Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases, are neglected globally despite growing awareness of the serious burden that they cause. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. In this first paper in The Lancet Series on Chronic Diseases and Development, the authors, led by Dr Robert Geneau, University of Ottawa, Canada, and Professor Robert Beaglehole, University of Auckland, New Zealand, analyse why the world is not yet confronting the chronic disease challenge.
Out of every 10 deaths globally, 6 are due to chronic non-communicable conditions; 3 to communicable, reproductive or nutritional conditions; and one to injuries. As for funding it is common in high income countries to see at least 60% of all heath care costs being attributed to chronic diseases. So while chronic diseases are not neglected in countries like the UK and Canada, what is neglected in rich nations like these is the use of population health approaches and primary prevention to prevent them. In low- and middle-income countries, data are poor but it is fair to say all parts of the chronic disease sector are neglected. Some of the poorest countries depend on official development assistance, and only up to 3% of that money goes toward the fight against chronic diseases despite the huge burden that they cause. Furthermore, less than 15% of WHO's budget, and less than 2% of the total health budget of the World Bank and Gates Foundation are directed to chronic disease prevention and control.
The authors highlight several possible reasons for this apathy. Chronic disease control is a long-term goal in a short-term world. Thus a politician facing frequent re-election is more likely to go for quick fix solutions (e.g. focusing on access to drugs and services). Also, targeting chronic diseases is likely to be more troublesome to vested interests than targeting an infectious disease such as HIV or malaria. For example, persuading people to eat healthily in large numbers—which would have a huge impact on the chronic disease burden in countries of all incomes—would cost unhealthy food industries a great deal, although it would increase profitability of healthy food suppliers. Chronic disease advocates also have to battle years of entrenched opinion within the international community (especially donors and governments of low- and middle-income countries) that targeting infectious diseases is sufficient in itself to improve global health and human development. A small group of powerful individuals are deciding these priorities, paying scant attention to the burden of chronic disease.
The chronic disease community also has to battle past the stereotypes that a person with an infectious disease is a victim, while those with chronic diseases are said to have made lifestyle choices that have led to their situation. People regard taxes of soft drinks, smoking in public places and other public health interventions as intrusions rather than strategies to improve their health. The victim blaming approach does not account for the techniques used by vested interests to further their causes, such as powerful marketing campaigns to promote alcohol and unhealthy food, and the tobacco industry developing ways to make cigarettes even more addictive.
The authors say: "In addition to overcoming these myths through rebuttal, the generation of a new narrative that evokes compelling, symbolic, and emotive images of the victims and causes of chronic diseases is needed. Evidence about the possible addictiveness of many products that cause chronic diseases, especially in children, will need to be acquired and disseminated through scientific research and discovery of corporate strategy documents that refer to evidence for addictiveness, to dispel dominant myths."
The donor community must recognise that chronic diseases play an important part in the cycle of poverty, as do infectious diseases. Chronic diseases also disproportionately affect the poor, who are much more exposed to the classic risk factors: tobacco use, poor nutrition, physical inactivity, alcohol misuse, indoor air pollution, and poor health services. In India, a household member having a chronic disease increases by 40% the risk of that home falling into poverty.
Interventions that are cheap and effective (eg salt reduction, tobacco control, and treatment for those at high-risk of cardiovascular disease) must also be scaled-up. The authors conclude: "On the basis of this analysis, we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build on emerging strategic and political opportunities....Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate."
Dr Robert Geneau, University of Ottawa, Canada. T) +1 613-291-8877 E) rgeneau@bruyere.org
Professor Robert Beaglehole, University of Auckland, New Zealand. T) +64 2102498065 E) r.beaglehole@auckland.ac.nz
For full Series paper 1, see: http://press.thelancet.com/cdd1.pdf
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The Lancet