Atul Gawande recently wrote in The New Yorker that important ideas may “attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful…” While he was referring to public health initiatives, this statement is particularly applicable to the non-communicable disease (NCD) crises around the world.
Until very recently, NCDs were in the remote background of a global health agenda dominated by infectious and maternal/neonatal ailments in lower- and middle-income countries (LMIC). And in fact, globally deaths from communicable, maternal, neonatal and nutritional causes dropped from 34% in 1990 to 25% in 2010. At the same time, however, NCDs have continued to increase and today account for almost two-thirds of deaths worldwide. Cardiovascular disease alone is the leading cause of death with 80% of those deaths occurring in LMIC.
Following widespread improvements in sanitation, immunization, nutrition and housing in high-income countries (HIC) during the early 20th century, declines in the morbidity and mortality of infection and malnutrition gave way to the emergence of hypertension, stroke, and coronary disease. Increasing prosperity, population growth, and longer lifespans helped usher in NCDs as the new public health epidemic. Urbanization and industrialization contributed modifiable risk factors (including tobacco use, unhealthy diet, low physical activity, excess alcohol, and environmental exposures) which set the stage for the four predominant NCD categories: cancer, diabetes, chronic pulmonary disease, and cardiovascular disease (CVD).
In the second half of the 20th century, consequently, focus shifted to these diseases. High income countries such as the U.S. showed impressive declines in NCD mortality rates due largely to targeted intervention and population measures to reduce risk factors.
JSI works in Indonesia, utilizing community health workers to diagnose hypertension in lower resource settings
During this same period, NCDs were rapidly increasing in low and middle income countries, resembling the trends seen in high income countries nearly a century earlier, with a striking disease burden and socio-economic impact. Furthermore, cardiovascular disease mortality rates tend to be higher in LMIC than in most western HICs and occur at a younger age (29% of all CVD deaths occur in people under age 60 in LMIC compared to 13% in HIC). Exacerbating this unequal burden are demographic shifts—2010 estimates had roughly 70% of the world’s elderly living in low and middle income countries. These figures are sobering, especially given the persistent health issues of communicable diseases and malnutrition which continue to flourish in these countries. Paradoxically, communicable diseases such as rheumatic heart disease are also atypical causes of NCDs in these countries.
The relationship between malnutrition and NCDs is also being examined in LMIC. In many LMICs over-nutrition contributes to obesity in higher income brackets while malnutrition and over-consumption of low-nutrition foods are greater problems in lower income groups. This malnutrition or under nutrition has led to the postulation of the Barker hypothesis: that people exposed to maternal and early-life malnutrition carry greater risks for NCDs as adults. The thrifty phenotype may be an adaptive maternal effect of malnutrition, imparting genetic programming during gestation that increases vulnerability to CVD and diabetes later in life. This concept and others are currently being studied in greater detail, and the results may provide important information and better understanding of the NCD epidemic in LMIC.
Understanding NCDs is crucial as the extensive medical and socio-economic effects of NCDs are both causes and consequences of poverty. Poverty and poor living conditions impede healthy lifestyle choices and increase the propensity for risk factor exposure and overall NCD development. The health inequalities seen in HICs are due to greater levels of behavioral risk factors and lower access to quality care for citizens at lower socioeconomic levels.
The financial implications of disease and disability, combined with the costs of long-term management, are major causes of impoverishment and barriers to socio-economic development. The annual financial burden on low and middle income countries is estimated at $500 billion, as every 10% rise in mortality associated with NCDs, overall economic growth is reduced by 0.5%. The World Economic Forum now ranks NCDs in the top five threats to global economic development worldwide.
With such a significant socio-economic impact and such profound medical implications for populations, the global health communities attention on NCDs, is timely—and essential—to halt the trends.
**This article was originally published on October 30, 2013 by the Global Health Council.