'100,000 Ugandans die of non-communicable diseases annually'

PIC: John Wilson Byansih Syagunya a person living with diabetes

HEALTH

Fourteen years ago, John Wilson Byansih Syagunya went to visit his personal doctor in Kajjansi along Entebbe road for a check-up. Little did he know that he had diabetes.

When the doctor checked the retired accountant, his sugar levels were below normal. Although Syagunya had not experienced any symptom of diabetes, the doctor recommended immediate treatment to manage the condition. "That is how I have managed to live up to today," said Syagunya.

The father of six worked with Uganda Cement Industries and Uganda Cement Corporation before he retired in 1990.

According Syagunya, 67, diabetes is a sickness that comes due to failure of the pancreas to produce enough  insulin  in the body. "If not well managed, diabetes causes some complications like loss of sight, amputation and at worst death," he said.

The resident of Bumooli ‘A' village, Buswale sub-county, Namayingo district, said the simple formula called ‘NEEDS'; which stands for - Nutrition, Exercise, Education, Drugs and Self-monitoring - is the magic to his survival. "Once you go with this formula, you can never go wrong."

He said many diabetic patients get misguided by herbal drug sellers, who deceive them that they can cure diabetes whereas not.

"Scientists have proved that once you contract diabetes, it cannot be cured. Herbal medicine can even worsen the condition, and those who refuse to go to hospital end up dying."

Although some people inherit Non-Communicable Diseases (NCDs), Syagunya said diabetes and many other NCDs are largely caused by our lifestyles. "That is why the survival formula (NEEDS) has a lot to do with lifestyle. If I had not adopted it, I would be no more today."

Now an executive member of the Uganda Diabetes Association and a board member of the Uganda Non- Communicable Diseases Alliance (UNCDA), Syagunya decried the shortage of insulin drugs in public health facilities and urged government to increase funding towards the same to avoid stock-outs.

Eunice Namambwe Kintu, a person living with hypertension and a member of UNCDA and Uganda Heart Research Foundation, said she became hypertensive 14 years ago when she was expecting her second child.

Since then, Kintu has been on medication, but says one can live longer if they adhere to doctors' advice. She now routinely exercises and avoids foods that contain cholesterol like red meat. Kintu noted that once affected with one NCD, it is very easy for one to get another.

"Government has tried to provide funding towards prevention and control of NCDs, but a lot more needs to be done.

For instance, I expect government to subsidise the drugs and extend treatment to rural areas so that even the poor Ugandans can access them and live longer," she noted.

She said some people use drugs for one week and abandon them because they are costly. Kintu also urged government to implement laws and policies, citing the Tobacco Act, which she said has not been fully implemented.

She also called on parliament to follow up on Bills to their logical conclusion, adding that this is also to their advantage since many of the parliamentarians are victims of NCDs.

To the civil society, Kintu asked them to reach out more to the grassroots to ensure increased access to medication for NCDs by the rural patients. "I urge the public to always test and know their status. Many people go to witch doctors instead of going to hospitals, and end up dying."

For Rebecca Mayengo, she survived breast cancer after it was detected early. It was towards the end of her summer holiday in Virginia, US, in 2004 when she checked into Inova Alexandria Hospital for a routine annual medical checkup.

Mayengo was working as a consultant at the Centre for Victims of Torture (CVT) at their Sierra Leone office, which sponsored her medical insurance in the US.

Now aged 70, Mayengo, the chairperson of Uganda Women's Cancer Support Organisation said she joined the organisation when she returned to Uganda in 2008. Mayengo said many people who develop cancer do not seek early medical care because they believe the disease cannot be cured.

 Eunice Namembwa Kintu a person living with hypertension

"This explains the high death rates because by the time a person goes for treatment, they are too sick and the cancer is in advanced stages, where even the best treatment cannot save a life.

When cancer is in remission, patients are advised to have medical checkups every year, to detect if the cancer is recurring.

I attend my medical checkups at the Uganda Cancer Institute Mulago hospital," noted Mayengo.

Mayengo, a professional counsellor, vividly recalls the day doctors examined her left breast and discovered a small lump, and that the doctor asker her; "how long have you had this lump?"

"At 60 years old then, I thought the doctor had not checked properly, because annually I would go for medical check-ups. Later, the specialist referred me to have a mammogram test on the breast," she said.

She added; "I underwent the tests and the biopsy confirmed it was a malignant tumour.  Fear gripped me, but the doctor recommended surgery."

