Noncommunicable diseases: the slow motion disaster
The disease burden and its implications
WHO estimates that noncommunicable diseases kill 40 million people each year, accounting for 70% of all deaths worldwide. The yearly number of deaths includes 15 million people who died between the ages of 30 and 70 years. The majority of these premature deaths could have been prevented or delayed. Among the premature deaths, 85% occurred in developing countries, including 41% in lower-middle-income countries where the probability of dying from a chronic disease between the ages of 30 and 70 years is up to four times higher than in wealthy countries.
The implications for health systems and the care they provide are profound, calling for a change in the mindset of public health. The traditional approach to health that relies on the biomedical model, focused on the cure of individual diseases, is inadequate. The essential emphasis on prevention requires a greater reliance on the social and life sciences. Though better care is needed everywhere, it is increasingly unaffordable – again everywhere.
In several countries, the management of diabetes alone absorbs up to a third of the entire health budget. The average cost of newly approved treatments for various cancer indications is $120 000 per person per year, suggesting that advanced cancer treatment is becoming unaffordable for even the richest countries in the world. A study conducted by the World Economic Forum estimated that, under a “business as usual” scenario, low- and middle-income countries could lose $500 billion per year over the period 2011–2025 due to NCD morbidity and mortality, amounting to roughly 4% of average GDP.
These high costs, in turn, have four implications. First, they underscore the ethical imperative of fairness in access to life-saving and health-promoting interventions. Second, they make the need for systems of social protection more sharply obvious. For example, in parts of sub-Saharan Africa, people with diabetes living in rural areas can spend up to 60% of total household income on insulin. Third, they make prevention the cornerstone of the global response. Finally, they make it clear that no country in the world can hope to “spend its way out” of the NCD crisis by investing in treatment services alone.
The greatest challenge arguably falls on the way health systems are designed and services are delivered. Most health systems were built to manage brief episodes of acute illness, in which the patient either survives or dies, and are ill-equipped, staffed and budgeted to manage the demand for long-term or even life-long care. The health workforce, too, is inadequate in numbers and training, as was acknowledged in 2016 with the launch of the report of the High-Level Commission on Health Employment and Economic Growth.
Prevention faces two main barriers. First, most doctors worldwide are trained to diagnose, treat, and cure diseases, but not to prevent them. Incentive schemes in many health care settings reflect that emphasis. Second, the risk factors for these diseases – tobacco use, the harmful use of alcohol, unhealthy diets, and physical inactivity – lie in non-health sectors and are strongly influenced by the behaviours of powerful economic operators.
"No country in the world can hope to “spend its way out” of the NCD crisis by investing in treatment services alone."
Dr Chan, WHO Director-General
To address the underlying determinants of health, public health has long relied on collaboration with friendly sister sectors, like education, nutrition, housing, and water supply and sanitation. Tackling the forces that drive the marketing of health-harming products is far more complex and contentious, but it can be done.
Noncommunicable diseases are a slow-motion disaster, as many take decades to develop overt signs of disease. However, predisposing risk factors are known to start early in life, calling for a life-course approach to prevention and control. WHO has internationally agreed guidelines for managing all four diseases, especially when detected early. Most medicines needed for treatment are included in the WHO Model Lists of Essential Medicines, and many of these medicines are low-cost generics.
The approaches needed to combat such a monumental and broad-based challenge are numerous – from considering the implications of trade and foreign investment agreements to legislative and fiscal measures that enforce population-wide prevention, from community engagement and a life-course approach to people-centred health services that focus on integrated care instead of individual diseases, from finding ways to shape the behaviours of powerful economic operators to persuading municipal authorities to create safe playgrounds and spaces for pedestrians and cyclists.
These demands have shaped the direction WHO and health ministries have taken when calling for health system reforms. Of all the diseases under the WHO mandate, few others depend so heavily on health systems organized around the principles of primary health care and oriented towards universal coverage.
