A Stitch in Time Saves Stroke: Losing African Youths to Deadly Health Scourge
Linked to hypertension and sometimes acting on its own, stroke is harvesting millions of young Africans in their prime. There is only one way to stop it. In this piece, Bayo Akinloye explores global and continental attempts and measures taken to stop stroke, a non-communicable disease (NCD), from decimating Africa’s teeming youth population
“Every second, 100 billion neurons in our brains are each firing five to 50 messages, each one a vital spark of connection that ignites our unique identity and writes the story of our life. But when a stroke strikes, that story is changed forever,” says the World Stroke Organisation as it marked this year’s World Stroke Day on October 29. This year’s campaign highlights the importance of stroke prevention and “encouraging us all to take steps to be #GreaterThan stroke.”
In Africa, stroke is striking, particularly in younger populations. Recent reports indicate that the annual incidence rate of stroke can reach up to 316 per 100,000 individuals, with prevalence rates reported as high as 1,460 per 100,000 in specific regions like Nigeria. A report conducted in Morocco found that 28.9% of stroke patients were aged between 18 and 45 years. “The predominance of ischemic strokes in this age group is concerning, as strokes typically result in significant economic and social impacts on young individuals who are often at the height of their productivity,” states the report.
According to the 100-year-old organisation, American Heart Association, stroke is a leading cause of death and severe, long-term disability. Most people who have had a first stroke also have high blood pressure. High blood pressure damages arteries throughout the body. It creates conditions that can make arteries burst or clog easily. Weakened or blocked arteries in the brain create a much higher risk for stroke. This is why managing high blood pressure is critical to reducing your risk for stroke.
The rising incidence of stroke among African youths highlights the need for improved awareness, prevention strategies, and healthcare resources tailored to this demographic. Addressing modifiable risk factors such as hypertension, obesity, and lifestyle choices will be crucial in mitigating the growing burden of stroke in Africa. Overall, while comprehensive statistics specifically detailing the number of African youths suffering from strokes are limited, the available data underscores a significant and alarming trend that necessitates urgent attention from health authorities and policymakers.
Prof Kolawole Wahab, the Head of the Stroke Unit of the University of Ilorin Teaching Hospital, warns that the high burden of stroke in Nigeria is taking an epidemic proportion. Wahab stated this while speaking on the sidelines of the free screening, consultation and treatment of hypertensive patients to mark the World Stroke Day in Ilorin on November 1, 2024. According to him, stroke is the leading cause of death and morbidity in Nigeria, and statistics show every 114 per 100,000 persons will have a stroke.
“Stroke is a leading cause of morbidity and mortality worldwide, and it is likely to worsen in developing countries. When compared to the rest of the world, Africa is having a disproportionate burden of stroke. This is because, in the developed world, the burden of stroke is reducing whereas in Africa, it is increasing,” Wahab says.
The medical expert adds, “What we see in our stroke unit is scary because out of 10 patients on admission at any particular moment, nine out of them are hypertensive.”
He discloses that most patients do not take their drugs regularly, adding that the control of hypertension leaves more to be desired, appealing that people check their blood pressure and blood sugar regularly to prevent stroke.
Dr Abiodun Bello, a consultant neurologist at UITH, describes the symptoms of stroke to include a change in balance, inability to walk well or staggering. He also said other symptoms are a weakness on one side of the body, difficulty seeing, arm weakness and speech abnormalities. Bello advised people with such symptoms to immediately seek medical attention for treatment and management.
Carol Odogwu, 40, an entrepreneur based in Lagos, Nigeria, could relate to Wahab’s observations. “I complained to a friend that I was battling a constant headache,” says Odogwu. “Two days after, I was struck by stroke. I lost control of my tongue, and part of my face became stiff. I could not feel anything on the side of my face.”
Peter Bassey’s (names have been changed) story offers more insight. He also lives to tell the tale.
A stroke story
Bassey was working in a biochemistry laboratory at the University College Hospital in Ibadan, Nigeria. Then, a colleague heard him repeatedly mutter to himself, “It is well!” Shortly after that terse statement, Bassey staggered and tried to grab the wall to avoid falling. He was rushed to the hospital’s emergency department. He was diagnosed with an ischaemic stroke. Bassey also had raised blood pressure and serum lipid concentrations, of which he was unaware. His stroke was managed conservatively because reperfusion treatment was unavailable. He was discharged after 10 days in hospital. At discharge, he was in a wheelchair. He could not handle basic activities of daily living without assistance and could neither talk nor walk unassisted.
