A public health emergency in slow motion

Governments and global health agencies turned a blind eye to the threat of noncommunicable diseases as they thought that these were problems of the rich countries.
(Express Illustrations | Soumyadip Sinha)
(Express Illustrations | Soumyadip Sinha)

About 15 years ago, speaking at a global health conference, I described the rising threat of non-communicable diseases (NCDs) as a public health emergency in slow motion. Relaxation of patent protection rules was permitted for responding to a public health emergency (PHE) under the Doha Declaration of the World Trade Organisation. I argued for its extension to medicines and technologies needed to provide essential healthcare for NCDs.

The Secretary-General of the United Nations later described a PHE when a high-level global leadership meeting was convened in 2011 to adopt a political declaration on the prevention and control of NCDs. The declaration acknowledged NCDs as the leading cause of death and disability the world over. While low and middle-income countries (LMICs) contributed to 70% of the global deaths due to NCDs, 90% of those deaths occurred below 70 years of age.

NCDs were not listed in the Millennium Development Goals of 2000, despite being the leading causes of death. International aid agencies declined to consider them while providing development assistance to LMICs, as did the World Bank. Governments of LMICs, too, did not accord priority to NCDs, guided as they were by the funding priorities of donor countries.

NCDs encompass many ‘non-infectious’ conditions affecting the heart, blood vessels, nervous system, lungs, kidneys, liver and gastrointestinal system, bones and joints, eyes, ears and oral health. They include cancers and diabetes. Despite the name, some of the conditions classed as NCDs have an infectious aetiology, like cancers of the cervix, stomach and liver, and rheumatic heart disease. The term ‘chronic diseases’ is preferred by some, but acute heart attacks and brain strokes challenge that description.

WHO identified four major NCDs (cardiovascular disease, cancers, diabetes and chronic respiratory diseases) as priorities in 2011. It also listed unhealthy diets, physical inactivity, tobacco and alcohol as four common risk factors linking these four major NCDs (‘4 by 4’). In 2018, the WHO added mental health disorders to the NCDs and air pollution to the risk factors (‘5 by 5’) to expand the priority list for global health action.

Why did governments and global health agencies turn a blind eye to the threat of NCDs for so long? Reasons were partly related to the ambiguous nomenclature of NCDs but mostly due to a misconception that these diseases were only problems of the rich countries and the rich within LMICs. Infectious diseases, nutritional disorders and conditions that compromised maternal and child health were considered health challenges for the poor. Some World Bank economists published a policy brief in 1999, ahead of the MDG debates in 2000, arguing that attention to NCDs will cause neglect of the diseases that affect the poor. This misplaced thesis did not reflect the state of global health then.

NCDs first started in Europe and North America among the rich who had the means to avidly consume new tobacco products, fat, sugar and salt-rich foods, and adopt labour-saving devices. However, mass production of these mediators of risk led to other sections of the society later succumbing to unhealthy behaviours. The rich were the first to use the emerging knowledge on risk factors of NCDs. Many of them gave up tobacco, adopted healthy diets and undertook physical activity. The social gradient of risk progressively reversed, as the poor among countries and the poor within countries became the dominant victims.

The rich also have access to better healthcare. They do get heart attacks but less often than the poor, suffer them at a later age, and die much older. The poor have limited access to health and nutrition literacy, are deterred by the high cost of healthy foods, and get addicted to mass-marketed ultra-processed foods, tobacco and alcohol. They find necessary healthcare inaccessible or unaffordable and are devastated by disease, disability and lost income.

In rich countries, NCD epidemics evolved over the course of the twentieth century, with shifts to older age groups and poorer sections manifesting after the 1970s. Health transition operations were telescoped in LMICs. Delayed industrialisation and growing urbanisation propelled the NCD epidemics in LMICs and they gained speed from globalisation which constituted the tailwind of the 20th century. By the beginning of the 21st century, there was sufficient evidence that the poor in LMICs were suffering in large numbers.

This recognition led the World Bank to partially course correct in 2007, acknowledging that NCDs were indeed a problem of the poor and their chronic nature impoverished people. A 2011 study by Harvard and the World Economic Forum stated that the staggering cost of NCDs to the global economy was estimated to be $47 trillion for the period of 2011–30. This study greatly influenced the UN meeting on NCDs in the same year.

Finally, NCDs were recognised as a threat to global development. Prevention and control of NCDs became part of the UN Sustainable Development Goals (SDGs). Covid-19 reminded us that the distinction between infectious diseases and NCDs is flimsy. The majority of people who became seriously ill or died from Covid-19 were those who had NCDs as co-morbidities.

In India, NCDs accounted for 66% of deaths in 2019. Many of those occurred in the productive prime of midlife. Till recently, our primary healthcare systems were exclusively focused on the MDG agenda. Recently, NCDs and mental health have been included under the rubric of ‘comprehensive primary healthcare’. Secondary and tertiary care capacity for the treatment of NCDs is growing. Prevention of NCDs requires multi-sectoral actions directed at the drivers in other sectors, with demands to prioritise health in all policies. Perhaps that is why NCDs evade reductionist specificity even in their nomenclature!

Cardiologist, epidemiologist and President, Public Health Foundation of India

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