11 May 2012

Non Communicable Disease = Not Currently Development?

As part of a Development Studies Association New Ideas initiative, Hayley McGregor and Linda Waldman, two Fellows at IDS,  hosted a workshop on non-communicable disease (somewhat  clunkily called NCDs by all).

I chaired a session on nutrition with two excellent presenters, Venkat Narayan from the Rollins School at Emory University and Andres Mejia Acosta a Fellow at IDS.

NCDs are what they say they are--diseases that are not communicable.  This is includes cardio vascular disease, some cancers, diabetes, some neurological conditions and mental health.

This is what we know (see slides from one of yesterday's speakers, Richard Smith, Director of United Health Chronic Disease Initiative):

  • the fundamental drivers of NCDs are increasing: urbanisation, ageing, consumption of processed foods, inequality
  • the global burden of disease will shift rapidly from infectious disease to NCDs in the next 10-15 years, even in the poorer countries (the above graphic on the website is from the Bangladesh Matlab nutrition surveillance sites -the red shows the % of deaths caused by non communicable disease--growing very rapidly)
  • NCDs rates are not related to income levels, and for some NCDs are higher in the poorest groups
  • we don't have effective interventions or policies and we don't have good evidence on what works

Why is this a development issue?

  1. Because it is a very bad byproduct of the dominant development pathway
  2. Because it threatens to close off future development pathways by overburdening health systems, workforce productivity, and taking away resources from communicable diseases.
  3. Because it profoundly affects wellbeing and the quality of life for very long periods of life.
Why is attention on NCDs so fitful? Apparently only 3% of global health resources (public and private) are allocated to NCDs (from Rachel Nugent) and it is certainly difficult to get aid agencies (and apparently Foundations) thinking about it.

The neglect is possibly because:
  1. the "narrative" around NCDs is fragmented (undernutrition has its 1000 days), what does over nutrition have?
  2. it is not seen as development, rather as a disease of affluence or lifestyle choice--but this is clearly not the case as the data presented by Richard Smith yesterday show
  3. the limited range of cost-effective interventions, backed up by rigorous evidence, is not reassuring enough for policymakers--we need more research
  4. civil society is not organised around these issues--on the one hand we have the MDG type NGOs and on the other hand the non-development NGOs concerned with single issue NCDs
  5. NCDs are not in the MDGs--will they get into the next round?
In the nutrition domain, the NCD field seems about 20 years behind the undernutrition world. The worrying thing is that we do not have 20 years to wait--the NCD elephant in the room is charging--fast.


Shanta Devarajan said...

Laurence, what is the rationale for pubic intervention in non-communicable diseases since, by definition, there is no externality? I see two. First is redistribution. Poor people suffer disproportionately from NCDs. But the instrument should be designed to suit the rationale. Targeted vouchers for health care for instance would address the equity issue without allowing the program to be captured by the non poor. The second rationale is the drain on the public health system. But this is a symptom of the distortion in the public health system (prices don't reflect costs). In that case, it may make more sense to reform the health system.
Best regards, Shanta

Lawrence Haddad said...

Hi Shanta,

1. I agree on the distribution issue and health care vouchers is one way of handling that, as is health insurance.. but this is likely to be better for mitigation than prevention, the latter being the Achilles Heel of even the best health systems

2. I think the drain on the health system is a key externality -- reforming the health system may work when such a system is relatively strong in the first place, but what if most people rely on private (not very good) services? (And of course tobacco smoking is the classic externality.)

3. But information asymmetries may be the strongest rationale for public policy interventions as the food and pharma industries are much more powerful at providing information and influencing behaviour than the public sector will ever be..

4. And then there is the public policy that is already having big effects on diet related chronic disease, but is introduced for other reasons (e.g. subsidising the production and consumption of cereals, but not fruits and vegetables)-- this needs rebalancing towards a healthier diet..

I'm no expert on interventions... but it seems to me like a very good topic for a WDR in the next few years... the Bank could really make this a Development issue..

Thanks for the comments!

Paul Isenman said...

