Published bySteven Nonde
Published on16 January 2017
On 1st January 2017, the Zambian President, Edgar Lungu and the First Lady, Esther visited clinics in Kanyama, Chipata and Ngombe slums meeting New Year’s Day babies (1). These areas are not only political strongholds for the ruling party but are amongst the most densely populated in the country.
Zambia is one of the most industrialised countries in Africa (2). According to the recent census, 39% of Zambians reside in urban areas (2). Lusaka, the capital and largest city was initially planned for 500,000 people (2). However, in recent years it has seen its population rapidly rise to 2.3 million (2). Across Africa, urbanisation has led to unplanned informal settlements and overcrowding of major cities (3). It is projected that by 2030, close to 50% of Africans will be living in cities (4).
Social services and infrastructure have been slow to keep up with the rapid urbanisation of African cities like Lusaka. Picture: Ubumi health, Zambia
The cost of urban living
The rate of urbanisation makes it very difficult to manage (3). Migration into cities has led to competition for land and puts more pressure on public services and infrastructure (3, 4). Kanyama slum in Zambia, which is home to over 370,000 people, has low coverage of piped water and lacks a functional sewer system (5). Residents rely on shallow wells, community boreholes and pit latrines (5). Much of the health problems in unplanned settlements stem from poor sanitation and lack of safe drinking water (3). As a result many slums have become accustomed to disease outbreaks. Around this time last year, Kanyama was among the areas in Lusaka that were affected by a severe Cholera outbreak. (5). There were 1,179 cumulative cases reported nationwide, of which 953 were in Lusaka. As of May 2016, only 31 Cholera-related deaths were reported (5).
The impact of urbanisation goes far beyond poverty and disease outbreaks. In developing countries, it is closely linked to increased incidence of non-communicable diseases (NCDs) (3, 6). A major part of the problem is that modern societies actively promote unhealthy lifestyles such as fast foods, physical inactivity, alcohol abuse and smoking (7). As countries develop, they are assaulted with aggressive advertising and promotions by corporations seeking to penetrate emerging markets (4). With some multinational companies having high income in comparison to the Gross Domestic Product of certain countries, it is fairly obvious that these companies are becoming more powerful than government. Inevitably, weak regulations have allowed increased consumption of commodities, including alcohol and tobacco across Sub-Saharan Africa (4). A study conducted in Kafue, Zambia, found that 8.2% of adolescents were smokers (8). Also, a demographic health survey involving several sub-Saharan African countries found that 15.6% of Zambians smoke cigarettes (9). Even though this figure was lower in comparison to Zimbabwe (22.1%) or Madagascar (27.3%), Zambia’s small population means that a large proportion of Zambians smoke (9). Such findings are indicative of how increasingly popular smoking is becoming amongst adults and even more worryingly, amongst young people.
The Epidemiologic Transition
Tobacco is the single most important risk factor of NCDs (8, 10). Globally, NCDs are among the leading causes of death. They account for at least 38 million deaths per year, of which half occur prematurely, that is, below 75 years (10). The four main types of NCDs are cardiovascular disease, chronic respiratory diseases, cancer and diabetes (11). Unlike communicable or infectious diseases, NCDs are not passed on from person to person, instead they are degenerative and progress much slower (11).
Public health experts argue that infectious (communicable) diseases are gradually being displaced by chronic (non-communicable) diseases, resulting into what is known as the epidemiologic transition (12). This changing pattern in disease and leading causes of death is driven by improved socioeconomic factors (such as income and education), increased life expectancy and widespread public health successes (like the recent eradication of polio and extensive ARV-treatment programmes) (12).
Strengthening health systems and what we learned from the 2016 outbreak
The rise of NCDs is increasing pressure on health systems and raises concerns over the future and sustainability of healthcare (6). Most health systems especially in sub-Saharan Africa may not be prepared to deal with the double burden of communicable and non-communicable diseases (6). Africa stands in a unique situation where the rise of non-communicable diseases is occurring at a time when communicable diseases remain prevalent (6). NCDs not only contribute to high death rates but significantly affect quality of life. This double burden of disease presents heavy financial costs to individuals and national economies. It also causes us to recognise the need for improved health systems (6).
