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Management of chronic respiratory and allergic diseases in developing

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Allergy 2003: 58: 265–283
Printed in UK. All rights reserved
Allergy Review Series VIII: Allergy: a global problem
Management of chronic respiratory and allergic diseases
in developing countries. Focus on sub-Saharan Africa
‘‘Chronic respiratory diseases (CRD) which include
asthma and chronic obstructive pulmonary diseases
(COPD) comprise a major cause of death and disability
for all age groups and regions in the world. In the absence
of effective interventions, risk factors such as smoking, air
pollution, allergen exposure, severe childhood respiratory
infection and TB are expected to cause a further rise in
the magnitude of these health problems in the coming
Abbreviations. ARIA: Allergic Rhinitis and its Impact on Asthma;
BTS: British Thoracic Society; CD: communicable disease; COPD:
chronic obstructive pulmonary diseases; CRD: chronic respiratory
diseases; DALE: disability-adjusted life expectancy; DALYs:
disability-adjusted life years; DFLE: disability-free life expectancy;
GBD: global burden of disease; GINA: Global Initiative for
Asthma; GOLD: Global Initiative for Obstructive Lung Diseases;
ISAAC: International Study on Asthma and Allergy in Childhood;
IUATLD: International Union Against Tuberculosis and Lung
Diseases; NCD: non-communicable disease; QALYs: quality-
adjusted life years; QOL: quality-of-life; SORDSA: Surveillance of
Work-related and Occupational Diseases in South Africa; TB:
tuberculosis; WHO: World Health Organization; WTO: World
Trade Organization; YLD: years lived with disability; YLL: years of
life lost.
Copyright
Blackwell Munksgaard 2003
ALLERGY
ISSN 0105-4538
J. Bousquet1,2, M. Ndiaye1,3,
N. At-Khaled4, I. Annesi-Maesano5,
A.-M. Vignola6
1
Service des Maladies Respiratoires and INSERM
U454, CHU Montpellier; 2Centre d'Allergologie,
Institut Pasteur, Paris, France; 3H$pital Fann, Dakar,
S'n'gal; 4Chief International Union Against
Tuberculosis and Lung Diseases (IUATLD) Asthma
Divisison, Paris; 5INSERM U472, Villejuif, France;
6
Department of Internal Medicine and Pneumology
and Istituto di Fisiopatologia Respiratoria, Palermo,
Italy
Prof. Jean Bousquet, MD, PhD
Centre d'Allergologie
Institut Pasteur
25–28 rue du Docteur Roux
75015 Paris
France
Accepted for publication 26 July 2002
years, particularly in developing countries. Evidence also
indicates that in many countries people with common
CRD have no access to acceptable standards of health care;
health systems may also provide inappropriate care due to
misdiagnosis arising from respiratory symptoms which
are often common for acute and chronic illnesses.’’ (1)
In low and middle-income countries, the capacity of
health professionals should be expanded to address CRD.
Sub-Saharan Africa appears to be an important region of
the world that could be used to assess how the CRD
program can be modeled and implemented.
In these countries, CRD (including allergic diseases)
represent only one type of major disease, and in many ins-
tances are not the main disease burden. Thus, it is import-
ant to propose an integrated management of disease that
covers communicable and noncommunicable diseases.
Needs for equity in health around the world
Equity in health and healthcare has become a priority for
developed and developing countries. If the efforts at
achieving equity are to have any basis in evidence
265
Bousquet et al.
concerning which strategies are likely to work, a research
agenda is necessary. An adequate research agenda needs
to (2):
1. assess the magnitude of the problem and the burden
of the disease;
2. understand the genesis and correlates of the problem;
3. propose methods to measure these correlates;
4. rigorously test alternative explanations and inter-
ventions.
Recognition of the need for integrated approaches has
re-emerged but the capacity to conduct appropriate
research in developing countries is weak and these
countries have relied on importing both researchers and
their methods. While qualitative methods are needed (and
used) in developing countries, their use will increase only
if appropriate training initiatives are undertaken (3).
The document entitled ‘‘Macroeconomics and Health:
Investing in Health for Economic Development’’ (WHO,
December 20, 2001; bookorder@who.int) highlights a
strong and clear message for the ‘‘central task of raising
the health of the poor’’. This commission was established
in order to assess the place of health and to promote
global economic development, especially for the world’s
poorest countries. Although this report is targeted at the
low-income countries where communicable diseases
(CDs) are the most important cause of death and
disability, it is also aimed at reducing the economic
burden of noncommunicable diseases (NCDs).
Reasons for the focus on sub-Saharan African countries
in the current document
A great diversity exists between developing countries.
Within a developing country there is a large heterogeneity
of the populations. Usually, a small number of inhabit-
ants have a (very) high income, a large part of the
population has a moderate-to-low income, and often the
largest proportion of the population is below the poverty
limit. These differences are increased by cultural and
social barriers. Healthcare systems should consider all of
these factors to implement a program and to achieve
equity in health.
Extremely large developing countries like China or
India, within which there is a great diversity, should be
studied separately and may even need subgrouping.
There are also clusters of countries with a similar
cultural, social and economic status, and similar health
problems. These countries may be studied more globally.
Sub-Saharan African countries represent a relatively
homogeneous group of developing countries with similar
health problems. Although there are significant differ-
ences in terms of their economic situations, cultures, and
health systems, as well as linguistic differences, they may
be grouped. Other groupings of countries may include
the Maghreb, some Spanish-speaking South American
266
countries, some Asian–Pacific areas, and the Caribbean
area. Such grouping has already been carried out
successfully when the GINA (Global Initiative for
Asthma) guidelines were applied to the Caribbean with
participants from English-, Spanish- and French-speak-
ing countries (4).
In sub-Saharan Africa, little information is available
concerning the prevalence, morbidity and mortality in-
curred by CRD, but the limited available data and clinical
practice suggest that chronic obstructive pulmonary dis-
eases (COPD) and asthma are important— at least in some
populations (5). Moreover, risk factors such as tobacco
smoking, air pollution, and respiratory infections are also
very common. Finally, asthma and COPD guidelines are
rarely (and sometimes not at all) implemented in most sub-
Saharan African countries except for South Africa (6, 7),
which is the wealthiest sub-Saharan country and can be
classified in the middle-income country group.
Global burden of disease
Disability-adjusted life years and related outcomes
Information on nonfatal health outcomes of disease and
injury has been largely neglected in health planning
because of the conceptual and definitional complexity of
measuring morbidity and disability in populations. Dis-
ability adjusted life years (DALYs) have been launched
by the World Bank and backed by the WHO as a measure
of the global burden on disease (GBD) combining
morbidity and mortality (8). Just like quality adjusted
life years (QALYs) (9), DALYs combine information
about morbidity and mortality in numbers of healthy
years lost. The calculation of disease-specific health loss
in DALYs is the sum of years of life lost (YLLs) and
years lived with disability (YLDs) weighted for severity.
In the DALYs approach, each state of health is assigned a
disability weighting by an expert panel on a scale from 0
(perfect health) to 1 (death). To calculate the burden of a
certain disease, the disability weighting is multiplied by
the number of years lived in that health state and is added
to the number of years lost due to that disease. Future
burdens are discounted at a rate of 3% per year, and the
value of the lifetime is weighted so that years of life in
childhood and old age are counted less.
New formulae for measuring DALYs have been
proposed (10) and have found that the global burden of
diseases and injuries as previously reported in the GBD
study (11) may therefore be underestimated. The differ-
ence is greatest for diseases of short duration (e.g.
infectious diseases). Although the approach is of interest,
there are several criticisms (12, 13) (Table 1).
Regional patterns of disability-free life expectancy
(DFLE) and disability-adjusted life expectancy (DALE)
were examined by the GBD study (11). Published and
unpublished data were systematically reviewed to esti-
mate the incidence, prevalence and duration of 483