Bassey was the main income provider for his family before his stroke and did not have health insurance. As the family income went south, he could not pay for physiotherapy or nursing services, which led to the development of joint contractures and decubitus ulcers, complicating his functional impairment. He did not have access to speech therapy either. He was unable to keep his outpatient clinic appointments, and his family considered traditional medicine. He developed post-stroke depression. About three months after discharge, he also developed a fever, difficulty breathing, and unilateral limb swelling, so he was rushed to the emergency department again. Investigations revealed that he had a deep vein thrombosis.
On November 15, 2023, one Lancet study reported that the burden of disability after a stroke is also large and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, it noted, the incidence of stroke is increasing in young and middle-aged people (55 years or less) globally. “Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met,” the research warned.
The absolute number of people affected by stroke, including those who die or remain disabled, has almost doubled in the past 30 years. Most of the contemporary stroke burden—86% of global deaths and 89% of global DALYs lost because of stroke in 2020—is in low-income and middle-income countries, according to the Lancet, and the burden of stroke is increasing faster in these places than in high-income countries. Stroke is also a leading cause of depression and dementia, which are other common non-communicable diseases (NCDs).
Most countries, particularly sub-Saharan countries, have yet to progress towards SDG 3.4 (to reduce premature mortality from NCDs by a third between 2015 and 2030). Achieving SDG 3.4 worldwide, which would, in turn, facilitate the achievement of nine other SDGs, “would require an additional $140 billion of spending on NCD interventions from 2023–30, but could help to avert 39 million deaths and generate $2·7 trillion in net economic benefits (with benefits outweighing costs by a factor of 19:1), stated a recent study.
Beyond the tragedies and griefs than numbers do not tell, the estimated direct (treatment and rehabilitation) and indirect (productivity loss) costs of stroke globally are more than $891 billion annually, illustrating the “substantial increases in the costs associated with stroke will cause distressing financial circumstances for many communities and national health systems.” The estimated aggregate economic costs of stroke, including direct costs and income losses, range from $746 billion to $1·08 trillion in 2017 prices. But by 2050, these costs are projected to rise to between $880 billion and $2·31 trillion.
The total direct costs of stroke were estimated to be R2.5–R4.2 million ($283,500–$485,000) in 2012, or 1.6–3% of the sub-district health expenditure. Of this, 80% was attributed to inpatient costs. Total costs were most sensitive to the underlying incidence rates and assumptions regarding service utilisation. “These unsustainable trends in burden and costs underline the importance of identifying interventions to prevent and manage stroke,” notes Lancet.
Countries in sub-Saharan Africa suffer severe shortages in all the above enabling areas, with many lacking any. For example, most sub-Saharan African countries have no local research funding mechanisms for stroke and rely on research funding from HICs. More data from sub-Saharan Africa is needed to address the mismatch between the disease burden and the available facilities, human resources, and funding. Nevertheless, studies from these paltry funding mechanisms have shown a higher burden and early mortality of stroke in sub-Saharan Africa. Patients with stroke in sub-Saharan Africa present with a higher prevalence of haemorrhagic stroke and at a younger age than in other regions of the world.
A similar story is told in Ghana. According to Dr Efua Commeh, the programme manager of NCDs of the Ghana Health Service, the West African country is experiencing a surge in stroke among people aged 40 and younger. Previously, in sub-Saharan Africa, stroke was synonymous with old people. Commeh says things have changed: individuals in their 30s and 40s are brought to local hospitals after being struck down in their prime by stroke.
“These strokes that originally we used to see in very aged people are now occurring in the productive work group, people who are actively working,” Commeh points out. “They bring them to the hospital, and they say nothing happened, and the person collapsed. You check them, and they have hypertension. It is this hypertension that gives them complications like stroke, heart attacks, and kidney diseases, among others.”
Commeh cites severe stress and underlying hypertension as the surging cases of stroke among young people in Ghana. “Some of them, it is pressure from school, pressure from work, pressure from the home and pressure everywhere; and on top of these stresses, closing quite late from work and getting home late before eating in the night.”
According to a published study in August 2023 by The Lancet, more people from sub-Saharan Africa aged 20 and 60 are affected by end-organ damage due to underlying hypertension than people in high-income countries. The study notes that 27 (55%) of 49 sub-Saharan African countries comprising relatively young populations are low-income countries. A combination of factors, including economic development and urbanisation, has led to an increase in many non-communicable conditions, including stroke and hypertensive heart disease. As a key indicator of cardiometabolic health, obesity rates are reportedly increasing among adolescents across sub-Saharan Africa.
