The hidden health crisis
A decade of initiatives to combat non-communicable diseases have failed to curb their growth. Policymakers need a more comprehensive approach that recognises the complexity of these health failures and takes lessons from successful infectious disease campaigns
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As the world grapples with an unprecedented viral pandemic, which has wreaked havoc on societies and economies around the globe, non-communicable diseases (NCDs) remain a less reported, but ominous long- term threat to human health.
Taken together, NCDs, primarily cancer, cardio- vascular disease, diabetes and chronic respiratory conditions, now account for around 70% of all deaths worldwide.
In the first six months of the covid-19 pandemic, more than eight out of ten premature deaths from NCDs occurred in developing and emerging market countries, which are often facing the additional challenge of persistently high infectious disease rates at the same time. In addition, developing countries often do not have access to health services that can provide both treatments and preventative care for conditions such as high blood pressure and diabetes—services that are taken for granted in much of the industrialised world.
Although NCDs have been identified as a threat for nearly a decade, policymakers have been slow to identify them as a priority compared with dealing with infectious diseases. Yet the economic losses associated with failing to treat and prevent NCDs could be as much as $47 trillion over two decades, according to some estimates.
At least some of those losses are avoidable. Many NCDs are preventable and sufficient knowledge and recommendations already exist to reduce their prevalence. Too often, however, a complex number of interlinked factors prevent government and decision-makers from bending the curve and implementing much needed policies and behavioural change campaigns to curb risk factors such as tobacco use, lack of physical activity, unhealthy diet, harmful use of alcohol and air pollution.
The scale of these risk factors suggests that a multi-sectoral, rather than piecemeal, approach will be needed to reduce rates of the major chronic diseases. In addition, many low and middle-income countries continue to struggle with severe fiscal constraints that force them to make difficult choices about where to invest and where not to invest the scarce health resources. Yet, if evidence-based interventions could be started earlier, the disease burden in many developing countries might be lower.
Governments continue to face a range of challenges in successfully combating NCDs. Weak health infrastructure and gaps in universal health coverage have made it difficult for countries to provide comprehensive programmes that focus on the risks for NCDs. In many places, policies have often lacked political commitment, especially where they have meant taking on powerful business interests.
To see real progress, health investment needs to be targeted appropriately, especially in developing countries where NCDs have received just a fraction of international aid money. Programmes must integrate expertise on health, environment and education. Where health systems are basic and will remain so in the medium term, policymakers should look to employ both technology and community health resources to expand awareness of risk factors and help people manage their conditions. These approaches were used innovatively to combat HIV/AIDS.
Pandemic underlines challenges
Times are difficult for those pushing the NCD agenda. With the world in the grip of the covid-19 pandemic in mid 2020, the focus is necessarily on those suffering from the virus or from related unemployment. The resources of time and money thrown at tackling the virus may lead to neglect of other global health problems, including rapidly expanding levels of NCDs. The pandemic has also shone a spotlight on the inadequacies in many health systems that will need to be repaired.
“The current pandemic highlights the work that needs to be done to make sure we have strong health systems that can address both acute and chronic disease challenges,” says Cristina Parsons Perez, Capacity Development Director for the NCD Alliance. “It also shows the importance of comorbidities in the real world. People don’t present to their doctors with siloed conditions and it is precisely those people living with non-communicable diseases that are most at risk at present from coronavirus.”
The pandemic is severely disrupting care for these people, according to a World Health Organization (WHO) assessment. Almost half of countries experiencing covid-19 community transmission in May 2020 reported disrupted services for cardiovascular emergencies, including heart attacks and strokes; over half had interrupted cancer treatment, while nearly two-thirds suffered disrupted hypertension and diabetes management.
“It’s vital that countries find innovative ways to ensure that essential services for NCDs continue, even as they fight covid-19,” WHO director-general Tedros Adhanom Ghebreyesus told the global health community in June 2020.
Back in 2011, the United Nations held its first-ever High-Level Meeting on Non-Communicable Diseases in New York. It was only the second such meeting to focus on disease, after one on HIV/AIDS in 2001. Campaigners hoped the event would mark a coming of age in the fight against NCDs.
But while the 2011 event did usher in greater recognition of the issue, nearly a decade later the world is still falling far short of meeting its targets. Indeed, WHO forecasts suggest the proportional global burden of NCDs will continue its current inexorable rise through 2040, in part due to older populations.
The numbers tell a stark story. In 1990, NCDs accounted for 57.7% of all deaths worldwide but by 2017—the latest year for which data is available—this had risen to 73.4%, according to the Institute for Health Metrics and Evaluation’s Global Burden of Disease (GBD) analysis. Worryingly, the curve has shown no real sign of flattening in the past decade, and could increase further as progress is made in reducing infectious diseases and as populations continue to age.
