Saturday, December 12, 2009

Throwing Coke Bottles at BRICS

When you work in the global health field long enough, specifically when you work with groups that advocate for increased “resources” (dollar dollar bills) for R&D (research and development) for new products (drugs, vaccines, and diagnostics) targeting “diseases of the developing world” (mostly HIV, Tuberculosis, and malaria) long enough, and you attend enough meetings and conferences around Washington, DC to last a lifetime, you will undoubtedly hear about the Coca Cola Syndrome. The Coca Cola Syndrome, when discussed in this context, refers to the fact that the Coca Cola Company has MUCH better supply chain management than pretty much any resource-poor country’s health system this world over. What this means is that you can go to the most remote, rural villages in the world and find people drinking Coke, but we are utterly unable to get the health care products most needed by those same people into their hands. This subject is almost always broached by someone opposed to giving the R&D folks more money: someone who then advocates that the money would be better spent strengthening the supply chain on the ground and enabling the products that we already have to reach the people who need them. If the naysayer feels exceptionally clever, he/she might even tell another little anecdote about warehouses full of medicines and vaccines that have wasted away and become useless over months and even years of neglect: more victims of the African or Asian or Latin American sun. But this entry is not intended to weigh the merits of the new products vs. supply chain debate; the truth is that both things are greatly needed. No, I would like to get back to the ever-present Coke.

one of thousands of roadside shops always stocked with Coca Cola

Many of you have asked me what the food is like. I have detailed a few dishes in previous entries, but if I had to describe Ghanaian food in one word, it would be “unhealthy.” For breakfast every morning we have what’s called “Hausa Cocoa”. It’s a delicious porridge-like drink made from ground millet and spices originally from Nigeria, which has now become engrained in Ghanaian culture as well; but that’s not what is unhealthy. It is served with fist-sized fried doughnut balls and other smaller fried morsels made from chickpeas. Dennis reminds me that the chickpea ones do have nutritional value, and I remind him that they are also fried and oily enough to lube his car. Lunch is usually something small like soup with rice balls or one of the many corn-based dough balls native to Ghana. The two main soups are a peanut-based one and a palm oil-based one. Both are very tasty, but I constantly remember Dennis, as we ate palm oil soup on my very first day in Ghana, telling me “Delicious…but VERY high in cholesterol.” Also, the vast majority of carbs I have encountered so far are the bad ones: white rice and white bread predominate healthier alternatives. The favored proteins for dinner are fish and goat meat. These are not too bad, but the fish is usually fried. Healthier bean-based dishes can be found if you do some searching, but it’s much more common to find fried fish and fried plantains. A late-night snack, which I have fallen prey to many times, is the plantain chips. Very similar to potato chips, they are made from plantains, a banana-like fruit, and the chips are sweet, salty, crispy and delicious…but definitely not good for you. So, what does all this mean?

fried doughnut balls and chickpea patties: breakfast of champions

In my first week, we visited a woman from Dennis’ church whose husband had just passed away from heart disease. In a country where the male life expectancy is under 60, he was under 50. When we pulled up to the house, she, along with several family members and friends, was sitting on the porch in all black observing what I took to be the Ghanaian version of what the Jews call Sitting Shiva: a week-long mourning ritual. Except that the Ghanaian version, I would learn, can last anywhere from one week to several months, depending on circumstances, and we would visit this woman 3 more times over the next week or so. I also learned that the man had well-documented high blood pressure and had been given medication for it from his doctor: medication he did not take. Dennis said that this is very common with hypertension medication in Ghana. It’s not that people are leery of or don’t understand Western medicine, but it is cultural. He explained that the symptoms are not overt, and because they cannot be felt on a daily basis, people just don’t take the pills. In my first 3 weeks, Dennis attended these observances for 2 other people as well, both of whom died from different chronic conditions (stroke and diabetes).

My Ghanaian experience is a microcosm of current global trends in disease burden shifting away from infectious diseases and towards chronic ones. And nowhere is this happening faster than in low and middle-income developing countries all over the world, where over 80% of the world’s population resides. As economies develop and individuals become better off financially, this expanding middle class is able to use the extra disposable income on red meat, cigarettes and sugary drinks. Add onto that the simultaneous demographic trend of rapid urbanization, where the masses moving from rural areas into cities find both everything they need in a smaller radius and the need to walk around and exercise less necessary. In fact, chronic disease experts agree that diet, along with tobacco use and lack of exercise are the three main factors driving this global trend.

sign at a hospital I recently visited

In 2003, employees at Goldman Sachs came up with a clever acronym for the largest, fastest-growing, developing economies in the world: BRICs. BRICs stands for Brazil, Russia, India and China (sometimes the S can represent South Africa), and together, they will completely redistribute the world’s power and financial balance sheet in the foreseeable future. They are also leading the pack for the changing disease burden. While Wall Street and the rest of the private sector is busy setting up offices in Durban, Bangalore and Sao Paulo, angling for this emerging middle class to provide their future revenues, the citizens of these countries are acutely experiencing some of the less-desired effects of this “development.” In 2000, none of these countries ranked in the top 5 global economies, in terms of GDP. By 2050, all 4 BRIC countries are projected to be in the top 6. In Russia, wages TRIPLED from 2001 to 2006. Income is projected to TRIPLE in India from 2005 to 2025.

But these huge economic gains are not being translated into reciprocal health benefits. From 2005 to 2030, life expectancy is only projected to increase, on average, by less than 5 years in BRIC countries (about 2-3 months per year). According to the WHO, three of the top 4 causes of death worldwide – cardiovascular disease (CVD), cancer and chronic respiratory diseases – are associated with chronic conditions. These three, together with diabetes, accounted for 60% of worldwide deaths in 2005, with more than three quarters of them occurring in developing countries. From 2005 to 2030, India, Latin America and Sub-Saharan Africa are projected to experience double digit increases in CVD burden. Over the same time span, the BRIC countries may experience a 3.29% compound annual growth rate in diabetes incidence. Similar projections can be found for cancer, respiratory disease and other chronic conditions, and this entry could go on and on.

Concession stand filled with doughnuts, meat pies and other deep fried things in the lobby of the SAME HOSPITAL

My former boss at the Center for Global Development, Rachel Nugent, is a population economist and an expert in this topic, so I was fortunate enough to be somewhat prepared. However, as I am finding out over and over again, it is a completely different animal when you experience it first-hand. Going to the mourning observance for someone who died from a very preventable and treatable condition is one thing. Consciously trying to exercise and eat healthy foods and finding it very difficult to do either is another. But Americans can rest assured that while we continue to lead the world in obesity, thousands more decide to join our ranks every day. I’ll keep fighting the good fight, but in the meantime, our fridge is never without Coke, and the plantain chips are delicious.
close-up of some plantain chips

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