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Noncommunicable diseases take a toll in the developing world

Yale Medicine Magazine, 2013 - Spring


There is good news in global health, but not for everyone. Over the past four decades mortality rates have decreased in all age groups, but some parts of the world still fare poorly. And while international public health efforts have focused on such communicable diseases as HIV and malaria, 75 percent of deaths globally are caused by noncommunicable diseases (NCDs), which include chronic diseases and injuries.

The rise in risk of NCDs are, in part, the consequence of economic progress. As countries develop, market forces promote tobacco, overconsumption, and less physical activity, said Sonia Angell, M.D., in her keynote address at the Third Annual Global Health Day Symposium. The theme of the symposium, held on May 9 at the School of Medicine, was “The Challenge of Noncommunicable Disease in Resource-Poor Regions.” The symposium was sponsored by the Department of Medicine’s Office of Global Health, which is led by Asghar Rastegar, M.D., professor of medicine.

“Risk crosses boundaries so that noncommunicable diseases are communicable,” Angell said in her talk, “The Threat of Noncommunicable Disease—The Global Community Responds.” Angell, Senior Advisor for Noncommunicable Diseases at the Centers for Disease Control and Prevention’s Center for Global Health, joined other speakers in highlighting the importance of NCDs.

Although most noncommunicable diseases could be prevented or treated effectively, many conditions continue to cost lives. Acute kidney injury (AKI), which can be treated with short-term dialysis, for example, is on the rise in developing countries. There is, however, a lack of resources to diagnose and treat AKI. Chronic kidney disease, which requires lifetime dialysis, is primarily due to diabetes and hypertension, which is easily treatable, said Frederic Finkelstein, M.D., clinical professor of medicine. End stage renal disease, however, is expensive to treat—in resource poor regions it often involves such tough decisions as rationing dialysis or transplantation.

The lack of both facilities and specialists takes a toll on patients in low- or middle-income countries (LMIC). Uganda, said Robert Kalyesubula, M.D., lecturer at the Faculty of Medicine at Makerere University, has only four nephrologists in a country of 35 million. The cost of dialysis is about $300 per week, well out of reach of most patients in a country with a GDP of $1,400 per person per year. Kalyesubula started an NGO to prevent and treat kidney disease and through advocacy the Ugandan Ministry of Health recently decreased the cost of dialysis by 60 percent. “We need to generate evidence showing cost effectiveness of our treatment” he said, noting that this strategy that has been effective in managing HIV epidemic.

Trauma, said Doruk Ozgediz, M.D., assistant professor of surgery (pediatrics), kills more people than HIV and malaria. In Uganda, he continued, surgery can cure 11 percent of the disease burden. Around the world, he added, about 2 million deaths can be averted through trauma care in countries with limited resources. “Surgery has not been perceived as part of public health because it’s resource-intensive, but it’s actually cost-effective,” he said. While the broad scope of conditions and lack of training is challenging, such strategies as training non-surgeons to do simple procedures and training first responders in basic first aid can help save lives. in 2011 to 83 residency programs in 2013.

A lack of attention and resources also plague mental health care. Suicide, said Robert Rohrbaugh, M.D., professor of psychiatry, is an important cause of death in young people. In China, decreasing stigma connected to mental health issues and changes in health policies have contributed to wider availability of treatment options, but access and quality continue to be problematic. China uses an apprenticeship model for most graduate medical education, with no standardized curriculum or training. Rohrbaugh helped establish a model for graduate medical education at Xiangya School of Medicine that he hopes might serve as a model for all Chinese graduate medical education; including psychiatry. It has grown from a pilot project with three residency programs in 2011 to 83 residency programs in 2013.

Funding for noncommunicable diseases is lagging, since many organizations are focused on infectious diseases. By 2030, however, these diseases will cost $47 trillion, according to Angell. Attention is shifting to this area of global health, as demonstrated by a 2011 declaration by the United Nations calling for a multi-sectoral commitment to curb the risk factors for NCDs and a 2011 WHO report on reducing the economic impact of NCDs in developing countries.

The CDC has global health assets devoted to improving global health, including 1,000 staff members deployed internationally, longstanding and productive partnerships abroad, and a field epidemiology training program focused largely on infectious diseases. While these efforts are focused on communicable disease, it becomes increasingly important to build on this infrastructure as attention to non-communicable diseases grows. Angell stressed that solutions require broad scale engagement and dissemination of findings beyond their original scope. She closed her remarks by urging the symposium’s attendees to share data: “There’s nothing like data to clearly and effectively communicate where we’ve been and where we need to go.”