The steady increase in the proportion of NCD fatalities among all deaths comes despite a far-reaching political declaration arising from the 2011 meeting that recognized the NCD threat as one of the major challenges for development in the 21st century. The declaration eventually led to a decision, affirmed by heads of states and governments, to include a target in the UN Sustainable Development Goals (SDG) in 2015 to reduce premature mortality related to non-communicable conditions by one third by 2030. “The 2011 meeting was a landmark event and the good news is that we now have NCDs included in the global health and development agenda. The bad news is that progress at the national level is insufficient and uneven,” says Parsons Perez. “It’s been five years since the SDG agenda was adopted. We’re ten years out from 2030 and we are not on track to meet these targets, so the situation is rather bleak.”
Shifting chronic care for HIV patients out of the formal healthcare system allowed scarce resources to reach more people. Enabling local blood pressure readings could do something similar to reduce the burden on hospitals, while at the same time offering patients added convenience
The policy failure comes despite a clear roadmap laid out for governments by the WHO, including interim targets to be achieved by 2025, such as reducing harmful alcohol consumption and physical inactivity by 10%; reducing high blood pressure by 25%; reducing salt intake and tobacco use by 30%; ensuring 80% coverage of essential NCD medicines.
Achieving these interim targets would go a long way to address the epidemiological shift in the burden of disease that has run in parallel with globalisation. As populations across Asia, Africa and Latin America adopt more urban and Western lifestyles, their prevalence of NCDs rises.
NCD Countdown 2030 is an independent collaboration of medical journal The Lancet, WHO, Imperial College London and the NCD Alliance. It warns that the SDG target to reduce by one-third premature mortality from NCDs will be achieved by fewer than one in five countries by the intended date of 2030. As a result, the world may well be faced with a tsunami of disease-related impacts, both human and economic, that could have been avoided.
Perhaps unsurprisingly, most of the countries that are on track to meet the 2030 target are developed countries where premature deaths from NCDs are already relatively low. In developing countries at the other end of the spectrum, however, mortality rates have stagnated or increased for men in 24 countries and for women in 15 countries since 2010.
Drilling down into specific conditions reveals the scale of the challenge. Only one in three countries, mainly those in the developed world, currently provide drug treatments and counselling services to prevent heart attacks and strokes, even though doctors have known for decades that cheap drugs like statins, aspirin and blood pressure pills are highly effective.
Lack of funding and poor healthcare infrastructure means access to screening and early cancer care is similarly inadequate, exposing millions of patients to unnecessary suffering from an increasingly common condition. Rates of type 2 diabetes, which is linked to obesity and lack of exercise, are also spiking particularly rapidly in the developing world.
“The real problem about obesity is the increase in the large metropolitan areas throughout the world. These large urban areas are very dependent on external food supplies, people are dissociated from food production and this leads to the consumption of a lot of unhealthy foodstuffs,” says Thomas Sanders, emeritus professor of nutrition and dietetics at King’s College London.
When the world eventually recovers from the dislocation wrought by covid-19, the strength of the arguments for tackling NCDs makes them a top priority for more investment. Countries have the opportunity to build back stronger, with multi-sectoral health policies that deliver better prevention, diagnosis and care, while stepping up the fight against the key risk factors: smoking, lack of physical activity, unhealthy diet, excessive alcohol consumption and air pollution.
It is clear that plenty can be done to reverse the dramatic growth of NCDs globally over the past couple of decades. A broader, joined-up vision of public health policy might make it easier to combat the political inertia that often undermines individual initiatives. Increased investment in health systems to build up preventative care capacity should be a key priority, especially in developing countries.
One problem is that the political payback on health initiatives, from single issue programmes like campaigns to stop smoking to far-reaching efforts to provide universal healthcare, are typically slow, so politicians are unlikely to see benefits in time for the next election. Moreover, policies such as increasing “sin” taxes on sugary drinks, alcohol and tobacco are unlikely to win many votes.
Critics complain that businesses, from Big Tobacco to Big Food, are adding to the headwinds by successfully lobbying governments to be only half-hearted in the fight. According to a recent Lancet study on the implementation of NCD policies in 151 countries, the policies recommended by the WHO that have been least widely implemented by governments around the world are tobacco taxation, anti-smoking mass-media campaigns and alcohol advertising restrictions, alongside the provision of cardiovascular therapeutics.
Despite these hurdles, health experts believe it is possible to successfully reduce NCDs by tackling health problems at their roots and influencing populations at all stages of life. This so-called “life course” approach is underpinned by evidence from a wide range of disciplines showing how chronic diseases are influenced by early life factors, according to Bente Mikkelsen, director for NCDs at the WHO’s European office.
“Many of the health problems we encounter in adulthood stem from our experiences early in life, in some cases, even from before we are born,” she and colleagues wrote in the last year. “The major non- communicable diseases are often associated with older age groups, but the evidence suggests that they affect people of all ages.”
Even before and during pregnancy, promoting healthy nutrition and regular physical activity can prevent hypertension and gestational diabetes in later life. Unborn children are adversely affected by harmful exposures such as air pollution, tobacco use and maternal consumption of alcohol. Similarly, their tendency to develop obesity may be reduced during fetal development, infancy and childhood by breast-feeding and healthy diet.
