In 2008, more than 36 million people worldwide died from non-communicable diseases, namely cardiovascular disease, cancer, chronic respiratory diseases and diabetes. Although historically thought of as diseases of the rich, non-communicable diseases actually disproportionately affect the world's poor, specifically those living in developing countries. In the past few years, a multitude of reports and statistics have emerged on this topic; according to the World Health Organization, 22 percent of men die prematurely from NCDs in developing countries, compared to only 8 percent in developed ones. These numbers reflect not only the greater incidence of NCDs in developing countries, but also the inherent difficulties of treating them in the context of underdevelopment.
The causes behind these changing trends are the same ones that plague the Western world. The myth that people in the developing world are too hard working and hungry to be sedentary or obese is just that: a myth. An increasing number of people in the developing world buy processed foods and have sedentary jobs, two major preventable factors that contribute to mortality from NCDs. The other major causes of NCDs in developing countries are also familiar and preventable culprits: alcohol and tobacco consumption. In fact, while overall tobacco consumption is decreasing in the developed world, more people light up each year in developing countries than did the year before. This is intimately tied to the lenient or often simply non-existent laws that limit tobacco advertising and/or sale of tobacco to minors in developing countries. Tobacco remains the most important avoidable risk for the common NCDs, significantly increasing the risk of dying from coronary heard disease, cerebrovascular disease and lung cancer.
The response from the international community to the growing incidence of NCDs worldwide has been predictable: There have been meetings and summits, most notably the U.N. Summit in New York this past September, from which reports have been generated and recommendations put forth for tackling the risk factors and causes behind NCDs. The consensus in the international community is that increased prevention efforts and access to services for early detection are the most cost effective approach to dealing with this problem, and also the easiest to implement.
But as often happens with such top-down approaches to complex problems, the recommendations are simple but not comprehensive. One specific issue is that non-communicable diseases are often asymptomatic until a fairly advanced stage, which is why screening and prevention are imperative. However people understand sickness predominantly through symptoms and changes in their bodies that they can feel or see. Thus increasing the rates of early detection and preventative medicine requires more than just putting health centers in place — it requires changing the way people understand sickness and disease.
Dr. Naureen Zafar is a family practitioner in New York City whose patients are exclusively West African immigrants living in Central Harlem. Dr. Zafar has had to actively combat the deep-set tradition of going to the doctor only when you are sick by reaching out to the members of her community and getting them into her office before they are symptomatic. Dr. Zafar encounters patients who have had exceedingly little interaction with health care providers and spends a majority of time during each visit teaching her patients about the basis of their diseases. Only if a patient understands what diabetes is, and specifically what the downstream and long-term effects of untreated diabetes are, will she be convinced to take medication even when she generally feels normal. The success of the Medina clinic, where Dr. Zafar works, hinges on this increased awareness amongst patients about their own health, which is fostered through their continual interaction with this community health clinic. A similar approach can be taken in developing countries as they try to expand their capacity for preventative care and diagnostic screening.
As part of the preparation for the September U.N. summit, the Global Health Council sponsored a side event that focused on how existing infrastructures in developing countries can be leveraged to deal with the emerging threat of increased mortality due to NCDs. One of the prominent panelists at this conference was Dr. Wafaa El-Sadr, Director of the International Center for AIDS Care and Treatment Programs at Columbia University. Dr. El-Sadr discussed how addressing the chronic needs of HIV patients in developing countries is a natural model for treating chronic non-communicable diseases in those same patient populations. The panelists highlighted multiple community-focused health care centers in developing countries that were established to treat HIV/AIDS and have now adapted to also tackle screening and prevention of NCDs as well. These health centers often employ many community health workers and have very active and well-developed educational and outreach programs that are at the crux of their effectiveness.
While the scope of community clinics, which are often started by NGOs, is limited and thus cannot handle all of the responsibility of widespread screening and preventative care, their model closely resembles successful preventative primary care coverage. This is in contrast to the frequently suggested large-scale government run prevention campaigns, which often skimp on patient education and longitudinal behavior change.
Yoanna Pumpalova is a first-year medical student at Weill Cornell Medical College in New York City. She may be reached at email@example.com. What’s Up, Doc? appears alternate Fridays this semester.