Table 1. Criticisms of the DALY (disability-adjusted life years) studies
The DALY approach explicitly presupposes that the lives of disabled people have
less value than lives of people with disabilities.
The method assumes that disabled people are less entitled to healthcare resources
for interventions that would extend their lives.
These assumptions may be in contrast with basic principles of the World Health
Organization (12).
DALYs have been used as an outcome indicator in microeconomic evaluations as
well as sectoral prioritization exercises using league tables of cost-effectiveness.
However, many of the current analyses are not comparable or transferable
because either the assumptions used differ or are unclear, and because results
are not presented in a way that allows researchers or policy-makers to
recalculate and reinterpret findings for use in an alternative context (170).
There are different ways of measuring DALYs (171). Incidence-based DALYs are
appropriate where the means of reducing the burden of disease is by prevention;
prevalence-based DALYs are appropriate when a disease cannot be prevented
but effective treatment is available.
disabling sequelae of 107 diseases and injuries. Prevalence
of most disability classes is highest in sub-Saharan Africa
and lowest in established market economies. Low-severity
disabilities (class I and class II) are the most common.
The expectation at birth of class I disability ranges from
6.5 years in established market economies to 14.7 years in
sub-Saharan Africa, and for class II disabilities, from 8.5
to 18.4 years. DFLE varies significantly among regions:
DFLE for class I disabilities at birth ranges from
9.9 years in sub-Saharan Africa to 47.7 years in estab-
lished market economies for women and DFLE for
class V disabilities ranges from 43.4 years for men in sub-
Saharan Africa to 74.8 years for women in established
market economies. In high-income regions, nearly 90% of
expected disability is due to NCDs and most of the
remainder to injuries. In poorer regions, almost half of
expected disability is due to CDs and injuries.
Mortality
Reliable information on causes of death is essential to the
development of national and international health policies
for the prevention and control of disease and injury.
Medically certified information is available for less than
30% of the estimated 50.5 million deaths that occur each
year worldwide. However, other data sources can be used
to develop cause-of-death estimates for populations. To
be useful, estimates must be internally consistent, plaus-
ible, and reflect epidemiological characteristics suggested
by community-level data.
The GBD study used various data sources and made
corrections for the miscoding of important diseases (e.g.
ischaemic heart disease) in order to estimate worldwide
and regional cause-of-death patterns in 1990 for 14
age–sex groups in eight regions, for 107 causes (14).
Ninety-eight percent of all deaths in children younger
than 15 years are in the developing world; 83% and 59%
of deaths at 15–59 and 70 years, respectively, are in the
developing world. The probability of death between birth
CRD and allergy in sub-Saharan Africa
and 15 years ranges from 22.0% in sub-Saharan Africa to
1.1% in the established market economies. Probabilities
of death between 15 and 60 years range from 7.2% for
women in established market economies to 39.1% for
men in sub-Saharan Africa. The probability of a man or
woman dying from noncommunicable diseases is higher
in sub-Saharan Africa and other developing regions than
in established market economies. The leading causes of
death in 1990 were ischaemic heart disease (6.3 million
deaths), cerebrovascular accidents (4.4 million), lower
respiratory infections (4.3 million), diarrhoeal diseases
(2.9 million), perinatal disorders (2.4 million), COPD
(2.2 million), tuberculosis (2.0 million), measles (1.1 mil-
lion), road-traffic accidents (1.0 million), and lung cancer
(0.9 million). In 1990, noncommunicable diseases were
therefore already major public health challenges in all
regions.
Information on cause of death among adults in sub-
Saharan Africa is essentially nonexistent (15) because
death certificates are not issued for most people. Scarce
published sources provide statistics on both cause-specific
and overall rates of mortality, but closer examination
reveals that these data consist mostly of extrapolations
and outright guesses (16). Noncommunicable diseases
account for a significant portion of adult deaths in sub-
Saharan Africa, yet the empiric bases for public health
policies and interventions are essentially absent. Meas-
urement of the local burden of disease in sub-Saharan
Africa may be done using years of life lost (YLL) (17).
Morbidity and mortality incurred by respiratory diseases
in sub-Saharan Africa
Chronic respiratory diseases impose an enormous burden
on the Society. According to the WHO World Health
Report 2000, the top five respiratory diseases account for
17.4% of all deaths and 13.3% of DALYs.
Chronic obstructive pulmonary disease (COPD)
DALYs for COPD, based on incidence and prevalence
rates from 1990, that are adjusted to 2000 mortality rates
and applied to 2000 population data, show an increase of
DALYs across all regions for men and across most
regions for women (1). It is estimated that mortality
for COPD will continue to increase within the next
10–20 years (18, 19) due, in particular, to tobacco
smoking, and possibly air pollution (20).
The recent review published on COPD in Africa (5)
explained the reasons of the paucity of data in this region
of the world and gave the results of several studies
conducted on the prevalence of chronic bronchitis in this
region. These studies were generally conducted among
men in occupational settings in whom smoking was
common. In the nonexposed control group, the preval-
ence of chronic bronchitis obtained by questionnaire is
lower than in the exposed group and varies between 3.5%
267
Bousquet et al.
in Annaba (Algeria) to 11% in Cape Town (South
Africa).
In sub-Saharan Africa, air pollution is a result of
tobacco smoking, industrialization, domestic pollution,
and vehicular fuel combustion. Risk factors for COPD
such as tobacco smoking and occupational agents are
well known. The role of indoor-air pollution appears to
be of importance in places like China (21), but little is
known about sub-Saharan Africa and more research is
needed (22). Cooking fuels (wood, charcoal, electricity,
and liquefied petroleum gas) were found to increase acute
respiratory infections in sub-Saharan Africa (23, 24).
Asthma
The assessment of the burden of asthma is more
difficult. Mortality is important in asthma and it is
estimated that 180 000 asthmatics die every year
(WHO, 1999). Deaths have also been recorded in sub-
Saharan Africa (25). The assessment of the burden of
asthma is also challenging (1). Even when using the
same research protocol, reports on asthma prevalence
have shown huge variations for children and adoles-
cents within and among countries. Less variable data
were shown for adults. To make country-specific
estimates of asthma for the GBD 2000, comparable
data are needed.
In African migrants, such as Ethiopian migrants in
Israel, asthma may be extremely common (26).
ISAAC study. Rhinitis is usually present in asthma and
constitutes a risk factor for asthma (27, 28), at least in
developed countries and in occupational asthma. In the
Figure 1. Prevalence of self-reported rhinitis in Africa (source: Aı̈t-Khaled).
268
ISAAC study, it was found that a very high percentage of
children were suspected of presenting rhinitis in sub-
Saharan Africa with prevalences (assessed by question-
naire) of up to 50% (29, and personal communication
from Aı̈t-Khaled,) (Figs 1 and 2). The reasons explaining
these very high prevalences of rhinitis are unclear and
may be related to the children misunderstanding the
questionnaire.
Systematic international comparisons of the preva-
lences of asthma and other allergic disorders in children
are needed for a better understanding of their global
epidemiology, to generate new hypotheses, and to assess
existing hypotheses of possible causes. The worldwide
prevalence of asthma, allergic rhinoconjunctivitis
(Fig. 3), and atopic eczema, was investigated by ques-
tionnaire in the ISAAC study; 257 800 children aged
6–7 years from 91 centers in 38 countries, and 463 801
children aged 13–14 years were studied in 155 collabor-
ating centers in 56 countries (30). The centers with the
lowest rhinitis prevalences were similar to those for
asthma symptoms. In the past year, the prevalence of
rhinitis with itchy, watery eyes (‘‘rhinoconjunctivitis’’)
varied across centers from 0.8% to 14.9% in the 6–7-
year-olds and from 1.4% to 39.7% in the 13–14-year-olds
(29). Some sub-Saharan African studies have been
published (31).
Prevalence of asthma in rural and urban areas in sub-
Saharan Africa. Asthma appears to be a growing but
neglected public health problem in Sub-Saharan Africa
(32–44). Urbanization was shown to increase asthma
prevalence in South Africa (45) and other parts of sub-
Saharan Africa (33–38, 43, 44) (Table 2).

