- Becky McCall — United Kingdom
Integrated health care has to happen
The covid-19 pandemic has illustrated how chances of recovery from a severe infectious disease are strongly influenced by the presence, or not, of a non infectious disease. People without underlying health issues are far less likely to succumb to covid-19. As societies age, health care must better integrate the care of NCDs with that of other diseases. It will save both lives and money.
The coronavirus pandemic has left little untouched, health services and systems included. Non-communicable diseases (NCDs) have heavily contributed to severe disease and death from covid-19, emphasising the close relationship between NCDs and infectious disease (ID), and reinvigorating the need for policies and plans for improved integration of health care.
Covid-19 has hit high, middle-and-low-income economies alike, and become a huge stress test for different countries. “One would never think that high-income countries with advanced healthcare systems would be put in serious difficulties by an infectious disease, but they were,” says Cherian Varghese, cross-cutting lead for NCD and special initiatives at the World Health Organization (WHO). “This brought in a new realisation about the need for preparedness for IDs and better control of NCDs and we need to build back better and be better prepared.”
The pandemic has provided a tiny glimpse of a growing, global problem. People living with more than one disease (NCD or ID), so-called multi-morbidity, usually die younger and experience greater physical and social impairment, and poorer quality of life. Estimates of the proportion of people living with multi-morbidity range between 14% and 68% in low-and-middle-income countries. The data reinforce the need to avoid treating NCDs in isolation and present a clear opportunity to further integrate the care strategies for people with multiple illnesses.
Richard Sullivan, professor of cancer and global health at King’s College London, worked during past peaks of the pandemic in clinical care of covid-19 patients and on international biosecurity aspects. He highlights the impact of obesity/overweight on disease severity. “We had wards full of people who had serious weight issues,” he says. Covid-19 has exposed public health weaknesses, Sullivan points out. “Covid-19 has shown us the vulnerability of ageing societies and poor public health.
As our societies become older and sicker, there is little sign of compression of morbidity and as such we are losing our intrinsic resilience. The covid-19 pandemic has ruthlessly highlighted unhealthy lifestyle and obesity.”
Dual disease of burden
NCDs are often referred to as chronic diseases and are categorised into five main groups: cardiovascular diseases (CVD), cancers, chronic respiratory diseases, diabetes, and mental disorders. Together, they account for 63% of all deaths (36 million out of 57 million global deaths) and 80% in low-and-middle-income countries.
Over the next decade, the prevalence of NCDs will increase by 17% globally and in Africa by 27%, stressing the acute need to find a workable way to manage the burden, especially in lower income countries. The problem is compounded by the added burden of infectious diseases. Novel data from a study tracking the development of NCDs in people diagnosed with HIV between 1985 and 2017 shows that, on the one hand, there has been an encouraging decline in death rates over the course of the HIV epidemic, but on the other, this success has been somewhat marred by the persistent higher burden of NCDs in the HIV-positive population. At the ten year follow up, the study found that the proportion of HIV-positive individuals with at least one NCD increased to 42% from 24% a decade earlier. In particular, the ten-year cumulative incidence of liver disease was nine times that of the control group without HIV; and kidney disease was found in 4.1% of people with HIV, compared to 1.2% of those without HIV.
Low-and-middle-income countries still lagging behind
NCD management has a mixed history. Prior to World War II, North America and Europe improved their health primarily due to advances in hygiene and sanitation. As living standards improved, life expectancy increased and NCDs became more common. LMICs lagged behind and around the mid-20th century, infectious diseases, combined with malnutrition and poor maternal and child health plagued these regions.
In 1978, the Alma-Ata declaration articulated the need for comprehensive primary healthcare for all countries. Many of these best intentions later got waylaid when the Millennium Development Goals siphoned much of available funding into disease specific initiatives, typically HIV/AIDS, malaria, and tuberculosis. Universal healthcare programmes that addressed the burden of NCDs took a backseat, says WHO’s Varghese, co-author of a 2019 report, Better Health and Wellbeing for Billion More People: Integrating Non-Communicable Diseases in Primary Health Care.
