Written by Kina-Kira Hiller
Edited by Zachary Gavry, DL Christensen & Helen Myrr
Part of the MSc Global Health program at KU is a five-week module in either Tanzania or Poland. I was part of the group that went to Moshi, situated at the foothills of Mt. Kilimanjaro in Northern Tanzania. During our stay, we gained insights and knowledge about the local health system through lectures at KCMUC, visits to different health facilities, interactions with people and working on research proposals. The topic my group decided to focus on was “whether diagnosed diabetes patients show specific socio-demographic characteristics compared to those who are undiagnosed.” Because of this, and in light of the recently celebrated World Health Day dedicated to diabetes, I would like to share our experiences and impressions on how the Tanzanian health system addresses this growing burden of disease.
The International Diabetes Federation estimated a 3.5 % national prevalence of diabetes in adults (20-79 yrs), with 5.8 % in urban areas and 1.7 % in rural areas of Tanzania. However, numbers vary and studies propose that most people who have the disease are unaware of it (up to two-thirds). In the whole African Region, around 20 million people are living with diabetes. This number is predicted to more than double by 2040. People of working age are particularly impacted as it affects their ability to work and more than 75% of diabetes deaths were in people under 60 years in 2013, threatening regional development and health systems.
In spite of this increase, even in reputable hospitals, screening for diabetes is rare. The main focus is on infectious diseases and reproductive health. Here, it is important to mention that diabetes is associated with infectious diseases such as tuberculosis probably due to a compromised immune function (diabetes leading to tuberculosis) or increased inflammation (tuberculosis leading to diabetes). These interactions influence treatment outcomes and mortality. In a specialized tuberculosis clinic that we visited, patients were therefore screened for diabetes. However, most often only pregnant women with gestational diabetes will be diagnosed due to the reproductive health focus. This is an important aspect since women with gestational diabetes are at increased risk of having manifest diabetes later in life as well as giving birth to large children (>4.5 kg) who are equally at increased risk of diabetes in adulthood.
Sometimes you find initiatives trying to integrate diabetes more into clinical practice. For example, we met a motivated team working at a big private hospital who screened 200 people at the Kilimanjaro marathon and provided weekly educational sessions for patients. However, their resources were very limited and we found little or no outreach to rural areas. They did not have a single nutritionist at the hospital and their diabetes unit only had one room, used as an office and for consultation. Examination rooms as well as nurses and doctors were shared with other units. It seems as if there is some progress but screening for diabetes is still too neglected and does not receive enough funding.
Furthermore, we noticed little or no awareness of diabetes and its risk factors in the general population. Tanzanian diet often includes a high daily sugar intake and consumption of starchy food. Many people working in the city do not prepare their own meals but rather eat in restaurants where white rice, beans, fries, and roasted meat are the most common and cheapest food choices. Juices and soda are offered everywhere and are highly consumed. Coca Cola is visible and sold on every corner, also in front of the hospital entrance. Even the most popular brand of water (“Kilimanjaro”) is owned by the Coca Cola corporation. The price per bottle is around 900 TSh or around 0.40 USD for water (1.5 l) and Coca Cola (500 ml) in stores, and around 1,500 TSh for 500ml of both in restaurants. The relatively low prices could be one of the reasons for the increased sugar consumption and the associated negative health outcomes.
It is also important to note than many still see diabetes solely as a disease of the rich since in developing countries it is mainly prevalent in the urban areas where most of the middle and upper class people reside. However, in our part of the world, diabetes is associated with poor lifestyle and is therefore associated with the lower end of the socio-economic classes!Therefore, members of all socio-economic classes can be affected and in particular those who cannot a healthy diet and lifestyle due to money or poor education.
In Tanzania, treatment and prevention of secondary complications of chronic diseases are free on paper but, unfortunately, the reality looks somewhat different. Drugs in hospitals are often not in stock, requiring patients to buy them in pharmacies where the cost may be very high in relative terms. Patients might be eligible for social welfare but the application process can take a long time. Costs for transportation to the hospital and loss of income due to long waiting times pose additional barriers. The health care system is very diverse, and traditional and even Chinese medicine play an important role. One may find little stores next to busy roads where herbal medicines are sold, where sellers claim their juices or products can heal all kinds of disease, including diabetes and hypertension. Patients often use these so-called ethno-medicines because they are less expensive than pharmaceutical medicine. The traditional medicine shops are, however, less regulated and some of the treatments can even be harmful. Hence, although diabetes is prevalent in all groups, it can still be seen as a disease of the rich because they are the only ones who can afford it.
Lastly, I would like to mention that we had the great opportunity to visit a Maasai village with our professor, Dirk Lund Christensen where we learned about their traditions, lifestyles and health situation. The Maasai have a high milk and meat consumption at least for certain periods of the year. Adult males, for example, may consume up to 2-6 l of milk per day, resulting in a 30% energy intake coming from saturated fat. However, the prevalence of diabetes and cardio-metabolic diseases as such is low, which is quite a contradiction to the perceptions of modern medicine. It could possibly be explained by high physical activity as well as seasonal variation in food intake. The Maasai seem to be left out of the public health care system, mostly because of financial and locational barriers to accessing it, as well as stigma and discrimination. Official screening and treatment programs are therefore rare in the communities. Diabetes and other diseases are treated mostly with herbal medicine, which can be barks, branches, roots or leaves of trees and bushes. One of the days during our visit, we searched, for example, for branches of the Enjani engahe tree in the bush which are used for treating diabetes and hypertension.
This text has hopefully made it clear that we learned quite a lot about diabetes perceptions, screening and treatment. Tanzania is developing its services but there are many challenges that need to be addressed in order to strengthen the health care system and battle the growing burden of cardio-metabolic disease. The Tanzanian government needs to improve screening and treatment, as well as make policies to prevent diabetes, e.g. by promoting a healthy diet and regular physical activity. There should also be a greater focus on equal access to health care for people with a lower socio-economic status as well as ethnic minorities such as the Maasai.