Vector Issue 10 - 2009

What lurks in the shadows:
non-communicable disease in the developing world
Words Fred Hersch, Medical student, University of Sydney
// Image by xymonau (sxc.hu)
www.ghn.amsa.org.au
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When we think about
the global burden
of disease and the
plight of the poorest
of the poor our minds often
turn to the scourge of HIV/AIDS,
malaria and tuberculosis - after
all, that’s where all the attention
is. Yet in the shadows lurks
an uneasy truth: the rise of noncommunicable
disease (NCD).
Historically thought to be a disease
of the “developed world”, NCD is in fact
a worldwide pandemic of devastating
proportions. In 2005 alone there were an
estimated 35 million deaths from heart
disease, stroke, cancer and other chronic
diseases - approximately 50% (17.5 million)
due to cardiovascular disease(1). Of
these, 80% occurred in low- middle- income
countries– (LMIC) twice as many
deaths as from HIV, malaria and tuberculosis
combined(1, 2). Cardiovascular
disease (CVD), responsible for 30% of
the total deaths worldwide(1)1, is the
second leading cause of death in Africa,
and the leading cause of death in those
aged 30 or older(3). The fastest growing
region for CVD is in the African region
(27%) and it is estimated that over the
next 10 years the burden from NCD will
rise by 17% whilst those from communicable
diseases will fall by 3% which
translates to approximately 28 million
deaths due to NCD over that period(1).
The consequences of this are profound
and far-reaching. Consider this:
In contrast to our experience of NCD
Cardiovascular disease and global health: threat and
opportunity. Health Aff (Millwood). 2005 Jan-Jun;Suppl
Web Exclusives:W-5-31-W-5-41.
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cardiovascular disease in the developing world. Health
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Leeder S. Prevention of chronic diseases: a call to action.
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12.Lim SS, Gaziano TA, Gakidou E, Reddy KS,
Farzadfar F, Lozano R, et al. Prevention of cardiovascular
disease in high-risk individuals in low-income
and middle-income countries: health effects and costs.
Lancet. 2007 Dec 15;370(9604):2054-62.
13.Gaziano TA, Galea G, Reddy KS. Scaling up interventions
for chronic disease prevention: the evidence.
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M, Ebrahim S, Kidd M, et al. Improving the prevention
and management of chronic disease in low-income and
middle-income countries: a priority for primary health
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Beaglehole R. Chronic disease prevention: health
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disease prevention with a multidrug regimen in the
developing world: a cost-effectiveness analysis. Lancet.
2006 Aug 19;368(9536):679-86.
being a disease of old age, in LMIC, it
is often men and women in their most
productive years (40‘s and 50‘s) who
are most affected(4). On a personal level
this is a tragedy for a family struggling
for survival. At a societal level this
lost productivity further compounds
the challenges of economic growth.
Inattention, rather than complexity
contributes to the lack of action to date.
A common set of known risk factors:
hypertension, elevated lipids, smoking,
obesity, sedentary lifestyles, and diabetes
accounts for about 80% of clinical
cardiovascular disease in every region of
the world(5, 6). As developing countries,
particularly those in sub-Saharan Africa
move to the next stage of the epidemiological
transition greater numbers
of people are being exposed to diseaseproducing
risk factors (2, 4, 7-11).
The challenges are vast yet not
insurmountable. We know from our
experience that prevention works and
there is a growing literature pointing
to opportunities for scaling up low
cost interventions. Tobacco control
measures and dietary interventions can
lead to small but significant changes in
large groups of people(12-15). Health
systems in LMIC traditionally oriented
towards communicable disease
will require re-orienting to address the
chronic nature of NCD(1, 8, 12-14, 16).
As we struggle towards goals such
as “health for all” it would be nice to
think that we can address the challenges
of disease in a linear fashion - communicable
then non-communicable.
The inconvenient truth in all of this is
that health, like life, is more complex
than that. It is time that we lift the
spotlight off to reveal the true picture of
the global burden of disease and direct
our efforts at addressing the health
needs of communities as a whole.
4 vector november 2009