“Therefore, people in sub-Saharan Africa are at risk of developing hypertension at a younger age than people living in high-income countries. Consequently, the already substantive disease burden attributable to undetected and untreated hypertension in the region is likely to increase,” the researchers state.
They added, “We believe our results support increasing calls to develop and fund appropriate policies and initiatives in sub-Saharan Africa to improve the rapid detection, formal diagnosis, and appropriate management of hypertension across the entire lifespan. Because of the high prevalence of adolescents with hypertension, most of whom were attending school, there is a strong argument to incorporate regular blood pressure monitoring into wider efforts to implement heart health monitoring in young people living in sub-Saharan Africa.
According to the report, there is also a continued need to apply proactive primary prevention strategies to address elevated blood pressure and the subsequent elevated risk of stroke and hypertensive heart disease at an early age in sub-Saharan Africa. From a research perspective, there is an urgent need to conduct a wider geographical distribution of methodologically standardised studies of elevated blood pressure among adolescents living in the region.
“Furthermore, a better understanding of the natural history of hypertension and end-organ damage is needed among people aged 20–40 years in sub-Saharan Africa. Such data will better inform efforts to reduce the future burden of hypertension-related disease in the region through targeted prevention and treatment programmes,” the researchers point out.
An earlier research conducted in 2018 noted that “stroke in lower and middle-income countries affects a young and productive age group. Data on factors associated with stroke in the young are sorely lacking from lower and middle-income countries.
“Our objective is to characterize the nature of stroke and its risk factors among young West Africans aged less than 50,” says the Lancet report.
The SIREN (Stroke Investigative Research and Educational Network), a multicentre, case–control study involving 15 sites in Nigeria and Ghana, reveals that 515 (24.3%) out of 2118 cases enrolled were less than 50 years old. The network had one conclusion: the high and rising burden of stroke among young Africans should be curtailed via aggressive, population-wide vascular risk factor control.
The study reveals that “recent trends suggest that sub-Saharan Africa now bears the highest burden of stroke worldwide with age-standardised stroke incidence rates of up to 316 per 100,000, prevalence rates of up to 14 per 1,000 population and one-month fatality rates of up to 40%. Stroke in these settings is characterised by a younger age of onset with poor long-term outcomes.” It stresses that stroke among young adults has devastating consequences because of the longer-lasting impact of stroke-related disability on quality of life and productivity.
“Very little is known about the burden, risk factors, and features of stroke among young West Africans. Given that stroke in sub-Saharan Africa levies a heavy economic toll by affecting a relatively younger age group, it is necessary to stem the rising tide of stroke by identifying risk factors for stroke among this productive segment of the population. Such data are crucial in designing evidence-based, context-specific public health interventions aimed at stroke prevention in a region at the throes of an epidemiological transition,” SIREN adds.
A journalist’s stroke story
“A stroke is a life-altering event, marking a clear divide between the life you knew before and the one after. Everything changes – you change, but you can come through it and prevail,” says Andrea Vianello, now 63, who suffered a stroke five years ago.
Vianello adds, “My stroke left me unable to speak. As a journalist, words have always been my banner, my identity, and the tool of my trade, so losing that ability was a significant blow. At first, I couldn’t even say my children’s names. Then, thanks to a long and challenging rehabilitation process, along with the support of my family, I relearned how to speak and returned to work in less than two years.
“Not everyone is as lucky as I have been. On the morning of my stroke, everything happened at just the right time. My wife acted swiftly, calling emergency services immediately. The responders quickly recognized the signs of a stroke and rushed me to the nearest hospital, where the stroke unit had already been alerted. The doctors were ready with the right treatment tailored to my needs, and I later received the necessary rehabilitation services.”
Sifting through sands of stroke
In the November 2023 document cited at the outset, Lancet forecasted that stroke mortality by 2050 will increase from 6·6 million in 2020 to 9·7 million in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million in 2020, to 189·3 million in 2050.
“These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation,” said the researchers. “We have also identified the barriers to, and facilitators for, the achievement of these four pillars.”
The study pointed to “identified and prioritised” recommendations, stressing that for each of the four pillars (surveillance, prevention, acute care, and rehabilitation), and proposed “pragmatic solutions” for the implementation of evidence-based interventions to reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.
