Non-Communicable Diseases (NCDs)

Health Systems, Healthcare Workforce, Non-Communicable Diseases, Vaccination

Battling Cancer across Different Income Settings

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

David Bowie, Alan Rickman and Rene Angelil, are a few of the well-known people that the world lost to cancer in the year 2015. My familiarity with cancer comes not just from losing my favourite celebrities to cancer, or dealing with patients in a tertiary care hospital in Lahore, but also from losing a few people very dear to me in my family. Every case of cancer is a battle for the person, their families, friends and doctors, as well as the healthcare system.

Cancer forms a major proportion of non-communicable diseases today. There were an estimated 14.1 million new diagnosed cases of cancer with an estimated 8.2 million deaths in 2012 (1). The most common sites of cancer have been recognized to be lung, colon, breast, liver, stomach and the cervix while the majority of cancer-related deaths are due to lung, stomach and esophageal cancer (2). Previously, cancer remained a low priority for low income (LICs) and low middle income countries (LMICs), as well as for donors (3). In 2008 72% of deaths due to cancer occurred in LICs and LMICs (4).  This may be a consequence of not only longer life spans and the majority of the world’s population being in the LIC and LMIC countries but also a lack of accessible and affordable treatment in these parts of the world.

Estimated global numbers of new cases and deaths with proportaions by major world  regions, for all malignant cancers (excluding non-melanoma skin cancer) in both sexes combined, 2012. Source: The Cancer Atlas

While higher income countries have progressed from chemotherapy and radiotherapy to gene therapy, LMICs continue to focus on finding ways for uneducated or less educated to identify cancerous conditions in order to seek medical help before it is too late, for instance promoting breast self-examination. The increasing prevalence of cancer in LMICs exasperates the health sector with an already increasing burden of infectious diseases like tuberculosis, malaria and diarrhea. In these contexts cancer contributes to altering the epidemiology of these countries adding to the burden of non-communicable diseases which in turn worsens the double burden of disease. This creates considerable strain on the healthcare system due to increasing needs of diagnostic and treatment modalities besides the already unmet needs concerning infectious diseases.

There is an immense need for healthcare systems in resource poor settings to focus more on prevention rather than cure. Health professionals working in LMICs need to place greater emphasis on informing and educating people about warning signs of cancer as many resource poor settings have technology constraints and limited means of gaining health information. There are no quick fixes and circumstances are never as simple as they seem. Campaigns against smoking to prevent lung cancer have been addressed by discussions advocating for the rights of the poor who own tobacco farms as their only source of income (5). Modification of social behaviours for instance, requires extensive out-reach programmes by medical professionals but also bring into question the financial constraints of the country in order to pay for the services of these local healthcare workers.

In summary, LICs and LMICs have a longer way to go to provide sufficient healthcare for cancer patients. While high income countries are more likely to make medical advances for cancer treatment, resource poor countries can make strides through preventive measures like vaccination, behaviour modification and self-examination.

References :

  1. Cancer. WHO Media Centre. World Health Organization; 2016 [cited 2016 Feb 14]. Available from: http://www.who.int/mediacentre/factsheets/fs297/en
  2. World Cancer Report published by the International Agency for Cancer Research, WHO
  3. Scaling up cancer diagnosis and treatment in developing countries: what can we learn from the HIV/AIDS epidemic? Can Treat International. Ann Oncol [Internet]. 2010;21(4):680–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20338877
  4. Cancer in Developing Countries International Network for Cancer Treatment and Research. INCTR. 2016 [cited 2016 Feb 14]. Available from: http://www.inctr.org/about-inctr/cancer-in-developing-countries/
  5. Tobacco Company Strategies to Undermine Tobacco Control Activities at the World Health Organization. Committee of Experts on Tobacco Industry Documents. World Health Organization. 2000.
  6. International Women ’ s Day 2014 : women ’ s health equity is progress for all. Ginsburg O. 2014.

