Consultation with the mediator at the Guinea Centre for Research and Training in Infectiology (CERFIG - IRD - Inserm)

© IRD - Alain Tendero, PostEboGui 2018

Health in Transition

Summary

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Updated 04.12.2019

It is no longer rare for inhabitants of the Global South to die from cancer or diabetes. In these regions, non-communicable diseases now cause more deaths than infectious ones. This is due to changing diets and new—more urban and industrialised—lifestyle habits. Populations must also cope with the emergence or return of certain infectious diseases. Along with these transitions, the health field has a vested interest in patient experts, and mediators, of their illness. IRD researchers and their partners are taking stock of these developments to support patients to the best of their ability.

In Nepal, air pollution is suffocating Kathmandu and its inhabitants.

© IRD - CNRS - Thibaut Vergoz, PRESHINE 2017

The Chronic Disease Epidemic

Living in a polluted city, smoking, engaging in very little physical activity and eating industrialised food: these are the characteristics of “modern life”, which are now common in Latin America, Asia and Africa. Chronic non-communicable diseases (NCDs) such as cardiovascular disease, diabetes and cancer have become more common than infectious diseases in these regions. Thus, out of the 15 million annual premature deaths People dying between the ages of 30-69associated with NCDs worldwide, more than 85% occur in low- and middle-income countries.

An alarming finding

“In these regions of the world, the epidemiological transition goes hand in hand with the emergence of a middle class”, said André Garcia, medical epidemiologist and director of UMR MERIT. “Urban populations, including the poorest inhabitants, now live in highly polluted areas, get very little exercise and have altered their eating habits: they view access to this way of life as a sign of development. But it is having a negative impact on their health.”

Non-communicable diseases are the main cause of death in countries where people have access to higher incomes.

© WHO

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In Cotonou, Benin’s largest city, respiratory diseases (asthma, bronchiolitis) have been on the rise among children for the past decade. This is due to exhaust fumes from cars, industrial fumes and fumes from the firewood and coal used by inhabitants for cooking and light. “Even toddlers and infants under three months of age can be affected”, warned Maroufou Jules Alao, a paediatrician at Lagune Mother-Child University Hospital in Cotonou. “We didn’t see cases like these a few years ago. Childhood obesity is also on the rise. We found that half of the children of executives living in Cotonou are overweight. The authorities cannot remain indifferent to this observation.”

Prioritising prevention over cure

This exceedingly rapid NCD “epidemic” poses a challenge for public authorities who are not sure how to combat it. Previously mobilised in the fight against infectious diseases and supported by international donors and research programs, health professionals must now receive additional training to manage these conditions. “The healthcare systems in place are not equipped to treat these chronic disease”, stated André Garcia. “Treatments are expensive and not readily available. Furthermore, the socially disadvantaged are the most affected and die more prematurely as a result of NCDs: this is because they have restricted access to both care and information. The first line of action thus consists of developing prevention campaigns, in schools for example.

Health survey on the management and monitoring of high blood pressure, a NCD, in Cotonou as part of the GlobalMed Project

© IRD - Rita Saudegbee

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Meanwhile, priority should be given to the surveillance and monitoring of behavioural and metabolic risk factorsFactors increasing the probability of developing a disease or suffering from a trauma. The World Health Organisation (WHO) also advocates monitoring the consequences of these risks (disease-specific morbidity and mortality) and country health system responses.The collection of such data will make it easier to assess these non-communicable diseases and thus better prevent them.

“We are currently collecting data by monitoring children, mostly in Cotonou, over the course of several years”, said Maroufou Jules Alao. “We would like to extend this data collection to rural populations in order to establish a general overview of the situation. The goal is to come up with recommendations that people can follow. This is why it is our duty to alert public authorities of the urgent need to act.”

Food market in the Philippines

© IRD - Jean Loirat

The Dangers of Junk Food

An obesity epidemic in the Global South? Not long ago, this was inconceivable. Today, two-thirds of the world’s overweight population lives in Asia, Latin America and Africa. This development first affected middle-income countries and urban areas. It now concerns the least developed countries and is spreading to rural areas.

