Chronic epidemics: non-communicable diseases in poor communities

Last week’s NYTimes article “Is Sugar Toxic?” created quite a stir; it was the #1 most-emailed article on the newspaper’s website. There’s nothing like the graphic image of a hot-tub filled with corn syrup to make yuppies New Yorkers question their lifetime ingestion of processed foods:

But are sugar and fat really suitable subjects for global health discussions? Or are they yet another uniquely-American problem of excessive consumption?

On a purely statistical level, there’s no doubt that the “non-communicable diseases” (NCDs) are major causes of global mortality. NCDs like heart disease account for 70% of total morbidity and over half of total global mortality. Approximately 80% of these deaths occur in developing countries:

But as Oxfam’s South African Country Director Innocent Nkata stated, “whereas hunger is an issue of rights, obesity is a ‘question of morality’…is it right or wrong that some people should be overeating while others are starving?”

We, too, once believed that diabetes and heart disease were the problems of the rich, while TB and malnutrition were the problems of the poor…until we looked at the data.

What do the data show?

Our popular conception of nutrition has been collapsed into a number line: either you’re gluttonous and obese, or emaciated and malnourished. But recent data suggest that this view mixes up “weight” with “nutrition”, and the two are quite different concepts.

Three large national surveys from Brazil, China and Russia reveal some striking household statistics: that among the poor, underweight and overweight family members increasingly co-exist. And both are malnourished. How can this be? Part of the answer is food insecurity: it’s not that one family member is eating “too much” while another is getting “too little”. Rather, when we don’t have assurances about our income or food availability, we often eat high-density foods to hoard calories, so that we don’t starve when future meals are unavailable. And the endemic problem of not having enough food is now superimposed by a new problem of having food that is of little nutritional value but is calorie-rich and very cheap (thanks to the entrance of mass-produced processed foods into developing country markets). A few household members simply don’t eat enough altogether, while others eat irregularly when money is available, consuming cheap, nutrient-low, calorie-dense foods—just as in the U.S., where a 39-cent hamburger fills the stomachs of the urban poor more readily than a $6 salad. What the cheaper foods do contain is a lot of salt (read: heart disease) and refined sugars (read: diabetes). So we’re seeing incidence rates of diabetes and heart disease rise dramatically in poor countries, particularly among the “malnourished” and food insecure.

By analyzing the UN database of diseases among 227 countries over 15 years, we found that the wave of chronic illness like heart disease and diabetes has actually interfered with “traditional” global health programs. In a series of statistical studies, we found that progress towards the Millennium Development Goals for infectious diseases and child/maternal mortality rates was inhibited by NCDs, even after correcting for the independent effects of poverty, healthcare infrastructure and health spending. How could NCDs worsen infectious diseases or child/maternal health outcomes? It appears that NCDs among adults have a number of downstream effects: the cost of managing chronic illness has become a leading cause of bankruptcy in poor countries and reduces preventive health visits (less vaccination and prenatal care), and several chronic diseases and their risk factors increase the risk of infectious diseases (e.g., diabetes and tobacco dramatically increase the risk of tuberculosis). It’s also a myth that NCDs affect the elderly: in low-income countries, nearly 44% of deaths due to NCDs occurred before the age of 60 years, compared to only 19% in high-income countries. So when household income-earners are affected by chronic disease, their dependents suffer.

Moral risks or risky commodities?

One inhibitor to addressing the NCDs in poor communities is our hesitation to acknowledge that these diseases are not all about individual choice. But suppose we thought about the major risk factors behind NCDs just like we thought about any other commodities—like cars, or electronics:

[1] Tobacco: If tobacco were a Toyota, the car would accelerate uncontrollably and kill half of its consumers. Just a few acceleration incidents in Toyotas generated a massive Congressional investigation, as the CEO of corporation was dragged to court. But tobacco, unlike Toyotas, also contains an addictive substance that renders it difficult for its users to quit. While massive regulations in the U.S. helped dramatically curtail smoking, cigarette smuggling and interference with local legislation have recently been used as strategies for tobacco companies to infiltrate “emerging markets” in developing countries, knowing that current sales will generate regular users among young people for decades to come. They’re trying to outpace implementation of the Framework Convention on Tobacco Control (FCTC), the world’s first public health treaty. Less than 10% of the world’s population is currently covered by effective tobacco control programs, but the FCTC requires a plan for such implementation; unfortunately, while all FCTC parties are required to report on their implementation progress, less than 20 of 172 countries who signed the treaty provided actual reports on their progress last year.

