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Tuesday, September 22, 2015

Museveni Advocates for Non-Communicable Diseases

By Rahimu Jabendo Via Uganda at Heart (UAH) Community (Edited by Esther Nakkazi) 

President Yoweri Museveni's statement at General Aronda Nyakairima's requiem service is a gold mine of advocacy against non-communicable diseases (NCDs). The 56 year old army General died on September 11 aboard a flight from South Korea en route to Dubai in the United Arab Emirates.

Museveni said Aronda was denied emergency treatment because he had no insurance, which the South Korean embassy in Uganda has refuted http://www.koreaherald.com/view.php?ud=20150922000404 and this could cause a diplomatic rift if not clarified. 

A statement from the Media Centre from the Prime Minister's office issued on 16th September said after a postmortem was performed at Mulago referral hospital by professionals it was found that internally, the brain had signs of lack of oxygenated blood supply. 

The heart was also enlarged, with presence of massive bleeding with in the muscle of the left ventricle involving the whole thickness of the heart muscle. There were also small areas of damaged heart muscle which also had an abnormal fat layer surrounding it. The lungs were also remarkably enlarged. 

The conclusion was that there was acute heart failure due to extensive and irreversible blockage of the heart blood vessel. 

Nobody could have stated the humongous challenge we are facing better and at a most appropriate time than Museveni. He said 'I am annoyed....he (the deceased) had a condition which was either not detected early or if detected was not managed properly'. 

Linda Aronda, the widow's statement then creates a very powerful contrast that clearly brings out how society perceives well-being:

“This heart problem you are talking about, OK it may have been there but we [the family] have never seen it', she said. 'My [two] children are my witnesses. Aronda was full of strength...For 19 years he has never failed to get out of bed or fall sick", she added.

How best to animate the insidious nature of cardio-vascular disease than in this statement. 

Of course family cannot 'see a heart problem' because seeing it requires an 'echo-cardiogram' which if you found in someone's home would be enough to scare the day lights out of you! The combination of the two statements (Museveni and Linda Aronda) show the expected vs. the norm regarding NCDs.

The current orientation of our health system is towards acute infectious diseases. Because of this, the anthropology of well-being is that: When you feel the symptoms (the fever, joint pains, etc) then you know you are sick. Unfortunately, cardiovascular diseases and indeed other NCDs present in the reverse. 

For a very long time (an average of 15 years) you feel very well yet some of the most vital organs of your body are ill! Unlike the developed world where cardio-vascular diseases are among the poor, in the developing world it is a mixed picture. 

Therefore, people develop CVD during the years that they feel they are enjoying life the most: Dollars are coming in, pork, unbelievably comfortable gas guzzling SUVs, and p.o.w.e.r! Society loves them big (the adage 'big is beautiful'). Combined with the 'stress to keep up there', this makes an optimum recipe for hypertension and heart disease.

Museveni expounded further in his informative speech: 'That the deceased was found to have had evidence of 'multiple heart attacks' that occurred in the past (as seen from the post-mortem); that he was known to have 'mild hypertension' for many years; that he complained of 'dizziness and abdominal pain in Korea'. 

Many people with heart disease actually get multiple 'silent' heart attacks, some of them going off unnoticed as vague pains in the left upper abdomen (around where the stomach is located) - sometimes the pain 'radiates' to the jaw - because the diaphragm (the tough membrane that separates the chest from the abdomen and is key for breathing), the heart muscle and the top of the lungs are served by the same nerve - so the pain is vaguely 'referred' to other places which further confuses the picture. 

I do not have an immediate off-hand publication but one physician at Mulago, in a conversation we had, chatted about seeing a series of middle-aged men who come to his clinic complaining of 'ulcers' and when he examines their hearts, he finds they are having real-time 'silent' heart attacks. Some of them report to have been on 'ulcer' medication for months or years.

Museveni expounds further: 'I know he is up there and we are all moving there, but he still had a lot to do here'. In this statement, Museveni alludes to the concept of 'early death' and 'life years lost due to early death'. 

A heart attack in the 50s can cut off an average of 20 life years because as we know, life expectancy at 50 years is much higher than life expectancy at birth in Uganda. A person who hits 50 in Uganda expects to live up to 70 at the minimum, on the average. In one of my small studies, I saw diabetes peaking at 45-50 years in Eastern Uganda yet it peaks at 65-70 years in other studies done in developed countries.

Museveni then gives a prescription in form of an order (unfortunately he gave it only to his generals): 'You all should have periodic medical check-ups!' The key point here is that unlike acute conditions like malaria, by the time you develop a 'seemingly simple symptom like 'abdominal pain' as a result of CVD, you are already terribly terribly ill! With much of the damage irreversible!

Unlike acute diseases, for chronic conditions, the signs (the things that health workers can detect) often precede the symptoms (what the patient complains of). So in order to detect the CVD early, you need a check up - at least every 5 years from when you are 40. And of course he talked about 'officers and their body-weight' and the diminishing levels of physical activity with rank. Then Museveni castigated the Medical Officers for writing 'jargon' that cannot be understood by the non-medical person.

The big butt has no problem as such. The problem is a big abdomen. The fats on the bum are relatively healthy - they are meant as a reserve to handle shocks like illness - it is those on the abdomen. Unfortunately, the two tend to go hand in hand but not always. If you can maintain a healthy 'waist-hip ratio' that is a smaller waist than your hip, it is fine. (But the waist in this case should be measured through the umbilicus, not the groin)

Museveni's speech and indeed the alter-ego speech by Linda Aronda are a gold mine for lifestyle education against the budding problem of chronic diseases in Uganda. They should be scrutinized for decades as our dual burden of disease unfolds. 

Because recent surveys show that as many as 20% of Ugandans have high blood pressure - and this is for all ages - when we zoom in on older age-groups, by age 40, at least one third of Ugandans have high blood pressure. Unfortunately the journalists picked the statement 'am annoyed' and will keep spinning this over and over without bringing out the real message of NCDs on the table.

RIP to the 'gentle giant'! General Aronda Nyakairima.
Adopted from the Uganda at Heart (UAH) Community and Edited 

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