Poverty, gaps in asthma care affect asthma management – ACUF

Etim Ekpimah

The Amaka Chiwuike-Uba Foundation (ACUF) has decried poor management of asthma in Nigeria, calling on the Federal Government and concerned authorities for urgent intervention.

World Asthma Day (WAD) is commemorated on the first Tuesday of May every year to raise awareness of asthma around the world, while the theme for the 2022 World Asthma Day is ‘Closing the Gaps in Asthma Care’.

A statement by the Board Chairman of Amaka Chiwuike-Uba Foundation (ACUF), Dr Chiwuike Uba, in Enugu on Sunday, May 1, 2022, noted that there is a critical gap in the public, and health professional’s awareness, and understanding of asthma, “which are reflected in some of the policies currently in place in Nigeria”.

Uba, who lamented gas flaring in Nigeria, said that 97% of Nigeria’s population is not covered by any kind of health insurance, while out of pocket expenses account for 77% of total health spending in Nigeria, adding that, “due to increasing poverty and the lack of access and affordability of asthma medications in Nigeria, the level of asthma control in Nigeria is poor, resulting to the high burden of asthma symptoms, limitation in activities and mortality”.

He said: “Asthma is a long term, non-curable, non-communicable disease that affects people around the world and across all age groups, genders, and ethnicities. Currently, more than 15 million Nigerians with about 5-10% of children in any given community suffer from asthma. This number is set to increase to over 100 million by 2025. Globally, asthma is one of the world’s most common long-term conditions and currently affects over 339 million people worldwide. As the 14th most important disorder in terms of global years lived with a disability, an additional 100 million people are expected to be affected by the disease by 2025”.

“Management strategies are designed to control the disease to prevent asthma attacks, also referred to as episodes or exacerbations and to reduce associated morbidity and mortality. Management strategies, therefore, require addressing gaps in asthma care and the deployment of interventions to reduce avoidable pain and costs incurred in treating uncontrolled asthma.

“According to the Global Initiative for Asthma (GINA), existing gaps include unequal access to diagnosis and treatment (medicine), particularly between care for different socioeconomic, ethnic and age groups.

“In addition, gaps exist in communication and care between primary/secondary/tertiary care, education for people with asthma and health care providers, among others. Additionally, there is a critical gap between the general public (non-asthmatic) and the health professionals awareness and understanding that asthma is a chronic (non-acute) disease.

“The above gaps are reflected in some of the policies currently in place in Nigeria. According to the World Health Organisation (WHO), air pollution causes over 12 million deaths annually.

“Deaths from non-communicable diseases such as asthma, strokes, heart disease, cancer and other respiratory diseases represent about 8.2 million or nearly two-thirds of the deaths resulting from unhealthy environments.

“By reducing levels of atmospheric pollution, Nigeria can reduce the burden of the disease caused by asthma. Therefore, the overall framework for managing asthma requires considerable attention to environmental exposures (indoor and outdoor) and control practices.

“Specifically, nitrogen oxides and hydrocarbons from fossil fuel combustion from vehicular traffic and second-hand smoke from automobile exhaust are associated with an increase in asthma symptoms.

“Moreover, sulphur dioxide (SO2) mainly formed by the combustion of coal or petroleum with high sulphur content has been allowed to continue in Nigeria for so long. One good example is continuous gas flaring in Nigeria.

“It is worrisome that currently, there is no well-articulated and followed-through government policy to reduce the level of pollution in Nigeria, even when Nigeria was rated as the most polluted country in the world as of 2015.”

He added: “According to the study conducted by the Amaka Chiwuike-Uba Foundation (ACUF) in 2017, the availability of medications for the treatment of asthma in Nigeria is limited.

“This finding is further supported by recent research led by Dr Obianuju Ozo, a pulmonologist.  These results show that none of the medicines which constitute the mainstay treatment of asthma is available in Nigeria. The two most available drugs are not on the WHO Essential Medicines List (EML) or part of the basic treatment recommended in the guidelines.

“Furthermore, the highest availability for any drug containing ICS, the mainstay treatment for asthma, accounted for only 47% of total asthma medicines in Nigeria. Unfortunately, 75% of those drugs are sold in privately owned pharmacies.

“The deep shortage of guidelines – recommended drugs in public pharmacies is worrying because most asthma patients in Nigeria seek care in public hospitals. In addition, the drugs available are those with multiple adverse side effects such as hypertension, diabetes, tremors and cardiac arrhythmias. These medications can also contribute to recurrent exacerbations and the risk of asthma mortality.

“These drugs are included in the WHO EML for the treatment of allergies and only indicated for the short-term treatment of asthma exacerbations or for patients with very severe asthma.

“Unfortunately, these oral formulations are on the Nigerian EML, which is clearly out of tune with the current WHO recommendations. A significant number of patients are still suffering from respiratory diseases, while a significant number still die from asthma in Nigeria largely as a result of these gaps. For example, it is estimated that 75 per cent of asthma hospitalizations and 90 per cent of asthma-related deaths are preventable.

“Unfortunately, none of the WHO EML medications for asthma treatment or those that constitute the mainstay of treatment are affordable in Nigeria. The most frequently found affordable medicines in any formulation are oral corticosteroids, oral salbutamol, salbutamol inhaler, oral prednisolone and oral theophylline-containing tablets.

“The reasons for the high availability of oral salbutamol and other non-guideline recommended treatments for asthma in Nigeria may be related to poverty. Ignorance and non-application of guideline-based care among doctors who continue to prescribe these medications are other factors.”

Furthermore, he said: “97% of Nigeria’s population is not covered by any kind of health insurance, while out of pocket expenses account for 77% of total health spending in Nigeria. This is on top of the level of poverty, which is alarming with over 50% of the population living in poverty. Due to the lack of access and affordability of asthma medications in Nigeria, the level of asthma control in Nigeria is poor, resulting in the high burden of asthma symptoms, limitation in activities and mortality.

“A further gap in asthma care in Nigeria is the insufficient number of licensed respiratory physicians to manage asthma patients. In 2015, the estimated proportion of licensed respiratory physicians in the national population was 1 per 2.3 million individuals.

“In addition to other infrastructure issues, 13 states with an estimated combined population of 57.7 million have no specialized respiratory services. Access to credible data is cause for concern. At present, it is difficult to obtain information about the number of respiratory physicians/pulmonologists in Nigeria.

“Although physicians in Nigeria appear to have good knowledge of asthma, there are practice gaps in the management of asthma compared with standard guidelines. A high standard of knowledge does not seem to directly imply high-quality practice.

“This suggests that part of the reason for the increase in mortality and morbidity is the poor diagnosis and poor governance and environmental management. This requires continuous training and retraining of physicians to keep them informed and up to date with international guidelines.

“Furthermore, it is urgent that the Federal Ministry of Health approves and publishes national guidelines on asthma management and also adopts international guidelines for local practice. This will assist in improving the quality of asthma care in Nigeria.

“To close the gap in asthma care in Nigeria, stakeholders must first recognize asthma as a public health priority. Second, this recognition should be followed by a political commitment to ensure adequate funding and multi-sectoral intervention through the development of partnerships and the use of multiple approaches. Government policy should encourage and improve local production of asthma medications, provide subsidies and rebates for purchase, and expand universal health coverage (UHC).

“In addition, the subsidy should be extended to ensure that physicians are adequately trained and central access to affordable WHO recommended medications for asthma treatment enhanced.

“Asthma, therefore, should be among the top priorities of Ministries of Health, development partners and CSOs when assessing health priorities, allocating resources, and evaluating the potential costs and benefits of public health interventions.”