Figure 2. Prevalence of self-reported asthma in Africa (source: Aı̈t-Khaled).
It appears that asthma is uncommon in rural areas and
more common in urban areas (38). In developing coun-
tries, asthma and allergy may be associated with the
Figure 3. Worldwide prevalence of allergic rhinitis (ISAAC
questionnaire) (28).
CRD and allergy in sub-Saharan Africa
adoption of an urbanized ‘‘western’’ lifestyle as suggested
by a study carried out in southwest Ethiopia (37).
Asthma was reported by 3.6% of the children in the
urban group and was absent in the rural group. Atopy
was a strong risk factor for asthma in urban Jimma.
In the rural areas, skin sensitivity to mixed threshings
was only slightly less common than in urban Jimma,
whereas sensitivity to Dermatophagoides pteronyssinus
was significantly more common. Wheeze or sensitivity to
D. pteronyssinus were positively associated with housing
style, bedding materials, and with use of malathion
insecticide, but no single factor accounted for the urban–
rural differences.
Links between asthma and allergy in sub-Saharan
Africa. The links between asthma and environmental
allergens have been recently questioned in developed
countries (46), but in these countries most asthmatics
are also atopic (47). In sub-Saharan Africa, little is
known concerning allergy sensitization, and the relation-
ship between allergy and asthma may present some
specificity.
In sub-Saharan Africa, aeroallergens have been iden-
tified (48, 49), but the exposure differs between developed
countries and sub-Saharan Africa. The frequency of cat
and/or dog ownership in Ghana is comparable to that in
the UK (approximately 50%). However, in Ghanaian
communities pets are predominantly kept outdoors.
Levels of pet allergens in Ghanaian homes with pets
were between 75-fold (dog) and 275-fold (cat) lower than
levels in homes with dogs and cats in the UK, and were
269
Bousquet et al.

Table 2. Urban and rural differences in the prevalence of asthma

Prevalence rate (%) Atopy (%)

Reference Country Age group Outcome measure Urban Rural Urban Rural

Godfrey 1975 (34) Gambia School children Diagnosed asthma Present None
Van Niekerk 1979 (35) South Africa Children Exercise challenge 3.17 0.14
Addo-Yobo 1997 (36) Ghana 9–16 years Exercise challenge 4.7* 1.4 6.55** 2.9
Ng'Ang'A 1997 (37) Kenya 8–17 years Exercise challenge 22.9 13.2 30.1 11.1
Yemaneberhan 1997 (38) Ethiopia Wheeze 13.3 4.35 11.0 7.6
Asthma 18.95 6.4
Odhiambo 1998 (39) Kenya Asthma 9.5 2.8 26 10.9
Rhinitis 9.7 1.5
Nyan 2001 (44) Gambia Wheeze 4.4 3.5 35.3 22.5
Walvaren 2001 (45) Gambia ‡15 years Wheeze 4.1 3.3 7.5 3.8
Diagnosed asthma 3.6 0.7
Chronic bronchitis 0.6 1.2

* Urban rich.
** Urban poor.

