Seeming virtuous on chronic diseases
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4239 (Published 06 July 2011) Cite this as: BMJ 2011;343:d4239All rapid responses
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I have just read the conflicting views on the subject of non-
communicable disease (NCD) prevention, by Iona Heath on the one hand and
Richard Smith and Susan Steven on the other, and feel an obligation to
contribute briefly. It is important and most logical to prevent disease,
whether NCD or communicable, and it does not matter what the socio-
economic circumstances or geographical locations are that determine the
prevalence or death rates of either disease category. Dr Heath makes some
valid points about the need for care and proportional response to the
problem of NCD vis-a-vis communicable (infectious) disease, arguing that
the latter are far more prevalent in poor developing countries where they
exact a heavy toll in disability and death.
While this is largely true for most poor sub-Saharan African
countries, the point must be forcefully made that NCDs are also fast
becoming a major public health problem in those countries. Having
practised clinical medicine in Nigeria for some 40 odd years, I have seen
how hypertension, for example, has emerged from being "rare" to a highly
prevalent disease and a major killer of poor people. I have also seen how
other cardiovascular diseases (including ischaemic heart disease,
myocardial infaction and stroke), diabetes mellitus, cancers of several
different kinds, neurologic illnesss, gastrointestinal disease,
rheumatological disorders and many others have declared themselves on the
public health scene in the country.
I returned to Nigeria from the UK in 1978, after training in internal
medicine, tropical diseases, rheumatology and immunology. Up to that time,
rheumatoid arthritis was virtually unheard of in Nigeria, so I naturally
set out in search of the disease and other connective tissue disorders. In
13 years (1978-1990) I found one confirmed case of rheumatoid disease and
one of progressive systemic sclerosis. However, these disorders are now
fairly common, though their manifestations are less severe than they are
in temperate European patients.
Yes, communicable diseases are still the biggest public health
problems in less developed and middle income countries, but NCDs are fast
taking root. Any initiative at curtailing NCDs in parallel with peventive
measures against infectious disease is most appropriate in these poverty-
striken countries whose few best trained health professionals have
unfortunately been poached by the rich and powerful world. I would rather
we prevent NCDs alongside infections, than allow them compound further, an
already badly compounded healthcare situation.
I do not know if Iona Heath has been to Africa sub-Sahel, but I know
Richard Smith is often somewhere on the continent. I trust his judgement,
and history has taught me to be wary of conspiracy theories.
Idris Mohammed
professor of medicine
iidrismohammed@aim.com
Competing interests: No competing interests
As the UN high level summit on non-communicable diseases approaches,
expectations on the outcomes have been mounting up. We view these
expected outcomes with mixed feelings: elation that at last attention will
be focused for what has oft-times been considered "neglected" diseases;
and trepidation on the kind of attention that will be given. We agree
with Iona Heath's concern on the possible effects of some of the NCD
Alliance's proposed outcomes on public health funds and equity (1).
Focusing on specific aspects of chronic diseases and creating special
programs to address these may only worsen the already much-verticalized
health systems of the developing world; on the other hand such health
systems may already be too weak to successfully implement additional
programs. Analysis shows that the different fully-funded global health
initiatives failed in countries where the health systems were regarded as
weak; select countries such as Thailand and Cuba has had reasonable
success due in great part to strong health systems responding to the
people's needs (2, 3). Whether for the delivery of acute or chronic
care, strengthening health systems is the most logical first step for
developing countries to take. The prevailing defeatist attitude towards
health systems strengthening needs to be addressed.
Provision of adequate
resources to strengthen health systems will always be a problem. However,
maximization of all possible resources such as task-shifting, utilization
of lay health workers, and patient enablement, as well as
horizontalization and harmonization of common vertical activities may
prove to be effective ways by which to start building, beginning
particularly with primary care. Barbara Starfield (4) aptly stated it in
one of her last commentaries: "Primary healthcare-oriented health systems
have been shown to be generally more effective in achieving better health
(particularly at young ages) at lower costs than is the case for systems
more oriented to disease management and specialty care."
References:
1. Heath I. Seeming virtuous on chronic diseases. BMJ 2011, 343:75.
2. Towse A., Mills A., Tangcharoesathien V. Learning from Thailand's
health reforms. BMJ 2004, 328:103-105.
