Miller School Hosts Discussion of Rise of Noncommunicable Diseases

The Miller School of Medicine and the Council on Foreign Relations (CFR) held a joint meeting last Friday to discuss the findings of an independent task force report, “The Emerging Global Health Crisis: Noncommunicable Diseases in Low- and Middle-Income Countries.” Task force leader Thomas J. Bollyky, CFR’s senior fellow for global health, economics and development, led the discussion — moderated by UM President Donna E. Shalala, who is a member of the task force — with faculty and students.

Shalala opened the discussion by noting that noncommunicable diseases are a little-discussed topic, despite the fact that they are now the leading cause of death in developing countries. In fact, the CFR considered the situation grave enough that it gathered its first task force ever devoted to a global health matter.

Bollyky said the task force members were asked to consider three questions:

1. Are noncommunicable diseases — cancer, diabetes, cardiovascular disease — an emerging crisis?

“The answer is yes,” he told the audience. “We knew they were on the rise, but we didn’t realize how fast, how young and how bad the outcomes are.”

Deaths from noncommunicable diseases have risen 53 percent since 1990 — almost double the rate of population growth — with as much as 80 percent of death and disability occurring in people 59 and younger, he said. In 2013 alone, noncommunicable diseases caused 8 million deaths in that age group.

Those deaths are what Bollyky called a “byproduct of success” — people who once would have died of diseases like malaria are now dying of diabetes or cardiovascular disease. What’s more, the increase in noncommunicable diseases is occurring 300 percent faster in low-income countries and one-third faster in middle-income countries than the decline in infectious diseases.

“The primary driver,” he said, “is poverty. People in low- and middle-income countries are living longer, but they aren’t getting any wealthier. Another factor is tobacco consumption, which tripled in middle-income countries between 1970 and 2000.”

2. If the answer is yes, should the United States care?

“People assume we invest in global health to try to prevent direct health threats to U.S. citizens — Ebola, things of that nature,” said Bollyky. “In fact, very little of what we invest goes to address those problems. Most of what we invest in is addressing malaria or poor maternal newborn and child health, or HIV/AIDS. It has very little to do with the prevalence of these conditions in the U.S.

“We invest in these conditions with our global health dollars because we care about the countries that are affected or we care about the people who live there. Those are the same reasons to invest in noncommunicable diseases. In the countries we invest the most in, the rate of premature mortality from noncommunicable diseases is almost twice as high as the mortality rate for communicable diseases. If we care about the health and welfare of the countries in which we invest heavily, we should care about noncommunicable diseases.”

3. What can international action do to assist developing countries?

“In the long run, the solution to noncommunicable diseases in developing countries is the same as it is here,” said Bollyky. “It’s functional, preventative and chronic care. It’s better agricultural policy. It’s better urban design. But those are long-term projects.”
What can be done now? Bollyky outlined a three-part strategy:

First, investments that he called “shovel-ready” — those that target noncommunicable diseases and risk factors that are especially prevalent in working-age populations, that are effective and low-cost, that are amenable to collective action, and that can leverage existing U.S. programs and platforms. Vaccines and tobacco control are examples.

Second, treatments in which we have made enormous progress — he cited a variety of cancer treatments and diabetes — but which need some adaptation to extend them to developing countries.

Third, areas in which the U.S. and developing countries can learn from each other, such as population-based prevention, nutrition initiatives, physical activity and other programs that can help stop the development of diabetes and other illnesses.

When the auditorium was opened to comments from the audience, Barth A. Green, M.D., professor and Chair of the Department of Neurological Surgery, told Bollyky he thought trauma, while not a disease, should be included in the conversation. Green has had extensive experience treating trauma — especially in Haiti since the earthquake five years ago — and he has seen first-hand the long-term health and economic impacts it can have in developing countries.

“On the issue of trauma, I couldn’t agree with you more,” said Bollyky. “The big issue with these countries is the limitations of their health systems in dealing with long-term challenges like the impact of trauma.”

Another comment came from Ralph L. Sacco, M.D., M.S., professor and Chair of the Department of Neurology.

“I’ve been part of the delegation in high-level discussions with the UN and the WHO about mortality targets they are setting for 2025,” he said. “It’s extremely difficult to measure, track and improve some of these targets. Most of our work is on hypertension and its relationship to heart attack and stroke, and how simple changes in diet and sodium consumption and access to drugs can have an impact. But it isn’t something that the UN or WHO is going to achieve on their own. Non-governmental organizations, advocacy groups and private industry, working together, are all going to be needed to bring changes to these countries.”

Sacco asked Bollyky whether the task force differed in its approach to the problem of noncommunicable diseases.

“We took a slightly different approach than the UN with this task force,” said Bollyky. “First, we looked at just low- and middle-income countries because their drivers are different and the strategy to address them probably needs to be, as well.

“Second, we just focused on the role of international collective action, not what needs to be done entirely for noncommunicable diseases. We did that because when you see what needs to be done by all sectors to build a functional health system, there’s a whole long list of what you need to address. In the long term, not all of those are going to need an international initiative or donors and support. We wanted to focus specifically on what the U.S., working with partners and international agencies, could contribute.

“For hypertension, program strategies are very similar to what was done internationally for tuberculosis — registries, identifying the patients, seeking access to effective medications, monitoring its use and its results.”

“This report is a perfect example of how you have to look at the data and look at it very carefully,” said Shalala. Developing countries, she added, “have to see the link to their economic future. They need to keep their populations healthy, and that’s why the connection to poverty is so important.”

A copy of the complete report can be downloaded here.

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