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Part I
Introduction
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1 Introduction
Africaâs epidemiologic transition of
dual burden of communicable and
non-communicable diseases
Ezekiel Kalipeni, Juliet Iwelunmor,
Diana S. Grigsby-Toussaint and Imelda K. Moise
Introduction
The chapters contained in this book are an offshoot of a symposium convened at the University of Illinois at UrbanaâChampaign, May 20â22, 2015. The symposium, titled âHealth in Africa and the Post-2015 Millennium Development Agendaâ, was sponsored by a grant from the National Science Foundation (NSF, Award 1461724) and the University of Illinois at Urbana-Champaign. An interdisciplinary group of scholars was brought together at this symposium to interrogate health conditions in Africa after 15 years of the implementation of the Millennium Development Goals (MDGs) that were adopted in 2000 by the United Nations. The result of the symposium is a collection of chapters that examine the current status of communicable and non-communicable diseases in Africa.
The coming to closure of the MDGs in 2015 prompted the need for a book of this kind. At this point in time the international community was in the process of formulating a new human development agenda to improve the lives of the worldâs growing population of over seven billion people. Questions on what the landscape of the Post-2015 Millennium Development Agenda would look like were being debated. The symposium was particularly concerned with socio-environmental and geo-political factors affecting health, wellbeing, and disease in Africa. The dual burden of diseases (i.e. the presence of both communicable or infectious diseases and non-communicable diseases [NCDs]) has already become a reality in many low- and middle-income countries (LMIC), including many countries in Africa (Miranda et al. 2008). For example, while highly developed countries have an 85% burden of NCDs versus communicable diseases, many countries in Africa experience an equal burden of communicable (44%) and NCDs (44%) (Aikins et al. 2010, Boutaye and Boutaye 2005). This burden makes already fragile, resource-constrained, fragmented, and siloed health systems on the continent of Africa even weaker. The scale of the challenge posed demands an extraordinary response which prompted us to bring together a leading interdisciplinary group of scholars and researchers to interrogate these issues, and examine the changing patterns of disease on the continent. As Aikins et al. (2010) points out, this dual burden of disease requires a careful rethinking about health care in Africa. To echo Aikins et al. (2010), there is an urgent need for African health policymakers and governments to prioritize the development and implementation of chronic disease policies as this burden continues to grow alongside the infectious disease burden.
The scholarly significance of the dual burden of diseases in Africa cannot be overemphasized. First, the scale of the challenge posed by the double burden has devastating effects for a continent already facing catastrophe in human health resources due to a shortage of health workers (Kalipeni et al. 2012, Moise et al. 2017). There are also demographic, economic, social, and epidemiological impacts posed by the double burden of diseases. Demographically, life expectancy is on the rise with increases in population size and aging in Africa (Murray and Lopez 2013). According to available evidence, life expectancy at age 60 is becoming a reality for an increasingly large number of Africans (Aboderin 2012). While most of sub-Saharan Africa is still in earlier stages of the demographic transition and will remain younger than other world regions, the population share of older people (aged 60 years and over) will, nonetheless, see a sharp four-fold rise from 5% today to 19% by the end of the century and in the same time span, the absolute size of the older population will grow a massive 15-fold from 43 million to 644 million (Aboderin 2012). This is a sharper increase than for any other world region or age group. Yet population aging in Africa is given little attention in policy debates, which raises a serious health equity concern as it is among the key drivers contributing to increases in the burden of NCDs on the continent (Murray and Lopez 2013). While infectious diseases still account for 69% of deaths on the continent, many African health systems which are under-funded and under-resourced will have to struggle to cope with the dual burden of infectious diseases and NCDs in the coming years (Aikins et al. 2010).