3. De Vos P., de Ceukelaire W., van der Stuyft P. Colombia and Cuba,
contrasting models in Latin America's health sector reform. Trop Med
& Intl Health 2006, 11(10):1604-1606.
4. Starfield B. Politics, primary health care and health: was Virchow
right? J Epidemiol Community Health 2011, 65(8):653-655
Competing interests: All three authors are members and spokespersons of the Network 'Switching International Health Policies and Systems' (SWIHPS), an international network of individuals and institutions to disseminate and exchange information, expertise and practice to contribute to stronger health systems and improved policy making. The network has a strong thematic focus on the organization of care for chronic diseases in low income countries. The secretariat of the network is hosted by the Institute of Tropical Medicine Antwerp, Belgium.
Richard Smith has identified a real ethical question relating to Iona
Heath's approach to ageing and NCD strategies, by highlighting that
probably most people in the real world would agree that death around
60 years of age is premature, whether occurring in low income countries
or to those living impoverished lives anywhere. Ethically a difficulty is
in that people registered with somebody who takes a different view are
highly unlikely to be told and, could actually suffer the consequences of
not receiving proper information or if they wished preventative treatment.
The opinion expressed by Iona Heath as a personal view and not that of
the College obviously highlights that there is leaway for a variation in
the way which people may be treated. Nobody though should hold the power
to in effect write off the possibility of others living perhaps further
decades of life, albeit less rigorously, by witholding preventative
information and treatments which are available and used by those who are
informed. It is akin to an apartheid between the well off, those who are
knowledgeable and in positions of power and the powerless. A person
living on garbage, sleeping in a cardboard box knows that all too soon
s/he is likely to develop a disease, as do those who live in dire straits
in many parts of the world. Neither social or medical policies are
controlled by the poor. When this NCD event or similar conference takes
place it would be good to see an obligatory matching quota of
representatives from groups whose lives are being discussed. Each of
those invited to attend as 'experts' on others' lives could invite a few
and pay for them out of the finances put aside at such functions for
expensive accomodation, meals, entertainments and other such unecessarily
immodest incentives. (This is not a critiscism of this particular
conference as I have no idea how attendees are being financed). In time
maybe a revolution by the poor of the world could have some effect on
specific health and social policies. Revolutions currently taking place to
demand democracy are something that was unpredicted, hopefully they will
incorporate in time the demand for preventative health policies which
offer longer, valued years of life to greater numbers of people
everywhere.
Competing interests: No competing interests
I sympathise with Iona Heath's anxiety about turning so many people
into "patients" by identifying people at risk of developing cardiovascular
disease and other non-communcable diseases (NCDs), but is she really
advocating that we should wait until people are "sick" and then have them
looked after by doctors? (1) She seems to be arguing for treatment rather
than prevention.
Her thinking perhaps flows from too strong an attachment to the
medical model. She is surely not against policy interventions like raising
taxes on alcohol, reducing salt intake, and promoting public awareness of
physical activity, the "best buys" recommended by the WHO in its Global
Status Report on Non-communicable Disease. (2) It's no mistake that most
of the interventions advocated by WHO are nothing to do with doctors and
even health systems. Few doubt that most of what needs to be done to
reduce the burden of NCDs lies outside the health system.
We also have strong evidence that people can be prevented from
progressing from prediabetes and prehypertension (I know Health doesn't
like the names, but they don't really matter) to the full blown conditions
by helping them change their lifestyles and lose weight. (3 4) But this is
nothing to do with doctors and drugs. The programmes are unaffordable if
they use doctors; rather they use community health workers. Surely Heath
is not suggesting that these people should simply be watched as they
develop full blown disease.
There are difficult questions about how much countries should invest
in policy changes, prevention, and treatment programmes. Interestingly
Heath's thinking is the opposite of many in low and middle income
countries. Our network of researchers from some low and middle income
countries, which has just published on NCDs in the BMJ, (5) thinks that
the emphasis must be on prevention--because the Western model of
emphasising treatment is not only unaffordable but also unachievable in
that health workers are in such short supply. The network agrees with
Health about strengthening primary care, but most of that care will not be
provided by expensive (and largely absent) doctors but by nurses and
community health workers.
