Co-authored with Jill Farrington
The 2011 UN Summit on Non-communicable Diseases (NCDs) elevated the importance of NCDs as a pressing global health challenge. While this recognition was long overdue, are we at risk of establishing a new vertical program, in direct competition for scarce funding with existing communicable diseases control programs and health system strengthening initiatives?
If we pay close attention to available evidence, that should not be the case. The health situation in sub-Saharan Africa nicely illustrates this point, as we have learned from an extensive review of the literature.
While the focus in this region has been on communicable diseases and maternal, perinatal and nutritional causes of morbidity and mortality, less attention has been paid to the extent to which these conditions contribute to the growing NCD burden and to potential common intervention strategies. Indeed the biggest increase in NCD deaths globally in the next decade is expected in Africa, where they are likely to become the leading cause of death by 2030.
The same underlying social conditions, such as poverty and insanitary environments, are associated with the onset of both communicable and non-communicable diseases, and there are close relationships between these disease groups in terms of causation, co-morbidity, and care.
Frequently, both communicable diseases and NCDs co-exist in the same individual, and one can increase the risk or impact of the other. Some infections cause or are related to NCDs; for example cervical cancer, a leading killer of women in Africa, is caused by the human papilloma virus. Treatment of communicable diseases can also increase NCD risk: Antiretroviral drug therapy for HIV is saving lives, but as the HIV-infected population ages, cardiovascular disease prevalence and mortality increase significantly as shown in recent research (Tseng, ZH et al. 2012). NCDs or their risk factors can also increase the risk of infection; for example, smoking and diabetes each increase the risk of tuberculosis, and co-morbidity of tuberculosis and diabetes can worsen outcomes for both diseases.
Many maternal illnesses and behaviors affect children, including tobacco use, anemia, and over- and under-nutrition. Gestational diabetes is a strong predictor of future illness, both of the mother, who may develop diabetes and cardiovascular diseases later in life, and the child, who also becomes at risk. Poor maternal nutrition before and during pregnancy together with smoking tobacco during pregnancy contribute to poor intrauterine growth, resulting in low birth weight which in turn predisposes to NCD risk later in life. Thus, the current poverty of much of sub-Saharan Africa may result in an epidemic of cardiovascular diseases in middle age for those who survive. The problem is compounded by HIV/AIDS: for example, low birth weight and malnutrition are more frequent in HIV-infected children.
The potential risks of setting up yet another vertical program in resource-constrained countries such as those in Africa need to be acknowledged and overcome, with integration and resource-sharing where feasible in the health system.
For example, at the primary care level, maternal and child health programs could include combined interventions to alleviate malnutrition and reduce smoking in pregnant women, increase the uptake of breastfeeding, monitor birth weight, promote healthy nutrition in families, identify and manage hypertension and diabetes in pregnancy, and promote smoke-free homes.
Collaboration with reproductive and sexual health programs could promote the use of condoms and safe sex practices and raise awareness of early signs and symptoms of breast and cervical cancer.
The scope of immunization programs could be expanded to include not only vaccine-preventable diseases among children but also improved access to HPV vaccines to prevent cervical cancer and Hepatitis B vaccination to prevent liver cancer. Models already exist for collaboration with tuberculosis control programs to benefit patients with non-infectious respiratory symptoms in primary care facilities, such as asthma and chronic obstructive pulmonary disease. Screening for hypertension and elevated blood sugar levels can be administered among people diagnosed with HIV infection.
Much illness and inefficient resource use can be avoided in sub-Saharan Africa – diseases and disabilities are frequently preventable – but comprehensive and systematic approaches need to be applied which build on existing resources and experience and capitalize on the inter-linkages between communicable diseases, NCDs, maternal and child health, and socio-economic development.
Although the largest share of costs of disease are borne by the individual concerned, Governments could play a catalytic role in tackling the main NCD risk factors as part of an integrated health agenda, since (i) there are substantial societal costs resulting from second-hand smoke and alcohol-induced injuries and fatalities; (ii) people are not always fully aware of the health (and other) consequences of unhealthy lifestyle choices such as smoking, alcohol abuse, physical inactivity, and poor diet; they may also be misled by information provided by the food, alcohol, and tobacco industries; and (iii) children and adolescents (and even adults) tend not to take into account the future consequences of their current choices, irrespective of whether they are informed about them.
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