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CHRONIC DISEASES

NCDs: a new phenomenon or an immediate threat?

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NCDs: a new phenomenon or an immediate threat?
Story Highlights

  • The cursory handling of NCDs in Kenya lacks the urgency deserving a threat already afflicting so many lives, causing disability and many deaths.

  • The chronic diseases and frustrations from dysfunction in the health care system predisposes patients to depression, impairing their ability to manage their condition and accelerating their deterioration.

The sun is just rising above the eastern horizon. Its golden rays pierce into the cloudless sky, the master of light overthrowing the cold and gloom of night. 
But inside this county referral hospital, at the waiting hall in the medical outpatient clinic, gloom reigns supreme. That inner darkness that not even the sun can dispel. The place chokes with patients. Many arrived from far away, traveling through that cold and pitch dark of dawn, pushed on by the physical and psychological strife of chronic diseases. 
They squeeze on the benches. They stand in a queue that goes out the door, meanders through the fire assembly point where the dew soaks shoes that have seen better days. The sheer numbers dispel any doubts about the growing burden of non-communicable diseases (NCDs) in Kenya. Their gloomy faces testify to the loneliness and mental torture that befall anyone living with chronic conditions. 
The sad faces of these patients are not only because of physical pain. Some are in pain. But for many, the gloomy look is a portal into the tormented souls within. 
Chronic diseases are life-altering. It is not something that will be gone tomorrow. It is not something that you can ignore for a day, or until after work. Once the diagnosis is made, your lifestyle, your aspirations, your social life, your occupation all must be redefined. The adjustments are trying. 
Many people go into prolonged psychological stress as they are forced to subject their lives to the demands of chronic disease. This often leads to depression and anxiety. The multiple forces, including the disease itself, the consequences of reduced productivity at work, and strain within families, become an incendiary mix that can bring down even the most resilient people.  
Research shows that a fifth to a quarter of people with chronic diseases have the constellation of symptoms that fit the criteria for depression and anxiety1. This includes those with conditions now prevalent in Kenya, such as diabetes mellitus, hypertension, and arthritis (ibid). This is very alarming, given that the prevalence of depression in the general population is less than 10%.2
This reality is never emphasized in policy papers and not even in clinical guidelines. It is difficult to pin-point depression in people with chronic illness. Diseases such as diabetes may cause people to lose weight, lack sleep, or become lethargic directly through the pathological processes. The treatment given may cause these problems as side effects. Physiological changes due to disease, as well as the medicines, may cause the patient to suffer acute mood changes. This makes the diagnosis of mental disorders challenges. Many are therefore left to suffer on their own, unable to piece together the complex issues afflicting them. Unable to cope, trapped in the whirlwind of progressive illness causing physical disability and worsening psychological distress.  
Multiple factors accelerate the descent to depression in our setting. These include the financial burden of monthly prescriptions, social isolation, and the lack of support from the health care system. Patients have to travel long distances to reach a hospital then queue for hours to see a doctor—shoes soaked in dew at dawn, faces baking in the mid-day sun, tortured by hunger pains, desperate. When a prescription is written, they face the empty shelves at the hospital pharmacy then move on from chemist to chemist looking for some difficult-to-find, expensive medicines necessary to stay alive. It is a wonder that not everyone breaks down.  
It is important to identify those with chronic illness who are most at risk of depression. The diagnosis is difficult, and the growing number of people with chronic diseases make it difficult to intervene for every single one of them. But understanding this connection is essential. Mental illness impairs the person’s ability to follow through with their therapy for chronic disease. This predisposes them to both acute and chronic complications. The consequence of these further strain on a struggling health care system.  
Depression affects one’s motivation to do even the things that matter in life. A person in a depressive state exaggerates the weight of their condition and finds no point in seeking help. It forms a vicious cycle in which the depression causes worsening of the chronic illness, and this negatively affects the person’s mental status. There are studies showing that those with heart disease and depression have higher rates of death than those with heart disease alone.3
Counseling for patients with chronic disease should become a core aspect of our NCDs strategies. At the time of diagnosis, patients must be helped to understand the causes and implications of their condition. Many people blame themselves for the diagnosis. This sets them, from the very beginning, into a problematic relationship with themselves, their families, and the healthcare system. They must be helped to understand the causal interplay between nature and nurture. Even those whose lifestyle may have contributed highly to the disease, they need to get past the guilt because it can only hinder their therapy going forward. 