In lower-income countries in Africa and Asia, the effort to control infectious diseases has paid off, with people living longer over the past 25 years. But at the same time, as life expectancy increased, people started to shift from typically active, rural lifestyles to more sedentary and urban living. The change was reflected in a rise in NCDs. Likewise, NCD risk factors also rose, notably obesity, poor diet, tobacco and alcohol misuse.
In India, for example, health services are dealing with outbreaks of malaria and dengue at the same time as managing cancer services
Despite significant improvements, infectious diseases persist in low-and-middle-income countries. Moreover, as seen with covid-19, not even high-income countries are immune to the devastating effects of such diseases. Sullivan, in his global health role, has worked across Afghanistan, South Sudan, India and Pakistan. “There is a paradox between the healthcare available for NCDs and that for infectious diseases in many low-and-middle-income countries,” he notes. “In India, for example, health services are dealing with outbreaks of malaria and dengue at the same time as managing cancer services. The Tata Memorial Centre in Mumbai delivers cancer care equivalent to a comprehensive cancer centre in the US, while in the same city people are succumbing to infectious diseases and malnutrition.”
Varghese compares managing infectious diseases to a 100-metre sprint, while NCDs are a marathon. “The health system is not prepared to look after this person who is running a very long distance. This is currently a fundamental weakness, but we can start to tackle it by some of the new approaches that came out of the pandemic and through universal health coverage,” he says.
By way of example, he mentions the rapid approval of some medicines for the treatment of covid-19: the generation of evidence was fast tracked to show that systemic corticosteroids rather than no corticosteroids helped improve the outcome for patients with severe and critical covid-19. Other examples from the pandemic include decentralised care, where local providers were given greater control of patient management, including routine care, without having to interact with higher levels of the health system. Further innovations included prescribing for longer durations to limit the number of clinic visits patients need to make, as well as the expansive adoption of telemedicine and self-care. “Covid-19 propelled a lot of things that were waiting at the threshold, over it. But we need to clarify the cross-over between NCDs and infectious diseases because otherwise, without a healthier population, both infectious diseases and NCDs will come and hit us again,” says Varghese.
Medical advances account for many improved outcomes in health, but not all. Sometimes a rethink of the healthcare infrastructure alone will deliver substantial patient benefit. In a low-income setting, travel to a healthcare facility can take a whole day and sacrifice a day’s wages. “In Afghanistan, people move to Pakistan to access cancer care,” Sullivan says. Practical changes to health care delivery alone can reap significant reward.
A project in Ethiopia has investigated the feasibility of conducting health checks when people are already at the clinic because it might be a long time before they return. Dr Netsanet Fetene Wendimagegn is a clinician and public health specialist at the Yale Global Health Leadership Institute in Addis Ababa, Ethiopia. Drawing on his experience within the Ethiopian healthcare system, he has developed an Integrated Healthcare Services (IHS) framework for an holistic approach to patient care. It draws on the continuity of care needed between chronic NCDs and their risk factors on one side of the balance and infectious and nutrition-related diseases on the other. “It aims to address the relationships among predisposing factors to NCDs along with the type of interventions needed at every step,” Wendimagegn explains.
He determined the four most common risk behaviours as tobacco use, misuse of alcohol, unhealthy diets, and a lack of physical activity. They lead to four key metabolic changes: raised blood pressure, overweight/obesity, hyperglycaemia (high blood sugar) and hyperlipidaemia (high blood lipids), all of which are intermediate risk factors for chronic NCDs. “A relatively small number of risk factors account for a large share of the disease burden. We need to identify and act upon these early,” he says.
Two approaches have emerged as being potentially suitable for implementation: case finding and preventative examinations. The first involves following up on undiagnosed symptoms or diseases during patients’ routine hospital visits, which meets the aim of viewing patients’ health needs beyond their presenting illness. The second is conducting periodic health examinations for disease prevention and health promotion during clinic visits. For case finding, hypertension, cervical cancer, diabetes, breast cancer, HIV and tuberculosis were all determined as plausible targets by Wendimagegn and clinicians. “The IHS framework focuses on the holistic needs of the patient. The health promotion and prevention needs of both symptomatic and asymptomatic patients is addressed along with the curative services,” states Wendimagegn.