Finally, Heath is right to criticise us and others for overemphasiing
total deaths rather than premature deaths or lost DALYs, but is she is
perhaps too casual in suggesting that a death at age 60 is not premature.
I doubt that her patients would agree.
Richard Smith
Director, UnitedHealth Chronic Disease Initiative
1 Heath I. Seeming virtuous on chronic diseases. BMJ 2011; 343: 75.
2 WHO. Global Status Report on Noncommunicable Disease 2010. Geneva:
WHO, 2011. http://www.who.int/chp/ncd_global_status_report/en/index.html
3 Knowler W, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM.
Reduction in the incidence of type 2 with lifestyle intervention or
metformin. N Engl J Med. 2002;346:393-403.
4 McGuire HL, Svetkey LP, Harsha DW, et al. Comprehensive lifestyle
modification and blood pressure control: a review of the PREMIER trial. J
Clin Hypertens. 2004; 6:383-90.
5 UnitedHealth, National Heart, Lung, and Blood Institute Centers of
Excellence. Global response to non-communicable diseases. BMJ 2011; 343:
76-8.
Competing interests: Competing interest: UnitedHealth together with the National Heart, Lung and Blood Institute funds and works with 11 centres in low and middle income countries that are doing research, training people, and developing policy to counter NCDs. Together with the Centers for Disease Control, UnitedHealth has developed a programme for preventing people with prediabetes developing diabetes. And by the way I'm 59.
We would like to congratulate the editors for including a series of
perspectives on the prevention and control of non-communicable diseases
(NCDs) in the 9 July 2011 issue of BMJ in preparation for this September's
High-Level Summit on NCDs at the United Nations. This Summit represents a
once-in-a-generation opportunity to bring together Heads of State and
Government to shape a global response to one of the most pressing health
and development issues of the 21st century.
The NCD Alliance (NCDA) was one of the earliest voices calling for a
Summit on NCDs, and has since been central to the preparations and build-
up to this unprecedented event. Behind the Alliance lies four
international federations (the International Diabetes Federation,
International Union Against Tuberculosis and Lung Disease, Union for
International Cancer Control, and the World Heart Federation) that are
world leaders in the fight against cancer, cardiovascular disease, chronic
respiratory disease, and diabetes. The recognition of our unrivalled
legitimacy as a global alliance grounded in the work of our 900 member
associations in 170 countries is now widespread. People with NCDs depend
on the essential support and treatment provided by our member associations
in many low- and middle-income countries (LMICs), and governments value
our evidence, expert advice and good practice solutions to the growing NCD
problem. Together with our broader network of supporting NGOs, private
sector partners, and our Common Interest Group (CIG) of 350 NGOs, we have
built a strong NCD civil society movement, elevated NCDs out of the
shadows and with the UN Summit on NCDs, we expect to change the global
health landscape forever. We have built consensus around the vision for a
successful UN Summit, and effectively advocated on the core elements of
the Outcomes Document that will generate a high-level and sustained global
response.
A vital element of the official preparations for the UN Summit has
been the development of the Global Status Report on Non-Communicable
Diseases by the World Health Organization. This report has been welcomed
by the NCDA as a key milestone in building the NCD evidence base, and
providing much needed data and insight into these under-prioritised
diseases. In a recent BMJ observation (1), Iona Heath questions the
statistics used by the NCDA, taken from the WHO report, regarding the
international morbidity and mortality due to NCDs. It is a fact that NCDs
make the largest contribution to mortality globally, and four in every
five deaths from NCDs occur in LMICs (2). It is also a fact that a huge
proportion of NCD deaths are avoidable and preventable. Eliminating just
the four main risk factors of NCDs (unhealthy diet, physical inactivity,
tobacco use and harmful consumption of alcohol) would prevent up to 80% of
heart disease, stroke and diabetes and more than a third of cancer (3).
Heath accuses the NCDA of being economical with the truth about the
importance of NCDs in LMICs, and compares the proportion of deaths due to
NCDs in Africa with the proportion in Europe, arguing that when people
live into old age most will die from NCDs and that the focus should be on
premature and avoidable mortality. What Heath fails to acknowledge is the
fact that in LMICs people die from NCDs at a much younger age than in
Europe, developing NCDs well before what we people in high-income
countries would consider to be old age. It has been shown that age-
standardised stroke mortality rates in those aged less than 65 years were
up to 10 times higher in Tanzania than in England and Wales (4).