Non-Communicable Diseases, Poverty, Built Environment, Economic Development

The Role of the Built Environment in Reducing the Incidence of Type 2 Diabetes

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

Diabetes is a chronic disease that affects many people worldwide. Type 1 diabetes is an autoimmune deficiency that often develops in childhood and impacts about 10 percent of those with the disease (Canadian Diabetes Association, 2009). However, type 2 diabetes develops later in life, is influenced by environmental and lifestyle factors, and is prevalent among nearly 90 percent of those with diabetes.  While Type 2 diabetes used to be considered a “disease of the West”, it has now spread to more countries; thus, more efforts need to be made to reduce the incidence of this disease. As healthy diets and regular physical activity are key components to reducing the prevalence of type 2 diabetes, the built environment needs to be taken into consideration. The built environment includes all of the aspects of an environment created by humans, such as neighborhoods and cities, and consequently plays an important role in ensuring that people can access healthy food, and increase physical activity.

The Importance of Community Gardens

The accessibility of healthy foods can increase with the implementation of community gardens. Preliminary studies reveal several benefits of community gardens, including the associated increased intake of produce. One study examined the benefits of community gardens in South-East Toronto, concluding that those who participated in the maintenance of the garden increased their intake of vegetables and fruits and bought fewer produce from grocery stores (Wakefield, Yeudall, Taron, Reynolds, & Skinner, 2007). While these community gardens were established by non-governmental organizations, city planning officials still have a large role to play, as they could ensure that there is land in urban areas specifically designated for community gardens.   

Gardens could also be incorporated into schoolyards. One example of this was in California where the “Garden in Every School” program was implemented, and vegetables and fruits were grown on school property.  The kids helped to maintain the garden and this promoted healthy eating and an overall increase in the local food supply (San Mateo County Food System Alliance, 2010; Dannenberg, Frumkin, & Jackson, 2011).

The Role of Active Transportation

Encouraging physical activity is also a key component in reducing diabetes prevalence and this can be done through changes in the built environment by encouraging active transportaiton. This would involve increasing the walkability of communities through the implementation of pedestrian infrastructure, such as sidewalks and safe crossings, to ensure that these places are easily accessible.  

Encouraging “Smart Growth” would also be important. This concept was developed in the 1990s by initiatives that were being implemented by various organizations, including the American Planning Association (Dannenberg et al., 2011). “Smart Growth” policies encourage the preservation of open space, and making communities more walkable. This could be done through the implementation of mixed-land use development, which would ensure that employment, schools and shops were within close proximity and walking became one of the main methods of transportation.

Another key component of Smart Growth is developing a variety of transportation methods through the implementation of Transit-Oriented Development, which also became prominent in the 1990’s. This would be another way to encourage physical activity and reduce reliance on cars. Implementing bike lanes also encourages biking as a means of transportation. In Portland, Oregon there was an increase in biking after several miles of bike lanes were added, as a quadrupling in bikeway miles resulted in a quadrupling of bicycle bridge traffic (refer to Figure 1).

 

Figure 1: An increase in bikeway miles in Portland, Oregon was led to an increase in bicycle traffic (Dannenberg et al., 2011).

There are other factors to consider when examining type 2 diabetes, such as biological factors among certain ethnic groups, and the difficulties associated with trying to make behavioural changes. However, by making sustainable changes to the built environment to increase accessibility to healthy foods and encourage active transportation, government officials and non-governmental organizations can begin to greatly reduce the prevalence of type 2 diabetes.  

 

References:

Canadian Diabetes Association. (2009). An economic tsunami of the cost of diabetes in Canada. Retrieved March 28, 2015, from http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/economic-tsunami-cost-of-diabetes-in-canada-english.pdf 

Dannenberg, A. L., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places: Designing and Building for Health, Well-Being, and Sustainability. Washington: Island Press.