It is in this regard that the contributions contained in this book are situated in the revised Epidemiologic and Nutrition Transition Model (Popkin 2002) in order to capture the current situation with reference to communicable and NCDs on the African continent. The epidemiologic transition model has been of great appeal to demographers, sociologists, population geographers, epidemiologists, public health care researchers, and others. This model, first described by Abdel Omran (1971), focuses on the shifting web of health and disease patterns on population groups and their links with several demographic, social, economic, ecologic, and biological changes as is currently happening in Africa. Essentially, in this model there are shifts in health and disease patterns as mortality moves from high to low rates. In this model it is argued that as a society experiences a decline in death rates due to socioeconomic changes, the major causes of death shift from communicable or infectious to degenerative or chronic diseases. With reference to the nutrition transition, large shifts have occurred in dietary and physical activity/inactivity patterns reflected in nutritional outcomes such as average stature and body composition. Modern societies have diets high in saturated fat, sugar, and refined foods and low in fiber, the so-called âWestern dietâ which is associated with high levels of chronic/degenerative disease (Popkin 2002).
Barry Popkin (2002) has revised the demographic, epidemiologic, and Ânutrition transitions to show that these three models are really one and the same. In his conceptualization,Popkin (2002)argues that the nutritional shifts are related to the demographic and epidemiological transitions.Both the epidemiologic transition and nutrition transition are shown as being intertwined with the demographic transition. As we move into the Post-2015 Millennium Development Agenda and the newly adopted Sustainable Development Goals (SDGs), it is imperative that we ascertain the position of Africa with reference to these transitions (demographic, epidemiologic, and nutrition). As noted above, Africa appears to be a special case where both degenerative and communicable diseases continue to ravage its peoples. The authors of the chapters contained in this book realize the importance of these frameworks to examine the current health status and conditions in Africa, i.e. the communicable/NCD complex. Borrowing on the concepts contained in the revised epidemiological and nutrition transition framework, this book interrogates and offers case studies of the dual burden of communicable and NCDs in Africa, obstacles posed by rising risk-factors in a continent with fragmented and siloed health systems and lack of financial resources. Although this will be a common theme and thread running through all the chapters, the contributions in this book represent different perspectives and approach the issues from different angles through its assemblage of interdisciplinary and transdisciplinary teams of experts.
Guided by the Popkin (2002) revised Epidemiologic and Nutritional Transition framework, the main body of this book is divided into the following parts: Part I: Introduction (two chapters); Part II: Emerging and re-emerging infectious diseases (five chapters); Part III: Non-communicable/degenerative disease complex (five chapters); and Part IV: Food security, nutrition and health (two chapters). Chapters in Parts II, III, IV are organized based on the Barry Popkin (2002) revised Epidemiological Transition, also referred to as the âStages of Health, Nutritional and Demographic Change Modelâ.
The second chapter (Chapter 2) in the Introduction section offers an index on how to measure a countryâs advancement in development (Elliot et al. in this book). Using Kenya as a case study, Elliott et al. apply the Canadian Index of Wellbeing (CIW) as a useful model to measure wellbeing given the just ended MDGs. These authors argue that such an index can be useful in both assessing change over time vis-Ă -vis the wellbeing of a population, as well as change introduced through (policy) interventions. The chapter offers an overview of existing measures and assesses their robustness and application to an LMIC context. The chapter concludes with next steps and policy implications for developing a robust index that captures wellbeing.
The second part of the book (Part II) offers a set of chapters that examine emerging and re-emerging infectious diseases, particularly Ebola, HIV/AIDS, Malaria, and Buruli ulcer (Chapters 3â7). Shapiro et al. in Chapter 3 employ the disease ecology framework to understand the factors that led to the Ebola outbreak starting in February of 2014 in West Africa. They outline a political background to provide the historical context of the three most severely affected countries: Guinea, Liberia, and Sierra Leone. With an overview of the Âhistorical context, considering Ebola through a disease ecology lens highlights various aspects of human activity that explain potential avenues by which Ebola entered the human population. Additionally, these authors argue that historical conte...
