March 2001 Insights Health Issue #1

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Taking poverty to heart
Non-communicable diseases and the poor

Non-communicable diseases (NCDs) are the leading cause of death worldwide. Their emergence as the predominant health problem in wealthy countries accompanied economic development. As a result, NCDs are often referred to as 'diseases of affluence'. But is this a misleading term? It suggests that these are not major problems for the world's poor, which is quite simply wrong, as this issue of Insight Health illustrates. Is it time to rethink policy on NCDs?

NCDs include cardiovascular disease (CVD), such as stroke and heart attack, diabetes, chronic lung disease, cancer, diseases of bones and joints, and mental illness. The single biggest killer is coronary heart disease, followed by other CVDs, cancer and chronic lung disease. Diabetes is a major contributor to deaths from CVD, but also causes its own unique complications. Common risk factors for these conditions include smoking, physical inactivity, obesity and diets high in saturated fat and sodium and low in fruit and vegetables.

By 2020, NCDs will be the biggest cause of death in all regions apart from sub-Saharan Africa. It is predicted that in 2010, the number of people with diabetes worldwide will be double the level in 1995 and that the biggest increase (both proportionately and in absolute number) will be in poorer regions. CVD occurs at an earlier age in developing countries, increasing the potential adverse economic and social consequences. For example, when an adult dies in Bangladesh (most commonly from CVD), there is a 12-fold increase in the probability of death for children under two years in the same family.

NCDs are already major health problems for adults in the poorest countries of the world. Demographic data show that age-specific death rates from NCDs in Tanzania are higher than in wealthier countries. Mortality rates for some NCDs, such as stroke, are particularly high. However, while NCDs account for 80 percent of adult deaths in developed regions, the figure is less than 30 percent in Tanzania, reflecting the continuing burden of infectious disease. Thus, as Setel et al point out in this issue, countries like Tanzania suffer the 'worst of both worlds'.

Even within a country, 'diseases of affluence' is a misleading term. A more accurate label is 'diseases of urbanisation'. Several studies from developing countries show increased levels of high blood pressure and other NCD risk factors in urban compared to rural populations. Even within urban areas, the more affluent do not always suffer the greatest burden. Mbanya's data from an urban area of Cameroon show a mixed picture. Those with the least education have greater rates of high blood pressure and smoking but lower levels of obesity and alcohol consumption than more highly educated individuals. This pattern has also been found in urban Dar es Salaam, Tanzania, and slum areas of South-East Asia.

The rise of NCDs in developing countries is inextricably linked to economic and cultural globalisation. This is exemplified by the activities of multinational tobacco companies. Tobacco-related deaths will exceed the toll due to HIV and become the single largest preventable cause of death by 2020 (see Global Trends and Predictions). As Collin discusses, preventing this epidemic will require new transnational strategies to tackle powerful vested interests. WHO's Tobacco Free Initiative and Framework Convention on Tobacco Control provide ammunition for this fight. Curbing the effects of globalisation on the prevention and treatment of NCDs will also require regulation of food and agriculture multinationals and the pharmaceutical and healthcare industries.

Much of the projected rise in NCDs is preventable, particularly that due to smoking, poor diet, physical inactivity and obesity. Early action in some populations could prevent the emergence of these risk factors altogether; in others, the challenge is to reduce established levels. Although it is unclear whether all major risk factors are equally important in every region, the strength and consistency of data on the core risk factors in several ethnic groups justify preventative action now. Lessons from risk factor intervention studies in rich and middle income countries suggest that success requires:

• broad intersectoral action

• community participation

• appropriate legislation

• involvement of appropriate NGOs

• health services changes - to manage those at high risk and promote public education.

Bovet describes a prevention programme in the Seychelles involving many of the above features. Even apparently minor changes, such as a small fall in average population blood pressure, can have substantial benefits. However, some preventative programmes have produced disappointing results and almost all have failed to halt the ubiquitous increase in obesity. This highlights the difficulty of promoting healthy behaviour by individuals who are surrounded by barriers to change and inducements to lead an unhealthy lifestyle.

Health systems in developing countries face both a growing need for prevention programmes and increasing numbers of individuals requiring treatment. The complications of high blood pressure and diabetes can be reduced by the delivery of effective healthcare. Crucially, this entails:

• partnership between patients and health professionals with the knowledge, ability and resources to take appropriate measures over many years

• cheap and effective drugs and the implementation of simple treatment protocols, as promoted by WHO and the CVD initiative of the Global Forum for Health Research (see Sites for Sore Eyes).

• An appropriate policy and strategic framework is essential for such initiatives to be effective on a large scale. Green and Collins discuss the challenges involved.

Even in the poorest countries people are already seeking healthcare for NCDs in both the public and private sectors, particularly in urban areas. Whatever the balance of priorities between different conditions, existing resources should be used as effectively as possible. Rapid evaluation methods (see Quick decision?...) can provide policy-makers with information on the current levels and quality of care and identify the main opportunities for improving health services.

The proper planning and co-ordination of NCD prevention and treatment, whether globally or nationally, requires up-to-date data on risk factor and disease levels - currently missing for much of the world. To address this lack, the WHO Non-Communicable Disease and Mental Health Surveillance section (see Sites for Sore Eyes) is promoting a standardised approach to enable comparisons across regions and over time, preparing the first ever 'world risk status' report for the major NCDs. This will provide a truly global perspective on the size and nature of the problem.

As this issue of Health Insights has shown, NCDs are major health problems even in the world's poorest countries, including those regions where infectious diseases continue to take a huge toll. The NCD burden will grow substantially in low and middle-income countries over the next 10 to 20 years. NCDs will increasingly demand attention and require the right balance between competing priorities for prevention, cure and care. In meeting this challenge, national policy-makers will need to follow the lead of WHO and develop a strategic framework that plans for surveillance, prevention and appropriate health sector reforms.

Nigel Unwin
University of Newcastle
Departments of Diabetes and Epidemiology & Public Health
Medical School, Newcastle
NE2 4HH
UK
T: +44 (0)191 222 5407
F: +44 (0)191 222 0723
N.C.Unwin@newcastle.ac.uk