With one out of every three deaths in the world now being caused by four types of chronic disease—heart disease, respiratory disease, common cancers, and type 2 diabetes—what path should public health practitioners take to stem the rising human and financial cost of non-communicable diseases? David Stuckler and Karen Siegel have edited a new data-driven tome that addresses this question better than any text I’ve seen to date—providing essential reading both for epidemiologists and public health campaigners looking for data and guidance in their movements for healthier foods, cleaner air, and access to essential medicines and primary care medical homes. In this week’s post, we review the key conclusions from their new book Sick Societies.
Causes and consequences
(First of all, a disclosure: this review is not unbiased; I have contributed to several chapters of the book, and work closely with David Stuckler, so I naturally agree with many of the book’s conclusions. However, I do not receive any financial compensation from book sales.)
As we discussed in a previous post, chronic diseases have now emerged as a cause of most deaths in the world, with 80% of these deaths occurring in low- and middle-income countries, and increasingly shifting towards the poor. As Stuckler and Siegel review in their book, there is critical data showing that the majority of this burden is coming from tobacco use, diet (sugar, fat and salt intake), increased physical inactivity and alcohol. What is more surprising about their book is the data revealing that a “transition” does not seem to be taking place from infectious to non-communicable diseases—by contrast, many of the same households in poor countries are continuing to face the burden of infectious diseases like tuberculosis and classical diseases of poverty like undernutrition while simultaneously having family members with diabetes and heart disease (a “double burden”, not a “transition”).
Both under and over-nutrition seem to occur in families with poor purchasing options, leaving them with oily and fatty processed foods that are both inadequate in micronutrients and excessive in useless calories. The combination of tobacco and indoor air pollution from “dirty cookstoves” has similarly led to a rise in chronic lung disease while heightening the risk of tuberculosis. Hence, dichotomizing between the infectious and chronic diseases as diseases of the poor and rich, respectively, seems unsupportable by the evidence.
The authors also tackle the common assertion that chronic diseases are a sign of progress or are a “rational slow suicide”—a matter of personal choice. Indeed, the data from both household surveys and econometric assessments suggests that price, availability, marketing and perceived costs and benefits strongly influences the choice of, for example, unhealthy food consumption—which is one reason that chronic diseases are becoming increasingly concentrated among the poor even when they start among the wealthier groups of a country.
The clearest phenomenon occurring in many nations in “dietary dependency”—or the process by which food availability in low- and middle-income countries shifts toward multinational imports from Western nations, increasingly due to market “divergence”, in which products deemed unhealthy in the West are increasingly imported to poor nations. This is particularly apparent in Mexico, where the North American Free Trade Agreement led to the collapse of Mexican farms as these farmers were unable to compete with the heavily-subsidized US corn industry; the farmers migrated to urban centers where less fruits and vegetables were available, and where heavy marketing of soft drinks has now led to a higher consumption of Coca-Cola than of milk (largely thanks to former Mexican President Vicente Fox, a former Coca-Cola President), and a corresponding rise in obesity to over 70% of the adult population.
Beyond the human toll of these diseases, the economic consequences are huge, but the authors delve into some detail about how economic assessments are complicated by a number of assumptions. Many studies measure non-communicable disease burdens based on crude mortality rates, rather than age-standardized rates that could better capture broad consequences of disease on the working-age population; in several cases, non-communicable disease rates are also estimated based on income levels given the absence of actual disease data, then later studies are done claiming that these disease rates did not effect income growth, a circular argument. There is debate within the economic literature about whether chronic diseases are merely a sign of progress, rather than a market failure. Yet Stuckler and Siegel, along with a series of colleagues, present emerging evidence that the costs to governments, firms, households and individuals is substantial no matter how economic externalities are calculated. Furthermore, given inadequate and imperfect information given to individuals about the consequences of their choices, and given the addictive nature of alcohol and tobacco and possibly certain foods, there is substantive evidence of market failures in chronic disease risk factors like the food sales environment.
What to do?
