Non-Communicable Diseases (NCDs): A repeat case of too little, too late?

Thematic article

Non-Communicable Diseases (NCDs): A repeat case of too little, too late?

Musa Lawrence Lewis

Introduction
Even though it may happen organically, learning is more effective if done intentionally. Sad to say the demands of the present and the pressure to show quick results leaves little if any room to critically reflect and learn from experiences. The writer and philosopher, George Santayana aptly cautioned in saying that “Those who cannot remember the past are condemned to repeat it.” There is an urgent need of critical reflection to learn from HIV/AIDS pandemic experiences with a candid desire to nip the glaring threat posed by NCDs in the bud.  
 
Background & Scale
A NCD is a medical condition or disease that is not caused by infectious agents (non-infectious or non-transmissible). NCDs can refer to chronic diseases, which last for long periods of time and progress slowly (Wikipedia, 2018).
 
NCDs include cancer, diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular disease and mental health conditions (Allen and Feigl, 2017). NCDs are the world’s largest killer, disproportionately affecting developing countries, pushing millions of people into poverty and causing 30 times more deaths compared to HIV/AIDS yet receiving 17 times less funding (Ibid).
 
In 2015, out of the 56.4million global deaths, 39.5million, or 70% deaths were due to NCDs. Of those, over three quarters or 30.7million occurred in low and middle income countries with about 48% of deaths occurring before the age of 70 (WHO, 2018). The societal and economic effects of the productive age group losses is immense.
 
A closer look at cancer profiles reveals similar trends where elevated cancer incidences are in very High Development Index (HDI) regions compared with low HDI regions (ASR 64.5 vs 46.2 cancer cases per 100,000 people per year). However, mortality burden is three times higher in low HDI regions (ASR 25.4 vs 9.2 cancer-associated deaths per 100,000 people per year). (Fidler et. al., 2017). It is highly likely that the statistics from low HDI regions are understated due to weak health systems, weak data management systems and poor health seeking behaviours at formal health facilities.  
 
This stark reality has stimulated discussions on the need to rename NCDs for them to receive deserving attention. Calling the world’s biggest killer “non-communicable” is argued to be counterproductive as “non” may be associated with a “non-issue” or a “non-starter” perpetuating confusion, militating against any sense of urgency, deflecting attention from potentially effective system wide interventions and blaming and placing of emphasis on individual behaviours rather than societal (Allen and Feigl, 2017).
 
Many people will die prematurely because of four NCDs—cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. This is despite that these four diseases are largely preventable through public policies that tackle four main risk factors: tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity (WHO, 2018).
 
HIV/AIDS early responses
In the infancy stages of HIV/AIDS, so many countries, individuals and institutions misunderstood and therefore underestimated the posed threat. In the 1980s, the USA President Ronald Reagan’s administration initial reaction apparently treated HIV/AIDS as a joke. The administration called it a “gay plague,” clearly exuding loads of apathy (Online, 2015). 
 
Several years later, in South Africa, the HIV/AIDS epicenter of southern Africa, it took more than a decade to effectively respond to the pandemic despite the ghastly evidence of its effects in other countries. When the response was eventually initiated, it was described as bewilderingly slow, fragmented and marred with contradictory efforts by various players (Dickison, 2004). With the benefit of hindsight, the massive human lives lost mostly of those in their peak productive years, immense financial burden on various financiers, stunted development of large proportions and inconceivable societal scars that could have been avoided are still being felt to this very day, more than 38 years after the initial formal cases of HIV/AIDS. 
 
By the end of 1986, HIV/AIDS cases reported to WHO by regions were: Americas 31,741, Europe 3,858, Africa 2,323, Oceania 395 and Asia 84, (Avert, 2018). At the end of 2017 the numbers of people living with HIV had reached: Africa 26million, Asia and Pacific 5,2million, Americas and Europe combined 4million, Eastern Europe and central Asia 1,4million (UNAIDS, 2018). If it had not been a case of too little too late the pandemic would have been more cost effectively curtailed in its infancy steps. The WHO projects that by 2020, approximately 16million new cases of cancers are anticipated worldwide with 70% of those in developing world (Newsday, 2015).  
 
Given that the four main NCDs risk factors: unhealthy diets (foods high in fats, sugar or salt), tobacco use, harmful alcohol use, and physical inactivity are largely modifiable, millions of lives can be saved by healthy diets, exercise and avoidance of tobacco and alcohol (Musau, 2017). To avoid a repeat of HIV/AIDS trajectory history, governments, private companies, societies, financiers and ultimately individuals all have a role to play and this required action is clearly time bound with the clock ticking.          
 
Have we learnt something?
Does the wide gap between knowledge of evidence of NCDs prevalence (of pandemic proportions), appalling effects on morbidity and mortality, risk factors and means within our powers to address the scourge compared against absent concerted efforts to appropriately address NCDs point to a case of history repeating itself? The only difference is that with HIV/AIDS evidence was scant compared to that which we currently have on NCDs.
 
The HIV/AIDS response has established systems of responses that are a good platform to address NCDs. We have at our disposal a reasonably equipped “toolbox” of interventions that could be used to address the present NCDs threat. However, apathy and what may be perceived as an underestimation (if not little comprehension) of the threat posed especially to developing nations already ailing from a high burden of infectious diseases at the backdrop of weak health systems stand in the way of a timely and effective prevention and control of the NCDs.
 
HIV/AIDS primary prevention is the most cost-effective and desired response. The same holds true for cancers despite that a few cancer cases can be effectively detected with screening i.e. cervical, prostate and breast cancers. Cancer surveillance is highly recommended (Henderson & Oeffinger, 2017). Other prevention methods already known and proposed include those to do with tackling the risk factors as discussed above.   
 
Good intents low implementation
The discordance and misalignment between what is said and what is being done remains the reality on the ground. There have been a lot of resolutions, commitments and engagements on the NCDs, however it is critical at this point to put the money where the mouth is if the painstakingly meagre progress is to be addressed. On the 27th of September 2018, the third United Nations High-Level meeting on NCDs will be held where a High-Level Commission on Non-communicable Diseases report will once again highlight further evidence and appalling (once again) progress achieved in the implementation of commitments made.
 
The co-chairs of the Report of the WHO Independent High-Level Commission on Non-communicable Diseases presented that “many policy commitments are not being implemented, countries are not on track to achieve targets. Country actions against NCDs are uneven at best. National investments remain woefully small and not enough funds are being mobilized internationally. There is still a sense of business-as-usual rather than the urgency that is required. Plenty of policies have been drafted, but structures and resources to implement them are scarce (WHO, 2018.)”
 
The cost of inaction outstrips that of waiting to respond to a fully-fledged NCD pandemic. A rising NCD epidemic will put more pressure on already overstretched health systems as the systems will require adaptation and strengthening (Musau, 2017).
 
Conclusion
NCDs have become the leading cause of disabilities and deaths worldwide and disproportionately affects developing nations. In spite of the scale of evidence available and its increase, a lack of concerted and sincere efforts to respond to the threat posed by NCDs persists. This was the same journey that HIV/AIDS took, where meaningful response implementation started too little, too late resulting in pandemic proportions whose effects are still being felt today – more than 40 years since the first cases were detected. Would HIV/AIDS have caused as much havoc as it has done and continues to do if the early responses were different? Undoubtedly not necessarily so. Sadly, the current trajectory of NCDs, closely resembles that of HIV/AIDS. We all have work to do both in our individual and corporate roles.