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Journal of Epidemiology and Global Health (2017) 7,5– 9
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Are we facing a noncommunicable disease pandemic?
Luke Allen ⇑
Nuffield Department of Population Health, University of Oxford, Oxford OX1 2JD, United Kingdom
Received 6 May 2016; received in revised form 4 November 2016; accepted 4 November 2016 Available online 22 November 2016
KEYWORDS Abstract The global boom in premature mortality and morbidity from noncommu- Non-communicable dis- nicable diseases (NCDs) shares many similarities with pandemics of infectious dis- eases; Pandemic; Global eases, yet public health professionals have resisted the adoption of this label. It is health; Nomenclature; increasingly apparent that NCDs are actually communicable conditions, and Response although the vectors of disease are nontraditional, the pandemic label is apt. Argu- ing for a change in terminology extends beyond pedantry as the move carries serious implications for the public health community and the general public. Additional resources are unlocked once a disease reaches pandemic proportions and, as a long-neglected and underfunded group of conditions, NCDs desperately require a renewed sense of focus and political attention. This paper provides objections, def- initions, and advantages to approaching the leading cause of global death through an alternative lens. A novel framework for managing NCDs is presented with reference to the traditional influenza pandemic response. Ó 2016 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).
Contents
1. Noncommunicable diseases ...... 6 2. Definitions...... 6 3. NCDs as infectious diseases ...... 6 4. Temporal profile...... 6 5. Hyperendemic versus pandemic ...... 8 6. An untapped seam ...... 8 7. Conclusion ...... 8
⇑ Corresponding author. E-mail address: [email protected]. Peer review under responsibility of Ministry of Health, Saudi Arabia.
http://dx.doi.org/10.1016/j.jegh.2016.11.001 2210-6006/Ó 2016 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 6 L. Allen
Conflicts of interest ...... 8 References ...... 9
1. Noncommunicable diseases and person-to-person transmission underlying their global dissemination. It could also be argued that Noncommunicable diseases (NCDs) are a group of the wavelength of the outbreak has been too conditions that include cardiovascular disease, protracted to represent a classical epidemic, and chronic respiratory diseases, cancers, diabetes, that the high global prevalence is in keeping with and mental illness. Six of the top 10 leading causes ‘‘expected” levels when we consider Omran’s [3] of death in 2012 were NCDs, including the top three epidemiological transition, i.e., NCDs may be (ischemic heart disease, stroke, and chronic hyperendemic, but they are not pandemic. We will obstructive pulmonary disease). The latter two examine each objection in turn. have unseated lung infections and diarrheal dis- eases from the top 10 since 1990. Over the same 3. NCDs as infectious diseases period the number of deaths from NCDs has increased from 27 million to 38 million, currently The dominant NCD narrative has been that these representing 70% of all global mortality [1]. Once conditions are caused solely by individual lifestyle confined to a clutch of high-income countries, choices, famously ‘‘gluttony and sloth” [4].In NCDs are now the leading cause of death in devel- recent years, it has become apparent that social, oped and developing countries alike. political, and economic trends (including national The rapid rise of morbidity and mortality from economic performance, urbanization, population NCDs has not been accompanied by the usual aging, globalization, and the increasing marketing, scramble to raise resources and quash spread affordability, and availability of unhealthy prod- across international borders. A high-level political ucts) are the most significant drivers of the NCD meeting on NCDs in 2011 was years in the making boom, rather than a sudden uptick in human lazi- and had a limited impact on the level of financial ness [5]. These external drivers operate by increas- support for prevention and control activities. ing exposure to various ‘‘vectors of disease” According to Global Burden of Disease data, NCDs including ultraprocessed food and drink, alcohol, cause 28 times more deaths than human immunod- tobacco products, and wider social and environ- eficiency virus, but receive 17 times less funding mental changes that limit physical activity [6]. [1]. The comparison with Ebola, Zika, severe acute These vectors are embedded within complex com- respiratory syndrome, and H1N1 is even more mercial, political, and social systems. damning. Research from a range of fields supports the position that NCDs are not entirely self-inflicted: 2. Definitions many NCDs can be passed from person to person either through viral transmission, as with liver With classical infectious diseases, such as influen- and cervical cancer [7,8], or through social net- za, the disease is always present in the population works, the built