Unsuspecting 35 year old, with a wife and 3 children. He is quite certain he will live to 90 or at least 70; to see his youngest son become an engineer, to hold his grandchildren (every African parent’s dream). He works from 8a.m to 8p.m, 6 days out of 7 at a rubber factory, taking extra hours to pay his junior sisters schooling. In the evenings after work he stops at a bar for a drink with friends, shares a cigarette and stories. Life is hard, but he does not complain; he is young and hopeful. What can go wrong? One day notices he is increasingly tired, his face and feet are swelling up, he cannot understand. At the factory dispensary he is repeatedly treated for malaria. Eager for relief, he takes herbal remedies. He continues struggling to work; his family needs to feed. Eventually unable to hold up, he finds his way to a hospital, hoping for a cure. The doctor gives his verdict; kidneys are failing, going downhill, and it is irreversible. In any part of the world this is a grave diagnosis, for this poor Cameroonian laborer and farmer, it is more; it is a death sentence. We all receive our death sentences, the day we are born, for death is the only sure thing in our fortunes. Yet the blissfully uncertainty of when or how this will be; makes life livable. To be robbed of this bliss, to see death loom near, to know that your death will rob your family of hopes
and dreams; is cruel reality indeed.
Chronic kidney disease (CKD) simply explained is; damage to the kidneys that persists longer than 3 months, thus becoming irreversible (in contrast with acute disease). CKD, probably unheard of by this simple laborer. In fact it might be the first time he learns that he has organs called kidneys. That these kidneys (or filters I might say), have been busy all his life, eliminating waste, and putting him to the often bothersome task of urinating. Not until that day, might he learn that kidneys can actually get unwell, infected, or tired. Something always taken for granted, like producing urine becomes the very string on which his life depends. As grave, as kidney disease is, the common belief is that it is a rare condition. The average Cameroonian, is truly ignorant of the magnitude of the problem.
CKD is at least 3-4 times more common in Africa than in developed countries! How possible you ask? Are we not supposed to have the lower burden of non-infectious diseases? Here comes our deception. Not only are we growing a massive load in non-communicable/non-infectious diseases, but we are not getting rid of the communicable ones fast enough. Furthermore, CKD is not just a disease entity, but all also, a common final pathway to many other chronic diseases. Put simply, hypertension in Africa is going up rapidly; HIV coming down all too slowly; and the kidneys are caught it the middle. Two major risk factors for kidney disease found in our setting are; hypertension and glomerular disease. The glomeruli, “the filters of the filter”, are susceptible to damage from Diabetes, HIV, and other infections. Obesity, smoking, alcohol consumption, longstanding use of herbal/street medication; have also been implicated in CKD, in our setting. In Cameroon, population studies have revealed chronic kidney disease to be present 10- 14% of persons, that is more than 1 in every 10 Cameroonians! Our average family size being roughly 5, this implies 1 person in every 2 families! Therefore if not in your family then in mine, is at least one person with kidney disease, and very likely unaware, because, for every 1 patient with overt disease, the are 25 others with silent disease.
The picture gets gloomier still. Globally, CKD prevalence has increased by 26.9% in the last10 years. In addition, in Sub-Saharan Africa unlike in developed countries, mainly the young people between 20-50 years are caught in the nightmare! What is more, erroneously, we tend to assume, that our rural population is safe, that such diseases are limited to cities, due to greater lifestyle changes. Kidney disease has been found to be just as prevalent in rural Africans, as in urban, and in Cameroon, one study, even found it to be more common in the rural setting, with the same risk factors.
Kidney disease clearly constitutes a public health threat, for us, yet, we are very ill equiped. Beginning with physician, and nurse densities, we are grossly understaffed. CKD being irreversible, virtually every patient will eventually advance to stages where the kidneys can no longer support life, at this “endstage”, alternatives to replace the kidneys (renal replacement therapy), are necessary. This can be dialysis; where a device replaces the kidneys and filters out the waste, or a more definitive solution; kidney transplantation. In any case these are highly specialized procedures, requiring an adequate technical platform and specialists. Nephrologists in many parts of Sub-Saharan Africa are like precious stones; rare to come by, and expensive to assess. Most countries have less than 1 nephrologist per million population. Less than 5% of those who require renal replacement therapy in Sub-Saharan Africa have access to it. In Cameroon, haemodialysis is available in 9 government centers, in major cities. However, kidney transplantation is still a distant dream. Here in lies the death sentence for our labourer. In the cities, we have the nephrologists, the health facilities; but the patients are in the villages. In addition; the cost of dialysis in Cameroon, though greatly subsidized by the government, is still expensive for the average Cameroonian, who would have to spend a minimum of 30, 000frs a week, for 2-3 dialysis sessions including accessory treatments, like for anaemia, and vitamin D deficiency (for mind you, kidneys equally have major production, transformation, and regulatory functions, including participating in blood and vitamin D production). Thus even where available, the effectiveness of dialysis is limited by resource inadequacies, long travel distances, and cost.
Before this sober landscape how do we proceed? To address this problem, I believe Cameroon, must look at the big picture. Most of Sub-Saharan Africa, Cameroon inclusive has been branded “under developed”. We have accepted this, and consequently, are striving to achieve standards for success/development set by another, using their methods. However it is important I believe, to define for ourselves, what our own idea of success/development is in all sectors including health, and work towards this. Otherwise following current trends, we may end up replacing hunger, with depression; social oppression with gang violence; abuse of the girl child with sexual depravity; food insecurity with unsafe over processed foods high in additives and all the wrong lipids; HIV with cardiovascular disease; tuberculosis with chronic kidney
disease… and the list goes on. Let us keep in mind that many of risk factors for CKD like; hypertension, diabetes and obesity, are not problems we had 100 years ago, but problems we have developed, as we follow the development trail. It becomes clear that we are copying the mistakes. We must trace our own path, avoid repeating others’ mistakes, and only copy what works for us.
This said, to tackle CKD we must begin at the national level. We lack a coordinated national prevention program for CKD, just like we have for HIV or tuberculosis. We need one, and it must include strategies that cut across all sectors. An example; urban development laws prohibiting the building of structures above 5 stories in our cities, and the exclusion of elevators, (except in special cases like hospitals) will be novel approach, may imply economic loss in short term, but will help curb of obesity in the long term.
Manipulating fiscal policies to reduce over processed, high-sugar, high-salt, high-cholesterol products on our markets; has worked for others, and could for us. Reinforcing quality control of imports; will halt our
becoming a dumping ground for unhealthy food. In our health facilities, reliable and validated screening tools, will improve early detection. Simultaneous screening, and treatment of risk factors; instituting functional registries in hospitals; all these can go a long way.
At a societal level; health information cannot be over emphasized. Researchers, research institutes, medical faculties have to meet the need for epidemiological data on CKD. Nongovernmental organizations, private facilities, all stakeholders of the health sector must get involved.
Finally for you and I, to protect our kidneys, we need to; eat more vegetables and fruits; reduce the amount of salt we consume; abandon coffee; avoid store bought processed foods, walk to work (or cycle); replace breakfast of bread/puff-puff with a fruit; keep the amount of oil in the pot at a minimum; get good quality sleep (keep phone away when in bed); make time for a leisure; go to the hospital when you feel ill, (very case of fatigue is not malaria); beware of herbal remedies (they are NOT always safe) ; and finally, pass on what we have learnt in this article to another person.