This is due to an obesogenic environment, which includes poor nutrition. “The inhabitants of these countries consume large amounts of fat, sugar and salt. Most of their foods are industry produced”, explained Pierre Traissac. “They get little daily exercise, whether at work, in transit or during their leisure time. They also get less sleep, which increases their risk of obesity.”

This process, dubbed nutritional transition, corresponds to gradual lifestyle changes—particularly dietary shifts—with a significant increase in the consumption of animal fats and processed foods. While this shift began several generations ago in the West, it took place in just a few decades in Global South. Coupled with the demographic transition, it resulted in a sharp increase in obesity and associated chronic diseases such as diabetes, hypertension and cardiovascular disease. The populations of these countries suffer from this situation in two ways: they or their ancestors have often experienced periods of nutritional deficit during their childhood. The expression of their genetic heritage is thus better adapted to a state of undernutrition, which favours the development of obesity.

High-risk food environments

As is the case in many countries in the Global South, street food is an easy and inexpensive way to eat in Madagascar.

© IRD - Hardi - Thibaut Vergoz

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These individuals are also surrounded by an unhealthy food environment. They are eating out more frequently and doing so at snack bars and fast food restaurants, where the food is of poor nutritional quality. Even at home, processed foods, rich in trans fatsForm of fat derived from the partial hydrogenation of vegetable oils that increase cardiovascular risk, have become common, while sweetened drinks and soft drinks are regularly consumed. Fruits and vegetables—which are more expensive because they are often destined for export—are neglected, even though they offer protection against these types of diseases.

The nutritional transition does not affect all social groups equally. The risk to women is greater, particularly in certain regions. “In Tunisia, women are three times more likely than men to become obese”, explained Jalila El Ati, Head of the “Studies and Planning” Department at the National Institute of Nutrition and Food Technology of Tunisia. “While pregnancy and breastfeeding predispose women to body fat gains, this obesity differential does not exist in European countries. Today, only the most highly educated women, exercising a profession, do not exhibit this male/female weight differential. This is because of their increased equality within the household and the public sphere.” 

While obesity has primarily affected the wealthiest social classes, it is now affecting the poorest. If the nutritional transition in this region follows the Western example, these disadvantaged populations will exhibit high obesity rates in the future, adding to existing inequalities.

A double burden of malnutrition

Food insecurity can cause several forms of malnutrition, undernutrition and obesity among them. The same household may be faced with this “double burden”.

© FAO

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Nutritional deficiencies continue to exist. In many households, obese adults live with stunted children: this is the double burden of malnutrition. Obese individuals, most notably women, may also suffer from nutritional deficits such as iron deficiencies. This is due to a poor quality—often industrial—diet high in calories but low in vitamins and minerals.

How can these various forms of malnutrition be prevented? “The environment determines people’s behaviour”, affirmed Pierre Traissac. “For example, if fruits and vegetables are too expensive, prevention messages will not work. States are trying to act by offering incentives to agri-food stakeholders. But their task is difficult: they have to face companies whose profits come from the sale of unhealthy food.”

Food consumption frequency questionnaire as part of a survey conducted for a project on food and nutrition transition in Southern and Maghreb countries

© Jalila El Ati

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Tunisia has thus launched a national obesity prevention plan based on research projects conducted in collaboration with the IRD. In Bizerte, a town in northern Tunisia, bakers were encouraged to reduce the amount of salt in their bread by 40%. In return for their efforts, the State has set up a promotional display encouraging consumers to buy from these bakers. The government has also asked manufacturers to use unprocessed natural ingredients (flour, eggs, wheat bran) and jam with no added sugar to make biscuits for children. A special “Good for Your Health” label has been created for these products in order to motivate manufacturers. Jalila El Ati added: “We hope to broaden the scope of these pilot projects and extend them to other economic actors. I am quite optimistic: certain manufacturers are enthusiastic and want to get involved. Our objective will then be to legislate regulatory levels of sugar, salt and trans fats in industrial foods. Beyond incentives, regulation is an essential step towards concrete action.”

