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Strategic Responses to CRD in Africa CHRONIC RESPIRATORY DISEASES (CRD) IN AFRICA Identifying social determinants and formulating appropriate, strategic responses Executive Summary, English

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Executive Summary of the Strategy Paper
Ku, Campos da Silveira, Kegels. Strategic Responses to CRD in Africa
Identifying social determinants and formulating
appropriate, strategic responses
With contributions from:
Patrick Develtere
Benoit Nemery
Bruno Marchal
Jean-Paul Doussou
Paul Bossyns
Karel Gyselinck
Correspondence to: GMKu at
Ku, Campos da Silveira, Kegels. Strategic Responses to CRD in Africa Executive Summary
Chronic respiratory diseases (CRD in this note restricted to bronchial asthma and chronic obstructive
pulmonary disease or COPD), the entry point to the subject of this note, are an underestimated and
largely neglected problem in Sub-Saharan Africa. Underestimated because frequency and severity are
much higher than commonly intuited: several prevalence surveys on asthma yield figures of 4-14%,
tending to be higher in urban environments, and for COPD results range from 4 to 25%, with the higher
figures in rural areas and higher age groups. Neglected because in most countries of interest (the 11
Belgian Cooperation partner countries in SSA
) effective care for people suffering from CRD is mostly
absent or highly defective. Especially frontline health services are devoid of knowledge and tools to
assist people suffering from CRD.
The avoidable (non-genetic) fraction of the CRD burden can be attributed to several physical, chemical,
social, cultural, demographic and biological determinants, in different causal layers and interconnected
between them. Most visible among these is poor and worsening air quality, in its turn driven by socio-
demographic phenomena leading to accelerating rural-to-urban migration and mobility needs, by
industrial and agricultural pollution, fossil fuel driven transport, inadequate waste management,
polluting electric power generation, but also, to a surprisingly high degree, composed of indoor air
pollution caused by inefficient burning technologies of unclean fuels (fossil and biomass), mainly for
cooking, and by tobacco smoke, combined with insufficient ventilation. While urban environmental air
pollution appears to contribute to increasing incidence and exacerbations of bronchial asthma attacks,
indoor air pollution is the main culprit of high rates of COPD in rural areas, affecting mainly women
and young children, causing lung damage and negatively affecting normal lung development from the
foetal stage and onwards.
Mauritania, Senegal, Burkina Faso, Benin, Niger, Guinea, Democratic Republic of Congo, Rwanda, Burundi, Uganda,
Mozambique. In the World Bank classification these are Low Income Countries, except Mauritania, Benin and Senegal, which
are classified as Lower Middle Income.
Inefficient burning technologies
for cooking & home heating
Fossil fuels
air pollution
Ku, Campos da Silveira, Kegels. Strategic Responses to CRD in Africa Executive Summary
Air pollution, indoors as well as outdoors, does not only contribute to induce and exacerbate CRD; it is
also a major determinant of infectious respiratory disease (including pulmonary tuberculosis), cardio-
vascular disease and (lung) cancer. As such it is a background cause of multiple communicable and
especially non-communicable diseases NCDs), the relative importance of which is now increasingly
being recognised.
Polluted air shortens lives and makes many lives more miserable than they ought to be. In this respect,
insalubrious air is in the same class as insalubrious water, defective sanitation and child undernutrition.
And it may come as a surprise to many, but Sub-Saharan Africa’s air is among the most polluted of all
Given the multitude of elements influencing the quality of air people breathe, it is not unexpected that
air quality can be directly linked to a surprisingly great number of the Sustainable Development Goals
(SDGs): SDGs 3, 5, 7, 8, 11, 12 and 13 are all involved, directly or indirectly
. Given this extraordinarily
broad field of application, one of the main challenges for action on improvement of air quality will have
to consist in the formation of a widely shared and coherent discourse, centred on (1) a common
understanding of public goods (ideally leading to the notion of ‘the right to clean air’), (2) a forward-
looking vision based on a correct historical understanding of the present situation (‘where are we now
and how did we come to this?’) and (3) a vision of development that is adapted to present-day global,
national and local challenges (‘what should be the way forward, given what we now know, in this day
and age?’).