How to treat stroke
A 2021 study published in the International Journal of Stroke investigated the state of stroke services globally, revealing a significant difference between stroke units in low-income and high-income countries. While stroke units were found in 91% of high-income countries, they were only found in 18% of low-income countries.
The Nigerian Stroke Organisation recommends treating all stroke patients in a dedicated stroke unit. Still, the number of stroke units in Nigeria and how they are organised have yet to be well known.
“We wanted to explore the number of stroke units in Nigeria and how they are structured. Not only would this help us understand the current state of services, but it would also provide us with information about how to best improve outcomes for stroke patients in Nigeria,” says a team of researchers, including Dr Babawale Arabambi, who set out to learn more about the state of stroke units in Nigeria.
They identified five centres with stroke-specific units, with the oldest established in 2010 and the newest in 2021. Based on the number of patients admitted to the five centres with CT scanners and ECG machines alone, “we believe that creation of more stroke units is certainly needed at other hospitals in Nigeria,” they state.
When the researchers looked at the organisation and structure of these units, they established that all stroke units had the infrastructure for basic-level stroke investigations, and most had multidisciplinary stroke teams. However, the researchers note that the use of reperfusion therapies was low, indicating that “thrombolytic therapies were not commonly used, and none of the stroke units had the resources to be able to perform thrombectomy,” due to the high cost of these therapies in Nigeria, and delayed stroke presentation to the hospital.
Et tu Ghana?
To raise awareness at Korle Bu Teaching Hospital, Ofei-Palm (President of the Korle Bu Senior Staff Association) and his team investigated cases of fatality for stroke patients in their hospital in 2007. Korle Bu Teaching Hospital (founded in 1923 and gained its current status in 1962) is located in the Ablekuma District of Accra, Ghana. It is considered the largest teaching hospital in Ghana, with a bed capacity of 2,000 and is the third biggest hospital in Africa.
“Stroke was the third leading cause of admission to our hospital in 2007,” explains Ofei-Palm. “Not only this, but it was also the leading cause of death in our hospital that year. In terms of age, we saw that most of our admissions were in those below the age of 65, and our highest stroke admission rates were seen in those between the ages of 45 and 54.
Striking out stroke
On August 22, 2024, the Nigerian government launched four policy documents aimed at addressing the rising burden of NCDs in the country. The documents were launched in Abuja by the Coordinating Minister of Health and Social Welfare, Prof. Ali Pate. The documents include the National Policy for the Prevention and Control of NCDs, the National NCD Task-Shifting and Task-Sharing (NTSTS) Policy and the National Guideline for the Prevention and Management of Hypertension. Others are the National Tobacco Control Strategic Plan of Action (2024 – 2028), Newsletter for People Living with NCDs (PLWNCDs) and the Federal Republic of Nigeria Official Gazette – Fats, Oils, and Food Containing Fats and Oils Regulations 2022.
“These conditions account for 27 per cent of all annual deaths in our country, equating to approximately 447,800 lives lost each year. Many of these deaths are premature, occurring between the ages of 30 and 70, highlighting the urgency of our intervention,” says Pate. “These challenges are exacerbated by demographic and epidemiological transitions, as well as the adoption of unhealthy lifestyles such as tobacco use, alcohol consumption, poor diets, and physical inactivity.”
NCDs are a significant health problem in Nigeria. The age-standardised mortality rate across four major NCDs (Cardiovascular Disease, Chronic Respiratory Disease, Cancer and Diabetes) was 565 per 100,000 in males and 546 in females in 2021, according to the 2023 WHO’s disease outlook for the West African nation. It says Nigeria has implemented efforts on the NCD progress indicators in areas including the NCD policy and plan, tobacco taxes, tobacco advertising bans, tobacco health warnings, and alcohol taxes. However, there needs to be more progress against a subset of the indicators. These include tobacco smoke-free/pollution, tobacco media campaigns, salt policies, trans fat policies, marketing to children, and physical activity awareness.
Similarly, NCDs are a significant health problem in Ghana. The age-standardised mortality rate across four major NCDs (Cardiovascular Disease, Chronic Respiratory Disease, Cancer and Diabetes) was high at 750 per 100,000 in males and 563 in females in 2021. Ghana has implemented initial efforts on NCD guidelines just like its neighbour, Nigeria. In April 2022, Ghana launched its updated NCD Policy and Strategic Plan, prioritising a strategic plan to ensure that all actions taken are inclusive of community voices, particularly those living with NCDs
According to the Lancet scientists, measures to facilitate this goal include the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension. Others are planning and delivering acute stroke care services, including establishing stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally).
