My first experience of working in Africa was as a registrar before I had commenced higher training in geriatrics. Having always been interested in working in low and middle income countries (LMICs), I undertook the Diploma in Tropical Medicine and Hygiene (DTM&H) at the Liverpool School of Tropical Medicine (LSTM) in 1989 and having learnt all about infectious diseases, and nothing about non-communicable disease in the tropics, took up a post as senior medical registrar employed by ODA (Overseas Development Administration) in the Royal Victoria Hospital (RVH), Banjul, The Gambia.
On my first ward round I saw four young patients with strokes, which was certainly not what I had been expecting. A quick literature search established that there were very few previous data on stroke in sub-Saharan Africa (SSA), and none on long term outcome, so I undertook a study in which I recruited all patients admitted to the RVH over a one year period (seasonality has more to do with wet and dry season than summer and winter) along with an age and sex-matched control population made up of hospital visitors (there are no GP registers) to investigate risk factors. Without the normal basic requirements such as contact addresses or phone numbers, I then successfully followed the survivors up for three years. Twice as many males were admitted to hospital and long term survival was very poor. Is this because stroke is twice as common in males in SSA or is there differential access to hospital following a stroke?
The only way to address this problem is to look in the community and thus began my more than twenty year involvement with Tanzania where the presence of demographic surveillance sites (DSS), at that time linked to Newcastle University, enabled me to investigate stroke mortality based on verbal autopsy as very few people have death certificates (Walker et al 2000a), and prevalence based on a house-to-house survey (Walker et al 2000b). Even more challenging was the first, and only, fully community-based stroke incidence study in SSA which demonstrated some of the highest stroke incidence rates in the world (Walker et al 2010) with HIV as an independent risk factor (Walker et al 2013), whereas carotid disease was almost non-existent (Jusabani et al 2011). The stroke incidence study was only possible because of the advent of mobile phone technology in SSA, allowing village enumerators to text if a possible new stroke occurred and the patients could then be transported to hospital and undergo appropriate investigations.
We have also become involved with epidemiological research in relation to Parkinson’s disease (PD) with the first large scale prevalence study of PD in SSA (Dotchin et al 2008) and the subsequent demonstration of the dramatic effects of cueing therapy in the drug naïve patients from this prevalent cohort (Rochester et al 2010), the first such study worldwide. In the study less than one fifth of people had previously been diagnosed and based on our figures we estimate that more than half the people in the world with PD have never been diagnosed even though effective drug treatment is potentially available. This led me to initiate the setting up of a SSA special interest group within the BGS Movement Disorders Section, and the subsequent African Task Force the main aims of which are to increase public awareness, improve training for doctors, nurses and allied health professionals and advocate for the availability of affordable drug treatment (Mokaya et al 2015) which is the most challenging of all.
We have run courses for PD nurse specialists and doctors throughout SSA and have also enabled doctors, nurses and allied health professionals to gain further training in Europe. We have also informed update of the WHO Essential Medicines List (EML) for PD.
We are currently looking at other areas including dementia and frailty, which throws up new challenges such as how such conditions are identified in populations who often have little or no contact with medical services. Standard cognition tools developed in high income countries such as MMSE or MoCA are inappropriate in such populations where, for example, a large proportion may never have been to school. We have investigated hypertension and atrial fibrillation (AF), risk factors for both stroke and cognitive impairment demonstrating very high rates of hypertension (mostly undiagnosed) in those aged 70 and over with few of those previously diagnosed on drug treatment, and even fewer controlled (Dewhurst et al 2013). One of the other areas we have become interested in is health seeking behaviour and the role of traditional and faith healers, and the various conditions we have investigated, including dementia (Hindley et al 2017) in which diagnosis rates for dementia are even lower than those for PD.
Based on our research findings we are always looking at to how we might improve things. We have adapted cognitive stimulation treatment (CST) effectively for use in SSA and, in relation to dementia, have helped with adapting undergraduate curriculae in medicine, nursing and occupational therapy, as well as influencing national guidelines in Tanzania.
Therefore, having initially taken up a clinical job in The Gambia, I became involved in research to answer important and intriguing questions that I identified but it has not been easy. Having never had a research job, I spent 12 years in my spare time writing up my MD from The Gambia. Securing research funding for non-communicable diseases in LMICs has been very difficult until relatively recently but the rewards are there if one persists and there are many, many important unanswered questions, with the potential to be writing chapters rather than dotting I’s and crossing T’s. It has been very gratifying for me to enable other people, both from the UK and Tanzania, to carry out their higher degrees (MDs or PhDs) as well as many intercalating Masters of Research (MRes) students at Newcastle University. After many years of very limited funding there has never been a better time to be involved in global health research.