A second consequence of the multitude of influencing elements is that, in the search for solutions, there
will be no one size to fit all local situations. Although certain ‘blanket’ measures, to be applied across
SDG 3 (healthy lives and well-being), in the fields of NCDs, tobacco use and availability of relevant essential medicines; SDG 5
(gender equality) pertaining to women’s contribution to household chores including the fetching of biomass fuels for cooking
and the cooking itself; SDG 7 (affordable and sustainable energy for all), focusing on clean fuels and technology; SDG 8
(decent work for all), focusing on secure working environments; SDG 11 (safe, resilient and sustainable cities, including solid
waste management and control of fine particulate matter levels in cities); SDG 12 & 13 (sustainable consumption/production
and combating climate change), pertaining to greenhouse gas emissions and sustainable forest management.
(incl. TB)
Ku, Campos da Silveira, Kegels. Strategic Responses to CRD in Africa Executive Summary
the board, do exist (e.g., in the areas of tobacco control, cleaner fuels, fiscal measures encouraging
reduction of fossil fuels use, …), the most adequate sets of measures at local level will have to be
informed by intelligent situation assessments. This will have to include, at least, needs assessment
(technically defined); technology assessment (presently available vs. desirable technology); demand
assessment (socially defined) and stakeholder assessment (power and influence differentials, who
stands to gain, who stands to lose).
Regarding stakeholder assessment, a first attempt to map actors and organisations showing awareness
of the problem and willingness to do something about it (in Africa) yields a somewhat surprisingly high
number of ‘alliances’ at global and international level, many of them having some offshoots at national
level (in Africa), though mostly in a dispersed manner and not (yet) leading to much action on the
ground. To these can be added practical local initiatives, often by (inter)national NGOs, mostly
introducing technological solutions like improved cooking stoves and more efficient fuels, with variable
levels of success
Activating this potential will need an effort at coalition building at local, national and international
level, aiming at synergy and complementarity through coordination ideally in a consultative and
participatory manner.
Minimal and feasible actionable points beside the already mentioned coalition building and
formation of a coherent narrative (preferably making optimal use of the SDG agenda) include the
- Closing the existing gap for CRD care by integrating a basic effective CRD care package at
frontline and referral level in the healthcare system: responding to unmet demand;
- Ensuring clean air in all environments through (1) improvement of energy efficiency; (2)
facilitation/encouragement of clean fuel use; (3) introduction and/or enforcement of secure
working conditions where needed;
- Tobacco control through strengthened implementation of WHO’s Framework Convention of
Tobacco Control (FTCT);
- Initiating and strengthening of community and patient engagement for adequate
attitudes and action.
In the spirit of this note it would not suffice to formulate a ‘shopping list’ of potential actions without
providing shared guiding principles on which to base the selection and implementation of such
Although top-down blanket measures have their place in all this, it is strongly suggested to act on the
basis of the following principle:
The more local the action to be undertaken, the more it should be based on specific local needs and
demand assessment, ideally starting from existing but unmet demand. The postulated mechanism
justifying this principle is that meeting unmet demand combined with the provision of adequate and
credible information is more likely to create the necessary trust and confidence to go in search of
upstream determinants, leading to the necessary preventive action. As the domain of prevention almost
invariably involves difficult choices and behaviour changes, motivation is of the utmost importance.
A second principle, partly following from the previous one, is that a seemingly a priori low likelihood
of immediate success is no reason for abandoning all action. Some goals take longer to achieve, but
progress can be achieved in stages: ‘signalling’ the problem can be a necessary first step, putting it on
the agenda and keeping it there, a second, and pushing the issue forward through constant monitoring
can be necessary. It is good to keep in mind that the issues of chronic respiratory disease and air quality
are far-ranging, touching upon numerous aspects of life and society. The problem is likely to be messy
and complex and will require flexible attitudes and close follow-up in order to adjust to ever-changing
A list of actors and organisations so far identified can be found in annex to the present note.
Ku, Campos da Silveira, Kegels. Strategic Responses to CRD in Africa Executive Summary
Finally, it would seem obvious that, in all this, the healthcare sector is well-placed to take the lead
and, moreover, has to shoulder the responsibility to lead by example. The challenge appears to be
urgent. Circumstances on the African continent are such that at present air quality is already among the
worst on the planet, and further deterioration and its consequences is inevitable if adequate action
is not undertaken. Clearly, henceforth this issue deserves to be a constant concern for international
cooperation agencies like Enabel in dealing with Belgium’s African partner countries.
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