Another structure for integrated healthcare has been developed in a cross-Atlantic co-operation between North America and England and dubbed the “flex-competence©” approach. Behind it is Dr Norman Coleman, senior scientific advisor to the International Cancer Expert Corps, an international organisation that aims to transform global cancer care, working with colleagues from the University of Pennsylvania Perelman School of Medicine, the United States Embassy in Mexico and England’s Oxford university. The concept supports an integrated approach to routine care for NCDs, including cancer, while being able to rapidly adapt to changing needs as presented by infectious diseases and other catastrophic incidents; a prime example is the surge capacity required for the recent covid-19 pandemic.
The cross-over between cancer and infectious disease via disease-causing mechanisms is clear. Human papilloma virus (HPV), which causes cervical cancer, is a case in point, while hepatitis C can lead to liver cancer.
Essential NCD interventions
WHO has developed and launched a Package of Essential Non-communicable Disease Interventions (WHO PEN) for use in primary care in low-resource settings. “This package of NCD interventions covers CVD, diabetes, chronic lung diseases, pain management and palliative care, and created a set of protocols that we felt all facilities could manage to prevent life-threatening complications such as heart attacks, stroke, kidney failure, amputations, and blindness,” says Varghese.
Underpinning the WHO-PEN cross-cutting approach is management of multi-morbidity. “It’s important to see the person as one entity. Take an average middle-aged person from an average income country, it is very unlikely that person has only one adverse health condition,” he says. “They’ll usually have high blood pressure, possibly some cholesterol abnormality, or high blood sugar. They might also have issues with smoking or alcohol.”
A project in Bhutan illustrates what can be achieved with a structured approach like that of WHO-PEN. Here, interventions were implemented in two primary healthcare settings where patients were assessed over three months for the effect of the interventions on their cardiovascular outcomes. Among the 444 patients who completed three follow-up visits, the proportion with high ten-year cardiovascular disease risk declined from 13% to 7.3% and among those with hypertension, use of medication increased and high blood pressure declined from 42.3% to 21.5%. Among 115 persons with diabetes, use of anti-diabetes medication increased and high blood sugar declined from 68/100 to 51/100.
Social and commercial influence
Underpinning models of integrated care and novel point-of-care services lie the social and commercial determinants of health that the pandemic has highlighted and that serve as both barriers and enablers to prevention, diagnosis and treatment, says Victoria Haldane, health services researcher at University of Toronto in Canada. “We saw the disproportionate impact of Covid on different communities globally. It’s looking beyond hospital beds to income, employment, education and other wider determinants,” she points out. “When I think of health care and health systems since the pandemic, my lens has spread wider. Healthcare can be an anchor institution in society. We can’t just take a piecemeal approach and take point-of-care without looking broader.”
Haldane also stresses the importance of focusing care on people and nurturing trust to optimise integrated care interventions. “In low-income countries, we see effective community models of care that have played a huge role during the pandemic,” she says, highlighting the example of how community health workers in Thailand leveraged their long-established networks built on trust among local residents to effectively mobilise surveillance and prevention activities. “Thailand had a lot of experience with avian influenza previous to the pandemic, so when Covid hit, systems were already in place that they could add to or pivot to respond,” Haldane says. “We need to draw on these examples as ways to integrate care of NCDs and IDs and consider this in our preparedness arsenal in low, as well as high-income countries.”
Integrating care across NCDs and combinations of NCDs and infectious diseases, is a huge and unwieldy challenge. Best-laid plans, programmes and packages have met with success, but NCDs continue to gather momentum and escape many of these efforts. If there is a silver lining to the covid-19 pandemic, it has given global health a booster shot, awakening the sleeping giant that is integrated NCD care. •
TEXT Becky McCall — ILLUSTRATION Trine Natskår