Last year’s Cholera epidemic showed how strengthening health systems can avert possible disasters. The government’s response to the outbreak was commendable. The Ministry of Health set up Cholera treatment centres, educated the public through national media fraternities and devised an effective surveillance system to follow up reported cases (5). Lusaka Water and Sewerage Company (LWSC) chlorinated shallow wells and increased the number of water kiosks and standpoints that supplied chlorinated water (5). Handwashing soap and chlorine were distributed to public places and households in the affected areas (5). Furthermore, the Lusaka City Council also banned the selling of food in places without good water and sanitation facilities (5). Zambia’s experience with previous outbreaks meant that existing response capabilities were already in place (5).
In order to manage the double burden of chronic (NCDs) and infectious diseases, we need to have improved health capabilities in place. Currently, much of public spending in Africa is concentrated on programmes to control malaria, HIV, tuberculosis and other infectious diseases (13). There are few initiatives to support key personnel, drug supply systems, equipment and infrastructure, disease surveillance systems and the governance structure required to provide health services to the population (13).
Out of every disaster lessons are learned. The 2016 outbreak in Zambia highlighted the importance of leadership and advocacy in the midst of a crisis. But chiefly it proved that healthcare is indeed a coordinated effort. The response was multidisciplinary involving various sectors of government. Even though, public health faces a number of daunting challenges in the years to the come, “good health and wellbeing for all” is by no means an unattainable feat.
- Adamu P. Pres. Lungu Graces Lusaka Slums on New Year’s Day. Zambiareports.com. Available from: https://zambiareports.com/2017/01/01/pres-lungu-graces-lusaka-slums-new-years-day/ [12 January 2017].
- Sladoje M. Zambia urbanising part 1: Tackling bad contagion. IGC. Available from http://www.theigc.org/blog/urbanising-zambia-tackling-bad-contagion/ [12 January 2017].
- Ramin B. Slums, climate change and human health in sub-Saharan Africa. Bulletin of the World Health Organisation. 2009(87):889-886.
- Barbra SL. Africa in the global health village: challenges and opportunities. Presented at the African Health: Public Health Conference June 2016.
- UNICEF. Zambia: cholera outbreak report Number 5. Available from: www.reliefweb.int/report/Zambia/Zambia-cholera-outbreak-unicef-situation-report-5-9-may-2016 [Accessed 27 May 2016].
- Maher D, Sekajugo J. Health transition in Africa: practical policy proposals for primary care. Bulletin of the World Health Organization. 2010;88(12):943-948.
- BBC World Service. Healthy Vision: Health creating societies. [Podcast]. Available from: http://www.bbc.co.uk/programmes/b05q13vv [Accessed 28 November 2016].
- Siziya S, Rudatsikira E, Muual A. Cigarette smoking among school-going adolescents in Kafue, Zambia. Malawi Medical Journal. 2007; 19(2).
- Pampel F. Tobacco use in sub-Sahara Africa: Estimates from the demographic health surveys. Soc Sci Med. 2008; 66(8): 1772–1783.
- World Health Organisation. World Health Statistics 2016.
- World Health Organisation. Noncommunicable diseases: Fact sheet. Available from: www.who.int/mediacentre/factsheet/fs355/en/ [Accessed 12 January 2017].
- McKeown RE. The Epidemiologic Transition: Changing Patterns of Mortality and Population Dynamics. American Journal of Lifestyle Medicine. 2009; 3(1S), pp.19S-26S.
- Epstein H. 11 312 unnecessary Ebola-related deaths: Building citizen trust in health systems. Brenthurst Foundation Special Report 1/2016. Available from: www.thebrenthurstfoundation.org [Accessed 28 November 2016].