Burden of disease in francophone Africa 1990–2017: the triple penalty?
Authors: Yap Boum, Yvonne Mburu
Journal: The Lancet Global Health (2020)

Recently, several francophone countries in Africa have become the epicentre of major infectious disease outbreaks. In 2014, Guinea contended with Ebola, and currently the Democratic Republic of Congo is facing the world's worst measles outbreak.1World Health OrganizationDeaths from Democratic Republic of the Congo measles outbreak top 6000.https://www.afro.who.int/news/deaths-democratic-republic-congo-measles-outbreak-top-6000Date accessed: January 29, 2020Google Scholar Given this situation, it is worth taking a look at potential differences between anglophone and francophone regions. Such reflection can serve as a first step towards attracting the resources, partnerships, and commitments necessary to mobilise attention to francophone Africa's disproportionately low rankings on all human development indices. Health data, particularly on disease burden, remain scarce. The systematic analysis in The Lancet Global Health by Charbel El Bcheraoui and colleagues2El Bcheraoui C Mimche H Miangotar Y et al.Burden of disease in francophone Africa, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet Glob Health. 2020; 8: e341-e351Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar is therefore welcome. It provides crucial information on burden of disease, allowing for a more targeted approach to seeking solutions and sharing resources between francophone countries to tackle common challenges.3The Lancet Public HealthTwo days in Abidjan: finding the voice of francophone Africa.Lancet Public Health. 2017; 2: e56Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Such focus is important in addressing what can be referred to as a triple penalty borne by francophone African countries. The first penalty is reflected in the fact that these countries bear the highest burden of diseases in Africa. One key finding from El Bcheraoui and colleagues' analysis is a nearly 50% decline in mortality and morbidity between 1990 and 2017 in francophone countries. Although encouraging, the current number of deaths (779 per 100 000 population) remains remarkably high despite the heterogeneity between countries, with the Seychelles being the healthiest country with 29 200 disability-adjusted life-years (DALYs) per 100 000 population and a life expectancy at birth of 73·6 years, compared with the Central African Republic, which recorded the highest burden of morbidity with 89 700 DALYs per 100 000 population and the lowest life expectancy of 51·9 years. The high burden of disease was mainly due to malaria, lower respiratory infections, neonatal disorders, and diarrhoeal diseases. Unlike in anglophone countries, where HIV/AIDS has become the leading cause of death,2El Bcheraoui C Mimche H Miangotar Y et al.Burden of disease in francophone Africa, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet Glob Health. 2020; 8: e341-e351Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar the top five killers in francophone countries remain diseases of poverty and other structural barriers. All are preventable diseases—for example, through protection such as mosquito nets for malaria, vaccines for lower respiratory infections, or adequate hygiene for diarrhoeal diseases. As noted by El Bcheraoui and colleagues, the fact that years of life lost (YLLs) represent the majority of DALYs for the top five causes of death in francophone countries emphasises the weakness of the health-care system. The second penalty lies in the fact that, despite carrying the highest burden of disease, francophone countries receive the lowest funds globally.4Confraria H Wang L Medical research versus disease burden in Africa.Research Policy. 2020; 49103916Crossref Scopus (6) Google Scholar In fact, the ratio between their share of the burden of disease and their share of medical research funding is 29:1 for west African countries, compared with 16:1 for east African countries and 3:1 for southern African countries.4Confraria H Wang L Medical research versus disease burden in Africa.Research Policy. 2020; 49103916Crossref Scopus (6) Google Scholar Most non-African public funding institutions (eg, the US National Institutes of Health, USAID, and the UK Medical Research Council), followed by philanthropic funding institutions (eg, the Wellcome Trust and the Bill & Melinda Gates Foundation), make particularly large contributions in eastern and southern African countries that are mostly anglophone.4Confraria H Wang L Medical research versus disease burden in Africa.Research Policy. 2020; 49103916Crossref Scopus (6) Google Scholar However, some multilateral institutions, such as the Global Fund, are investing at least some resources in francophone countries, yet the ability of these countries to manage these funds is limited. The third penalty is directly linked to the inequalities that arise from the dominance of the English language in global health. As English is the de-facto language of science, most funding opportunities and scientific papers are published in English. For the majority of non-English-speaking researchers, this situation is a real impediment to accessing these opportunities.5Roca A Boum Y Wachsmuth I Plaidoyer contre l'exclusion des francophones dans la recherche en santé mondiale.Lancet Glob Health. 2019; 7: 701-702Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Even when they manage to perform crucial research that could impact the burden of disease in their countries, francophone researchers struggle to publish as first or senior authors because of this language barrier. They are therefore not telling their own story.6Boum Y Burns BF Siedner M Mburu Y Bukusi E Haberer JE Advancing equitable global health research partnerships in Africa.BMJ Glob Health. 2018; 3: 5-8Google Scholar, 7Mbaye R Gebeyehu R Hossmann S et al.Who is telling the story? A systematic review of authorship for infectious disease research conducted in Africa, 1980–2016.BMJ Glob Health. 2019; 4e001855Crossref PubMed Scopus (28) Google Scholar These limitations, coupled with the difficulties local actors have in accessing available health information in their own language, probably contribute to the disproportionate burden of disease seen in francophone African countries. A major contribution of El Bcheraoui and colleagues' study in this issue is that a full version of the Article is published in French alongside the English version, for which the authors and the journal should be commended. A more equitable publication system would—and should—make this format the norm for all research conducted in countries where English is not an official language. 60 years after their independence, it is remarkable that African countries are still distinguished on the basis of their colonial languages. And while a common language unites countries that carry this triple penalty, the challenges they face obviously cannot be attributed to language only, but also to poorer governance structures. Capacity building initiatives by anglophone institutions in francophone countries are taking place8Linnander E Nolna SK Mwinsongo A Bechtold K Boum Y Reaching across the linguistic divide in management and leadership education.Lancet Glob Health. 2019; 7e1177Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar and should be encouraged, as recommended by El Bcheraoui and colleagues. The high burden of disease and low funding create opportunities for new players, including African philanthropists particularly from the francophone world (sports stars, business leaders, corporates, and African diaspora), to catalyse public investments in health care. Start-ups, such as Nexakili are playing a pivotal role in building innovation ecosystems that catalyse knowledge circulation between anglophone and francophone countries and contribute effectively to making regional integration a reality. There is, of course, a secret sauce: good governance, which is the key to coordinating the efforts of well intentioned actors involved in global health today. We declare no competing interests. Download .pdf (.1 MB) Help with pdf files French translation of the comment Burden of disease in francophone Africa, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017Francophone Africa still carries a high burden of communicable and neonatal diseases, probably due to the weakness of health-care systems and services, as evidenced by the almost complete attribution of DALYs to YLLs. To cope with this burden of disease, francophone Africa should define its priorities and invest more resources in health-system strengthening and in the quality and quantity of health-care services, especially in rural and remote areas. The region could also be prioritised in terms of technical and financial assistance focused on achieving these goals, as much as on demographic investments including education and family planning. Full-Text PDF Open Access