In addition, there is also growing awareness of environmental factors driving some NCDs. In recent years, new data has revealed the significant health hazards of air pollution, with research by scientists at the University Medical Centre Mainz in Germany calculating that 8.8 million early deaths a year are caused by outdoor air pollution worldwide.
“It is not a secret that air pollution is the new tobacco, so the public health implication is very clear: authorities need to act swiftly and comprehensively to protect their citizens from air pollution through science-based policy,” according to Samuel Cai, a senior epidemiologist at the George Institute for Global Health at the UK’s Oxford university.
THE BURDEN GETS HEAVIER After a decade in which NCDs received increased prominence on the global health policy agenda, progress in reversing their growth remains painstakingly slow
Lessons from HIV/AIDS
Taking proper account of so many factors affecting billions of people is clearly a formidable challenge. But global health pioneers, including Peter Piot, director of the London School of Hygiene and Tropical Medicine, believe there are useful lessons to be drawn from fighting earlier crises, in particular, the very different problem of HIV/AIDS.
One of the most important innovations in the fight against HIV was the empowerment of patients to self-manage their condition under community-based healthcare supervision.
The introduction of antiretroviral therapy from the mid-1990s made HIV the first major chronic disease that many low and middle-income countries had widespread experience of treating. Coping with the burden was very different to managing acute infections. Patients with HIV were able to return home from hospital, but they then required long-term care. The traditional public health systems could not cope, so countries across Africa turned instead to local village and family-based support, which proved remarkably successful at getting drugs to patients and conserving resources, which in turn allowed more cases to be treated.
A similar approach is possible with NCDs, Piot argues. One concrete example is a community-based blood pressure management project in Ghana, a country where one-third of adults have hypertension that is not under control. By offering blood pressure screening points in local communities, including in certain shops, and sending people mobile phone reminders, the project has been able to improve hypertension control dramatically. Significantly, hypertension control rates for patients who were followed up for 12 months doubled to 72% from 36%, resulting in an average reduction in systolic blood pressure of 12 millimetres of mercury.
Shifting chronic care for HIV patients out of the formal healthcare system allowed scarce resources to reach more people. Enabling local blood pressure readings could do something similar to reduce the burden on hospitals, while at the same time offering patients added convenience. Paying a visit to a nearby shop is a lot easier than travelling for hours to a government clinic or hospital.
Community-based civil society organisations were also a potent force in holding governments and businesses to account in fighting the HIV pandemic. It was a battle that yielded breakthroughs in making antiretroviral medicines affordable and accessible, even in the poorest settings. Similar progress is still awaited for many NCDs, especially cancer, where drugs are often hugely expensive and targeted at relatively small numbers of patients. The average cost of a newly approved cancer treatment is now around $10,000 a month, a price that stretches the budgets of even the richest countries in the world.
Jayasree Iyer, head of the Access to Medicine Foundation, a global charity, is concerned that efforts to improve access for new products to treat non-communicable diseases, particularly cancer, lag far behind those for communicable diseases.
“People say it is because the health systems are not ready, but if we keep using that argument then we are never going to actually solve the problem,” she says. “There has been quite a lot of effort, particularly in sub-Saharan Africa, to develop more community-based healthcare systems, but it doesn’t always mean treatments are getting to more patients. As long as some products are not as affordable as they need to be, you still won’t get the necessary large-scale access.”
Worryingly, even well-established products like insulin for people with diabetes are not getting to millions who need them in resource-scarce countries. A study of 15 insulin price and availability surveys— carried out in developing countries and published in the British Medical Journal in 2019—found that globally, one in two people needing insulin lacked access to it. Insulin can be especially out of reach in poorer countries with poor infrastructure because of tortuous supply chains and high markups by middlemen. “In infectious diseases we have a global approach but in NCDs we don’t,” points out Iyer, with a nod to big donor-backed organisations for infectious diseases like the Global Fund to Fight AIDS, Tuberculosis and Malaria and the international vaccine alliance Gavi.
The economic case for greater action on NCDs by all parties is not hard to make. The WHO has identified plenty of “best buy” interventions that represent good value for money in preventing the risk of patients developing chronic disease at all stages of life. These include regulations and taxation on tobacco and alcohol, promotion of healthy foods and the reformulation of products to reduce salt and sugar, and measures to cut air pollution. More broadly, better access to basic health coverage, preventative care in particular, will be necessary to reverse the NCD growth trend.
The WHO estimates that investing in its best buy strategies will yield a return of at least $7 for every $1 invested, mainly due to reduced loss of workplace productivity. The total return equates to $350 billion in aggregate economic growth in low and middle income countries between 2018 and 2030. The cost of inaction, meanwhile, is huge.
Yet despite such economic arguments, only 2% of overseas development assistance for health is currently going to NCDs, the world’s biggest cause of death from ill-health.
Late last year there was a glimmer of hope for global health campaigners when the government of Norway launched a first-ever strategy designed specifically to combat NCDs in low-income countries as a pillar of international health. “What we hope is that more countries will now follow suit,” says Parsons Perez of the NCD Alliance.
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