Hu, F. B. (2011). Globalization of Diabetes: The role of diet, lifestyle, and genes. Diabetes Care , 34 (6), 1249-1257.

San Mateo County Food System Alliance. (2010). A Garden in Every School. Retrieved March 25, 2015, from Ag Innovations Network: http://aginnovations.org/images/uploads/call-to-action_GBL_final.pdf 

Wakefield, S., Yeudall, F., Taron, C., Reynolds, J., & Skinner, A. (2007). Growing urban health: Community gardening in South-East Toronto. Health Promotion Internationl , 22 (2), 92-101.

Poverty, Government Policy, Health Systems, Disease Outbreak, Infectious Diseases, International Aid

Keeping the Spotlight on Neglected Tropical Diseases (NTDS)

-Written by Adenike Onagoruwa, PhD (Contact: adenike.onagoruwa@gmail.com)

Neglected tropical diseases (NTDs) are a group of diseases with different causative pathogens that largely affect poor and marginalized populations in low-resource settings and have profound, intergenerational effects on human health and socioeconomic development. The WHO has prioritized 17 NTDs that are endemic in 149 countries, of which some such as dengue, Chagas disease, and leishmaniasis are epidemic-prone.

NTDs can impede physical and cognitive development, prevent children from pursuing education, frequently contribute to maternal and child morbidity and mortality, and are a cause of physical disabilities and stigma that can make it difficult to earn a livelihood. Largely eliminated in developed, high-resource countries and frequently neglected in favor of better-known global public-health issues, these preventable and relatively inexpensive to treat diseases put at peril the lives of more than a billion people worldwide, including half a billion children. Several reasons have been postulated to explain the neglect of these diseases; an underestimation of their contribution to mortality due to the asymptomatism and lengthy incubation period that is characteristic of many of the diseases, a greater focus on HIV, malaria and TB because of their higher mortality, and a lack of interest in developing (non-profitable) treatments by pharmaceutical companies.

Progress has been made in recent times in combating these diseases and several international measures have been taken. Resolution WHA66.12 adopted at the sixty-sixth World Health Assembly in May 2013 highlighted strategies necessary to accelerate the work to overcome the global impact of neglected tropical diseases. Previously in January 2012 at the “London Declaration”, representatives of governments, pharmaceutical companies and donor organizations convened to make commitments to control or eliminate at least 10 of these diseases by 2020. They proposed a public-private collaboration to ensure the supply of necessary drugs, improve drug access, advance R&D, provide endemic countries with funding and to continue identifying remaining gaps.

So far, the coalition has made progress with delivering on their promises:

Pharmaceutical Companies - In 2013, drug companies met 100% of drug requests, donating more than 1billion treatments. On the R&D front, clinical trials for some NTDs have been started. In addition, several drug companies have enabled access to their compound libraries.

Governments - Compared to 37 in 2011, 55 countries requested drug donations at the end of 2012. Also, over 70 countries have developed national NTD plans. Within a year of the Declaration, Oman went from endemic trachoma to elimination and by 2014, Colombia eliminated onchocerciasis.

Donors - NTDs have become more visible on the development and aid agenda, especially with the £245 million earmarked in 2012 by DFID for NTD programs. Other donors have since followed suit.

However, despite these strides, challenges remain as treatments are not reaching everyone in need. Although 700 million people received mass drug administration (MDA) for one or more NTDs in 2012, only 36% of people in need worldwide received all the drugs they needed. There’s also the anticipated challenge of environmental and climate change on NTDs; with dengue being identified as a disease of the future due to increased urbanization and changes in temperature, rainfall and humidity.

The spotlight needs to remain on NTDs and their contributions to ill-health and poverty for efforts to be sustained. 