Her surgeon's examination found that one lymph node in her armpit had been eaten up, and another was half destroyed. "The fact that only two lymph nodes had been destroyed so far was good news. The surgeon recommended a lumpectomy (removal of the breast tumour and some of the tissue that surrounds it)."

The operation went on well and after recovery, Mayengo was placed on chemotherapy. Mayengo now tests every year at the Uganda Cancer Institute, and believes the story would have been different if the cancer had not been diagnosed early enough.

The above are some of the cases of NCDs that many Ugandans are faced with, and contribute to at least 100,000 deaths annually.

What are NCDs?

NCDs are diseases of long duration and generally slow progression. The four main types of non-communicable diseases are cardiovascular diseases (like heart attacks and stroke), cancer, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.

NCDs are by far the leading cause of death globally, representing 63% of all annual deaths. NCDs kill more than 36 million people each year and about 80% of all NCD deaths occur in low- and middle-income countries. More than 9 million of all deaths attributed to NCDs occur before the age of 60, and NCDs affect women and men almost equally.

NCDs are not only a health problem but a development challenge as well, NCDs force many people into, or entrench them in poverty due to catastrophic expenditures for treatment, and they also have a large impact on undercutting productivity.

According to data from UNCDA, tobacco use is the main risk factor leading to most NCDs. "Globally, tobacco use kills nearly 6 million people a year and by 2020, if nothing is done.

This number will increase to 7.5 million people, accounting for 10% of all deaths. Eliminating tobacco use as a major risk factor to NCDs would translate into reducing premature death by 10% by 2020," said Christopher Kwizera, the UNCDA programme manager.

Although some cases are hereditary, Kwizera noted that if the major risk factors for NCDs were eliminated, around 75% of heart diseases, stroke and type 2 diabetes would be prevented; and 40% of cancer would be prevented.

State of NCDS in Uganda

With a projected population of over 40 million people in Uganda, the four major NCDs kill up to 100,000 people annually; which is 35% of the total annual deaths in the country, according to findings that UNCDA sourced from the World Health Organisation.

Kwizera noted that the risk of premature death (probability of dying between the age of 30 and 70) due to the four major NCDs in Uganda is 22%, the highest within the East African region. "In Uganda NCDs are treated in the contextual diseases based programmes of the Ministry of Health, with no special attention or integration into the primary health care plan," he stated. 

Although Uganda has one the most organised and structured health care systems up to the community level, Kwizera revealed that there is gross understaffing in terms of human resources for health with only about 33% of established positions of all cadres filled.

He added that while Uganda has a good integrated diseases surveillance and health information and management systems, the surveillance system for NCDs is yet to be established. As a result, NCDs are poorly documented since routine epidemiological data - the national health information and management system does not include them.

The health ministry last carried out a survey on NCDs risk factors in 2014, and according to Dr. Gerald Mutungi, the head of NCDs prevention and control at the Ministry of Health, they have not yet got funds to carry out a current survey. According to the 2014 survey, alcohol users were at the highest risk of contracting NCDs at 28.5% followed by those who are hypertensive at 24.3%.

Men were more at risk compared to women at 40.1% (men) and 17.9% (women) for alcohol users and at 25.8% and 22.9% for those who were hypertensive respectively. Being overweight was the third most risk factor followed by smoking.

More alcohol users were found in rural areas compared to urban areas, while the eating of junk foods was more prevalent in urban areas than rural ones.

What is government doing?

Dr. Gerald Mutungi, the head of NCDs prevention and control at the Ministry of Health, said the ministry's focus is prevention through creating awareness of the risk factors and asking people to adjust their lifestyles.

"We encourage people to have a healthy diet by avoiding processed foods with much salt, sugar and fatty foods. We also encourage people to at least go for a 30-minute physical activity including riding bicycles and jogging," Mutungi noted

To people who have especially clocked 40 years, Mutungi said the ministry encourages them to go for screening for high blood pressure, blood sugar, cholesterol and obesity. "For NCDs, the older one grows, the more vulnerable one becomes."

Together with partners like UNCDA, Mutungi said they also provide screening services for cancer of the cervix for females and roll out a vaccination campaign against cervical cancer targeting girls ranging from nine to 13 years.

NCDS in primary health care

Mutungi said they have plans to start screening and early diagnosis of NCDs through establishment of wellness clinics in the health facilities where people can go and get tested.