In addition, by focusing only on mortality Heath overlooks another
crucial element of the burden of NCDs. NCDs also account for half of all
global disability (5), including blindness and amputations. The impact of
NCD-related morbidity is being shouldered by families, healthcare systems,
business and national economies alike. Loss of income and high cost of
care and treatment can pitch vulnerable households into cycles of debt,
impoverishment and illness, and the economic effects of NCDs add up to a
substantial drain on society's economic potential by adversely affecting
productivity and economic growth. The costs of inaction on NCDs are
already staggering and will continue to increase as NCDs rise, and for
this reason, the World Economic Forum has consistently ranked NCDs as one
of the top global threats to economic development.
And yet, the case for investment in NCDs is strengthened by the
existence of not only cost-effective, but cost-saving interventions. As
the recent article co-authored by the NCDA and the Lancet NCD Action Group
outlined (6), many effective interventions have a net economic benefit,
costing far less than the full costs of treatment of illness, and in some
cases generate about a $3 return per $1 invested. Interventions such as
the implementation of smoking bans and efforts to reduce sodium intake are
proven to have greatest benefits, be pro-poor and reduce inequalities.
This evidence is reflected in the NCDA Proposed Outcomes Document for the
Summit (7), within which we recommend governments commit to effective
population-wide awareness-raising and prevention, screening and early
detection programmes, where feasible.
While Heath notes that in Norway three quarters of the adult
population have high blood pressure and yet live long and healthy lives,
it would be misleading to suggest that this situation is representative
for the vast majority of people living with poorly functioning health
systems in developing countries. In Sub-Saharan Africa, for example,
approximately 80% of people with diabetes are undiagnosed (8). This burden
of undiagnosed diabetes which could have been managed with cheap, generic
drugs manifests itself in hugely debilitating and costly complications. It
is therefore vital that health services have the capacity to provide NCD
care to those that need it, and attention is given to screening techniques
and strategies implemented to prevent onset of disease or disease
progression.
Like Heath, we strongly support the expansion of the role of primary
care in combating NCDs, and call for both population-wide prevention
approaches, and where appropriate, those that target high-risk
populations. These therefore feature prominently in our Proposed Outcomes
Document for the UN Summit (9).
The NCD Alliance welcomes vibrant debate and discussion about NCDs in
the lead up to the UN Summit and beyond. However the question up for
debate must no longer be 'is this a problem?' We have the evidence to show
this is an issue we cannot afford to ignore, we have the cost-effective
solutions, and with the UN Summit we have the political opportunity. The
debate has now shifted to focus multiple sectors on the more pressing
issue of 'how do we solve this problem together?' For NCDs are more than
just a health issue and too big for governments to solve alone. Turning
this around will require the combined efforts of government, business,
NGOs, researchers, the UN, the media and the general public. It will take
a 'whole-of-society' approach, with innovative partnerships and solutions
at the heart of the global response.
With political leadership and cooperation at both international and
national level, a comprehensive balance of prevention and treatment
commitments, and a strong cross-sector accountability mechanism to drive
implementation of measurable commitments post-September, the UN High-Level
Summit will prove to be the turning for NCDs we have all been working for.
We look forward to joining world leaders in September, continuing to build
global commitments for NCDs, and working together to fight against NCD
morbidity and mortality.
References:
(1) BMJ 2011;343:d4239 DOI:10.1136/bmj.d4239
(2) Preventing Chronic Diseases: a Vital Investment: WHO global report,
Geneva, Switzerland, 2005
(3) World Health Organization (2008) 2008-2013 Action Plan for the Global
Strategy for the Prevention and Control of Noncommunicable Diseases,
World Health Organization, Geneva
(4) Walker RW, McLarty DG, Kitange HM, Whiting D, Masuki G, Mtasiwa DM,
Machibya H, nwin N, Alberti KG. Lancet. 2000 May 13;355(9216):1684-7
(5) UN High-Level Meeting on Non-Communicable Diseases: addressing four
questions. Beaglehole R, Bonita R, Alleyne G, Horton R, Li L, Lincoln P,
Mbanya JC, McKee M, Moodie R, Nishtar S, Piot P, Reddy KS, Stuckler D; for
The Lancet NCD Action Group. Lancet. 2011 Jun 10. [Epub ahead of print]
[Accessed 2011-07-08]
(6) Priority actions for the non-communicable disease crisis. Beaglehole
R, Bonita R, Horton R, et al. Lancet NCD Action Group; NCD Alliance.
