African Countries Made Huge Gains in Life Expectancy. Now That Could Be Erased.

NAIROBI, Kenya - Hannah Wanjiru was plagued by dizzy spells and headaches for years. After a half-dozen costly trips to the doctor, she was finally diagnosed with high blood pressure. It took two more years - and some fainting spells - before she finally started to take medication. By then, her husband, David Kimani, had been shuttling between doctors himself and ended up with a diagnosis of diabetes, another condition the couple knew nothing about.

The couple might have wished for different diseases. Not far from their small apartment in the Kenyan capital, there is a public hospital where treatments for HIV and tuberculosis are provided for free. Posters for free HIV prevention services paper the streets in their low-income neighborhood.

There is no such program for high blood pressure or diabetes, or for cancer or chronic respiratory conditions in Kenya and much of sub-Saharan Africa. The health systems and the international donations that support them are heavily weighted to the treatment of infectious diseases such as H.I.V. and malaria.

"Sometimes I have to wait all day to get my sugars tested, and I almost faint while I'm waiting in line," said Mr. Kimani.

The World Health Organization reported that countries in sub-Saharan Africa have achieved extraordinary gains in healthy life expectancy over the past two decades. This is due to success in fighting H.I.V., malaria and other deadly infectious diseases, as well as an expansion of essential services. These countries have seen an improvement of 10 additional years, the largest improvement in the world.

"However, this was countered by the significant increase in hypertension, diabetes, and other noncommunicable diseases, as well as the lack of health services targeting these diseases," the agency said while launching a report on health care in Africa. The agency warned that the predicted rise in life expectancy could be erased before the next decade is over.

More than half of hospital beds in Kenya are now occupied by patients with noncommunicable diseases, and more than a third of deaths are caused by these diseases. The rates are similar across the rest of sub-Saharan Africa, and people in this region are being affected at younger ages than those in other parts of the world.

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"Vaccination programs are running very well and H.I.V. programs are running very well, but these same people will die of noncommunicable diseases while they are young," said Dr. Gershim Asiki, a research scientist focused on management and prevention of these conditions at the African Population and Health Research Center, an independent organization in Nairobi.

"It's hard," Ms. Wanjiru said. "You have to choose."Ms. Wanjiru and Mr. Kimani both suffer from hypertension, and the medications and supplies they need to control their conditions cost $60 each month, a huge portion of the income from their small convenience store, Ms. Wanjiru said over tea in their sitting room. Both skip their medication on months when school fees are due for their four children.
"It's hard," Ms. Wanjiru said. "You have to choose."

"I get headaches and I feel weak, and then I feel stressed knowing I need to buy medication instead of food for my family," Mr. Kimani said.

The following text has been rewritten:High blood pressure screening is not common here, and diagnosis and treatment are often only available at specialized centers in urban areas. The general public is not aware of the symptoms of high blood pressure everyone can recognize malaria, but few connect blurry vision or exhaustion with hypertension and primary care health workers often don't know what to look for either.

When Dr. Asiki's organization set up random screenings in a low-income community in Nairobi a couple of years ago, researchers found that a quarter of adults had hypertension. But 80 percent of them did not know they had it. Of those who did, fewer than 3 percent were controlling their blood pressure with medication.This is a serious problem because uncontrolled hypertension can lead to heart attacks, strokes, and kidney failure. Dr. Asiki is working to educate people in low-income communities about hypertension and how to control it.

"A fraction of Kenya's health budget goes to noncommunicable disease. In 2017-18, the latest figures in the government's strategic plan, 11 percent of the budget was earmarked for these diseases. But people come with cancers that are already Stage 4, with very little chance of survival, because they cannot get diagnosed," said Dr. Asiki.

"There is no perceived political value in investing in a long-term screening program," said Catherine Karekezi, executive director of the Kenyan chapter of an international patient advocacy organization called the Noncommunicable Disease Alliance. This is despite the fact that government ministers like to cut the ribbon on new cancer centers.

"Noncommunicable diseases are responsible for eighty percent of deaths in this country, but many of these deaths are preventable," said Dr. Karekezi. "We can prevent the diseases themselves, and even if someone has already developed a noncommunicable disease, we can often prevent it from becoming worse."

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"Instead, she said that younger people are falling ill and developing serious complications and sometimes are unable to work. 'It's the economically active segment of the population that is affected,' she said."

