIV/TB programs that either already exist or use existing funding. While this may address some of the problem, funding focus will have to evolve to include a new portfolio for diabetes in the coming years to address urgent needs for Type 1, gestational diabetes, and the emerging Type 2.
“Pop” and Tribal Mindset: Diet in Kenya
Few families are able to afford a regularly healthy diet in Kenya. Unlike much of Asia, the Middle East, or South America, healthy foods can be scarce and financially out of reach for many households. The Kenyan diet is traditionally comprised of “pop,” a cornmeal based porridge consumed as the main meal daily in the late afternoon (e.g. around 4pm). Githi Theuri, a Nairobi based nutritionist in a cardiologist office, described the diet as a resemblance of the earlier “tribal” mindset. Many tribes ate only one meal a day in the late afternoon with game meat about once a week. Fruits? Vegetables? These were not perceived as important factors in a traditional diet and, many believe, a root cause of the growing Type 2 diabetes prevalence.
I spent my weekend in Kenya on the border of Kenya and Tanzania with a Maasai tribe learning about their lifestyle and perceptions as one of the regions only preserved tribal cultures. Similar to what Githi illustrated, they eat one meal a day of grains and kill one cow a week to feed their living community: about 25-30 people. Cows are the only currency used by Maasai and almost anything that is produced by them is reused for food or shelter including blood, milk, meat, hides, bones, etc. Dairy milk with fresh cow’s blood is considered the equivalent to a Maasai energy drink, if you will. In recent years the government has encouraged Maasai to adopt “modern” technologies such as currency or bank accounts, but the community has largely refused.
Despite the vast and fertile land available in this region, farming is not pursued due to lack of agriculture education and irrigation technologies. In addition to confirming what I had learned in Nairobi about Kenyan diet, the Maasai helped me understand what I heard repeated in interviews as the “tribal mindset” to which affects urban perceptions on family, money, and priorities. This could not be more opposite than the Western consumer-driven culture; tribal mindset incorporates a desire to only work as hard as needed to survive. Not much value is placed on surpluses of “things” or money, and there may be little trust in the longevity of both.
Therefore, few families have a lot of extra income to spare and the concept of setting aside finances for healthcare is unknown. Diabetes will sink a boat in tribal mindset – both resulting from diet and financial impact. Simultaneously, the modern or urbanized form of a tribal diet is a large plate of French fries smothered in ketchup, mayonnaise, or your condiment of choice. I became a loyal client of the Java Coffee house near the hospital district in Nairobi and witnessed this with even their highest-end of customers. French fries! Kenyan diet has evolved but remains a mainly carbohydrate and protein-based diet with few variety in food and nutrients.
Challenges for Diabetes in Kenya
The primary and most urgent challenge for diabetes in Kenya is the need to increase resources for children with Type 1 diabetes. Similar to India, lack of resources for families with Type 1 children is a death sentence. Insulin and community-based educational programs for families and educators are essential. The Kenya Diabetes Management and Information Center (DMI) in Nairobi has been a leader in addressing this need with funding primarily from Novo Nordisk’s World Diabetes Foundation. The financial burden of Type 1 diabetes is not manageable for most Kenyans and the center focuses now on sponsoring insulin and monitoring for 90 children and a youth camp which was attended this year by 70 or so patients and family members.
Although they are the first to acknowledge this is a drop in the bucket. I met with Mrs. Eva Muchemi, the head of DMI, who described the challenges in securing this funding on an ongoing basis and future plans to expand to training of healthcare workers throughout the healthcare system in Kenya. 80% of Kenya’s population is rural creating significant infrastructure and resource challenges for patients in non-urban areas. Through their persistence, DMI’s efforts and coordination with the emerging Diabetes Association in the region are admirably leading the way for patients in Africa.
