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Vaccines: A Top Priority for Global Health

Vaccination Week in the Americas Goes Global

On the Brink of a Watershed Moment for HIV Vaccine R&D

Reflections of a Lifetime Dedicated to Public Health Advocacy - In Memory of Beth Waters

The Killers We Ignore

Nellie Bristol

Americans and other rich country denizens have been hearing the message for years: snub out the smokes, cut out the chips, crawl off the couch, and move your body. But in many low- and middle-income countries, daily lives were consumed with ensuring children lived past the age of five and getting through the days’ back breaking labor to feed the family. Now globalization, urbanization and successes in combating infectious disease are bringing the burden of “lifestyle” diseases to health systems that are still struggling to catch up with rich-country levels of vaccine coverage and sanitary standards. Experts say the trend adds another formidable argument for focusing scant resources less on specific diseases and more toward health system strengthening and public health activities.

Chronic diseases, including cardiovascular disease, chronic respiratory disease, diabetes and cancer, now account for about half of all deaths and disability in low- and middle-income countries, a figure that is expected to increase dramatically in the coming decades. The rise is occurring in compressed form, catching health systems and donors unprepared.

“It’s quite astonishing how quickly chronic diseases have overtaken infectious diseases in developing countries,” said Rachel Nugent, the Center for Global Development’s deputy director for global health. She cites figures from Bangladesh that show an 86 percent reduction in age-standardized mortality for diarrhea and dysentery, and 79 percent for respiratory infections (excluding TB). The same time period (1986-2006) shows a 3,500 percent increase in deaths from cardiovascular and cerebrovascular disease, and a 495 percent increase from cancer.

Several factors contribute to the rapid rise: successful efforts against infectious diseases, which both decreased the total disease burden and allowed more people to age to the point where chronic disease could become an issue. Also fueling the surge is the spread of smoking, which the UN Food and Agriculture Organization says is growing at a rate of 1.5 percent a year, almost exclusively in developing countries. Add to that urbanization, resulting in changes in exercise habits, providing greater access to a less healthy diet, and increasing exposure to toxic agents like air pollution and industrial waste.

The change in conditions can affect a family in as little as a generation and has been shown to have even more harmful biological effects as a result. Research indicates that fetuses and infants whose mothers are malnourished develop bodies that have adjusted to the nutritional shortfall. The adaptation has been shown to make those children of shorter stature even more susceptible to obesity and its associated metabolic effects if overnutrition becomes an issue later in life.¹  “Their lifestyles have changed dramatically in a pretty short time,” Nugent points out.

Further, chronic diseases are disabling and killing those in the developing world at a younger age since cholesterol reducing pills and screening for pre-diabetes are rarely available. The World Bank reports that more than three-quarters of chronic disease disability in low- and middle-income countries affects those between the ages of 15 and 69, prime age for economic productivity.

Keith Norris, interim president of Charles Drew University of Medicine and Science and an ambassador In Research!America’s Paul G. Rogers Society for Global Health Research, points out another factor that exacerbates conditions in the developing world. Globalization not only introduces Western World sedentary, fast food lifestyles to developing countries, but also results in the dumping of toxic technology trash in some areas. The lack of environmental pollution controls and some countries’ acceptance of contaminated waste contribute to “an exposure to environmental toxins that is going to be many fold greater than what people in developed nations may experience,” he said.

The combination could prove to be particularly lethal, Norris added. ”We’ll have numerous children who not only will be developing obesity and diabetes at higher rates than previously – they’re also going to be exposed to an additional burden of toxins and substances that are going to further accelerate the vascular complications for them,” he said.

WHO, the World Bank and others have expressed concern over this development for several years, but voices calling for greater attention are getting louder. The Institute of Medicine is working on a report with recommendations for combating cardiovascular disease in developing countries. It follows a 2007 report on cancer control in low- and middle-income countries and is expected to be released next year. Chronic disease is likely to be addressed in recommendations released in January 2010 by the Center for Strategic and International Studies’ Commission on Smart Global Health Policy.

“We wanted to signal that in many of the countries we’re working in … we often focus on the traditional infectious diseases and maternal and child health and increasingly, chronic diseases are going to be the more important on the landscape for low- and middle-income countries,” said commission co-chair Helene Gayle, president and CEO of CARE.

Greater attention both within countries and from donors is desperately needed. In numbers she is developing for a new paper, CGD’s Nugent estimates chronic disease attracts a mere 0.23 percent of donor funding compared to an Institute for Health Metrics and Evaluation estimate of 23 percent of disease-specific funding for HIV/AIDS. Meanwhile, cardiovascular disease alone kills five times as many people as HIV/AIDS in low- and middle-income countries, according to WHO.

Experts agree that the trend calls for concerted public health education efforts in developing countries. Not only is awareness of the negative health effects of their new lives limited, but resources to deal with them are scant. “I think particularly in low-income countries, when resources are low, prevention is absolutely paramount,” said Montserrat Meiro-Lorenzo, senior public health specialist for the World Bank. Relatively inexpensive measures for primary prevention include smoking cessation, increasing taxes on tobacco and alcohol, ensuring vaccination coverage, and improving water and sanitation. Overall health improvements and vaccinations, she said, will reduce exposure to agents linked with cancer, including hepatitis and the human papillomavirus.

The increase in chronic diseases also will force new thinking on the provision of screening and prevention methods. Since some of the technology required, such as mammograms, is very expensive, centralization may be required. Dissemination of new, less expensive tests, such as use of Lugol’s iodine to identify women at risk of cervical cancer, also is necessary.

“We’re going to have to think about ways of making those services available at a reasonable cost because otherwise the cost of these secondary measures is going to overwhelm the health system,” Meiro-Lorenzo said.

Retraining of health-care providers, and patients themselves, is also required. In places where many people encounter the health-care system rarely and sometimes never, providers need to ensure patients remain connected for a number of years, and probably for the rest of their lives. “Treatment [for chronic disease] requires a completely different mindset for the person that provides the health care,” Meiro-Lorenzo said.

The diseases also require a different economic approach for the family. Whereas an acute disease can require a bankruptcy-inducing cash outflow for many families, chronic diseases can have similar but more subtle consequences, requiring the family to devote substantial resources to it on a regular basis. “The burden on the family, while it may not be as catastrophic as an acute disease, it may be more progressive and it may be much more insidious,” Meiro-Lorenzo said.

This makes properly regulated risk-sharing insurance arrangements even more necessary, a solution that will need to be developed by a country’s legislators.

But getting policy-makers to give chronic disease proper attention will be difficult in countries already overwhelmed by acute diseases and a global recession. Gayle, the co-co-chair of the Commission on Smart Global Health Policy, notes, for example, that it will be difficult to convince major tobacco producer China to cut back when it counts on the industry for a substantial percentage of its net government income.

But some of the tools needed to improve detection and treatment in the developing world are simple and available. Blood pressure and diabetes screening can be incorporated into vaccination days; pharmacists can be trained to track patients; and developing world public health officials can implement the same messages in their countries that have become the mantra here.

“If pushed now [public health interventions] could have a huge impact on the health of nations in the future,” Gayle said.

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Reference

1 Gluckman, PD and Hanson, MA, 2008, Developmental and Epigenetic Pathways to Obesity: an Evolutionary-Development Perspective, International Journal of Obesity, vol. 32, pgs S62-S71.

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Bobbi Nodell is a freelance writer.