Apparently, he said, they have decentralised health care treatment for NCDs to health centre IIIs, which have been empowered to carry out screening of the diseases. "We have integrated treatment of NCDs in the HIV/AIDS care at health centre IIIs to offer treatment for diabetes, high blood pressure among people living with HIV."

He said the ministry is also focusing on creating awareness about the risk factors, citing the publicisation of the ‘Tobacco Control Act', which was enacted with an obligation of banning smoking in public places among other things.

Mutungi said his ministry discourages the use of herbal medicine because there are critical laboratory tests that need to be made to verify their effectiveness and toxicity levels. "Some of the herbal medicines have been found to be toxic to the liver, and injuring other internal organs," he warned.

Attitude change

Mutungi said if nothing is done to change people's mindset, cardiovascular diseases will be the commonest cause of death in Uganda in five years to come. "In Uganda, If people see one walking or riding a bicycle, they say that one is poor, yet in developed countries people ride bicycles as a measure to fight NCDs," Mutungi  said.

He added; "being fat is celebrated in some of our communities. There are those who believe that when a bride is getting married, they have to be fattened intentionally yet they are promoting obesity."

He cited other unhealthy habits including; tobacco and alcohol abuse and physical inactivity as well as increased unhealthy dieting of; sugary, fatty and salty foods as the factors that put one at risk of excessive weight gain referred to as obesity, which is a major risk factor for NCDs.

Mutungi warned youth who have of late resorted to smoking shisha, saying "a person who smokes Shisha is likely to suffer from lung cancer and heart diseases among others."

NCDs budget

The health ministry's undersecretary, Ronald Segawa Gyagenda, noted that according to the Budget Frame Work paper 2018/2019, the Uganda Cancer Institute Budget is sh38.3b, while the budget for Uganda Heart Institute is sh11.83b.

"If approved by the Finance ministry, Parliament shall appropriate the funds for treatment of cancer and heart diseases respectively, as well as procurement of diagnostic equipment for the institutes in the next national budget," he said.

What has parliament done?

The Parliamentary health committee chairperson, Dr. Micheal Bukenya (also Bukuya County MP), said they ensure that government provides funds in comprehensive packages to different health departments in health sectors.

He cited organisations such as Uganda Cancer Institute, Uganda Heart Institute, Uganda blood Transfusion Services, that receive funding as well as funds allocated to procurement of vaccines to carry out vaccination against killer diseases, including NCDs like cervical cancer.

Bukenya said funds are also sent for treatment of complications involving major body organs such as the liver, kidney, lungs, which form part of NCDs. Also, he added, there is a budget allocated to procurement of drugs for treatment of hypertension and high blood pressure.

However, Bukenya said the committee recommends that government increases the budget for sensitisation to create awareness about NCDs.

Quoting the Kiruddu hospital patients' death report of 2017, Bukenya noted that NCDs contributed to 30 out of 100 patients who died at the health facility.  "This shows that the prevalence is high."

What do experts say?

Heart expert

Dr. Charles Lugero, a cardiologist at Uganda Heart Institute (UHI) in Mulago says the gist of NCDs approximately takes 40% according to World Health Organisation (WHO) report 2014 while in Uganda 10 out of 100 people were diagnosed with cardiovascular diseases.

Quoting the WHO report he said  in 2014, WHO estimated the prevalence of hypertension to be over 40 per cent in the adult population of most African countries including Uganda.

Lugero says apparently the prevalence of high blood pressure in Uganda  is 30 out of 100 people who are 40 years and above and  suffer from high blood pressure.

Lugero says   the most common causes of heart failures include high blood pressure, diseases of the heart muscles, Rheumatic heart disease ,  a consequence of rheumatic fever caused by repeated throat infections caused by Group A streptococcus bacteria that thrives in this environment.

Currently our research has shown that rheumatic fever and rheumatic heart disease is driven by overcrowding but there are chances that a strong genetic factor may play a role.

"Rheumatic heart disease is the most common cause of heart failure in children and adults below 35 years. It is preventable and treatable as it arises from a poorly treated sore throat," said Lugero.

Lugero explained that 47 out of 100 people with heart failure suffer from uncontrolled high blood pressure He explains that 21 out of 100 people have been diagnosed with Rheumatic heart disease, 28 out of 100 people are due to heart muscle diseases, while 4.6 out of 100 people are due to heart attacks.

