Combating non-communicable diseasesBMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7510.174 (Published 21 July 2005) Cite this as: BMJ 2005;331:174
- Patricio V Marquez, lead health specialist (, )
- Marc Suhrcke, economist
- Europe and Central Asia Region, World Bank, 1818 H Street NW, Washington 20433
- World Health Organization, European Office for Investment for Health and Development, Palazzo Franchetti, S Marco 2847, I-30124 Venice, Italy
Non-communicable diseases account for most of the global burden of disease. This share is forecast to grow in the decades ahead, particularly in low income and middle income countries.1 In the countries of eastern Europe, chronic non-communicable diseases among people of working age drive high rates of adult mortality.2 3 This obviously concerns the lives of the affected individuals and their families, but who else should be concerned about this?
Non-communicable diseases have not been considered sufficiently important to be included among the health related targets of the Millennium Development Goals, leading some to question the relevance of these goals for Europe's transitional countries.4 The resources earmarked for them are extremely low. Despite the obvious epidemiological trends, few countries have implemented comprehensive policies for preventing and controlling non-communicable diseases.5
The public health community has not made a sufficiently strong case for the importance of non-communicable diseases. Decision makers are unaware of the full health and economic burdens attributable to these diseases. This lack of awareness may have held back the actions needed to curb this rising toll.
A cynical, but not uncommon, response argues that, because deaths from non-communicable diseases occur mainly towards the end of an individual's working life, any relevant expenditure on public health would simply lengthen the lives of those who have already delivered their lifetime contribution to society. This argument is flawed.
A substantial share of mortality from non-communicable diseases afflicts people of prime working age. A period of poor health typically precedes mortality and, although the association between mortality and morbidity is not uniform, eastern Europe has high morbidity as well as mortality from these diseases.7 Such morbidity reduces the productivity and active participation of people in work.8 Furthermore, adults respond to chronic illness in ways that may obscure direct effects on the labour market. Such coping responses may involve taking a spouse out of work or a child out of school to care for an ill member of the household. These impacts on others should also be considered as costs.9 Lastly, those who are not part of the formal labour force, such as pensioners, also contribute to economic outcomes—particularly when in good health—even though the benefits rarely appear in official measures.10
Taken together, these microeconomic effects may well add up to a substantial macroeconomic impact on a country's overall development; and adult mortality is known to be a reliable predictor of subsequent economic growth.11
All of these arguments sound highly plausible. However, plausibility is rarely viewed by policy makers as a substitute for rigorous empirical research. We are only beginning to build the case,12 and we need empirical evidence. Nevertheless, progress towards restoring balance in the agenda for global health will almost certainly be furthered by economic evaluations of the impacts of non-communicable diseases. If we really intend to make a difference to health in eastern Europe and beyond we must use the universal language of decision makers, based on sound epidemiological, clinical, and economic evidence.