Non-Communicable Diseases: A Global Priority

Globalization over the last few decades has resulted in rapid shifts in economic development and population health. The improved health outcomes and longer life spans are a testament to this trend, though the globalization phenomenon does not go without harmful effect. In this blog I will explore the increasing relevance of non-communicable disease (particularly in the developing world), highlight several of these conditions, as well as look specifically at China in the regard.

The focus in the developing world has historically been on communicable diseases caused by infectious agents. The common perception has been that low-income countries are overwhelmed with the communicable disease burden and chronic diseases are ailments of the wealthy. (1) This notion is becoming increasingly inaccurate; it is estimated that in 2004 there will be 56 million deaths globally, 60% of which will be due to non-communicable disease. Along with high income countries, this majority burden hold true in both low- and middle-income countries as well. Even so, there is a noticeable neglect of non-communicable disease investment in the developing world. In order to continue to improve health outcomes in these populations, chronic disease must be better addressed in the future.

The increase in chronic disease is most often attributed to the ageing of populations combined with the nutrition transition through global trade and marketing. (2) When I think about this transition, it is tough to argue that overall it’s a bad thing. We all die of something, and chronic disease is far better than acute infectious episodes. As Dr. Samet said in lecture, ideally we would like the quality of life very high all the way until death at 90 years old, and this is precisely what chronic disease prevention and management aim for.

Cardiovascular disease is now the leading cause of death in the world, with over 16.4 million deaths attributable to the disease and it is predicted that by 2020 more than half of all deaths worldwide will be associated with CVD. (3) It is important to realize the contributing factors of globalization to CVD, such as the increasing rates of tobacco and higher proportions of dietary fat and sugars.

These factors are also important for cancer, which is an increasingly relevant disease in the developing world. As the health infrastructure in these populations is often insufficient, cancer screening and treatment is a luxury few achieve. I found it interesting that in South Asia, the leading cause of deaths is oral cancer with over 140,000 deaths which is associated with the commonly chewed betel nut. Worldwide, over 7 million deaths result from cancer.

When considering overall disease burden, mental disorders are also given less attention in global health. This disease burden is definitely not the first that comes to my mind when considering global non-communicable disease, but I was surprised to learn that over 10% of DALYs lost in low- and middle-income countries come from mental disorders. (3) Health systems undoubtedly have an effect on this burden where persons often go untreated, producing large amounts of disability in these populations.
The global obesity epidemic is one of the hot topics in global health today. The westernization of diets, decrease in manual labor, and improvements in transportation technology all direct effects on this trend. Our civilization is developing at a much faster rate than any physiological change may be allowed, and this discrepancy will need to be directly addressed in order to curb the growing rate. In the past 20 years, obesity rates in the developing world have tripled. Today, about 1.7 billion people are overweight while almost 400 million are classified as obese. (4) The poverty transition from low-income countries to high income countries is very intriguing. In the former, poverty is associated with malnutrition and being underweight where the poor in middle- to high-income countries are more often overweight.

Obesity is associated with a slew of other chronic conditions and has lasting financial costs. In the United States, obesity is second only to smoking as the leading cause of preventable death. In 2001, the direct and indirect cost of obesity in the United States was $123 billion. Globally, it account for 16% of the disease burden. (5) Disease associated with weight gain includes type 2 diabetes, cardiovascular disease, and certain cancers. An increase in these diseases will have astronomical direct and indirect costs with their management, loss of productivity, and DALYs. Stroke, nephropathy, and other renal disease will also increase, which is all but a death sentence in the developing world.

Pediatric obesity is also a growing epidemic. Adult-onset diabetes (now type II) was renamed as children began exhibiting the disease. It is especially worrisome in this population as obesity can have lasting psychosocial effects and since it is extremely difficult to cure can last the duration of an obese child’s life. Curbing this epidemic will require fundamental social and political changes dealing with nutrition, agriculture, trade, urban development, education, occupation, and other facets of life. This is an extremely complex battle. I am also taking the Global Implications on Obesity class this semester, and it seems with every week’s topic we are further and further from an answer.

I wanted to look specifically at China in this blog, as it is has experienced exponential change over the past 50 years, moving from a 3rd world country to the highest GDP. The entire epidemiological transition took place in only several decades following the formation of the Republic in 1950. The population saw great increases in lifespan with improved hygiene, sanitation, access to medical care, education, and urban development. I find it truly mind-boggling that in only 40 years the national life expectancy increased by 20 years. (6)

The speedy economy, of course, also brought the consequences of widespread tobacco use, decrease in physical activity with autos, and modified diets. As a result, chronic disease escalated and lifespan has begun to plateau (Enter thought once more: You gotta die from something!). Rural areas still see large amounts of communicable disease and are lagging behind the more urbanized coastal regions.

Today, there are some suspect trends in the People’s Republic. The one-child family policy has been an immense driver of population ageing, and it is projected that they country will have over 400 million citizens over 60 by 2050. That number is staggering and I can’t imagine how they are going to support so many people in their golden years. Yang, et al also notice a rapid increase in high risk behaviors, including high dietary fat intake, decrease physical activity, and rampant smoking. No other country has a larger group of people with hypertension (177 million) and one in every three smokers globally is a Chinese man.

The country has begun to undertake more prevention and public health efforts, but will need to apply broad social action, policy, and surveillance to properly combat their unique shift in disease burden. It is hoped that China can have similar success with non-communicable disease as it did with infectious disease in a short amount of time. This will not only be beneficial to China’s own citizenry, but can also provide guidance for countries around the world.

1) Skolnik R. Non-Communicable Diseases. Essentials of Global Health. Sudbury, MA: Jones and Bertlett Publishers; 2008: 213-231.
2) Beaglehole
3) Lopez, A., Mathers, C., Murry, C., Global Burden of Disease and Risk Factors, New York: Oxford University Press, 2006
4) Hossain, P., et al, Obesity and Diabetes in the Developing World – A Growing Challenge, NEJM, Jan 2007
5) Wang, Y., Lobstein, T., Worldwide trends in childhood overweight and obesity, IJPO, 2006:1
6) Yang, G., Emergence of non-communicable diseases in China, Lancet, October 2008