The treatment of chronic disease should begin with a discussion in which the patient’s life as a whole is considered. Work, family, ambitions, feeding preferences, and attitudes toward medicines are important influences on the therapeutic journey. The patient must feel that he or she is crucial in the process and that the more they do, the better the outcome. The pitfalls of chronic treatment need to be made plain to them, including the side effects of medicines and the complications that are part of the natural progression of the disease. They need to understand how the next five years are likely to be if the right treatment is followed vis-à-vis if it is not. 
For those with underlying depression, psychotherapy and anti-depressants should be initiated from the outset. These should proceed in tandem with the treatment of the chronic illness. It helps if the patient’s loved ones are involved in the treatment from the beginning. Social support is crucial to fending off the feelings of isolation and helplessness that befall chronic patients. 
A doctor’s empathy should play a vital role in all this. Communication should be sensitive to the patient’s psycho-social bearing. The patient must feel that it is they who are cared for, not the disease. There should be enough attention to their preferences and acknowledgment of the sacrifices they make. Understanding why every new test is essential, why every new prescription is necessary, helps to make the sacrifices of compliance tolerable. They must also be allowed to express themselves and vent out their frustrations. The persisting notion of paternalism where only the doctors speak, giving orders and recommendations, alienates the patient. 
Systemic changes
It is a tall order to ask that doctors spend so much time with a patient, explaining this, describing that, verifying the other. It is simply impossible. Looking out the window confirms it. 
The sun is high in the sky, dreadfully hot, it’s rays no longer an attractive golden hue. The dew is long gone. The queue extends further and further, meandering so that it is impossible to tell who is where. Some have lessos on their forehead; a few have umbrellas, most simply brave the incinerating heat. You see the despondent look of a hungry, angry person replicated on so many faces. Many want to leave to grab some food or water. But you can’t risk losing your place in the queue. 
And the poor doctor goes on. He has seen so many in the hours since starting but is aware so many more remain. He no longer hears everything they say, no longer asks too much, no longer says much. He is tired, hungry, overwhelmed. 
Not a state conducive to counseling patients or caring about their mental status. It only allows for a quick prescription and, “next!”. 
What more can you expect in a system of mass treatment? 
For people to be cared for holistically, there must be significant changes in the health care system. There is only so much that can be done by a doctor seeing hundreds of patients in an outpatient clinic all day, taking up a night duty in the wards, and waking up to a repeat of the same. Even they are at risk of the same mental disorders they are supposed to protect their patients from.
There is a need for more doctors, more facilities, more, better everything. If not, patients with chronic diseases remain as if alone, uncared for. Those quick minutes with a distracted, tired doctor once or twice a year are more harmful than useful. It is as if people with chronic conditions are neglected by the system, left to the ravages of the NCDs, and the mental disorders they bring. 
The picture this story conjures in your mind must be disturbing indeed. Yet, it is inadequate to convey the reality on the ground. A reality which questions whether the ongoing discussion about NCDs is serious enough: every once in a while we hear something about NCDs. I am sure there are entire blueprints, white papers, and commission reports somewhere. Yet the impersonal nature of policy documents fails to convey the actual cost of NCDs on individuals and families. 
The reality on the ground is very different from the filtered image seen from the balconies of Afya house, the Senate, and even the county headquarters situated so close to county hospitals. If you develop policies and directives on NCDs looking out into manicured lawns or benchmarking in an advanced north-American hospital, what chance is there what you come up with will contain even a small hint of the reality one sees down here. 
And the reality is, NCDs aren’t an emerging issue to be dealt with tomorrow. They are already a threat to the population. Evidence is overwhelming—in hospital wards where patients share beds. In outpatient clinics like this one. In homes where the deep voice of a father is no longer there to reassure. In cemeteries where another widower, another widow, another orphan, shed tears as they lay a wreath of remembrance.
As these sad faces wait in the endless queues, counties hire ever fewer doctors, delay their pay, and cause strikes and disruptions. Hospital pharmacies echo with emptiness, dust burying their empty shelves. Drug supplies remain a crisis, and patients spend more on medicines in chemists that line our streets. Those who can afford risk getting counterfeits, suffering the same fate as the many others who will never afford medicines, never afford anything needed to remain alive and productive in the setting of NCDs.

Bibliography

  1. Mayou R, Hawton K, Feldman E, et al. Psychiatric problems among medical admissions. Int J Psychiatry Med 1991;21:71-84.
  2. Guthrie E. Emotional disorder in chronic illness: psychotherapeutic interventions. Br J Psychiatry 1996;168:265-273.
  3. Glassman AH, Shapiro PA. Depression and the course of coronary artery disease. Am J Psychiatry 1998;55:4-11.
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