Gestational diabetes has been explored as a focus due to its higher rates than seen in other countries. This could result from diet during pregnancy and is often overlooked by both pregnant mothers and health professionals if untested. One of the largest issues with gestational diabetes is that without treatment the impact – a significantly larger baby – is often celebrated as a good and healthy outcome considering traditional perceptions of health and weight. Later resurgence of Type 2 diabetes is not prevented or addressed and can create a number of health risks for the mother and child years later. A recent initiative from the MOH has required all pregnant mothers to be tested for gestational diabetes, however successful implementation of this effort is still pending. Despite a positive push in the right directly, many hospitals don’t have the equipment, processes, or expertise to execute standardized testing.
Type 2 diabetes is growing quite rapidly in urban, but also rural areas. I met with Dr. Rene Kiamba and Jotham Nkonge, the J&J Manager Sub-Saharan Africa and LifeScan Sales Manager to learn more about their programs in diabetes management. J&J has demonstrated substantial leadership in training health professionals and increasing educational programs for patients with diabetes globally. They described financial limitations as the largest inhibitor to effective treatment – as all care for diabetes is out of pocket. They also illustrated the emergency of a “new” Type 2 diabetes seen in underweight or malnourished patients. This creates more challenges as health professionals struggle to standardize risk signs for testing and diagnosis with limited resources.
Africa & the Skinny Type 2 Diabetic
How are patients developing non-obesity driven Type 2 diabetes in Africa? All research indicates that abdominal fat, diet, and exercise are the key contributors to the progression of Type 2 diabetes. Dr. Eva Njenga, one of the founding members of DMI and currently the lead of their board of directors, described her experience treating patients with diabetes for decades in Nairobi and the Kenyan region. Her hypothesis, and a common perception among leading physicians in Kenya, is the carbohydrate-rich diet essentially wears out the pancreas and triggers insulin resistance. Of course, there is no research to validate this making it difficult to stand behind any prevention-based effort.
Jean Suren, an American diabetes care and training nurse in Nairobi, has reiterated Dr. Njenga’s sentiments with the need to focus on training and capacity building in physicians, but also nurses in the region. Disagreements over the training curriculum that should be adopted in Kenya, due to lack of research and its unique challenges and limitations, have slowed the progress for nation-wide objectives and programs. DMI and the Diabetes Association in development have focused on this as a critical first-step in fighting diabetes in Kenya. Still, the “new” skinny Type 2 diabetic continues to perplex health professionals and contributes to the total growth of diabetes in the region.
Community-Based Efforts
In addition to children-focused programs at DMI, educational campaigns to the community for both awareness are screening are critical and in development. Dr. Maina, the Noncommunicable Disease head for the Ministry of Health of Kenya, described this as the focal point of their effort in the ministry of health. How they plan to achieve this is by targeting the district hospital level in Kenya for training of healthcare professionals and distribution of posters raising awareness on diabetes in 12 of the most common languages. Similar to India, Kenya has 50-100 languages creating another layer of challenges for nationwide programs.
I also see a great potential for agriculture-based programs at the community level. Anything that supports families or communities in producing healthy food options economically will help prevent Type 2 diabetes. Also basic education on cooking affordable but healthy meals with available resources would boost family eating habits without impacting finances. However, many families are simply concerned about getting enough food so efforts should be focused primarily on increasing resources in addition to learning how to use existing ones better.
Finally, national surveys and research that provide accurate data on the disease burden, contributing risk factors, and effective treatments are essential, but costly. A reoccurring challenge in many countries, these efforts are vital to establish metrics and objectives for programs but are hard to fund as they compete with programs that directly impact patients (such as insulin relief and healthcare worker training).
As the MOH works to increase capacity for diabetes awareness, detection, and treatment nationally – it will benefit from the strengthening of organizations like the Kenya Diabetes Association and International Diabetes Association’s presence in Africa. Recognition of the unique challenges from the patient, physician, clinic, and larger community-wide perspectives will help Kenya develop more programs to better address the needs of diabetes patients going forward.
DMI Office in Nairobi
