Medicosnext
Non-communicable diseases (NCDs) have become the leading cause of global deaths, with 41 million deaths (71%) each year mainly due to cardiovascular diseases, cancers, respiratory diseases, and diabetes, according to the World Health Organization. NCDs disproportionately affect people in low- and middle-income countries, with more than three quarters of global NCD deaths and 85% of all premature (30-69 years) deaths occurring in these countries.
Nepal is no exception, and like other South Asian countries, it has to tackle simultaneously the double burden of infectious or tropical diseases and NCDs, which is straining the health services with two-third (66%) of deaths annually (Nepal Burden of Disease 2017 report).
Due to asymptomatic nature of the diseases and low awareness of chronic diseases in the population, they remain unidentified until the complications or other comorbid conditions bring them to attention of medical service. According to WHO and study done by Sharma SK and his group, Nepal has been witnessing an “epidemic” of diabetes (4%), hypertension (24%), chronic kidney disease (CKD), and ischemic heart disease, which pose many challenges.
In addition, Nepal grossly lacks resources to manage advanced complications of chronic diseases like renal replacement therapy for end stage renal disease. A study conducted by Acharya (2009) and Bolton and Das (2015) also observed that people with acute cardiovascular events do not reach hospital in time, and of those who reach hospital, most of them cannot afford treatment even if it is available.
“In order to cope with these challenges, developing countries, such as Nepal, with limited access to healthcare and scarce resources need to think out of the box,” says Dr. Sanjib Kumar Sharma, nephrologist and professor of Cardiology and Internal Medicine at B.P. Koirala Institute of Health Sciences (BPKIHS), adding, “it doesn’t always require sophisticated medical technology, highly trained manpower, or huge investment to beat NCDs. Sometimes, very simple efforts like changing one’s behavior and attitude can save many lives.”
Dr. Sharma was associated with Norvic Hospital in Kathmandu, before he joined the Department of Internal Medicine at BPKIHS, Dharan, in 2055 B.S.
He was instrumental in initiating dialysis service for the first time outside Kathmandu. One day, in dialysis unit he met a young man who was in need of dialysis. The man had been working in Qatar for six months when his kidney was damaged and he was sent back to Nepal. He initially started dialysis in Kathmandu, and after learning dialysis was available in Dharan he approached BPKIHS. But he had no money to buy the medicines. Dialysis was not free at that time. “When we told him we couldn’t start his treatment without the consumables and medicines, he quietly went to the corner of the small room where we provided the service. Then, he lay down on the floor and said: don’t I have the right to live? When he said that, I regretted being a doctor for the first time in my life. He left without receiving treatment that day. I never saw him again. He probably died.” The tragedy was that his condition could have been easily diagnosed by some simple urine and blood tests, and if he had done the tests and received treatment on time he would still be living, says Dr. Sharma.
He adds, “Many of these diseases are easy to detect and treat at the beginning. In fact, effective low-cost prevention strategies to reduce the burden of chronic diseases and their complications already exist. The four most economical lab tests: blood sugar, blood creatinine, urine protein, lipids, and blood pressure can help detect heart and kidney diseases. However, people still die simply because such preventive strategies are not implemented.”
The major risk factors of conventional kidney and heart disease are diabetes mellitus (DM), diabetes, proteinuria, blood pressure, smoking, and cholesterol. According to a recent research, controlling BP and LDL cholesterol alone can avoid 75 percent of heart attacks.
After the incident in BPKIHS, Dr. Sharma realized that if he wanted the community to be healthy he needed to go to them. Then he designed a model: to go to the villages/communities with a semi automated analyzer and his students to provide services.
“When I spoke with my students about going to different communities to run a health screening camp, they readily agreed. So, to start with every Saturday we went to one community and asked people for urine (a clean midstream spot urine to assess protein concentration), collected their blood samples, and measured their height, weight, and blood pressure.” They organized the first health camp on November 14, 2003, with the support of Rotary Club of Ghopa, Dharan, and a local pharmaceutical company that provided syringes, urine strips and glucometers, among other things.
This eventually led him to create KHDC Nepal (a program for early detection and management of Kidney, Hypertension, Diabetes, and Cardiovascular diseases). In 2006, KHDC, in collaboration with BPKIHS, developed awareness, screening and intervention program for hypertension, diabetes, chronic kidney disease and cardiovascular diseases, and their risk factors.
In the beginning, they went to the localities with MBBS and nursing students along with community volunteers. They made door-to-door visits to draw blood and collect urine, and brought the samples to the lab. When the report came, counseling was provided to those who had disease and risk factors. Over the years, people sponsored them with a technician, BPKIHS helped them with the lab, and the International Society of Nephrology provided them seed funds.
“We were providing services on our own at first. When we received the fund, which was a small grant but significant for us at that time, we became a little organized. We started taking blood samples to test for fasting blood glucose, cholesterol and serum creatinine concentrations and made a local committee of volunteers in the place we were running the program. Before the program, we met local leaders to explain the benefits of a screening and intervention program. After these individuals gave their approval and support, we carried out a series of community awareness activities with the help of local leaders, community volunteers, and medical students and doctors from BPKIHS. We also collected patients’ general information, demographic data, diet, alcohol consumption, physical activity, and smoking habit.”
The collected samples were confirmed for fasting hyperglycaemia, hyperlipidemia, proteinuria, or impaired renal function in 10 to 15 days and verified by qualified doctors. “We followed up patients with hypertension, hyperglycaemia, dyslipidemia, proteinuria, or renal function impairment. Then, we prescribed them cheap antihypertensive, antidiabetic, statin, or renoprotective drugs as deemed appropriate,” the doctor shares.
Now, they have a small lab of their own in Chata Chowk, Dharan, donated by the local community. It tests around 50 people daily. The KHDC program has reached more than 40,000 people in Dharan and its neighbourhood, and allowed counselling, treatment, and follow-up for those positive on screening. In Dharan, this program highlighted the very high prevalence of hypertension (33.9%), diabetes (6.3%), metabolic syndrome (22.5%), and projected 10 years cardiovascular risk (28%) and chronic kidney disease (10%) in population of >20 years of age. In the subsequent years, the program was able to achieve significant control of these chronic diseases. According to a report published in Lancet journal in 2014, the prevalence of participants with a predicted 10 years cardiovascular risk of 10% or more decreased from 28% to 17% after three years in this cohort.
The program has demonstrated that community based screening is an effective means of identifying subjects at risk of diabetes, kidney, and cardiovascular diseases early to allow for proven effective intervention and management of their condition. Dr. Sharma states, “In a country like Nepal, due to various reasons, such as loss of day wages, lack of disease awareness, and belief of ‘being healthy’ in the absence of symptoms, people don’t seek regular medical attention, leading to late presentation of NCDs, including their acute and chronic complications.”
This was apparent in the community screening, where people with very high blood pressure, very high blood sugar, advanced CKD, and silent myocardial infarctions were detected during screening.
Therefore, implementation of projects like KHDC will not only help to create awareness in the community level and prevent NCDs, it will also help to detect disease at the early stage and help low cost management, besides complementing the government initiative of ‘healthy Nepal’ like PEN (Package of Essential Non-Communicable Diseases) implementation.
“Many of the NCDs are avoidable, and its health and financial costs can be reduced if such programs are initiated at individual level, at primary care level, and at the community, with the moto of “reach one each one, teach one each one, treat one each one,” says Dr. Sharma.