also lower than or comparable to levels in homes without
pets in the UK (50).
Sensitization to dust-mite and cockroach allergens,
inner-city residence, and low position in sib-ship were
found to be independent risk factors for asthma in
Ghanaian children (51).
In a recent study in East Africa (52), it was found that
although most patients were atopic, few were asthmatics,
and there was no correlation between atopy and asthma.
The study suggests that in tropical areas where parasites
are endemic, the relationship between asthma and immu-
noglobulin E (IgE) is different from that of areas without
major parasitic disease. However, in this study, atopy was
defined ‘‘as any specific IgE over 0.35 kU/L’’ and this
definition may raise some problems (53). Levels of specific
IgE between 0.35 and 0.70 kU/l are positive using the CAP
system (Pharmacia, Uppsala, Sweden) but may be consid-
ered as borderline in allergic patients, and even more so in
people with very high IgE levels. In the study, over 30% of
subjects had total IgE > 2000 kU/l and over 60% had
total IgE > 1000 kU/l. Although the CAP system is a very
reliable test, which does not appear to be influenced by
total IgE levels (54), it is possible that extremely high total
IgE levels may induce some nonspecific binding.
Many local allergens may not yet be identified. Nonal-
lergic triggers may be more important than in developed
countries. Indoor- and outdoor-air pollution, including
tobacco smoke, is an important cofactor for asthma.
Links between asthma, allergy, and parasitosis in sub-
Saharan Africa. Parasitic diseases may be a confounding
factor. Early studies suggested that parasitic diseases
prevent the onset of asthma (33, 55, 56). On the other
hand, different studies suggested that groups of patients
who respond immunogenically to Ascaris infestation
might be predisposed to allergic diseases such as asthma
(57). Recent studies have confirmed independent effects in
Ethiopia of intestinal parasite (hookworm) infection and
domestic allergen exposure with risk of wheeze. This
suggests that a high degree of parasite infection might
prevent asthma symptoms in atopic individuals (58). The
differences in these studies may, however, be related to
the parasite concerned.
Th2 responses without atopy may be associated with
immunoregulation in chronic helminth infections and
reduced allergic disease (59). The increase of allergic
diseases in the industrialized world has often been
explained by a decline in infections during childhood
(60). The immunological explanation has been put into
the context of the functional T cell subsets, known as Th1
and Th2, which display polarized cytokine profiles. This
notion is contradicted by observations that the prevalence
of Th1-autoimmune diseases is also increasing and that
Th2-skewed parasitic worm (helminth) infections are not
associated with allergy. More recently, elevations of
antiinflammatory cytokines, such as interleukin (IL)-10,
which occur during long-term helminth infections, have
been shown to be inversely correlated with allergy (61, 62).
The induction of a robust antiinflammatory regulatory
network by persistent immune challenge offers a unifying
explanation for the observed inverse association of many
infections with allergic disorders (Fig. 4) (63). A high
degree of parasite infection may prevent asthma symp-
toms in atopic individuals (58). Some studies suggest that
in tropical areas where parasites are endemic the rela-
tionship between asthma and IgE is different from that in
areas without major parasitic disease (52, 64–66).
The lack of cross-reactivity between parasite and
inhalant allergen antigens has been discussed (67). It has
been shown that Dermatophagoides and cockroaches
share common allergens with some unrelated allergens
such as snails (68), crustaceae, or Anisakis (69). Both
parasites and house-dust mites contain cysteine proteases
(70, 71) which may cross react.

270
 CRD and allergy in sub-Saharan Africa

Figure 4. Divergent outcome of Th2 responses in industrialized and developing countries (63). Depending on the nature of the signals
they receive from the microenvironement, dendritic cells (DC) develop into distinct subpopulations and direct T cell differentiation
into polarized subsets (Th1 and Th2). When uncontrolled, strong Th1 or Th2 responses can lead to autoimmunity or allergy. High
pathogen burden can change the physiology of the microenvironment that endow dendritic cells to induce T regulatory cells (Tr),
which produce immunosuppressive molecules interleukin (IL)-10 and transforming growth factor (TGF)-b.

king, and possibly tuberculosis, were found to be

Occupational lung diseases
For several years, miners and founders have been known
to suffer from pneumoconiosis, often associated with
tuberculosis and tobacco smoking (72–75).
More recently, asthma, COPD, chronic cough, and/or
rhinitis induced by occupational exposure have been
identified in developing countries (76–83). They represent
a major burden for many workers. In the world’s poorest
countries, technologies that are obsolete or banned in
industrialized countries are still largely used (84). Result-
ing occupational illnesses are also generally less visible
and not adequately recognized as a problem in low-
income countries (85). People outside the workplace can
also be affected through, for example, work-related
environmental pollution.
The same agents are found in developed and develop-
ing countries (86, 87), but some agents are specific to
developing countries, and the levels of exposure are not
usually controlled, making the diseases more prevalent
and severe than in developed countries. Tobacco smo-
confounding factors.
A large nationwide surveillance study is now available
in the region. The Surveillance of Work-related and
Occupational Respiratory Diseases in South Africa
(SORDSA) was established in 1996 to provide systematic
information on occupational respiratory diseases (86, 87).
In the first 2 years of the program (ending October 1998),
