Tackling noncommunicable diseases among poor
This week, global health leaders are gathering in Bangkok for the 2019 Prince Mahidol Award Conference. This year's conference theme is the political economy of noncommunicable diseases (NCDs). NCDs include a diverse array of conditions ranging from heart disease and cancer to congenital disorders and mental illness and kill approximately 41 million people globally each year. Addressing NCDs is key to achieving the Sustainable Development Goals (SDGs).
But while there has been strong momentum in recent years, interventions -- such as detection, treatment and care -- have largely failed to reflect the experience of those living in extreme poverty. This jeopardises any effort to realise universal health coverage. We hope this conference sparks a turn in a new direction -- one that includes the voices and needs of the world's poorest billion.
NCDs have long been a crushing burden for children and young adults living in extreme poverty in rural Sub-Saharan Africa and South Asia: hundreds of thousands will die each year before the age of 40 from an NCD. In addition, the out-of-pocket expenses necessary for treatment can be catastrophic for families already living on next to nothing. And that's if these conditions are diagnosed at all, which is far from guaranteed.
Despite their severity, NCDs among the poorest billion have gone under the radar of the global health community. One reason is that for these populations, NCDs often strike at young ages. They also don't look like the NCDs that are common among adults in higher-income populations. In older groups, lack of physical activity and other behavioural risk factors are well-understood causes of afflictions such as coronary artery disease and type 2 diabetes. In contrast, childhood conditions among the poorest billion, such as type 1 diabetes, rheumatic heart disease, or sickle cell anaemia, often have genetic, infectious, or environmental determinants.
And because these NCDs are diverse and relatively uncommon, they have so far failed to garner needed health policy attention: they don't easily fit into a traditional public health agenda, structured around highly standardised approaches to preventing disease or minimising risks.
Now is the time for that to change. Since 2014, our institutions have collaborated with the shared goal of increasing access to high-quality health care for the world's poorest billion people, beginning with a focus on type 1 diabetes. In 2017, we made a visit to the work underway in Rwanda. There we met a young man named Justin, who amid chronic food insecurity and other challenges of poverty also has type 1 diabetes. Though he lives in a remote village in the country's Northern Province, he's within reach of a district health facility offering an integrated approach to care and treatment. As a result, Justin was diagnosed early and receives the insulin he needs to live a healthy and productive life.
But when it comes to health care Justin is one of the fortunate few; he isn't the norm. We believe everyone should have access to quality care, no matter where they live. To achieve this, we need more partners -- especially governments and other donors -- to build solutions to fix the bottlenecks for diagnosis, care, and treatment for the world's poorest people, whose health is a key asset to surmounting the hardships wrought by impoverishment.
That means changing the way NCDs are viewed and financed. We advocate a three-prong approach. First, we must reframe the issue of NCDs and injuries (NCDIs) to include a broader range of conditions and a focus on the world's poorest billion people. The Lancet's NCDI Poverty Commission, launched in 2016, is working to rethink global policies and to broaden the current global health agenda in the interest of equity. So far, the Commission has supported national NCDI Poverty Commissions in more than 10 countries focused on finding solutions based on local data and priorities. Six of these national commissions have already published reports, and at least three more will present their conclusions in 2019. We hope more countries will follow, ensuring the unique needs of the poorest people are included and prioritised nationally and globally.
Second, we should promote a research agenda that guides the integrated delivery of priority NCDI interventions. We call it "integration science".
In Rwanda, for example, teams of nurses and generalist physicians have successfully decentralised care for type 1 diabetes, as well as manage anticoagulants for children who have valve replacements for rheumatic heart disease. Similar delivery models could be designed in other regions to address a range of conditions, including NCDs.
Finally, we need to establish implementation and financing partnerships to scale-up delivery of these kinds of integrated solutions. Without financing and the exchange of technical expertise, progress will be halting, especially in low-income countries. Knowledge exchanges facilitated by the World Bank have brought together NCDI policymakers and implementers from low-income areas of Asia and Africa to share their solutions, but, so far, financing has been inadequate to deliver solutions at scale.
As governments consider how to meet the SDGs and expand universal health care with equity, addressing NCDIs for the poorest billion is more than a conference theme, it's an imperative. We look forward to a productive conversation and ensuring quality health care access for all.
Dr Gene Bukhman directs the Programme in Global NCDs and Social Change at Harvard Medical School and the NCD Synergies project at Partners In Health. He is a cardiologist and medical anthropologist in the Divisions of Cardiovascular Medicine and Global Health Equity at Brigham and Women's Hospital in Boston, Massachusetts. Gina Agiostratidou is the Director of the Type 1 Diabetes Programme at the Helmsley Charitable Trust in New York.