The researchers further listed the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other healthcare providers working in stroke rehabilitation, and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders as other measures.
Since stroke “is highly preventable and treatable,” health experts recommend that governments, health ministries, and other stakeholders apply the pragmatic approaches suggested by the Lancet. In these poorer countries, the proportion of global stroke deaths is projected to increase from 86% in 2020 to 91% in 2050. That is, more than 90% of the deaths caused by stroke worldwide will occur in areas like sub-Saharan Africa by 2050 “if circumstances remain the same as today,” Lancet scientists warn.
Urgent measures to reduce stroke burden worldwide are needed, with an emphasis on low- and middle-income countries, to increase a trained healthcare workforce that can implement effective primary prevention strategies, including the early detection and adequate management of hypertension. Asia’s share of global stroke deaths would rise from 61·3% of the global total in 2020 (about 4·1 million) to about 68·9% of global deaths from stroke in 2050 (around 6·6 million deaths). The proportion of annual global stroke deaths that sub-Saharan African countries will contribute, although smaller than that contributed by Asia, will also rise from 6·2% in 2020 to 8·0% in 2050. Therefore, by 2050, the economic implications of stroke will be considerable, and they are more likely to be felt in Asia and Africa than elsewhere.
Effective interventions could result in substantial economic gains (because of reduced treatment and rehabilitation expenses). Evidence suggests that achieving the Sustainable Development Goals and WHO health targets with low-cost interventions—that is, early detection and adequate control of hypertension, reduction of salt content in processed foods, and smoking cessation campaigns—that cost less than US$1 per person per day in low-income countries and less than $3 a day in middle-income countries could reduce mortality from stroke and ischaemic heart disease by about 10%.
Another promising strategy to reduce stroke incidence and mortality is population-wide primary prevention across the lifespan. It has been estimated that, for every $1 spent on the prevention of stroke and cardiovascular disease, there is a more than $10 return on investment. Additionally, primary prevention efforts directed at stroke would probably yield large gains because of the secondary effects of reducing the risk of heart disease, type 2 diabetes, dementia, and some types of cancer that share common risk factors, thus supporting achievements for a range of Sustainable Development Goals.
In Ghana, a sextet of researchers, Joseph Attakorah, Kofi Mensah, Peter Yamoah, Ebenezer Wiafe, Varsha Bangalee, and Frasia Oosthuizen, stress the urgent need for both clinical and public health measures to minimise the burden of stroke in Ghana, warning that the “burden of stroke in Ghana is now evident and substantial and can no longer be swept under the carpet.
“As life expectancy increases in Ghana, the number of people who will experience a stroke will increase significantly soon. It is therefore imperative that urgent measures be taken to reduce the risks and thereby optimize the health outcomes for stroke and other CVDs in Ghana,” the researchers point out in their report published last October titled ‘A Systematic Review of the Burden of Stroke in Ghana’.
They explain that stroke prevention is best accomplished by controlling risk factors, particularly hypertension, and call for a strong political commitment to promote relevant policy and environmental changes to support adequate education and prevention programmes in Ghana. “The establishment of national guidelines for prevention, detection, treatment, and control of stroke and risk factors such as hypertension will be a tangible essential step,” states the group of researchers.
“It has been shown that there have not been many studies done to analyse the burden of stroke in prevalence, incidence, and mortality in Ghana for the past 20 years. Hence, there is a need for more studies to be conducted in this area to draw a better conclusion, which will inform policy,” add the Ghanaian scientists. “Policymakers, as well as local and national organisations, need sustained and intensified educational efforts to promote knowledge of stroke, particularly among high-risk groups, especially elderly, and improve funding for health infrastructures, provision of medical instruments (CT scanner and MRI scans), and availability of skilled personnel to managed cerebrovascular disease in Ghana.”
Although Bassey had an inadequate support system as a result of major gaps in the availability of acute care and organisation of post-stroke rehabilitation services in Nigeria, the provision of educational materials to him or his caregivers about self-management and some rehabilitation tips could have gone a long way towards avoiding some of the complications he experienced after discharge, notes Lancet researchers. Furthermore, community-based rehabilitation, generally less expensive than hospital care, could have been useful, or perhaps telemedicine-based care.