Lancet. 2011 Apr 23;377(9775):1438-47. Epub 2011 Apr 5
(7)http://www.ncdalliance.org/sites/default
/files/rfiles
/NCD%20Alliance%20Proposed%20Outcomes%20
Document%20for%20the
%20UN%20High-Level%20Summit_0.pdf [Accessed 2011-07-08]
(8) International Diabetes Federation. IDF Diabetes Atlas, 4th edn.
Brussels, Belgium: International Diabetes Federation, 2009.
(9)http://www.ncdalliance.org/sites/default/files
/rfiles
/NCD%20Alliance%20Proposed%20Outcomes%20Document%20for%20
the
%20UN%20High-Level%20Summit_0.pdf [Accessed 2011-07-08]
Competing interests: No competing interests
The recent issue of the BMJ contains two very different takes on the
same subject. One considering the global problem of NCDs and measures
necessary to reduce it. One questioning the basis for assessing the
magnitude of the problem and suggesting undue influence of big pharma in
presentation of the figures, in order to increase its profits.
I hold no brief for the pharmaceutical industry, but must point out
that determination of NCDA policy is not the preserve of any single group,
whether it be disease- specific organisations, faith-based organisations,
commercial organisations or any others. Certainly no commercial
organisations, or their representatives, participated in the recent Moscow
Global Ministerial meeting, which formulated the Moscow Declaration for
presentation to the September UN High Level Summit meeting on prevention
& control of NCDs.
One of the tenets in the struggle to combat NCDs is the need for
widespread availability of cheap generic medication. Without support from
pharma this will not be available. Similarly to achieve dietary change to
reduce risk factors requires the support of the food industry.
Looking at the size of the global NCD problem, surely the total size
of the problem must be of prime importance. Of course, we all die and
extending life span increases the likelyhood of developing NCDs. Any
measures which can reduce mortality & morbidity from cardiovascular
disease or lung cancer at any age must be valuable.
Measures to reduce risk factors should aim to reduce the incidence of
NCDs in high, medium & low income countries. This must entail a
financial cost. It is estimated that savings in reduced cost of healthcare
related to prolonged morbidity and increased industrial efficiency due to
lower sickness absence from work will far outweigh theses costs1
The important role of primary healthcare in reducing NCDs is
generally recognised, but without political will, global availability of
improved healthcare facilities, involvement of civil society & the
corporate sector and International collaboration it will be impossible to
translate these aims into practical measures.
Global measures require global application of universal standards and
methods, with modification when necessary for local requirements. To
achieve reduced levels of illness and death related to hypertension and
hypercholesterolaemia, for example, requires general acceptance and
implementation of common criteria, based on WHO protocols2
1. NICE Public Health guidance 25 pp 43-44 June 2010
2. WHO Prevention of CVD: guidelines for assessment & management
of cardiovascular risk 2007
Competing interests: Member Non-Communicable Diseases Alliance
Iona Heath's analysis of the causes of global, non-communicable
diseases shows the extent of ambition and greed in contemporary healthcare
(1). The "Global Status Report on Non-Communicable Diseases", confirms
that we are exporting Western lifestyle diseases to lower-income countries
(2). These exports include poor diets, poor bowel habits, limited
exercise, alcohol, tobacco, drugs as well as prolonged labours, low
birthweights and low infant weights at twelve months of age. In 2010,
MacDonalds identified China as their fastest-growing market accounting for
16% of their global profits while under-developed Chinese county hospitals
encounter previously-unseen, Western diseases.
