Tackling chronic diseases is vital to improving child and maternal health
Governments and donors must find ways to tackle the rise in non-communicable disease, which can mean reassessing health priorities in developing nations.
In global health, as in much of life, perception can sometimes be more influential than reality. Take the vastly disproportionate attention given to that research in, and treatment of, communicable diseases such as HIV/AIDS, TB and malaria, despite the far greater number killed by, for example, cancer or cardiovascular disease.
Infectious disease remains rampant across the developing world. But developing countries face a new and growing threat from chronic diseases. Meteoric rises in illnesses like cancer and diabetes are predicted for the next few years. Yet the global health community still pays far too little attention to this challenge.
A key factor in this inertia is the way these illnesses are still perceived as diseases of the elderly in wealthy countries — despite mounting evidence that, overall, developing nations bear the main brunt. If developing countries are to make any headway in fighting chronic diseases, the global community needs to change the way it perceives such illnesses.
Cancer alone, for example, kills more people annually than HIV/AIDS, malaria and tuberculosis put together. Yet the WHO spends only US$ 0.50 per person on chronic diseases (excluding mental health), compared with $7.50 per person for major communicable diseases.
Similarly, the portfolios of the Gates Foundation and other big donors, such as the Wellcome Foundation, are notable in their lack of major investments in chronic disease programmes.
Mounting evidence, little action
Until the late 1990s, not much was known about the extent to which chronic diseases affected poor countries. But since then, researchers worldwide have learnt much more about both the scale of the problem and the risk factors making these diseases increasingly prevalent.
So why the lack of action? Partly, rich countries and donor agencies don't donate resources on the grounds, they argue, that poorer nations don't identify chronic disease as a priority. At the same time, developing nations don't ask for funding because they think they have a better chance of securing money for research and treatment of infectious diseases. Both parties must strive to shake out of this stalemate.
In developing countries themselves, the dearth of policy and research programmes on chronic diseases stems from two problems. One is that many policymakers lack a robust evidence base. Although the WHO is gathering global data, there are few in-country initiatives collating data on local trends and their contexts.
Second is that in many countries (both developed and developing), decision makers see risk factors for chronic diseases as lifestyle choices, which in their view puts prevention (and sometimes treatment) beyond their jurisdiction.
But this is disingenuous. The choices we make to smoke cigarettes or eat hamburgers are strongly influenced by the messages their producers bombard us with. And these industries are an enormous source of national revenue, so governments are not disinterested parties.
They clearly have a responsibility to help individuals reduce their smoking or drinking. If a government allows the advertising and widespread sales of tobacco, alcohol and processed food, surely it should also offer help in controlling or curbing excess use from addiction?
The curricula of public health research needs to catch up too, ensuring the next generation of scientists tackling disease in the developing world will align their research priorities with the fundamental needs.
Most public health research for developing countries still focuses on infectious diseases. But there is some progress. The US Institutes of Health's Fogarty International Centre, for example, has just launched a $1.5 million-per-year grant programme to build research capacity in areas such as stroke, lung disease and cancer.
On the whole, however, except for the biggest schools such as Johns Hopkins and Yale, most public health research needs of developing countries still focus heavily on infectious diseases.
Leadership is needed
Last month, the WHO's African ministerial meeting, in Algiers, strongly emphasised that developing countries must take the lead and state their health research priorities to global funders (see Time to turn words into deeds on health research). But there was no explicit discussion of what these priorities should be.
The Algiers meeting was in preparation for a larger ministerial conference this November in Bamako, Mali. It is important that the Bamako meeting puts chronic diseases explicitly on the agenda and highlights their importance to decision makers around the developing world.
There are several reasons for this, beyond purely humanitarian ones. For example, chronic diseases don't just affect the old, and poor nations' development will be catastrophically affected unless this growing problem is addressed. India lost 9.2 million person years of productive life to cardiovascular disease in people aged 35–64 years in 2000 alone.
Furthermore, we risk undermining all the progress made against HIV and tuberculosis if those who survive such deadly infections go on to die early of heart disease or cancer.
Globally, there is an already vast amount of research into chronic diseases, especially in developed countries. But although some of the findings could be applicable to poorer countries, developing nations can face different challenges.
For example, people in developing countries have different ethnic characteristics to those studied in the world's major trials on cardiovascular disease, and cancers are far more likely to be triggered by viruses. So developing countries will need their own research and trials to find locally relevant solutions.
Developing nations' health systems are generally not yet geared towards managing chronic diseases. Radical changes are needed to health systems' design and to training for healthcare workers. This process would benefit from western countries sharing their knowledge of how to deal with diseases that have long been prevalent in their own countries.
For one thing, treatments are complex. Malaria or HIV/AIDS can be treated by pills. By contrast, fighting cancer might require expensive radiotherapy, while people with chronic diseases also tend to need more palliative care, perhaps because the treatment they need is not available in their country.
This complexity adds expense, which is an issue countries will need to grapple with. Securing funds for antiretrovirals against HIV/AIDS has proved hard enough. Those transactions could be a one-off agreement between a donor and recipient. How will countries ask for aid for treatment that could span a lifetime?
Tackling chronic disease will need significant buy-in from both donors and developing country governments. Both need to realise that achieving the health-related Millennium Development Goals — such as improving maternal and child mortality — cannot be done by focusing on infectious disease alone, but will require an equal commitment to tackling the problem of chronic disease.
John Daly ( United States of America )
23 July 2008
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