Facing a “Slow-Motion Disaster” — The UN Meeting on Noncommunicable Diseases
N Engl J Med 2011; 365:2345-2348December 22, 2011DOI: 10.1056/NEJMp1112235
You might think Linda Ezekiel would always be in a hurry. As the first nephrologist in Tanzania, she started and now runs her country's only public-sector dialysis unit. She is currently spearheading Tanzania's first renal transplantation program. And she manages the postoperative care of 80 patients who have received transplants abroad. But her manner suggests infinite patience. Perhaps her calm reflects her hope.
In September, Ezekiel joined representatives from 192 countries at a United Nations (UN) conference on noncommunicable diseases. It was a moment of international recognition, when attention turned from the devastation wrought by well-known diseases such as AIDS and malaria to the quieter, though no less dangerous, threat of noncommunicable disease. Although the diseases on which the meeting focused — cardiovascular disease, chronic respiratory disease, diabetes, and cancer — may not ravage a society as quickly and visibly as uncontrolled infection, their death toll is real and increasing. Noncommunicable diseases, says World Health Organization (WHO) Director-General Margaret Chan, represent “a slow-motion disaster.”
Indeed, of the 57 million people who died in 2008, 36 million died of noncommunicable diseases. These staggering numbers convinced the UN to convene its second-ever high-level general assembly meeting on health. For 2 days, 30 heads of state and at least 100 other senior ministers and experts gathered to report on how these diseases are affecting their countries. One by one, world leaders spoke. In Nauru, an island in the Pacific, the prevalence of diabetes has reached more than 40%, one of the highest rates in the world. Heart disease now kills 25% of the population in Trinidad and Tobago. And in Tanzania, 30% of the population has hypertension.
Since these diseases affect people in the prime of their working lives, the World Economic Forum (WEF) predicts that their overall cost will reach $47 trillion by 2030. Many low-income countries have seen an “epidemiologic transition”: with fewer people dying at an early age from infectious causes, more are living long enough to bear the consequences of Westernizing trends such as tobacco use, an unhealthy diet, and a sedentary lifestyle.
In 2006, when Ezekiel returned to Tanzania from her medical training in India, thousands of Tanzanians were dying of end-stage renal disease. Without dialysis units, let alone a transplant center, she had to send countless patients home to die — and those were the few who had at least known to seek her help. Most never got that far. In a country accustomed to the ravages of infectious disease, the telltale signs of uremia — vomiting and confusion — were often assumed to be caused by malaria.
When Ezekiel advocated for providing dialysis, the medical community was pessimistic. “That could never happen!” she was told. Unfazed, she responded, “Well, that's a challenge.” When asked to elaborate on the challenges of navigating a government bureaucracy to drum up funds, she shrugged. “I built a case,” she said. Now the country has a publicly funded dialysis center as well as three private-sector units. Ezekiel acknowledges that medical facilities in urban centers remain inaccessible to the millions of rural Tanzanians.
Of course, neither dialysis nor transplantation is among the “best-buy” public health interventions cited by the WHO and WEF in a book published in concert with the UN meeting (see table“Best-Buy” Interventions for Tackling Risk Factors for Noncommunicable Diseases.).1 Those measures, such as raising taxes on tobacco and reducing the sodium content of foods, have been deemed both cost-effective and practical for diverse economic and cultural milieus. For instance, the four measures suggested for decreasing smoking are easy to adopt and estimated to cost less than 40 cents per person per year in low- and middle-income countries (a figure that must, however, be considered in the context of total annual expenditures on health care, which averaged only $22 per capita in low-income countries in 20062).
But as Ezekiel's work makes clear, although prevention on a global scale may ultimately be more cost-effective than a strategy of focusing limited resources on particular treatments, clinicians cannot rest easy when effective therapies exist but remain unavailable to their patients. Though higher-income countries have now had some success in reducing modifiable risk factors, such as smoking, in resource-poor settings, balancing the immediate needs of the sick with the possible future benefits of prevention will be an ongoing challenge.
To that end, Ezekiel's efforts thus far have focused on treatment, which she knows is a necessary step for any country beginning to address a new epidemic. Certainly the awareness generated by the UN meeting is a critical first step toward addressing noncommunicable disease at the global level. However, it remains to be seen whether the meeting will foster the dissemination of effective therapies as well as prevention. Although the meeting ended with the adoption of a declaration enumerating the problems, the statement was notably silent with regard to deadlines or explicit targets for member nations to meet. And despite a general call for evidence-based interventions, there is no accompanying requirement for ongoing data collection to track outcomes. Without a system of accountability, the declaration, though ambitious in its goals, may well fall short.
Perhaps, however, the greatest concern regarding the declaration is that it did not explicitly allocate funds toward either prevention or treatment. The state-of-the-art care we have come to expect in the industrialized world depends on adequate resources. A myocardial infarction is best treated with percutaneous coronary intervention. Cancer is best treated at a cancer center, where therapy, from surgery to advanced chemotherapeutics, can be delivered in an integrated manner. And even preventive measures, such as vaccination to prevent the cancers that result from hepatitis B or human papillomavirus, depend on money.
Still, although the leaders of member nations did not leave with money in their pockets, the assembly did provide an opportunity to exchange ideas. For example, Tanzania, though ravaged by poverty, has a government that has been uniquely receptive to addressing the population's health needs. For the past few years Tanzanian physician leaders like Ezekiel have been working to build an infrastructure to address the country's burden of chronic disease. Yet if Tanzania's successes serve as a model for other countries, its continuing challenges are representative of those that the UN's broad constituency will face as many disparate countries attempt to put the declaration's words into action.
Although the most concrete and economically feasible measures described at the UN meeting are geared toward prevention, adopting these measures will bring its own set of difficulties, since lifestyle modification is a challenge for any country. How does one convince a society plagued by poverty, long accustomed to the scourge of infectious disease, to mobilize now to address the slow-motion disaster of noncommunicable disease? Even the most culturally astute strategies may not be sufficient to overcome the cognitive bias that affects both populations and individuals: if you can't see it, it doesn't exist. A 49-year-old, overweight Tanzanian blogger who accompanied his country's delegation to the conference spoke to the challenge of prevention when asked about his own experiences with the Tanzanian health care system: “I'm not sick,” said the occasional smoker. “Why would I see a doctor?”
Neither a 2-day conference nor a book of best-buy interventions can instantly change human nature, but the conference did herald opportunities for meaningful progress. When asked whether this first public recognition of noncommunicable diseases in developing countries will transform the approach to chronic disease in Tanzania, Ezekiel remains realistic. “We'll make it happen,” she says. “We'll just need to work very hard.”
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1112235) was published on November 16, 2011, at NEJM.org.
Drs. Rosenbaum and Lamas are editorial fellows at the Journal.
Prevention and control of NCDs: priorities for investment — First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control. Table 1: interventions to tackle noncommunicable disease risk factors: identifying `best buys.' Geneva: World Health Organization (http://www.who.int/nmh/publications/who_bestbuys_to_prevent_ncds.pdf).
World health statistics, 2009: health expenditure. Geneva: World Health Organization (http://www.who.int/whosis/whostat/EN_WHS09_Table7.pdf)
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