Ethiopia, alleviating nutritional deficiencies with injera

The nutritional transition is already taking place in Ethiopia. Nevertheless, Ethiopians, who generally eat few vegetables, continue to suffer from nutritional deficits, particularly folate deficiencies. This deficiency presents a major risk to foetal development during the first three months of pregnancy: it can cause central nervous system birth defects and lead to mental retardation. To address this issue, JEAI AnemiNut (dietary ways to combat NUTritional ANEMIa) has cultivated microorganisms that promote fermentation and produce folates. “These lactic acid bacteria can be added during the production of injera, a flatbread made of teff flour (a cereal native to the region). Injera is a staple of the Ethiopian diet”, explained IRD microbiologist Christèle Humblot (UMR Nutripass). “Bacterial fermentation increases folate concentration in the injera, providing 30% of the daily recommended allowance.” After successful laboratory tests are conducted, scientists hope to produce these ferments in large quantities. Ethiopians will then be able to use them to produce injera on a daily basis and thus reduce their risk of folate deficiency.

The Aedes aegypti mosquito is the main vector of dengue fever, Zika virus, chikungunya and yellow fever.

© IRD - Patrick Landmann, Vectopôle

Infectious Diseases: the Challenge of Prevention

“Prevention is still the best medicine!” While this statement appears logical, it constitutes a new paradigm in the fight against infectious diseases. “We must move away from an approach that is primarily based on diagnosis and treatment: it leaves pathogens one step ahead”, explained Frédéric Simard. As director of the MIVEGEC unit, Simard studies the behaviour of infectious disease vectors (mosquitoes, ticks, bedbugs, etc.). To use his own words, he has been “running after pathogens” for research purposes for several years. “Currently, there are very few accessible vaccines and treatments to effectively treat infectious diseases. So, in order to prevent epidemics, we must determine where the threat comes from, study pathogens before they attack humans and identify transmission channels, risk behaviours and conditions that promote the emergence and spread of these diseases in humans. We must be able to pre-empt the fight against pathogens and their transmission through the informed management of the socio-ecosystems in which they occur.”

Brazilian Red Cross Zika, dengue and chikungunya epidemic prevention message

© IRD – Daina Rechner

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This evolution is taking place in a context of emerging new infectious diseases. Through deforestation operations, humans are increasingly in contact with wild animals. Many of these animals carry viruses. As for vectors, they have become resistant to insecticides and have adapted to human habits. For example, Anopheles mosquitoes now settle in cities, while previously they couldn’t tolerate pollution. They now bite during the day, outside the house: insecticide-treated nets are therefore less useful. Finally, transport globalisation has favoured the circulation of insects, such as Aedes albopictus, also known as the tiger mosquito, a vector of Zika, chikungunya and dengue fever. Originally from Asia, it colonised all continents in approximately thirty years’ time.

Local surveillance

Prevention is the first step in the fight against infectious diseases. “In Burkina Faso, arbovirus transmission is monitored through entomological surveillance(1)”, explained Roch Dabiré, medical entomologist and regional director of the Research Institute for Health Sciences (IRSS) in Bobo-Dioulasso. “We are studying mosquito population dynamics in the cities most affected by dengue fever, including Ouagadougou and Bobo-Dioulasso, as well as the insecticide resistance of potential vectors, such as Aedes aegypti. We regularly set traps to assess their presence in the area. We can thus sound the alarm whenever there are population increases, prior to an epidemic breaking out.” Scientists also carefully monitor the areas that follow the railway line between Côte d'Ivoire and Ouagadougou: they are on the lookout for tiger mosquitoes (Aedes albopictus), which are found in the neighbouring country.

Tests being conducted to diagnose the visceral form of leishmaniasis, the most severe form of the disease, affecting 500,000 people worldwide each year

© IRD - Anne-Laure Banuls

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The second step is the fight against lymphatic filariasis [note: Caused by an infection of thread-like worms, this disease is characterised by the abnormal enlargement of body parts, hence the synonym elephantiasis] spearheaded by the National Neglected Tropical Disease Programme: the disease remains endemic in southwestern and eastern Burkina Faso. This programme focuses on communication and prevention through mass treatment with ivermectinA drug used to control several types of parasitoses to combat the persistence of parasites.