3285 cases of occupational respiratory disease were
reported to SORDSA by 203 doctors and 97 occupational
health nurses. After pneumoconiosis, occupational
asthma was the second most commonly reported disease
(6.9%). The average annual incidence for occupational
asthma in South Africa was 13.1 per million employed
people. Latex was the most frequently reported agent for
occupational asthma, followed by isocyanates and plat-
inum salts. Low-molecular-weight agents accounted for
59.6% of the cases of occupational asthma. Such a
comprehensive program may be used in other developing
countries to assess the prevalence of occupational CRD
and to develop prevention and intervention programs.

271
Bousquet et al.

However, in sub-Saharan Africa, occupational diseases tious and parasitic diseases of childhood remain a
are not usually compensated, and patients continue to priority. At the same time, noncommunicable diseases,
work with lung diseases of increasing severity. including CRD, are emerging as a serious problem in
countries at intermediate stages of the epidemiological
transition (100). Noncommunicable diseases will
Other chronic respiratory diseases
undoubtedly represent tomorrow’s pandemics in devel-
Other CRD are of great importance in sub-Saharan oping countries (101). There is already evidence that the
Africa and should also be taken into account for a global prevalence of certain noncommunicable diseases, such as
program. Some of these are important and include: diabetes, asthma, COPD, epilepsy, and hypertension, is
increasing rapidly in some parts of sub-Saharan Africa
1. Sequelae of tuberculosis and of acute pulmonary in-
(102, 103). However, in many sub-Saharan African
fections in the form of bronchiectasis, pachypleuritis,
countries such as Zambia, there is no obvious policy on
aspergillosis, and/or fibrothorax (88–91). In sub-Saha-
noncommunicable diseases and no accurate information
ran Africa, HIV infection represents a very important
about their burden (104). Tobacco smoking is a critical
risk factor for recurrence of tuberculosis (92).
problem to be dealt with urgently (105).
2. Tropical pulmonary eosinophilia results from a
Concern has been expressed that the available
hypersensitivity reaction to lymphatic filarial para-
resources to deal with communicable diseases would be
sites and may lead to long-term sequelae of
reduced by increasing the emphasis on noncommunicable
pulmonary fibrosis with chronic respiratory fail-
diseases. The latter, however, already present a substan-
ure (93).
tial burden because their overall age-specific rates are
3. Two forms of pulmonary involvement in schistosomi-
currently higher in adults in sub-Saharan Africa than in
asis can be observed. The acute form usually occurs
populations in established market economies (102). To
about 6 weeks after the infection (Katayama syn-
ignore the noncommunicable diseases would inevitably
drome) and seems related to an allergic manifesta-
lead to an increase in their burden; the provision of health
tion to the presence of worms or eggs. The chronic
services would be largely undirected by issues of clinical
involvement is in the form of pulmonary hyperten-
and cost-effectiveness, and their treatment and prevention
sion with cor pulmonale, pulmonary granulomatous
would be left to the mercy of local and global commercial
schistosomiasis, and pulmonary arteriovenous fistu-
interests (102).
las (94–96). These chronic pulmonary complications
Health systems should have short-, medium- and
usually occur in less than 5% of infections (94) but
long-term policies. The management and prevention of
some limited data suggest a prevalence of up to 25%
noncommunicable diseases should be considered in con-
of infected people (97).
junction with those of communicable diseases with which
they often interact.
Improved surveillance of all diseases within sub-Saha-
Prioritization of health programs in developing countries
ran Africa is needed in order to place noncommunicable
and importance of the CRD program
diseases properly within the context of the overall burden
Importance of noncommunicable diseases in developing countries of disease. Research is needed to guide improvements in
the clinical and cost-effectiveness of resources currently
There is no doubt that, for the next 10–20 years,
committed to the care of patients with noncommunicable
communicable diseases will remain the predominant
diseases, and to direct and evaluate preventive measures
health problem for the populations in sub-Saharan
(102).
Africa, even for adults. In sub-Saharan Africa, there is
a high childhood and maternal mortality and relatively
short life expectancy. Mortality in childhood is mainly Importance and diversity of CRD in developing countries
due to diseases like malaria, measles, poliomyelitis,
In developing countries, CRD represent a challenge to
tetanus, diarrhea, and acute respiratory tract infections.
public health because of their frequency, severity, pro-
Diseases like filariasis, schistosomiasis, and leprosy,
jected trends, and economic impact. Healthcare planners
which are now readily controlled by drugs, still cause
are faced with a dramatic increase in tobacco use and
considerable morbidity. In adults, tuberculosis and
must establish priorities for the allocation of limited
malaria will remain the highest priorities among public
resources. Major CRD in both developed and developing
health problems during the next two decades.
countries include COPD (21) and asthma (106). Thus,
Economic transition is the term used to describe the
smoking prevention and standardized management pro-
change in disease patterns associated with economic
grams for asthma and COPD should be implemented in
development (98, 99). Health systems in developing
developing countries whenever possible (107). However,
countries faced major challenges in the 1990s and beyond
other CRD should be taken into account (see Other
because of a growing epidemiological diversity, rapid
chronic respiratory diseases).
economic development and declining fertility. The infec-