It’s no surprise that systems of chronic disease care are largely uncoordinated and fragmented in poor countries, with a focus on acute care rather than chronic primary care that delivers both preventive medicine and chronic treatment to avoid the costly complications of diseases like diabetes. Market-based systems, as reviewed by the authors, are highly unlikely to remedy this problem, given inadequate incentives for preventive care and numerous incentives for fee-for-service charges once people become ill (and see Nobel Laureate Kenneth Arrow’s old paper on why markets can’t provide efficient healthcare, given asymmetric information). Stuckler and Siegel powerfully argue for a move away from ‘magic bullet’ interventions that focus on education and technology as the essential solutions for emerging diseases, showing instead that these rarely produce a lasting impact. While many efforts at ‘sustainable’ technology are focused on providing extremely low-cost and very limited interventions in poor countries, they tend to suffer from what Paul Farmer has called the circularity problem: if you give shit to the poor, they will never have more than shit. To build a really effective health system, real and meaningful infrastructure has to be developed over time.
The authors look at a number of examples of extending current systems to control chronic diseases: a case of Malawi, for example, which involved training personnel including community health workers, providing access to low-cost medicines, monitoring patients serially, and providing national supervision for quality control and monitoring of outcomes. The critical pharmacological interventions in many countries appear to include improved diabetes supply and medication availability, blood glucose monitoring devices, antihypertensives and anticholesterol medications, and improved screening programs. The possibility of a “polypill” is also reviewed.
But Stuckler and Siegel are appropriately skeptical of whether healthcare services will be adequate to address the rising burden of disease. They turn to population-level public health interventions that have shown an impact, highlighting that these usually affect the social and economic system rather than just introducing educational or technology-focused interventions that have shown poor efficacy on a population level. The interventions will be politically challenging, but particularly involve modifying standards for food production including lower salt, sugar and fat content; discouraging sales of tobacco, alcohol and unhealthy foods through taxes and subsidies; and engaging in participatory community-based approaches to devising community physical activity and risk factor reduction programs, such as the Agita Sao Palo and Isfahan Healthy Heart Programs.
The politics of these programs are debated in the book both by industry representatives invited to contribute (most notably Derek Yach of PepsiCo) and their critics (such as William Wiist). The industry representatives highlight, expectedly, a number of their public relations and educational campaigns, as well as their focus on using food science to invent new alternatives to sugar and high-fructose corn syrup as well as oils like palm oil (devising alternatives like Palmolein). They report being constrained by consumer choice and lack of R&D investment from the public sector. But their critics highlight corporate activities designed to subvert public regulation of their industry and maintain early consumption of unhealthy foods, alcohol and tobacco among youth, as well as the interlocking relationships between these industries and key global health policy-setting groups like major foundations and donor governments.
Progress in delivery
Actually implementing reforms to chronic disease risk factors to produce healthier diets and less consumption of alcohol and tobacco, and reforming health systems to manage chronic disease, has seemed a formidable challenge. But Stuckler and Siegel appropriately highlight key positive efforts from countries facing the greatest burden of these diseases: Brazil, China, India, Mexico and South Africa. Each of these countries has experienced “double burdens” of disease—both chronic and infectious diseases—and each has experienced a growth in heart and lung disease, as well as diabetes, through major trade transformations (such as the GEAR program in South Africa). While the details of each case study won’t be reviewed here, it’s notable that each country’s campaigners have learned from the tobacco control movement—that to generate major changes in the context of limited resources, it’s important to give a high political priority to regulating markets and taking on political challenges from industries invested in the status quo—whether the industry producing the “risky commodity” or the healthcare delivery industry that is incentivized to treat complications rather than prevent them. In China, this has meant addressing the fact that the federal government is itself invested in tobacco production. In India, it has meant addressing the economic system that preserves inequality in slums for cheap labor, leaving only processed and other unhealthy foods affordable for consumption by this vast semi-employed population in slums. In Mexico, it has involved taking-on Coca-Cola.
Stuckler and Siegel end their book by highlighting how major campaigners and public health activists have galvanized support for a changed risk factor environment—building social networks, reframing debates from individual responsibility to collective focus on social inequalities and gaining the resources for healthy living, and supporting regulation and litigation when necessary. Their concluding chapters—showing how successful mobilization happens, and providing resources for global health mobilization around chronic diseases—are essential reading. They provide a clear guide to how solidarity can be built in a public health sector that has often been characterized by internal infighting about “whose disease in more important”, rarely highlighting the common underlying social inequalities of power and wealth that have driven these epidemics. Ultimately this is a subversive book as much as it is a data-driven epidemiology text. And it has become increasingly clear that such discussion of power and politics must play a central role in our epidemiological debates if we are to effect change to the rising burdens of chronic disease.