Causes  

Lugero pointed out  that though genetic factors can increase ones  risk of developing heart disease, unhealthy lifestyle choices play a big role.

Some unhealthy lifestyle choices that can contribute to heart disease such as living a sedentary  lifestyle and not getting enough physical exercise.

Feeding on  un unhealthy diet that's high in fat proteins,  fats, sugary foods, much salts,   smoking tobacco,  lack of exercise, increasing consumption of alcohol, fast foods.

 Lugero says people can prevent heart disease by exercising regularly, maintaining a healthy diet,  a healthy weight, reducing stress,  avoiding  smoking  and  taking supplements, as advised by a doctor.

He said primary prevention is very important thus government has to ensure that it communicates the mesage   to the public.

In terms of management, NCDs require a multi sectorial, multileveled patternship with different stake holders.  There is need of a national plan, with sufficient laboratories support at all levels. This includes regional hospitals, district health centre 4, and 3 where the majority of Ugandans live. Parliament should appropriate enough funds for the diagnostic equipment in all health centres.

Cancer expert

 Dr.  Noleb Mugisha, an oncologist at the Uganda Cancer Institute (UCI) in Mulago hospital, defined cancer as a disease which results from abnormal growth of body cells.

Mugisha, who is also as a member Comprehensive Community Cancer Programme (CCCP), noted that; "Cancer can develop in any part of the body. Besides, abnormal growths cannot be controlled by the normal growth mechanisms of the body."

Mugisha adds some cells can break off the growth and move in the blood streams and settle in other parts of the body and multiply there.

Mugisha says annually worldwide, one out of every 100 patients of breast cancer is male.  Current records from UCI Mulago Hospital indicate at least 5 to 6 new cases of male breast cancer are registered annually.

For breast cancer, Mugisha said the disease attacks the breast tissues and affects both men and women with similar symptoms. "Common signs include; a painless breast lump, nipple pain, nipple discharge which could be clear or cloudy, sores on the nipple, enlarged lymph nodes in the armpit of the affected side."

Mugisha explained that when breast cancer occurs in men, it is more aggressive than when it affects women. "This is because the male breast is a small tissue that is easily affected compared to the female one."

Mugisha said most male breast cancer patients tend to seek treatment in advanced stages, arguing that this is because men rarely get screened for breast cancer, and that women are more likely to feel the tumour while breastfeeding, bathing, or through self-breast examination.

Diagnosis of breast cancer in men is done by biopsy just like in women, where a small tissue from the breast mass is taken to confirm cancer and assess how far it has spread, Mugisha observed.

Quoting the 2012 GLOBOCAN cancer factsheet, Mugisha said a total of 3, 915 cases of women were diagnosed with cervical cancer, while 2,275 patients died in Uganda. The data, which is compiled after every five years, also noted that 2,420 cases of breast cancer were diagnosed, and 1,183 deaths were registered.

"A total 2,843 men were diagnosed with prostate cancer, while 2,288 patients died in a period of five years.  This was followed by a total of 2, 514 cases of Kaposis Sarcoma in men, with 1,720 deaths registered. In women, 1,395 cases of Kaposis Sarcoma were diagnosed, where 917 died in the same period," the data shows.

Statistics also indicate a total of 1,609 cases of oesophagus cancer in men, while 1,461 patients died. In women, 768 cases were diagnosed, while 698 died.

To treat cancer, Mugisha said choice of treatment modalities depends on the stage and the hormonal status as well as other illnesses that the patient may have. The modalities used include surgery, chemotherapy, radiation and hormonal treatment.

Mugisha says the risk of men developing breast cancer increases with age. He says men above 45 years are at higher risk. He says as one grows older, the mechanism of controlling growth of the cells weakens.

Mugisha attributed cancer to consumption of high fatty diets, which can eventually lead to obesity. "Fat foods turn it into oestrogen hormones, which make the cancer very aggressive," Mugisha explained.

Mugisha advised against sedentary lifestyles, consumption of alcohol and smoking, saying they expose many people to cancer.

He said the most common cancer is cervical which accounts for 90% of the patients at the cancer ward at Mulago Hospital. "In Uganda, about 4,000 women are diagnosed with cervical cancer every year. Besides, those who die without coming to hospitals for screening probably are many."

This is followed by leukemia (blood cancer), which is on the rise among children; and it is caused by genetic mutation. Prostate cancer follows closely, to which Mugisha advised men, especially those who have clocked 50 years, to test because "most men are diagnosed between the age of 60 and 70 years."