In my role as Associate International Director for SSA for the Royal College of Physicians (RCP) we have undertaken training programmes in West Africa and currently have a programme for training in neurology and oncology in East Africa, as well as helping to establish the East, Southern and Central African College of Physicians (ESCACOP), a core aim of which is to improve postgraduate training. Another way that I have been involved with training in Africa is through our Trust higher education link with Kilimanjaro Christian Medical Centre (KCMC) in northern Tanzania since 1999. This has included working with the physiotherapy and occupational therapy schools, the only ones in Tanzania, and other areas such as burns, laparoscopic surgery and foetal ultrasound. There are other such links throughout the country run by geriatricians such as the Wessex link with the stroke unit in Accra, Ghana.
This also gives the opportunity for being involved in training and I think this should be a big agenda for the BGS. There would definitely be a demand for geriatrics training whether this be short courses for interested doctors or long term training programmes with mentorship. It would be an opportune time to develop a special interest group in LMICs to increase training in geriatrics as the projected figures for ageing of the world population are massive and yet most of the increase will occur in LMICs where there are very few geriatricians (Dotchin et al 2013) and other health professionals with appropriate training and with very little in undergraduate curriculae. I am sure there are many members of the BGS who would be keen to contribute given the opportunity and we could have a potentially substantial impact.
Consultant Physician (Northumbria Healthcare NHS Foundation Trust) and Professor of Ageing and International Health (Newcastle University)
Richard W Walker, Donald G McLarty, Henry M Kitange, Dave Whiting, Gabriel Masuki, Deo M Mtasiwa, Harun Machibya, Nigel Unwin, K G M M Alberti. Stroke mortality in urban and rural Tanzania. Lancet, 2000a; 355: 1684-1687. PMID:10905244
Richard W Walker, Donald G McLarty, Gabriel Masuki, Henry M Kitange, David Whiting, Adess F Moshi, John G Massawe, Richard Amaro, Ali Mhina Dip, K G M M Alberti. Age-specific prevalence of impairment and disability relating to hemiplegic stroke in the Hai district of Northern Tanzania. Journal of Neurology, Neurosurgery and Psychiatry 2000b; 68 (6): 744-749. PMID: 10811698
R W Walker, D Whiting, N Unwin, F Mugusi, M Swai, E Aris, A Jusabani, G Kabadi, W K. Gray, M Lewanga, G Alberti. Stroke incidence in rural and urban Tanzania: a prospective community-based study. Lancet Neurology 2010; (9): 786-792. doi: 10.1016/S1474-4422(10)70144-7. Epub 2010 Jul 6. PMID:20609629.
R W Walker, A Jusabani, E Aris, W K Gray, N Unwin, M Swai, G Alberti, F Mugusi. Stroke risk factors in an incident population in urban and rural Tanzania: a prospective, community-based case-control study. Lancet Global Health, November 2013; 1 (5): e282-e288 Published on-line
A Jusabani, W K Gray, M Swai, R W Walker. Post-stroke carotid ultrasound findings from an incident Tanzanian population. Neuroepidemiology 2011; 37 (3-4): 245-248 DOI: 10.1159/000334610) PMID: 22156625
C L Dotchin, O Msuya, J Kissima, J Massawe, A Mhina , A Moshy, E Aris, A Jusabani, D Whiting, G Masuki, R W Walker. The Prevalence of Parkinson’s Disease in Rural Tanzania. Movement Disorders 2008; 23 (11): 1567-1572, PMID: 18581482
L Rochester, D Rafferty, C L Dotchin, O Msuya, V Minde, R W Walker. The Effect of Cueing Therapy on Single and Dual-Task Gait in a Drug Naïve Population of People with Parkinsons Disease in Northern Tanzania. Movement Disorders 2010; 25 (7): 906-911 PMID:20175212
J Mokaya, C L Dotchin, W K Gray, J Hooker, R W Walker.
The Accessibility of Parkinson’s Disease Medication in Kenya: Results of a National Survey. Movement Disorders Clinical Practice 2016. 3(4); 376-381. Doi:10.1002/mdc3.12294
M J Dewhurst, F Dewhurst, W K Gray, P Chaote, G P Orega. R W Walker. The high prevalence of hypertension in rural-dwelling Tanzanian older adults and the disparity between detection, treatment and control: A rule of sixths? Journal of Human Hypertension 2013 Jun; 27 (6): 374-80. doi:10.1038/jhh.2012.59. PMID: 23235367
G Hindley, J Kissima, L L Oates, S M Paddick A Kisoli, C Brandsma, W K Gray,
R W Walker, D Mushi, C L Dotchin. The role of traditional and faith healers in the treatment of dementia in Tanzania and the potential for collaboration with allopathic healthcare services. Age and Ageing. 2017 Jan 4;46(1):130-7. DOI: 10.1093/ageing/afw167
C Dotchin, R Akinyemi, W K Gray, RW Walker. Geriatric Medicine: Services and training in Africa. Age and Ageing 2013; 42 (1): 124 – 1280:1-6 AA-12-0026.R2 DOI: 10.1093/ageing/afs1 1 9, PMID: 23027519