Blog entry by Arif Khwaja

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by Arif Khwaja - Sunday, 14 July 2013, 9:20 PM
Anyone in the world

There is a fascinating editorial on the 'Equity and Economics of Kidney Disease in Sub-Saharan Africa'  by Luyckx and colleagues in this weeks Lancet, as part of their series focussing on kidney disease. The statistics bearing out the human/financial cost of ESRD are horrendous.

Data is presented from Nigeria reporting a median survival of 2 weeks in 760 patients presenting with ESRD with only 6·8% able to continue for more than 12 weeks - invariably bankrupting their families in the process. PD and transplantation are not widely available and again the cost of the fluids seem to preclude the widespread use of PD whilst the infrastructure required to build a transplant program is not there in most countries. 
The authors highlight a number of key issues:
i) the scale of the problem of CKD and ESRD is simply unknown in most Subsaharan countries making service planning almost impossible
ii) the need to identify and treat kidney disease early in those at high risk of kidney disease - in part this will involve a strategy dealing with non-communicable diseases such as diabetes and hypertension. These can be delivered cheaply by trained healthworkers rather than more expensive doctors as was shown in Iran.
iii) finally the authors call for a strategy to treat those who develop ESRD - the need to develop an infrastructure for transplantation and the need for dialysis. This of courses raises important questions of equity - is it worth funding RRT in such resource-poor environments when the cost in countries such as  Malawi, is almost 1000 times the national per-head health expenditure and 65 times the gross national income per head.
There are a few other points that aren't discussed that are perhaps also worth considering:
i) even within Sub-saharan Africa that are significant variations in care that can't be explained by money. For example the GNP per capita for Nigeria and Sudan are broadly similar and less than $2000. Yet Sudan has been able to provide RRT for its population - this must reflect political decision making and prioritisation.. I was fortunate to hear Professor Abu Aisha ( nephrologist and ex minister of health in Sudan) give an inspirational talk a few months ago about how nephrology (and healthcare in general) were transformed in a low-resource setting when the political will is there.
ii) clearly prevention is the key -managing non-communicable disease, improving obstetric care and infectious disease management, preventing and treating HIV will all impact on the numbers with ESRD. i.e. its essential that resources arent nephro-centric but rather focussed on key public health areas which in turn feed the ESRD epidemic. And of course spending money on eduction, sanitation  and clean water supply will all positively impact in public health in general as well as ESRD and CKD numbers
iii) whichever way you look at the problem you cant divorce it from politics and economics. The Nobel Prize winning economist Joseph Stigilitz has highlighted Mauritius as an example of country whose healthcare system has been transformed as a result of political decisions. Public health policy is de facto political and clinicians shouldn't shy away from getting involved in controversial political debates.
iv) there has to be an onus on industry and academia to come up with cheap, technological solutions for RRT. Cheap fluid for PD, aggressive transplantation, a cost effective model for dialysis are all areas of urgent research.
v) Like myself both the first and senior author of this paper are not primarily based in Africa  ( the middle author is Prof Naicker, a nephrologist from South Africa) but in a high-income western economy. This in itself is a problem. Journals such as the Lancet should perhaps try to provide a platform for African clinicians to come up with local solutions  and models of care. I hope some of the OLA readers working in Sub-Saharan Africa will educate me on what needs to be done......
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