Interesting note on an important and still relatively neglected topic.
I'm surprised that tobacco, as by far the biggest killer among NCDs, or among disease as a whole, did not get sufficient mention to be in the summary. The same applies, even more so, to tobacco taxation, in my view the most cost-effective intervention in public health, or development overall. Interesting also that the high returns to some direct nutrition
interventions, along with tobacco taxation, didn't get mentioned as effective interventions.
I'm also surprised at the ordering of your list of why NCDs are important for development. The third one, combined with killing huge numbers of people, seems to me by far the most important. Maybe they WERE NOT meant to be in order of importance, though.
Best regards,

shukla said...

Dear Sir,

Firstly, I would congratulate you to share this thought-provoking details of NCD burden.

I feel that as NCDs are costly affair, everyone cannot afford even the treatment and follow it through lifetime so if we need to control NCDs, then we must target the following

Robust, vigorous and cost- effective nutrition intervention across the country targeting the poors and educating them to deal with the NCDs.

Another way of educating could be through schools, colleges, community groups, NGO's etc.

There is no mention of tobacco wherein the intake of tobacco and alcohol is growing very high even in the case of females, adolescents etc. We need to provide a rationale to control this.

W need to reform our health system with effective policies and interventions to control these life style diseases..

Best Regards


Rachel said...

Thanks, Laurence, for raising some interesting issues around NCDs (and the shout-out on the low funding that NCDs receive globally.) I completely agree that we should be thinking about the economic and social costs of NCDs, beyond a narrow market failure perspective. If we do (and certainly those responsible for health care in rich and poor countries alike do), then we'll see the urgency of a stronger response to this problem both globally and within countries. Interestingly, the Nobel Laureates in the Copenhagen Consensus (not known for being wild-eyed socialists) put NCD interventions into the top tier of their recent priorities, just after some tried and true infectious disease and hunger interventions. This was based on benefit-cost analysis I presented to them. And yes, while we need much more experience and measured results to guide what interventions are made to address this high burden, if one compares the current state of knowledge around at least treatment of NCDs with where we were on AIDS treatment at the early stages of the epidemic, we are vastly ahead in proven approaches and -- sadly -- vastly neglecting the low-cost options, such as screening and prevention of high blood pressure, salt reduction, tobacco taxes, etc. Yo can see the CC results and download the paper here (www.copenhagenconsensus.com)


Lawrence Haddad said...

Dear Paul/Lawrence

1. The Copenhagen Consensus paper on chronic diseases and 5 priority interventions is summarised on Slate at: http://www.slate.com/articles/technology/copenhagen_consensus_2012/2012/04/copenhagen_consensus_ideas_for_reducing_cancer_and_heart_disease.html

The paper has some estimation of the economic losses from tobacco as well as a discussion on welfare benefits.
On Monday, the CC panel will rank the various interventions.

2. A longer paper on tobacco and its importance in India (which makes the general point relevant for many countries) is attached.

3. Urbanisation, ageing, consumption of processed foods, inequality`are more distal determinants of increasing chronic diseases (indeed, there really is no such thing as ageing, but rather the accumulation of risk factors with age). The main driver of increases is tobacco, and perhaps in some populations obesity.

I'm happy to send you more information as required.

Best wishes

Prabhat Jha

University of Toronto Chair in Disease Control

Lawrence Haddad said...

Dear Rachel and Prabhat thanks for the comments--you highlight my obesity centricity...

Rachel, I take your point about the evidence outside obesity--tobacco, salt, screening of high blood pressure-- a lot of low cost work and well done on the background analysis for the CC paper!

Dear Shukla and Prabhat, your points about tobacco are well taken--chalk it up to my food focus.

The point about ageing is also well taken.


Ellie Savage said...

I’m diagnosed with diabetes, no wonder I experience dysfunction problems sometimes, that’s why I plan to purchase generic Viagra online to give solution to my illness. I just do wonder if how you conduct your experiments in determining if it’s (NCD) “Non Communicable-Disease.” If the disease is a NCD, what will happen to the person infected with this disease?

Irene Burch said...

Prevention or slowing down the widespread of communicable diseases can be made by recognizing the different characteristics of various diseases. There are methods being used in order to prevent transmission of pathogens like disinfection and pest control.

Owen Burrows said...

Early detection is key to overcoming non communicable diseases. NCD's are mostly chronic, so there would be a higher chance of defeating the disease if it would be detected on its early stages.