272

The CRD program should be applied together with
other health programs. There is need for concerted efforts
on the part of African governments, health administra-
tors and health workers to ensure that necessary attention
is given to multidisciplinary research on the subject so
that meaningful control measures can be formulated,
thereby ensuring clean air for the people to breathe. As an
example, several recent initiatives by nongovernment
organizations (NGOs) and the WHO have highlighted
the need for concerted approaches to lung health that
require addressing two major threats, tuberculosis and
tobacco smoking (108).
Features of developing countries: social and economic
vulnerability and barriers
Low-income developing countries can be characterized by
social and economic vulnerability that induce cultural
barriers to CRD management (1, 109, 110).
Generic barriers
There are several generic barriers, of which heavy debts
and poverty represent major problems. Poverty is wide-
spread among rural Africans and increase in elderly (111);
it is associated with poor health and unsatisfactory access
to healthcare. In sub-Saharan Africa, a large part of the
population is rural, consisting of farmers and breeders.
They live in small communities with a heavy workload.
Rural exodus is explained by the dryness and the spread
of the desert, and by poverty, causing overpopulation of
the towns, and development of shantytowns in so-called
‘‘suburban’’ areas.
This vulnerability (over half of these populations live
below the poverty threshold) is going to cause an
important disparity in the different methods of financing
healthcare.
There are many other barriers including poor educa-
tion, illiteracy of many people, lack of sanitation, and
poor infrastructure.
Environmental barriers
Tobacco smoking is a common environmental barrier
throughout the world, particularly so in some parts of
sub-Saharan Africa. In many countries, the recently
decreed anti-tobacco-smoking legislation has been
adversely affected by successful advertising of the multi-
national tobacco companies. Aware of their economic
weight and importance, they have reinforced their pro-
motional policies in these countries, promoting tobacco
in terms of modernity, liberation, and well-being.
These ill-founded ideas are sure to have an effect on
smoking habits, with an increase in the number of
smokers, especially in young adults, and more smoking
in public places (both passive and active). According to
CRD and allergy in sub-Saharan Africa
the WHO Global Report, in 1990–92, the overall
consumption in Africa is estimated at 600 cigarettes/
adult/year. The richest countries of Africa show the
highest consumption. In low-income countries, smoking
and other uses of tobacco indicate a relative increase in
wealth (112). Currently, Mauritius, South Africa, and
Botswana have consumption rates similar to those in
developed countries. Consumption in middle-income
countries such as Cameroon and Senegal is around
800/adult/year (113). While consumption rates have
declined slightly in developed countries, rates are increas-
ing throughout the developing world. The Food and
Agriculture Organization (FAO) estimates that the level
of consumption in Africa will be one of the highest in the
world if nothing is done to stop this rate of growth (112).
The aggressive marketing campaigns of international
tobacco companies are encouraging young men and boys
in particular to spend their precious disposable income on
cigarettes, which can be bought one at a time (114).
Women in Africa and Asia, whose smoking rates are low,
are the next market to be targeted by the tobacco industry
(115).
Pollution is another well-identified barrier that appears
to be of great importance, but precise information is
unavailable for sub-Saharan Africa. Automobile pol-
lution is often extensive in urban and suburban areas
since most cars and diesel vehicles are old and poorly
maintained, emitting far more pollutants than in devel-
oped countries. Occupational pollution is also important
(see 3,4). Indoor-air pollution is another poorly under-
stood problem related to indoor cooking fuel. The effects
of indoor pollution are worsened by poor living condi-
tions.
Poor nutrition is common in sub-Saharan Africa
(116–118). It was felt that urbanization of the popula-
tion would lead to improved nutrition (119) but
economic problems and structural reforms have had
dire effects on urban populations. Today, increasing
poverty and the effects of globalization are again
increasing nutritional problems for the suburban areas
(120).
Drug availability and accessibility: from the Bamako Initiative
to the Doha declaration
There is increasing pressure on developing countries to
improve the social, political, and economic status of their
people. Despite the Bamako Initiative (121, 122) there
remain situations where drugs are unavailable or there is
poor access to drugs; efforts must be made to ensure that
essential drugs are available to all (123), particularly
inhaled corticosteroids (124) and, b2-agonists. The non-
availability of drugs most needed for healthcare and
disease control in sub-Saharan Africa is not only due to
insufficient funding, but also due to the use of limited
funds for expensive drugs that have little bearing on the
disease pattern.
273
Bousquet et al.
The Bamako Initiative in the African region of the
World Health Organization was designed to ensure
regular availability of drugs, especially to primary
healthcare facilities. Seed drugs are provided to the
health institutions either by the National Government or
through external aid. These are sold to patients for a
small profit. The proceeds are used to replenish stocks
and the small profit is used to improve services in the
health center. The introduction of these programs to
countries like Nigeria, Gambia, Guinea, and Senegal has
improved considerably the availability of drugs over the
past couple of years and should soon start to yield
measurable improvements in the health situation
(125–129). Like any other form of financing health
service, the Bamako Initiative is not free of difficulty
(130). Moreover, many people cannot use Bamako
Initiative Health Centers for financial reasons.
The members of the World Trade Organization (WTO)
issued an historic Ministerial Declaration in Doha stating
that the Agreement on Trade-Related Aspects of Intel-
lectual Property Rights (TRIPS) should be interpreted
and implemented so as to protect public health and
promote access to medicines for all. WHO welcomed this
declaration and looks forward to working together with
WTO and others to achieve these objectives (Statement
WHO/18, November 15, 2001).
International agencies should define the essential drugs,
and encourage the use of generic drugs, particularly for
inhaled corticosteroids. For such programs to be effect-
ive, producers of high-quality generics will need to be
identified, and the medications added to national lists of
essential drugs and included in procurement procedures
(107).
Organization of healthcare services
Economic and cultural barriers in sub-Saharan Africa
usually result in at least three distinct groups of medical
care: people living in urban areas, suburban areas, and
rural areas. These groups need to be addressed separately
for the management of CRD (Table 3). In sub-Saharan
Africa, a minority of people are in the first category; the
majority are in rural areas.
Table 3. Distinct groups of medical care in Sub Saharan Africa
People living in urban areas with a high income and with a settled and sedentary
lifestyle. These include:
rich people who can afford expensive investigations and treatments
government workers who are compensated for investigations and treatments
workers of industry, agriculture, or the third sector who are compensated for
investigations and treatments
People living in urban areas who are jobless or have limited financial resources, and
people living in the poor so-called ``suburban'' areas. These usually have similar
healthcare management and will be in the document ascribed to ``suburban
areas''
Poor people living in rural areas
274
In the rural and suburban areas, the organization of
healthcare services has common major drawbacks
(Table 4 and Fig. 5). In rural areas, most resources are
used for the management of acute infectious or parasitic
diseases, and for prevention of maternal and perinatal
mortality.
Patient barriers
Patient barriers are also of major importance, such as
associated languages (131), and religious and cultural
beliefs and taboos. For example, in Senegal, hematuria is
considered a sign of virility within the Soninké ethnic
group where schistosomiasis is highly prevalent.
The number of elderly people in sub-Saharan Africa is
growing rapidly, and there is an increase in life expect-
ancy; at the same time the proportion of children is
declining (132). This has several implications, such as the
erosion of social support by extended families, dramatic
Table 4. Major drawbacks in the organization of healthcare services in the rural
and suburban areas
Inaccessibility of healthcare facilities (distance, nonexistence, lack of application)
Disparity in the establishment and implantation of healthcare facilities
Poor and insufficient technical support
Lack or nonexistence of qualified personnel: the health posts are usually run by
nurses. Training is not similar between the different countries
communicable
diseases
non-communicable
diseases
low-income middle-income high-income
country country country
Figure 5. Coexistence of communicable and noncommunicable
diseases in the same country. Communicable and noncommu-
nicable diseases coexist within the same country. In low-income
countries, communicable diseases are more common than non-
communicable diseases. In high-income countries, the inverse
relationship exists. However, within a single country there are
differences such as those found in urban (communicable diseases
and noncommunicable), suburban (communicable diseases >
noncommunicable) and rural (communicable diseases >>>
noncommunicable) areas of sub-Saharan Africa.