"People die of undiagnosed heart disease or complications from diabetes in their 50s and that's chalked up to 'old age,'" Dr. Asiki said. "The systems to accurately track causes of death are weak, which means that neither the public nor policymakers understand the true scale of the problem."

"Treatment for diabetes or blood pressure are usually out-of-pocket expenses for families, and often cripplingly expensive," said Dr. Jean-Marie Dangou, who coordinates the noncommunicable disease program of the W.H.O.'s Africa regional office. This is unlike H.I.V. medication and care, which is usually free and subsidized by international donors.

"In the Democratic Republic of Congo, hypertension treatment costs two-thirds of the typical household income each month," he said. "That's absurd, for that family. But it is not unusual."

Annah Mutindi, 42, used up all her savings from her job as a clerk in a Nairobi dress shop on doctor visits and tests before a painful lump in her breast was diagnosed as cancer in January 2021. She was prescribed a course of 12 biweekly sessions of chemotherapy. She could have had them for a minimal cost, in theory, at a large public hospital in the center of the city, but the treatment was continuously out of stock.

She had to wait until her family and friends scraped together $360 every few weeks so she could pay for the treatments one by one, stretched over the next nine months.

"I was in shock when they told me it was cancer," Ms. Mutindi said, recalling her diagnosis. "They said maybe it was environmental factors."

"The share of deaths caused by noncommunicable disease is increasing across the region, most rapidly in the continent's most populous states," Dr. Dangou said. "In Ethiopia, for example, mortality caused by these conditions climbed to 43 percent of deaths last year from 30 percent in 2015, and made a similar jump in the D.R.C."

The increase in conditions is being driven by rapid urbanization and an increase in sedentary lifestyles, growing use of tobacco and alcohol, and consumption of processed foods.

Kenya's government has been slow to update policies to discourage these. And all three industries have powerful lobbying organizations that are focused on stalling legislation such as a tax on sugar-sweetened beverages. Kenya is a major producer of tobacco and the industry reminds the government of the jobs it creates, Dr. Asiki said.

The simple fact that people are living longer could be because of the progress fighting infectious diseases. However, other causes, such as possible genetic factors and a correlation with exposure to infectious disease, are less understood.

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Why are noncommunicable disease rates rising so quickly, and in comparatively younger people, in this region? There is little public investment in researching this mystery.

"The experience of high-income countries is of limited relevance to the situation in a country such as Kenya," Dr. Asiki said. "Scarcity of nutritious food in childhood appears to prime people metabolically for obesity in adulthood. There is some evidence that malaria infections predispose people to cardiovascular disease; hepatitis infections put them at risk for cancer."

"H.I.V. control drugs can lead to heart disease"This is according to Dr. Asiki who stated that increased rates of air pollution, environmental toxins, and stress from living in areas with high rates of violence and insecurity are all contributing factors. The combined effect of these factors is not yet well understood.

"The government is concerned about the soaring rates of noncommunicable conditions," said Dr. Andrew Mulwa, who directs preventive and health promotion programs for the Kenyan Ministry of Health. "But it's slow work rolling out diagnostics and treatment to the primary care level in rural areas."

"When I worked as a clinician in a rural area 10 years ago, you would see 50 patients a day with these conditions," he said. "Now it is 500 to 1,000 at the same facility."

Dr. Asiki refers to poor nutrition as 'a double burden of under-nutrition,' as it is influencing the rise of noncommunicable diseases in multiple ways. This region is home to both the largest number of stunted children in the world and the fastest-rising rate of obesity.

In low-income households, it is common to find both malnourished children, who lack the protein and nutrients essential for growth, and adults who are obese. This is because they are reliant on cheap, fatty and energy-dense street foods. Street food is often a more affordable option than paying for vegetables and cooking gas to make food at home.

"You can have too much of the bad food, but not enough of the good food," Dr. Asiki said. "The body stores excess energy as fat, but in the end, it's still a scarcity."

He speculated that the government had been slow to roll out screening programs because it could not respond to the extent of the problem.

"When you suddenly realize you don't have enough medications for hypertension or to treat people with cancer, it's clear that screening would pick up cases that are treatable," said Dr. Asiki. "But the question is, do we have the resources to treat them?"