This surveillance system has also revealed cases of Onchocerca volvulus infection, an onchocerciasis parasiteTransmitted by midges, the infection causes itching, eye disease and epilepsy. found in the Burkina Faso Cascades Region (on the border with Côte d’Ivoire), although it has practically disappeared in other parts of the country. “Those who are infected are mostly displaced people from the Côte d’Ivoire”, said Roch Dabiré. “IRSS carefully monitors regions bordering the Côte d'Ivoire, as the latter’s healthcare system was disrupted during the 2002-2012 civil war. The action plan that we’ve put in place to eliminate this disease is extremely local in nature and will continue until this disease disappears (with a target date of 2025).”

Multidisciplinary and multisectoral prevention

Today, scientists are working on multidisciplinary and multisectoral prevention systems. Such systems must be cross-border and integrate public (urban planning, transportation) and private (import/export, tour operators, etc.) stakeholders whose activities promote the diffusion of pathogens and vectors, particularly in terms of dengue. In the absence of a vaccine for most of these diseases, excluding yellow fever, vector control is an important preventive measure. Research and the use of innovative technologies adapted to each context will have a real impact on the fight against infectious diseases.

    Consultation with the mediator at the Guinea Centre for Research and Training in Infectiology (CERFIG - IRD - Inserm)

    © IRD - Alain Tendero, PostEboGui 2018

    Expert Patients

    How can a patient become more involved in his or her care pathway? How do you prioritise the needs and expectations of patients? In the Global South, such participation is rare because the relationship between physicians and patients is often paternalistic. Physicians have a great deal of authority and rarely take the time to explain their diagnoses. Patients generally do not question medical opinions because they typically know little about their conditions and treatment options. In addition, certain treatments are difficult to access.

    However, the emergence of global partnerships involving HIV (human immunodeficiency virus) patients has enabled some African patients to further develop their relationship with health professionals. “Twenty years ago, people living with HIV in Senegal came together in associations where they helped each other, discussed their illness and treatment options and make collective demands”, explained Bernard Taverne, IRD anthropologist and deputy director of UMR TransVIHMI. “Some of them have become expert patients: they have acquired real medical knowledge and can discuss this knowledge with physicians on an equal basis. They have become community mediators and assist other patients, both socially and medically.”

    Psycho-social support

    Mediators act as go-betweens between physicians and patients. They introduce patients to healthcare and research facilities, where they can have their prescriptions explained to them. A great majority of mediators are former patients who want to assist individuals in understanding the many treatments available to them. This is the case with FatoumataThe mediator’s first name was changed in order to preserve her anonymity. 1: her illness was diagnosed in 2002, and she has been assisting patients for about fifteen years at the Dakar Fann University Hospital’s Regional Centre for Research and Training in the Treatment of HIV (Centre de Recherche et de Formation à la prise en charge du HIV or CRCF in French): “I was sick when I arrived at the CRCF”, she explained. “I was greeted and assisted by mediators who explained the treatments to me. Since then, I too have wanted to help sick people when they arrive at the University Hospital. We want patients to be autonomous, to understand and be involved in the medical process.”

    © IRD – Bernard Taverne

    The Fann Regional Centre for Research and Training in Clinical Treatment (CRCF) in Dakar provides antiretroviral drugs.

    The support given is primarily practical and psychological. The patient is guided through the medical facility, and assistance (community meals, transportation costs, etc.) is offered when available to provide financial relief. Mediators aim to restore patients’ confidence and defend their rights. “We have a very good relationship with the researchers and physicians”, added the mediator. “We attend patient consultations and try to provide all the information available on the proposed treatment.”

    Indispensable, and yet precarious

    Initially volunteers, the mediators have gradually become professionals. There are currently about 150 mediators in Senegal, but their status remains precarious. Sometimes they are given short, often intermittent, contracts. Sometimes they are paid volunteers. But above all, their commitment is personal. They have become indispensable for patients, health professionals and researchers alike. “Mediators can act as spokespersons, explaining HIV research findings to the population”, said Bernard Taverne. “They provide us with the patients’ point of view and can act as whistle-blowers in the event of health system shortcomings. Authorities now recognise their role in the fight against HIV but not in other areas. There is still a long way to go before the relationship between patients and health professionals improves in other health fields.