Many of DP Burkitt's list of Western diseases demonstrate
unexplained, autonomic denervation or reinnervation (3). Causes of
autonomic denervation include straining during defaecation, straining
during childbirth, surgery ,trauma, etc Consequences of autonomic
denervation include changes in the function of the organ, susceptibility
to infection, alcohol, tobacco, stress, drugs as well as pain associated
with anatomy-dependent reinnervation (4). These mechanisms account for
many different presentations of non-communicable, Western diseases.
The UN, September summit on non-communicable diseases aspires to
action on risk factors such as BP greater than 140/90 mm, or, cholesterol
levels of 5.2 mM per litre. We agree with Dr Heath that such limited, and
ill-directed, corporate, aspirations are likely to unleash "enormous harm
on an unsuspecting world." The meeting might reasonably discuss new
approaches to causation of non-communicable, Western diseases derived from
under-privileged, Western lifestyles - and their prevention.
(1) Heath I,
Seeming virtuous on chronic diseases,
BMJ 2011; 343:d4239.
(2) Smith R,
Global Response to non-communicable diseases.
BMJ 2011;342:d3823
(3) Burkitt DP, Trowell HC,
Western diseases; their emergence and prevention.
Harvard University Press, Cambridge, Massachusetts, 1981.
(4) Quinn M
"Autoimmune" conditions and auto nomic denervation.
Am J Med 2008; 121(8):e13.
Competing interests: No competing interests
NCD Alliance still economical with the truth and need of open disclosure
Yesterday I heard on Radio New Zealand the standard massive statistic
that almost two thirds of us are going to die of (this mysterious illness)
NCD and important people were meeting in New York to solve the problem.
Having read Iona Heath's article I thought she had raised some
important issues. I was amazed to read the responses. In particular the
letter from the NCD Alliance and Dr Richard Smith were quite intemperate
but more importantly hardly touched on her basic concerns. Even more
alarmingly they argued against things that she had not written or even
implied. It was as though they had not even read her article but were
incensed by her temerity to criticise their good work.
This is the classic response of hard working committed doctors. There
have been several articles recently in the BMJ about open disclosure and
admitting mistakes.It would have been more reasonable if these pundits had
really responded to her valid criticisms.
She accuses the NCD Alliance of being economical with the truth.
She points out that there is a clear need to differentiate between
premature and timely deaths. In press releases The committed still talk
about the total deaths rather than the high rate of premature death and
disability in LMICs. May be 36 million a year sounds big and will generate
more money. I did not anywhere interpret her observations to be advocating
curative rather than preventive measures but the theme seemed to be a call
to the NCD Alliance to make a more accurate presentation about the problem
and what can be achieved. I think her accusation has not been responded
to.
Her second concern was about the appropriateness of using certain
thresholds of Blood pressure or cholesterol as significant risk factors.
There was no answer from the critics about this. She expresses her concern
about Pharma. Her concern is not misplaced as more and more evidence is
uncovered about suppressed trials, manipulated results and the
inappropriateness of medicalising whole communities when the absolute
benefit if of doubtful gain.
Yes, do criticise her slip about doctors rather than using primary
care workers. But lets concentrate on what Richard Smith illustrates and
that is 'most of what needs to be done is outside the health system'.
From my perspective in Vanuatu only 3 of the ten WHO best buys apply
here. Hardly anyone smokes and few drink alcohol. What I would like the
NCD Alliance to concentrate on is transfats, now banned in Europe. Why is
margarine I buy in UK kept cool in a fridge and why does it not go rancid
here in Vanuatu at temperatures of 30'C. How much are the manufactured
foods kept edible by trans fats? What is the role of palm oil which is a
third of the price of sunflower oil? What is the role of the ubiquitous
consumption of white rice from Australia being responsible for the rise in
Diabetes? Why does the sedentary office worker in Vanuatu become so much
fatter than the sedentary office worker of England?
Yes more research and less hype. More regulation and from the history of
industry's obstruction to the work of WHO attempt to help the consumer it
does seem sensible to keep them at arms length. Be friendly but do not sup
at their table, you may not taste the poison.
Having worked in PNG, South Africa, The Solomon islands, Tanzania and
now Vanautu intermittently over the last 40 years and being a huge
supporter of the NCD initiative I welcome what NCD Alliance is trying to
achieve but feel a bit more humility is needed to place their work
appropriately in the context of people's needs.
Competing interests: No competing interests