environment, social and economic but at a relatively low level. Nonzero baseline conditions, and intergenerational transmission prevalence is termed the ‘‘endemic” level—the [9–13]. Even though NCDs do not meet the criteria expected amount of the disease in a given popula- for classical infectious diseases, recognition of the tion in a given geographical area. Persistent and significant overlap has led to trusted public health high levels of disease occurrence are referred to agencies (such as the US Centers for Disease as ‘‘hyperendemic”. The term ‘‘epidemic” applies Control and Prevention) and sources used by the to a situation where the level of disease in a com- general population (such as Wikipedia, the public’s munity rises above expected levels, especially if web-based arbitrator of reality) to concede that there is a sudden increase. The term ‘‘pandemic” we are experiencing ‘‘epidemics” of obesity and is used when an epidemic crosses continents and diabetes [14–16]. affects a large number of people [2]. The main objection to appropriating the term 4. Temporal profile pandemic is that NCDs are noninfectious—critics contend that it would be oxymoronic to suggest The second objection is that the NCD boom is rep- otherwise. Although NCDs do not act as classical resentative of major societal shifts rather than a infectious diseases, their name is an unhelpful temporally delineated disease outbreak, more akin misnomer that belies significant environmental to irrevocably rising sea levels than an isolated ocmuial ies:pnei?7 pandemic? disease: Noncommunicable
Table 1 World Health Organization (WHO) pandemic phase descriptors and main actions by phase for influenzaa with suggested noncommunicable disease (NCD) parallel.
Phase Classical description Suggested NCD descriptors Main actors
Planning and coordination Main actors Communications Reducing the Continuity of health spread of disease care provision
1–3 Animal-to-human Socioeconomic/physical Develop, exercise, and Develop robust national Complete communications Promote beneficial Prepare the health system transmission causes small environment becomes periodically revise surveillance systems in planning and initiate behaviors in to scale up clusters of disease in increasingly conducive: national pandemic collaboration with communications activities individuals for self- people Increasing availability and preparedness and relevant sectors to communicate real and protection. Plan for desirability of commercial response plans potential risks use of vectors of disease pharmaceuticals and vaccines 4 Human-to-human Environment is sufficiently Direct and coordinate Increase surveillance. Promote and Implement rapid Activate contingency plans transmission sufficient to pathogenic to establish NCDs as rapid pandemic Monitor containment communicate pandemic sustain community-level the leading cause of DALYs and containment activities in operations. Share findings recommended containment outbreaks premature death at a collaboration with WHO to with WHO and the interventions to prevent operations and other community level limit or delay spread international community and reduce population and activities; individual risk collaborate with WHO and the international community 5 Sustained community- Sustained community-level Provide leadership and Actively monitor and Continue providing Implement Implement contingency level outbreaks in P2 outbreaks in P2 countries in coordination to assess the evolving updates to the general individual, societal, plans for health systems at countries in the same WHO the same WHO region multisectoral resources to pandemic and its impacts public and all stakeholders and pharmaceutical all levels region mitigate the societal and and mitigation measures on the state of pandemic measures 6 Sustained community- Sustained community-level economic impacts and measures to mitigate level outbreaks in P1 outbreaks in P1 other country risk other country in another in another WHO region WHO region Post peak period Levels of pandemic Levels of premature mortality Plan and coordinate for Continue surveillance to Regularly update the Evaluate the Rest, restock resources, * disease in most countries 1/3 lower than peak in additional resources and detect subsequent waves public and other effectiveness of the revise plans, and rebuild with adequate countries with adequate capacities during possible stakeholders on any measures used to essential services surveillance have dropped surveillance future waves changes to the status of update guidelines, below peak levels SDG target 3.4 the pandemic protocols, and algorithms Postpandemic period Levels of disease activity Morbidity and mortality Review lessons learned Evaluate the pandemic Publicly acknowledge Conduct thorough Evaluate the response of have returned to baseline confined to later life (>70 y) in and share experiences characteristics and contributions of all evaluation of all the health system to the levels in most countries countries with adequate with the international situation monitoring and communities and sectors interventions pandemic and