K M Venkat Narayan: Global non-communicable diseases—the second in a series of reflections

On 30 April 2014, I wrote my first reflection on the topic of non-communicable diseases to whet your appetite, and promised seven more. My first reflection, if you recall, was: “Keep the growth of NCDs in perspective by acknowledging the incredible positive changes in life expectancy and economic wellbeing the world over—thanks to development and mechanization.” Here is the second:

Acknowledge the increasing convergence of health and economic challenges worldwide

The traditional view in international health has generally been that the health priorities for developed and developing countries are different. For example, when people think of developing countries, they often think of diseases of poverty: undernutrition, infectious diseases, and maternal and child health. This agenda is still unfinished, but as data from the massive Global Burden of Disease project are beginning to show, the world is making huge progress in reducing infant and maternal deaths, and deaths from major infectious diseases. In fact, the top three leading causes of death worldwide in 2010 were all chronic non-communicable diseases: ischemic heart disease, stroke, and chronic obstructive pulmonary disease. Furthermore, diabetes has jumped from number 15 in 1990 to number nine in 2010 as a cause of death. To put this in context: cardiovascular disease is now the leading cause of death even in rural Bangladesh.

Furthermore, when one examines the leading risk factors for death globally, the top seven out of 10 are NCD risk factors: high blood pressure, tobacco use, high blood glucose levels, physical inactivity, overweight or obesity, high cholesterol, and air pollution. What’s more, the top risk factors for death are becoming more similar worldwide—across high, middle, and low income countries—and this trend will only continue.

Another changing trend, which is bringing the world together, is the expansion of morbidity (e.g. disability-adjusted life years or DALYs) accompanying the reduction in mortality worldwide. Risk factors for morbidity are therefore important to pay attention to, and, indeed, the Global Burden of Disease Study shows that the leading risk factors for DALYs are increasingly NCD risk factors: high blood pressure, tobacco use, alcohol use, air pollution, diets low in fruit, high body mass index, and high blood glucose levels.

Thus, as David Hunter and Harvey Fineberg highlight in their editorial in the New England Journal of Medicine, global health challenges are converging. In addition, the picture of health is becoming more complex. Developing countries still have the unfinished agenda of major infectious diseases—such as malaria, tuberculosis, and HIV—and undernutrition, but are now also facing the ever growing burdens of NCDs and their risk factors. This is true for rural areas as well as for urban; for example, the prevalence of diabetes in rural parts of low and middle income countries has quintupled in the past 25 years.

NCDs are no longer diseases of rich countries, or of rich and urban people in poor countries. NCDs are ubiquitous and spreading like wildfire across the globe: through rich and poor parts, urban and rural. This means that, not only do we need innovative solutions for NCDs, we also need to stop thinking of the health problems of poor countries as distinct from those of rich countries. In fact, the globalization of health issues has broken that paradigm and now challenges the international health community to move away from neat models that prescribed one set of priorities for developing countries, and another for developed countries.

If we can make that shift in our thinking, we may find that the world suddenly opens up with new, innovative possibilities. Solutions for the developed world’s health may arise from NCD research in the developing world. The poor and emerging countries are challenged to find new low cost solutions to their expanding problem of NCDs, and the fruits of these can benefit the world. There are clusters of research excellence emerging in many countries traditionally regarded as developing, and this, together with a more interconnected world via the internet and travel, has already started to usher in an era of disruptive low cost innovations. For example, vaccines for pennies, incredibly cheap diagnostic tests and intraocular lenses, non-physician led healthcare delivery systems, the use of mobile phone and telemedicine technology, and low cost combination generics for a variety of diseases.

“Necessity is the mother of invention,” and developing countries have huge health needs—they are getting inventive, and their health requirements and those of the developed world have begun to converge. This presents huge opportunities to make the whole world healthy, but to achieve that will need radical new ways of thinking. If we can move toward a borderless world for global health research collaboration, we will all be better for it. But thorny problems of nationalism and protectionism come in the way. Can we overcome them, and soon enough?

K M Venkat Narayan is director of Emory Global Diabetes Research Center. He is also Ruth and O.C. Hubert chair of global health and professor of epidemiology and medicine at Emory University, Atlanta. He is a product of three continents, having lived and worked in India, the United Arab Emirates, the United Kingdom, and the United States of America.

Competing interests: The author has no competing interests to declare.