To sustain these efforts, greater advocacy has to be made for integrating NTD control into other community and even national level programming, without losing them in the crowd. Some anthelminthic drugs for preventive chemotherapy are on the WHO Model List of Essential Medicines and their distribution has been effective and economical. However, to succeed at NTD elimination, we have to look beyond mass drug administration to the removal of the primary risk factors for NTDs (poverty and exposure) by ensuring access to clean water and basic sanitation, improving vector control, integrating NTDs into poverty reduction schemes and vice versa, and building stronger, equitable health systems in endemic areas. There needs to be a consensus as to how to ensure this. At present, it seems there is a gap between elimination objectives and how to incorporate them into other health and development initiatives such as water and sanitation, nutrition and education programs. It has long been established that helminth parasite infection contributes to anemia and malnutrition in children. The presence of other protozoan, bacterial and viral diseases also contribute to school absenteeism. Guinea worm disease (dracunculiasis) can be recurrent when there is no access to safe drinking water.

There is also a need to maintain a surveillance and information system for NTDs in light of increasing migration and displacements. Another way to ensure that the spotlight is kept on NTDs is research that provides evidence of interactions and co-infections with other diseases. For example, epidemiological studies from sub-Saharan Africa have shown that genital infection with Schistosoma haematobium may increase the risk for HIV infection in young women (Mbah et al, 2013). Understanding that neglected diseases can make the “big three” diseases (malaria, HIV and tuberculosis) more deadly and can undermine the gains that have been made in health, nutrition and education is important (Hotez et al, 2006).

Erroneous overstating of the progress made in controlling and eliminating NTDs can have a detrimental effect on funding and public perceptions of their importance. Thus, there is a need for increased synergy between stakeholders. Achievements in polio eradication do not equal achievements in human African trypanosomiasis eradication. While some NTDs can be managed with specific drugs, some such as dengue do not have a specific drug. Therefore, while keeping the spotlight on NTDs collectively, it is important to emphasize their diversity and to also keep in mind the subgroup of NTDs categorized as emerging or reemerging infectious diseases, which are deemed a serious threat and have not been adequately examined in terms of their unique risk characteristics (Mockey et al, 2014).

Lastly, it is important to keep the heat on NTDs in the UN’s post-2015 sustainable development agenda by advocating that proposed goals support efforts to monitor, control and eliminate NTDs. As highlighted by the Ebola crisis, strengthening health systems is paramount. Nevertheless, the future looks optimistic regarding NTDs. Encouraging is the inclusion of neglected and poverty-related diseases on the agenda of the 2015 G7 Summit, which will be held in Germany in June.

References:

World Health Organization. Neglected tropical diseases: becoming less neglected [editorial]. The Lancet. 2014; 383: 1269

Holmes, Peter. "Neglected tropical diseases in the post-2015 health agenda." The Lancet 383.9931 (2014): 1803.

Feasey, Nick, et al. "Neglected tropical diseases." British medical bulletin 93.1 (2010): 179-200.

World Health Organization. Neglected tropical diseases. http://www.who.int/neglected_diseases/diseases/en/                              

Fenwick, Alan OBE. “The Politics of Expanding Control of NTDs.”  A Global Village Issue 7. http://www.aglobalvillage.org/journal/issue7/globalhealth/ntds/

Mbah, Martial L. Ndeffo, et al. "Cost-effectiveness of a community-based intervention for reducing the transmission of Schistosoma haematobium and HIV in Africa." Proceedings of the National Academy of Sciences 110.19 (2013): 7952-7957.

Hotez, Peter J., et al. "Incorporating a rapid-impact package for neglected tropical diseases with programs for HIV/AIDS, tuberculosis, and malaria." PLoS medicine 3.5 (2006): e102.

Mackey, Tim K., et al. "Emerging and Reemerging Neglected Tropical Diseases: a Review of Key Characteristics, Risk Factors, and the Policy and Innovation Environment." Clinical microbiology reviews 27.4 (2014): 949-979.