According to a study done at UCI, Mugisha said 90% of men have advanced prostate cancer because majority of men seek medical care late due to lack of knowledge about the disease.

Diabetes expert

Dr.Thereza Piloya-Were, an expert on diabetes, said the disease is comprised of mainly two major types. Type 1 affects children and type 2 majorly affects adults.

"Type 2 is approximated at 3.3% among adults above 18 years in Uganda, while type one in children is usually 10% of the number of adults with diabetes. However, in Uganda we currently know over 1,000 children and adolescents are living with type 1 diabetes in just over 20 centres," she  said.

Piloya-Were, a senior lecturer and Paediatric Endocrinologist at the Makerere University School of Medicine, noted that diabetes is one of the commonest NCDs both in children and adults.

"Diabetes is also a driver for other NCDs. For example, if not well controlled, diabetes will lead to heart and renal diseases among others," she said.

Quoting the 2014 NCDs risk factor baseline survey report, Piloya-Were said type 2 diabetes is the commonest form of diabetes in adults.

"The most affected age group was 50-69 years. However, the prevalence in the age group 30- 49 years was also worrying because this is the most productive group thus we need to prevent disease among them."

Overall, she added, the burden of diabetes in Uganda and Africa as a whole is more in the younger population compared to the western world. For type 1 diabetes, Piloya-Were said the commonest affected age group are the teens between 13-15 years, although it is also commonly seen in 7-8 year-olds.

Piloya-Were said type 2 diabetes is purely preventable through lifestyle modification; exercising, healthy eating, alcohol and smoking reduction. She called for prevention of some common infectious diseases like HIV since drugs related to HIV may lead to diabetes.

In addition, she said type 2 diabetes prevention is now being targeted at the level of the foetus while in the womb. "We ensure that mothers have a healthy baby with normal birth weight; that is 2.5 - 4kg. 

Good nutrition in pregnancy is also key to prevent future risk of diabetes. Type 1 diabetes is hardly preventable but you may reduce the risk and prolong its onset like if you encourage exclusive breastfeeding of children for a longer time and prevention of malnutrition in children."

Piloya-Were said the budget for NCDs is still too low as compared to the communicable diseases on the health ministry budget.

"It is just a pinch that may not cater for even one NCD. Therefore, the infrastructure for NCDs is still lacking or inadequate right from the primary to tertiary institutions. There is limited training in NCD care and management and hardly any prevention strategies on NCDs," she noted.

What the future holds for NCDs

Established in 2010, UNCDA is a national NGO that envisions "a society without preventable NCDs" and our mission is to lead CSO response against NCDs by placing people's health at the centre of national agenda through advocacy, empowering and inspiring the population. 

As a Ministry of Health's lead NCD partner and a leader in mobilising efforts to combat NCDs in Uganda, the organisation aims at leveraging the country's efforts in the fight against the major NCDs, raise awareness and recognize efforts made to fight them.

It is an alliance of mainly three member associations; Uganda Cancer Society, Uganda Diabetes Association and Uganda Heart Research Foundation. It is also a member of the East Africa NCD Alliance and Global NCD Alliance.

"We have reached up to 3,128,000 people across the country through open health education during outreaches, radio and Television talk shows.

Messages aired during sensitisation are mainly on; risk factors of NCDS which include; tobacco use and  cigarette smoking, excessive use of alcohol, physical inactivity, unhealthy diets (feeding on junk foods), and environmental pollutants.

We emphasise the importance of regular and periodic screening for NCDs so as to detect and avert risks," Kwizera said.

The organisation, he added, also carries out screening for the major NCDs at its headquarters along Mawanda road in Kampala, at work places (cooperate companies), in schools, at events and during outreaches during global health days, and as a routine in some selected partner health facilities.

"With screening services we have reached; 80,600 for cancer, 119,000 for diabetes, 137,600 for heart cases and 163,200 for overweight/obesity cases," said Kwizera. Besides its main offices in Kampala, UNCDA has 11 functional branches in the districts of; Luuka, Tororo, Amuria, Sheema Kasese, Mubende, Nakasongola, Gulu and Arua.

At the ministry level, UNCDA engages the NCDs desk to ensure increased funding towards prevention, treatment of NCDs, as well as creating awareness about the diseases amongst the public.  

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