changes in disease patterns, and increases in rates of
cancer and noncommunicable diseases, in particular
CRDs.
Parallel medicine
In sub-Saharan Africa, parallel medicine is extremely
important with many traditional healers. This is usually
the first step in the management of diseases due to
cultural beliefs and taboos, the inaccessibility of health-
care, and drug costs. The theory behind traditional
medicine in the several black ethnic groups of Africa is
essentially similar. Disease is a supernatural phenomenon
governed by a hierarchy of vital powers beginning with a
most powerful deity followed by lesser spiritual entities,
ancestral spirits, living persons, animals, plants, and other
objects. These powers can interact, and they can reduce
or enhance the power of a person. Disharmony in these
vital powers can cause illness. Thus, ancestral spirits can
make a person ill. Ingredients obtained from animals,
plants, and other objects can restore the decreased power
in a sick person and therefore have medicinal properties.
Traditional healers are enshrined in the minds of the
people and respected in their community, and they are
often opinion leaders. Unfortunately, there have been no
studies on the efficacy of traditional remedies (133). They
are believed to be effective in diarrhea, headache, and
other pains, as well as for sedation. Success in treating
psychological problems is well known and often recog-
nized. Traditional medicine has been confronted by the
quest for new sources of legitimation (134) that has not
been proven. In many places, traditional medicine and
modern medicine have tended to work in tandem (135).
In South Africa, traditional healers have flourished in
the face of competition from modern medicine. In 1995, it
was thought that about 200 000 traditional healers were
practicing in South Africa, compared with 25 000 doctors
of modern medicine; 80% of the black population use the
services of traditional healers (133).
Gaps, relevance and the integration of different guidelines
in developing countries
The CRD working group identified several gaps in the
current CRD guidelines (1). Moreover, GINA (Global
Initiative for Asthma) (106) and GOLD (Global Initiative
for COPD) (21) are not patient-oriented guidelines,
whereas ARIA (Allergic Rhinitis and its Impact on
Asthma) tends to be more global for patients with asthma
and rhinitis (28). GINA and GOLD are not targeted
towards their application to developing countries whereas
ARIA has a specific section. Asthma management for
developing countries was proposed in the IUATLD
(International Union Against Tuberculosis and Lung
Diseases) asthma guide (136). It considers affordability
and availability of drugs and local needs. Based on the
CRD and allergy in sub-Saharan Africa
same principles, a strategy for COPD management in
Africa has been recently proposed by IUATLD (5, 107).
The relevance of guidelines in developing countries is
difficult to assess and differences largely depend on the
area of the country. It is clear that in sub-Saharan Africa,
guidelines are inapplicable for the majority of the
population.
It has been proposed that it may not be desirable to
merge all guidelines, but it does seem that a patient-
targeted approach is required, and since there is much
overlapping among CRD, the merging of guidelines in an
integrated approach may be needed (1). Most asthmatics,
if not all, have rhinitis (28) and in many patients, COPD
and asthma are difficult to distinguish (21). Many
asthmatics smoke and are exposed to indoor- and
outdoor-air pollutants that can induce COPD. Finally,
it will be necessary to merge certain key elements from
each guideline document into an algorithm for use at the
first point of contact of a respiratory patient with the
health service. Such an approach has been discussed in
the CRD consultation document (1).
Existing guidelines are usually comprehensive and have
been developed using the evidence-based model. For
asthma, three updates have being finalized or are in the
process of being finalized: the GINA (137), the BTS
(British Thoracic Society) and the IUATLD guidelines.
Requirements and aims for CRD management in developing
countries
In a recent paper, Unwin et al. (138) proposed the
following characteristics to implement a program in a
developing country:
1. The disease is chronic.
2. Effective measures exist for controlling symptoms
and preventing complications.
3. These measures need to be delivered to the patients
over long periods.
4. They require well-organized healthcare systems for
this to be done effectively.
There are several objectives of a strategy for the
effective control and prevention of common CRD within
sub-Saharan Africa (Table 5) (107,138).
In order to implement the program, outcome measures
should be used. They will necessarily differ from those used
in developed countries.
Outcome measures for CRD in developing countries
Classical outcome measures
Assessment of interventions of the CRD program must
use outcome measures that are appropriate for develop-
ing countries (139). Outcome measures used in developed
countries are often poorly applicable to developing
275
Bousquet et al.
Table 5. Objectives for a strategy for the effective control and prevention of
common chronic respiratory disorders (CRD) (107)
Develop guidelines that are adapted to local contexts
Evaluate the adapted guidelines, including guideline review criteria and quality
standards
Ensure their distribution for the treatment of CRD at primary-care level in
sub-Saharan African countries
Develop and assess rapid evaluation methods for assessing the quality of CRD
care at a health district or country level
Upgrade equipment at district level
Purchase high-quality drugs at low prices
Provide routine training and supervision of health service personnel
Develop and implement a protocol for assessing current policy and opportunities
for health promotion at a national level for the different CRD
Through baseline prevalence surveys, provide new knowledge on the epidemiology
of CRD and major risk factors for these conditions, and on current national
policies for the prevention of noncommunicable diseases within the countries
countries; moreover, race, ethnicity, or culture may
influence asthma outcomes (140).
Asthma. For asthma, outcome measures include lung
function measurements, symptoms, rescue medication
needs, control of asthma, exacerbations, hospitalization
rate, and quality-of-life (QOL) measures (141). These
measures are usually not applicable to most parts of
developing countries, and QOL is mostly inapplicable
because there are social and cultural problems that are
not taken into consideration in these measures.
Hospitalization rates cannot usually be used since there
are very few ICU or hospital beds in central hospitals or
university hospitals, and they may not exist elsewhere. In
most African countries, there is one hospital per district,
but in rural areas this is devoted to CD and national
health programs. CRD are not yet listed as a national
health program in sub-Saharan African countries. More-
over, there is no register to account for hospitalization
rates. These registers were found to be of paramount
importance for the assessment of tuberculosis prevalence
and its management in district hospitals. The IUATLD
guide proposed the same information system as for
tuberculosis with a register for persistent asthma. A
routine evaluation of patient outcomes will be possible
using a quarterly report based on the register. This
evaluation is likely to be the cornerstone of a manage-
ment program for asthma in developing countries.
COPD. For COPD, outcome measures are even more
difficult to use since most treatments are not very effective
in preventing the alteration of lung function, and studies
should be carried out over long periods. Usual outcome
measures used in trials include symptoms, exacerbations,
hospitalizations, forced expiratory volume in 1 s (FEV1),
other functional parameters, and QOL. Hospitalization
rates cannot usually be used for the same reasons as for
asthma.
276
Table 6. Problems with measurements of FEV1 (forced expiratory volume in 1 s) in
sub-Saharan Africa
The reference values for lung function parameters have been published in some
populations (172–174) but may not apply to all the ethnic groups
FEV1 cannot be used at present for the vast majority of the population and a special
effort should be made to increase the availability of the test. However, it is clear
that spirometry will not be possible in the near future in all parts of developing
countries
Peak expiratory flows (PEF) can be used more easily everywhere. Although PEF may
not be as accurate as FEV1, reversibility of the airflow obstruction may be done
easily. In this case, the validity of the PEF measurement should be monitored by
specific studies in pilot trials
Training of healthcare personnel should be carried out
These outcome measures are usually less responsive
than in asthma (142–145) and should be applied for
longer times than for asthma (at least 1 year).
Thus, very few responsive outcome measures may be
applied to assess intervention for COPD in developing
countries.
Lung function measurement
Measurement of lung function using simple and inexpen-
sive methods is a major issue for the CRD program.
FEV1 and other lung function parameters can be studied
in all countries but only in reference hospitals (146,147)
or eventually in occupational settings (76,78–82). In the
middle-income countries of Africa (at least in Algeria,
Morocco, Tunisia, and South Africa), the spirometry is or
may be available at district level. In these countries, the
progressive development of health structure at district
level will be directly linked with the political involvement
for the management of CDR. The choice and the
maintenance of equipment will be essential for the
sustainability of eventual national intervention on
CDR. Moreover, there are problems with FEV1 meas-
urements in low-income countries (Table 6).
There are some other outcome measures used for all
diseases that may be used by the CRD program. They
include mortality rates, the assessment of the burden of
the disease, and the assessment and follow up of
occupational lung diseases.
Global burden of disease measures
Global burden of disease (GBD) measures seem to be
applicable to developing countries. DALY studies have
confirmed the efficacy and cost-effectiveness of many
interventions in middle-income countries for AIDS (148)
or in low-income developing countries, such as Sri Lanka,
where the highest burden was due to noncommunicable
diseases, as their duration and degree of disability are
high (149). In Africa, DALYs supported the environ-
mental management for malaria control (150). In Japan,
DALYs was used to assess the deleterious effects attrib-
utable to tobacco (151).