share with adequate surveillance community. Replenish assessment tools for the and communicate the implemented lessons learned surveillance resources next pandemic and other lessons learned; public health emergencies incorporate lessons learned into communications activities and planning for the next public health crisis DALY = Disability Adjusted Life Year; SDG = Sustainable Development Goal. a Available at: http://www.who.int/influenza/resources/documents/pandemic_phase_descriptions_and_actions.pdf. 8 L. Allen tidal wave. NCDs have been developing for decades demic response protocol to the NCD boom (Table 1) and are driven by globalization, market liberaliza- highlights gaping holes in the contemporary global tion, economic development, and population response. Health system planning, effective public aging. These ostensibly unidirectional trends communication, and comprehensive NCD preven- increase host susceptibility and foster the commer- tion and control measures appear conspicuously cial availability and cultural desirability of patho- absent when contrasted with this simple summary genic commodities. NCDs are not going away any of best practices. time soon, and their relative share of global deaths With the NCD pandemic model, early phases will continue to increase in the face of falling mor- (1–3) are defined by an increasing prevalence of tality from injuries, childbirth, and infectious environmental drivers of disease and a growing disease. share of premature NCD morbidity and mortality. The NCD pandemic rubric only operates in refer- Phase 4 mirrors sustained community-level out- ence to avoidable NCD mortality and morbidity. In breaks of infectious disease; at this stage, envi- 2012, 16 million individuals died from NCDs ronmental conditions are such that NCDs are the before reaching their 70th birthday, predominantly leading cause of disability adjusted life years in the developing world [17]. The majority of (DALYs) and death under 70 years. Phases 5 and these deaths are preventable. Although the time 6 use identical definitions to the influenza model. line is stretched, the rise of preventable NCD The post peak period is reached when Sustainable mortality is macrocosmic in displaying all the usual Development Goal Target 3.4 is met, a one third features of a traditional pandemic with a greater reduction in premature NCD mortality [18]. The level of complexity, played out on a much larger postpandemic phase will arise when premature scale. NCD mortality and morbidity is confined to later life. The activities recommended for responding 5. Hyperendemic versus pandemic to an influenza pandemic (under the heading Main actors) should be applied to the NCD pandemic The rise of preventable NCD mortality is more sig- verbatim. nificant than the overall rise of NCDs, because the former is preventable and reversible. It is hard to 7. Conclusion say what the baseline/expected levels of NCD mor- tality ought to be; however normative bodies, such NCDs are not classical infectious diseases, but as the World Health Organization, consistently call neither are they noncommunicable. While the for a situation where premature suffering is com- term pandemic will never be a perfect fit, there pletely eliminated [17]. NCD control rhetoric sup- is a good argument for a pragmatic adoption of ports the adoption of language that frames the term. Wittgenstein [19] argued that words premature suffering as an ‘‘out of the ordinary” act as tools and meaning is found in use. In the surge, rather than accepting the status quo. If we face of NCDs, the global health community needs accept that high levels of preventable mortality to leverage every tool at its disposal. Embracing can be reduced, then ‘‘pandemic” is the more the term ‘‘pandemic” may feel uncomfortable appropriate label. to epidemiological purists, but this lens affords valuable new perspectives on an intractable 6. An untapped seam problem. A review by Green and colleagues [20] found There is much to gain from viewing the rise of pre- that the term ‘‘epidemic” is used in many different ventable NCD mortality and morbidity as a pan- ways in the scientific literature, and that the gen- demic. This perspective engenders an expectation eral population generally understands the term to that the burden of disease can and will be curtailed imply ‘‘danger to the public and a very large num- if sufficient resources are brought to bear upon the ber of victims”. It is time to drop the pedantry and major drivers. It emphasizes the centrality of inter- mine this rich seam for new insights and resources national coordination, and of systematic attempts to help rid the world of preventable suffering from to neutralize adverse environmental conditions. NCDs. The current emphasis on individual ‘‘healthy choices” is exposed as a farcical distraction, and efforts to develop and implement necessary health Conflicts of interest protection measures are accelerated. Application of the traditional World Health Organization pan- None declared. Noncommunicable disease: pandemic? 9
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