In the afternoons, as people take a rest after doing their chores and working in the fields, Lydia Kabokondo starts knocking on doors. Her rounds take in people who have diseases that can easily go undiagnosed and untreated.
In rural Malawi, where a hospital or clinic is usually far away, illnesses – even serious non-communicable diseases (NCD) such as cancer and diabetes or sickle cell anaemia – are often just something that people live with, or die from, with little medical intervention.
Kabokondo describes herself as a bridge between the 20 households on her patch and health facilities far from their homes and villages.
Making sure that patients were taking their medications was a key part of the HIV programme that helped Neno district, in the south-west of Malawi, achieve the highest rates of patient survival, and maintaining their care, in the country.
Now the successful HIV outreach programme is being used as a model to improve treatment for the new major diseases on the block: diabetes, hypertension, cancer.
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A common condition
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The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
‘A common condition’ is a Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
“Some of these patients were close to losing their lives but through the information I shared with them we were able to visit the hospital and get the help they needed,” says Kabokondo. “It is such a great feeling to know that I’m playing a role in making a difference in people’s lives.”
There are about 1,200 community health workers employed through the integrated chronic-care model in Neno. They connect patients to 12 health facilities and two hospitals, and screen for both HIV and NCDs.
Getting advice from health workers at home reduces how many times people have to make often arduous and expensive journeys.
Dr Emily Wroe, who was for several years chief medical officer in Malawi for the charity Partners in Health (PIH), which supports the scheme, says the impetus for integrating HIV and NCD care came from staff on the ground, who first saw the need for such an initiative.
“This health system had figured out how to support people with chronic diseases – find them, keep them, ensure they stuck to their treatment,” she says. “We had already built a chronic-care system, so why not expand that to other conditions?”
The pilot project in Neno has reached 5,500 NCD patients in the area and proved highly cost-effective. While $2.1m (£1.6m) a year had been spent on reaching HIV patients, only $300,000 was needed for the integrated care of HIV and NCDs, according to research by Wroe. Annual costs for each patient were reduced from $327 to $260 as more and more people were reached.
Wroe says that while HIV has been well funded, there has been less concern about NCDs in developing countries and so combining care for these diseases has been an efficient way of tackling the problem without having to build an entirely new system.
“We think people with type 1 diabetes were just dying at home without being diagnosed,” she says. “But afterwards we saw thousands of patients going from having no care to having care. Most of them were just living with an NCD or didn’t have medication. There was honestly no option before.”
Neno has also been used to pilot the Pen-Plus programme, which was designed by the WHO to treat severe NCDs. Two new clinics were established after community workers identified patients who could not be treated through existing facilities.
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Dr Chiyembekezo Kachimanga, PIH’s current chief medical officer in Malawi, says that Neno district has gone from offering very limited NCD care to treating 5,500 NCD patients and 8,500 HIV patients at an integrated clinic.
The success has led to PIH supporting the government in setting up clinics in 28 districts across the country and training 1,600 health workers to identify and treat NCDs. They now treat 100,000 people across the country for NCDs.
“I know people who would not have accessed the care; their quality of life would have been lower. They would not have been diagnosed and that means people die,” says Kachimanga.
“If patients are diagnosed earlier that can improve their quality of life and for some you can prevent unnecessary death.”
Noel Gomani, 24, has type 1 diabetes. She spent a month feeling dizzy and constantly needing the toilet.
“I had a friend who fell ill at the time, back in 2019, in my community. When this friend was sick, he was visited by one of the community health workers and he asked them to also check up on me,” says Gomani, who was referred to a hospital for diagnosis and help to manage her condition.
“Now I’m very healthy and happy. Using the information that I obtain from these programmes, I’m very informed and I even get constant reminders on my medications.”
It takes time to earn trust but Kabokondo believes the work is making a difference. “We have cases of people coming to us just to thank us for saving their lives, and some even reminding us when they see that we have not visited them for some time,” she says.