Tertiary Hospital
referral
Secondary
referral Low level of
equipment
Health-care
workers
Patients
Figure 6. Referral of patients in developing countries.
New formulas for measuring DALYs have been
proposed (10) and have found that the global burden of
diseases and injuries, as previously reported in the GDB
study (11), may be underestimated. The difference is
greatest for diseases of short duration (e.g. infectious
diseases).
Reliable information on causes of death is essential to
the development of national and international health
policies for the prevention and control of disease and
injury. Mortality data can be used in COPD but not in
asthma because the numbers are too low. Moreover,
information on the cause of death among adults in sub-
Saharan Africa is essentially nonexistent (15). In the
absence of accurate and comprehensive registries of vital
events for the majority of the region’s inhabitants,
longitudinal studies of defined population-based cohorts
represent the only realistic strategy to fill this void in basic
public health information. Years of life lost (YLL) can be
used in sub-Saharan Africa (17).
Assessment and follow-up of occupational respiratory diseases
In places where longitudinal studies can be carried out,
the serial measurement of lung function and the assess-
ment of symptoms should be carried out. A comprehen-
sive program like the nationwide SORDSA surveillance
may be used in other developing countries to assess the
prevalence of occupational CRD and to develop preven-
tion and intervention programs.
Trials to assess efficacy of interventions in developing
countries
Double-blind, placebo-controlled, randomized controlled
trials (DBPC-RCT) can be performed in Africa (152) but
such trials do not seem necessary to evaluate the CRD
program and do not make it possible to assess cost-
effectiveness of interventions.
CRD and allergy in sub-Saharan Africa
A methodology should be developed to assess the
efficacy of interventions in populations. Trials similar to
those used to assess practice interventions may be
designed. These trials randomize practices instead of
patients and need some specific statistical methods
(153,154). In developing countries, a trial may compare
communities or villages in which an intervention has been
initiated with others in which there has been no
intervention. Randomization will not be based on the
patient’s characteristics but on the features of the site.
There may be baseline imbalances between sites and these
need careful understanding and evaluation. The choice of
the units of analysis (outcome measures) will be most
important where there are large numbers of patients
recruited from each site and/or a high degree of variab-
ility within patients (153,154).
In order to select the units (outcome measures) to be
used, the goal(s) of the program should be clearly stated.
As an example, the Roll Back Malaria (RBM) WHO
initiative, started in 1998, had the ambitious goal of
halving the malaria burden by the year 2010, and halving
it again in the next 5 years. Such goals are easier to
propose and implement for parasitic and infectious
diseases than for noncommunicable diseases.
Some models can be used such as the inner-city asthma
program (P15). Some studies have already assessed
differences in asthma management between white Euro-
pean and Indian-subcontinent ethnic groups living in
socioeconomically deprived areas in the Birmingham
(UK) conurbation (155). However, this study and the
National Cooperative Inner-City Asthma Study (NCI-
CAS) implemented in the USA (156,157), dealt with
health resources which were far more advanced than in
the suburban areas of sub-Saharan Africa.
Cost-effectiveness trials
Cost-effectiveness analyses should be included in all trials;
analyses using a decision-analysis model linking epidemi-
ological data with economic information have been
proposed for AIDS (158), meningitis (159), and tubercu-
losis (160,161). DALYs can be used for cost-effectiveness
analyses and were found useful for parasitic diseases such
as malaria (150,162,163) and AIDS (164,165). Since data
are scarce, even for a disease such as malaria, models that
include probabilistic sensitivity analyses have been pro-
posed to calculate DALYs, averted for each intervention
by economic strata (162).
Some projects have already started to tackle the
emerging pandemic of noncommunicable diseases in
sub-Saharan Africa. Methods are being developed and
piloted in urban and rural Tanzania and Cameroon for a
community-based program on high blood pressure (166).
A project, funded by the Department for International
Development of the British Government aims to provide
costed and evaluated treatment packages for use at a
277
Bousquet et al.
primary healthcare level, methods and materials for
evaluating the quality of noncommunicable disease care,
and a protocol for the assessment of national opportun-
ities for the prevention of hypertension, diabetes, asthma,
and epilepsy in Tanzania and Cameroon (138).
Prioritization within the CRD program
Economic and cultural barriers in sub-Saharan Africa
usually result in at least three distinct groups of medical
care (urban, suburban, and rural). These groups must be
addressed separately for the management of CRD.
However, this categorization may not always be easy to
use since the health strategy is not always followed. It is
anticipated that patients in rural areas will consult nurses
in the vicinity. Then, depending on the severity of the
disease, patients will optimally be sent to intermediate
structures run by physicians and eventually to referral
centers. People living in rural areas often try to have
direct access to the referral centers with the help of their
family members living in the cities. However, many poor
people cannot access healthcare centers since they die
before any action has been taken.
It seems that tobacco control is probably the highest
priority of the program because a reduction of smoking
will be associated with a decrease in COPD and other
tobacco-related diseases. This program is probably the
most important in urban and suburban areas, even
though it is difficult to measure changes in smoking
habits (167).
There is limited epidemiological data and clinical
experience about asthma; it is relatively common and
may be severe at least in urban and suburban areas. The
burden of asthma in rural areas is not generally known.
In central or university hospitals, which have well-trained
personnel and which are sufficiently well equipped,
guidelines may be tested with some local adaptations
using generic drugs. A program adapted from the
National Cooperative Inner-City Asthma Study (NCI-
CAS) (156,157) may be of interest.
Occupational diseases represent a major problem in
sub-Saharan Africa. There is an urgent need for improved
control of occupational pollutants and sensitizers in
factories in the developing world. Patients excluded from
work are skilled individuals needed by the country for
economic development. Patients with occupational asth-
ma or COPD working in large companies with a
compensation plan can be followed up after work
cessation and/or treatment. Patients with severe occupa-
tional asthma or COPD working in smaller companies
without a compensation plan are much more difficult to
manage. In occupational asthma, if people are removed
from exposure to the substance causing their asthma as
soon as they start to develop symptoms, they are likely to
make a complete recovery (http://www.hse.gov.uk/
condocs/). If exposure continues, symptoms become
278
Table 7. Aims of an algorithm model developed for the application of the chronic
respiratory disease (CRD) program in rural areas
Assessment of the prevalence and burden (GBD) of CRD in urban, suburban,
and rural areas since it seems that CRD are largely underestimated
Assessment of risk factors
Propose and evaluate a simple management scheme which will be tested
further for applicability and cost-effectiveness
For this purpose there is a need for:
improvement of availability of effective generic drugs
(e.g. inhaled salbutamol and beclomethasone)
making peak flow measurements possible at each site. However, peak flow
monitoring may be available only in the health centers
Education of healthcare workers
increasingly severe and may persist even after exposure
eviction (168). Symptoms of rhinoconjunctivitis are often
associated with occupational asthma (169). In many
patients, rhinitis appears earlier than asthma. Occupa-
tional rhinitis can be used as an early predictor of asthma,
as patients can be removed from exposure in order to
prevent persistent asthma.
For the management of CRD in rural areas, a new
model should be used. The model should be based on a
simple symptom algorithm, which will guide the health-
care worker (or physician) towards the accurate diagno-
sis of CRD and propose the treatment of symptoms. In
this model, acute and chronic respiratory symptoms
should be combined to make an optimal diagnosis of
tuberculosis, pneumonia, asthma, or COPD exacerba-
tion, and other possible CRD. Only patients with severe
symptoms are likely to need treatment and the algorithm
should make it possible to differentiate accurately
between the diseases and propose treatment for acute
symptoms. Such a model using algorithms is currently
being tested in Marrocco and Peru. The model should
have several aims (Table 7).
From the limited epidemiological data and clinical
experience, COPD is known to be relatively common and
can be very severe. The DALY model and related
measures can be used. However, the best and simplest
outcome measure is decrease in FEV1, which is not easily
accessible to the vast majority of people living in sub-
Saharan Africa.
Conclusion
Due to limited resources and the importance of commu-
nicable and noncommunicable diseases in sub-Saharan
Africa, priorities should be targeted at public health
problems that need to be decided at national levels.
It is clear that tobacco control is the highest priority
whichever country is considered. The management of
asthma using cheap and effective generic drugs and peak
flows is another priority. The prevention of occupational
diseases is equally important since it also has an economic

benefit. However, this may only be a high priority for
middle-income countries. For COPD, besides tobacco
and indoor-pollution control, most measures are not very
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