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Innovate to provide better access to the diagnosis and treatment of non communicable diseases

Marthe Frieden - MSF Project Coordinator
In the Manicaland Province of Zimbabwe, non communicable diseases are managed by peripheral health centers. Marthe Frieden, MSF Project Coordinator, explains how this approach is innovative.

    What is the situation in Zimbabwe and in Manicaland?

    Zimbabwe is a low-income country in Southern Africa. It is a former British colony that was called Rhodesia. In the local language Zimbabwe means “house of stone”, which is a reference to the majestic stone constructions erected by ancient civilisations.

    We are now approaching the end of the rain season, which extends from October to the end of March. This year the rains have been so abundant that they have caused floods in some areas. Cases of malaria have dramatically increased, as well as cases of typhoid fever and other diarrhoeal illnesses.

    Zimbabwe has had a dismal record in respect of the AIDS epidemic, with 14% of the population infected by the human immunodeficiency virus. It is because of AIDS that in 2002, MSF set up a project in the province of Manicaland. This is a vast frontier territory bordering Mozambique, with a land area 14 times larger than that of Luxembourg, and it has a population of 1,8 million.

    What is the nature of the MSF local project? What needs does it address?

    The previous project, focused exclusively on HIV and tuberculosis, came to an end in June 2015, and we followed on with this new project in July 2015. It was Provincial Health Director who launched an appeal to partners to combine efforts against non-communicable diseases. And we responded to this appeal with two teams working in close collaboration with the Ministry of Health in 40 health centres. Our approach is a “mentoring” one, which enables us to reinforce the capacities of staff of the Ministry of Health during consultations.

    We are continuing to be involved with the issue of AIDS.

    We are continuing to be involved with the issue of AIDS. Because so many lives have been saved using antiretrovirals, a large number of patients currently have an insufficient response to first line treatments. We are basing this on the viral load, which enables the quantification of the presence of the virus in the blood, to identify the failure of treatment at the earliest possible stage, before immunodepression reappears, and with it, the onset of illnesses. 

    It is against this background and rich experience with a chronic communicable disease (and which is of long duration) that we have embarked upon this new adventure, which is that of non-communicable diseases. Because what is involved here is a new "epidemic", whose proportions will soon exceed those of the HIV epidemic.

    What is non-communicable disease?

    Non-communicable diseases are not transmitted from one person to another. One could cite the cardiovascular diseases (cardiovascular or cerebrovascular accidents), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease (COPD) or asthma) and diabetes.

    On a world scale, these diseases kill more people than all other causes combined, and according to the World Health Organisation, nearly 80% of deaths due to non-communicable diseases occur in low, or intermediate income countries. The socially disadvantaged are particularly affected by this "epidemic".

    Amongst the risk factors, one can include, amongst others, smoking, the harmful use of alcohol, lack of a balanced diet, inadequate physical exercise, hypertension, excessive weight, obesity and excess cholesterol.

    How is this project innovative?

    The project is innovative in that it seeks to incorporate the diagnosis and treatment of diseases that are currently the responsibility of doctors into peripheral health centres. There is a shortage of doctors, who are based far from their patients in referral hospitals. For the patients, this entails travelling long distances on rain-damaged roads, and they dependent on a disorganised transport system. Drugs are often unavailable in the public sector, and very expensive in the private sector.

    Our project is one of the first in the world to address this challenge.

    Due to our intervention, nurses at these centres will be able to offer a vast range of treatments to the population in their coverage area. We hope in this way to contribute to the early detection and treatment of these diseases, which will enable the avoidance of severe and costly complications.

    This is no mean task, as the health system is already crumbling under the pressure of demand, and staffing is limited. The system needs to be reinforced without detriment to the other patients attending with much more urgent issues. Our project is one of the first in the world to address this challenge.

    How is a non-communicable disease diagnosed and how is it treated?

    We currently offer treatment for patients suffering from hypertension, diabetes or asthma, regardless of their HIV status. In our situation, it is a matter of simplifying diagnosis and treatment as far as plus possible using decision trees that are easy to use, and based upon scientific evidence.

    • Concerning hypertension, we measure blood pressure using manual or electronic blood pressure monitors at three successive consultations, and we then classify the degree of hypertension by category of severity, as recommended by the World Health Organisation.
    • For diabetes, we perform a fasting glycaemia test (level of instantaneous sugar in the blood of an individual who has not eaten for 8 hours). If there is a strong suspicion of diabetes, we use a test called glycosylated haemoglobin (HbA1c) which shows the overall equilibrium of the diabetic over a period of approximately three months.
    • For asthma, the medical history, supported by summary tables and a thorough physical examination form a significant part of the diagnosis.

    As for treatment, we must first differentiate between patients presenting with complications, or multiple pathologies. These are seen in situ by our own doctors, and if required, referred to hospital. On the other hand, those that are stable can be enrolled for monitoring by the nurses.

    We work on dietetic and life hygiene advice, and we provide, free of charge, the necessary drugs or combinations of medicines. On the other hand, for now, we are not yet able to manage insulin dependent diabetics.

    What is your role in this mission?

    I am a generalist doctor and I have a master’s degree in the control of diseases. So I am well “armed” to fulfil the roles of both clinician and field coordinator. I am responsible for scheduling the project’s activities and managing human and financial resources. In order to have an in-depth knowledge of the challenges and successes encountered in situ, I frequently accompany teams so that I can be at the heart of the action in the health units. This enables me to meet patients and staff, and to be involved in this professional activity that I am passionate about, namely that of a “mentoring” doctor: giving consultations while at the same time transferring my expertise and knowledge, and absorbing the same in return.

    It means that I know what I am talking about when I find myself once again in the role of co-ordinator, dealing with authorities or partners, for negotiations and lobbying.

    Do have an anecdote that you could share?

    We were heading for Mabee, one of the clinics located in the valley close to the Mozambique border, which is hard to reach during the rain season. The dirt road was slippery with deep wheel furrows in the mud. Here and there, men and women were working their fields, with yoked oxen before the plough, an image which conjured up in me memories of Luxembourg, of the small locality of Mertert, on the banks of the Mosel, a memory of a peasant and wine-growing family passed down through the generations in stories, paintings and documentary films.

    So, with their help, we managed to move on, patiently and as a team.

    My contemplations were soon interrupted and we had to wait a while, as we had become stuck in the mud! We had to work hard at pushing the vehicle and dragging it from the rear with a rope, but the wheels continued to skid. Shortly after this a man in his sixties approached us with a hoe on his shoulders, and set about clearing the mud that was trapping us, and then a young woman started breaking off branches to cover over the ruts. So, with their help, we managed to move on, patiently and as a team.

    Later, at the health centre, we were met by a crowd of patients who cheered us, despite our considerably delayed arrival. Two of our beneficiaries were particularly proud of our exploit: the “young man” with the hoe, diagnosed and treated for severe hypertension, and the young woman who had come for drugs for diabetes.

    * Main picture : Prisca started her treatment against HIV before Shamiso's birth, thanks to that, Shamiso is not HIV positive. © Rachel Corner / De Beeldunie