[2] Salt and sugar: Salt and sugar are to processed foods what nicotine is to tobacco. The salt and refined sugar content of foods reshapes perceptions of flavor, and reshapes the body’s circuitry to regulate blood pressure. If a software program were designed to slowly destroy your computer’s hard-drive, and could not be un-installed, surely it would be regarded as a virus. But salt and refined sugars are used in food in a manner that generates irreversible damage, yet they aren’t monitored and regulated the same way we police software products. Using a large-scale policy model of salt consumption, statisticians recently found that reducing the salt contents of food from extremely high to just moderate levels would be likely to dramatically lower heart disease deaths and result in several billions of dollars in healthcare savings. The UK has already begun such an implementation program, and further signs of progress in the US suggest that other countries could follow suit; however, the salt production industry remains active in its counter-regulatory efforts. Analogously, both the corn production industry and processed food manufacturers have engaged in heavy lobbying against critics and regulators of refined sugars. As Robert Lustig’s viral video discussed, there are creative means of regulating sugars that are being actively opposed by industry, such as a soda tax to discourage consumption:

[3] Alcohol: While food and tobacco regulations make sense to most people, alcohol consumption is harder for many to come to terms with. It’s often assumed that alcohol consumption is a matter of individual control, despite its strong genetic association. Sociological studies suggest that easy access is a major determinant of alcohol consumption, as is the marketing of high-alcohol content drinks, which stimulates early alcohol dependence among the young. But given moral attitudes around alcohol consumption, the field of alcohol regulation remains almost exclusively focused on behavioral interventions and addiction treatment. Policy regulations provide an avenue for new approaches, such as reducing the density of liquor stores in a community, or preventing the active marketing of alcohol to adolescents.

So we can assume a lot about individual responsibility and “choices” with regard to NCDs, but individual behavior is mediated by the problems of commodity availability (easy and cheap to consume) and personal agency (once addicted, hard to quit, especially in social and biological contexts that facilitate ongoing consumption).

The money question

Is it financially worth-it to invest global health dollars in NCDs?

Currently, the investment hasn’t been made, as shown by this graphic depiction of the WHO’s budget as compared to the actual burden of global disease (the y-axis is % of the WHO budget in 2004-2005; DALYs are disability-adjusted life years, a measure of disease burden):

Recent projections suggest that China, India, and Britain will lose $558 billion, $237 billion, and $33 billion, respectively, in national income over the next decade due to preventable heart disease, strokes, and diabetes.  So what should governments in these countries invest in? The U.S. approach has been to focus on medical care and forgo most regulation of risky commodities like salt and sugar. As a result, $132 billion is spent annually on diabetes care in the U.S., but control of blood sugar, blood pressure, and lipid levels (the three aims to prevent death from diabetes) is achieved in less than 10% of Americans with the disease. Alternatively, we could refocus our attention on creating healthier communities—to provide adequate quality food access and appropriate regulation of risky commodities. Implementing such preventive measures has, in some instances, reduced the risk of NCDs by more than 90%.

Who will take the lead in pushing for such changes? One group seems particularly ahead of the curve: the NCD Action Network, and its associated Young Professionals Chronic Disease Network (YP-CDN). Only yesterday, the group released its “manifesto” of seven key recommendations to the 2011 UN General Assembly High-Level Meeting on NCDs. The seven recommendations offer a pathway to addressing the risky commodities, but also tackle a broader agenda for changes in how chronic care is delivered in poor countries, and how we can finance regulations with the understanding that while sick individuals require health care, chronically sick populations require changes in the community.

6 responses to “Chronic epidemics: non-communicable diseases in poor communities

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