December 31, 2012
By Marie Meckel, MPH ‘12
|Marie Meckel, MPH '12|
For the last two summers I have traveled to Ghana with the University of Utah Physician Assistant program and participated in their annual Physician Assistant conference. Each trip taught me something new about public health and health care. This year, more than ever, I learned to appreciate the challenges developing countries face in regards to chronic disease management and prevention.
This July, I worked with Physician Assistants in a clinic in Sunyani and participated in a one-week conference where we provided informational seminars to our Ghanaian counterparts on medical subjects of their choice. The conference was a wonderful opportunity for me to meet fellow Physician Assistants and to learn how they operate in Ghana. I have always thought that Physician Assistants are wonderful solutions to the health care provider shortage often seen in low- and middle-income countries, and I appreciated the opportunity to see how they function and the roles they have in countries like Ghana. It is clear to me that Physician Assistants are a very important part of the health care system there, and I believe this model of health care could be replicated in similarly developing countries.
After visiting Ghana for the past two years, it has become increasingly clear to me that these same countries are facing a new health care epidemic. During each of my trips, I presented on diabetes and hypertension, two subjects with which I am very familiar from my work at Mason Square Health Center in Springfield, Massachusetts. In 2011, I conducted one of the few lectures on chronic disease; one year later, chronic disease comprised a major part of the conference. Clearly, my counterparts in the Ghanaian health care system saw an increasing need for knowledge and training in chronic disease prevention.
In recent years, Ghana has experienced dramatic economic growth that has coincided with dramatic increases in hypertension and diabetes. While infectious disease is still a leading cause of death in Ghana, chronic disease is quickly becoming an equally dangerous threat. Obesity, inactivity, and adaption of western lifestyles have put many of these countries at increased risk for chronic disease.
What I had observed is supported by a number of staggering statistics regarding chronic disease in Sub-Saharan Africa. The World Health Organization (WHO) estimates that non-communicable disease deaths will rise by 20% between the years 2010 and 2020 in Africa and is expected to surpass maternal child and infectious disease as the number one cause of death by 2030. The rate of obesity – a risk factor for both diabetes and hypertension – has also gone up significantly. Currently 37% of the people in Ghana are either overweight or obese. In 2005, the Ministry of Health reported that chronic disease was one of the biggest health threats and called for lifestyle and dietary changes as health care imperatives. Three years later, in 2008, the Ghana Health Service (GHS) reported that untreated hypertension was the fifth leading cause of in-hospital death. In Ghana’s largest city, Accra, death due to cardiovascular disease was the number one cause of death between 1991 and 2001.
|Photo: A patient has her blood pressure checked at a clinic in Ghana.|
These statistics are very concerning and will require many changes in the Ghanaian health care system and from health care providers. The treatment of chronic disease requires such a different approach than the treatment of infectious disease, and a shift in knowledge is needed. Unfortunately, these shifts take time – in the United States, it took a good fifty years to learn how to manage chronic disease in outpatient settings. Ghanaians cannot afford fifty years.
Countries like Ghana lack proper screening programs for diabetes and hypertension. We have learned – sometimes the hard way – how devastating chronic disease is to our population. We all know a friend, relative, or someone who has had a stroke or heart attack, and we appreciate the importance of good screening programs. While Ghana has wonderful screening and prevention programs for infectious disease, they are still unfamiliar with how to develop such programs for diabetes and hypertension.
Untreated hypertension and diabetes have hidden costs to a health care system, as stroke and heart disease require more intensive and costly health care services than treatment for infectious disease. Many developing countries simply cannot afford this.
Chronic disease also has a devastating effect on the “breadwinners” of the family; chronic disease often strikes those in the prime of their lives, unlike infectious disease which tends to affect the young and the elderly. Losing the family “breadwinner” often has lasting repercussions on the family unit.
Medical knowledge and practice is often based on personal experience with disease. While we learn many things in our medical training, what we practice and how we manage patients are often based on our experience and comfort level with the diseases we are most familiar with. I worked with many practitioners in Ghana and realized how “provider reluctance” to titrate up chronic disease medication is real. Providers fear they will harm patients by dropping blood sugars and blood pressures too low. I had read about “provider reluctance,” but witnessing it first-hand made me appreciate how hard it is for practitioners new to chronic disease to “trust” that if they titrate up insulin or hypertensive medications that they will not harm the patient.
Prescribing an insulin treatment is not easy for practitioners new to diabetes. Until recently in the U.S., practitioners were more likely to start insulin late in the development of diabetes because of inexperience or fear. However, as we have had an increase in diabetes we have learned to become more familiar with insulin as a treatment and introduce it earlier in the course of the disease.
I worry too that health care practitioners who are new to chronic disease management will struggle to recognize non-adherence as a barrier and to address it with patients. Many practitioners assume that their patients are taking the medications prescribed to them, but it was clear from the charts and the labs that many patients do not take their medications as prescribed. It is hard for patients to accept chronic disease as “real” because it often does not present with symptoms.
What I observed made me realize how hard it is for health care systems to convert from infectious disease models of care to chronic disease models. The systems we have in place in the United States are based on years of chronic disease treatments and programs. After two visits to Ghana, it became clear to me that while developing countries have tremendous expertise at infectious disease treatment and prevention, they are still struggling to understand the importance of chronic disease prevention. Chronic disease in developing countries is a growing health care concern, and I fear it will have a devastating effect on many generations to come. It is clear that something needs to be done, and it needs to be done now.
|Photo: Families at a clinic in Ghana|