G7 Summit Agenda. http://www.g7germany.de/Webs/G7/EN/G7-Gipfel_en/Agenda_en/agenda_node.html

World Health Organization. Investing to overcome the global impact of neglected tropical diseases: third WHO report on neglected diseases 2015. 

Non-Communicable Diseases, Poverty, Government Policy, International Aid

Managing the Global Burden of Chronic Illnesses

-Written by Mike Emmerich, Specialist Emergency Med & ERT Africa consultant (contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich_

An article on an EMS blog caught my eye in the past week:

"COPD was the third-leading cause of death in the U.S. in 2011 and is expected to become the third-leading cause of death worldwide by 2020." (Source: Hoyert DL, Xu JQ. Deaths: preliminary data for 2011. Natl Vital Stat Rep, 2012; 61(6): 1–65. Lopez AD, Shibuya K. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J, 2006; 27(2): 397)

This caused me to dig up a presentation I did in 2006 at a Fitness Seminar, wherein I was discussing chronic medical conditions, which are caused by poor lifestyle choices and I noted then:

" In 1999 CVD contributed to a third of global deaths. " In 1999, low and middle income countries contributed to 78% of CVD deaths. " By 2010 CVD is estimated to be the leading cause of death in developing countries. " Heart disease has no geographic, gender or socio-economic boundaries.

I further stated: Chronic illness have overtaken communicable disease as a major cause of death and disability worldwide. Chronic diseases, including such noncommunicable conditions as cardiovascular disease, cancer, diabetes and respiratory disease, are now the major cause of death and disability, not only in developed countries, but also worldwide. The greatest total numbers of chronic disease deaths and illnesses now occur in developing countries.

I then dug deeper to see how this has changed since 2006, and the outlook has become even more bleak!

More than 75% of all deaths worldwide are due to noncommunicable diseases (NCDs). NCD deaths worldwide now exceed all communicable, maternal and perinatal nutrition-related deaths combined and represent an emerging global health threat. Every year, NCDs kill 9 million people under 60 years of age. The socio-economic impact is staggering. These NCD-related deaths are caused by chronic diseases, injuries, and environmental health factors. Important risk factors for chronic diseases include tobacco, excessive use of alcohol, an unhealthy diet, physical inactivity, and high blood pressure.

The world now suffers from a global epidemic of poor lifestyle choices! Medically we call them chronic illnesses or NCD's, but the issue at hand is that they can be avoided, reversed and prevented; with smarter lifestyle choices. The why and the how of these lifestyle choices is a debate for another blog, but poor socioeconomic conditions, poverty, malnourishment and diets deficient in basic nutritional building blocks all form part of this dynamic.

These poor lifestyle choices and the death, illness, and disability they cause will soon dominate health care costs and should be causing public health officials, governments and multinational institutions to rethink how they approach this growing global challenge. To exacerbate the matter; the deaths, illnesses and disability are spiralling at even faster rates in the developing world, where the infrastructure is even weaker than in the developed world.

It is estimated that by 2020 the number of people who die from ischemic heart disease will increase by approximately 50% in countries with established market economies and formerly socialist economies, and by over 100% in low- and middle-income countries. Similar increases will also be found in cerebrovascular disease (Stroke) by 2020!

This is indeed a frightening prospect; NCDs are expected to account for 7 of every 10 deaths in the world! The overextended healthcare systems in Africa and Asia will battle to cope with these spiralling patient numbers.

A (positive) point to ponder as we consider this bleak outlook; the principal known causes of premature death from NCDs are tobacco use, poor diet, physical inactivity, and harmful alcohol consumption – all of these are preventable and manageable; as they relate to personal choices. Therefore we need to focus on creating a environment where these same individuals can make the correct choices which will have a positive impact on their lives. This is where governments, aid agencies and multi-nationals should focus their energies, and the approach should be more carrot than stick, which is not the case at present.

References:

http://apps.who.int/iris/bitstream/10665/128038/1/9789241507509_eng.pdf