The patient profile in clinics all over the developing world is changing. Non-communicable diseases (NCDs) have already established themselves as the predominant cause of disease and death in many middle-income countries.⁽²⁾ This trend is slowly emerging in Sub-Saharan Africa (SSA) where, to date, communicable diseases have been the primary challenge facing health care providers. Consequently, health systems in SSA that are still battling with infectious diseases are potentially faced with a fresh challenge, namely the double disease burden. This paper seeks to analyse the underlying factors with regard to this ‘double burden of disease’,⁽³⁾ identify the potential effects on SSA and discuss the possibility of action to prevent the continuation of this trend.

The doubling of disease burdens

Since the Alma-Ata Declaration in 1978,⁽⁴⁾ there has been an emphasis on infectious or communicable diseases in population health programmes for developing countries. Initiatives directed at the ‘Big Three’ - malaria, tuberculosis and HIV & AIDS - have been the focus, with observed decreases in disease and death rates achieved globally.⁽⁵⁾ Equal emphasis is placed on issues that affect mothers and children as these groups are especially vulnerable to infectious disease and are often unable to seek adequate care.

Reports from the World Health Organisation (WHO) indicate that globally, 33 million people live with HIV & AIDS, about one million people die from malaria annually and 8.8 million people are living with tuberculosis.⁽⁶⁾ However, these figures do not encompass the global impact of communicable diseases, as there are many more diseases, which receive less attention but could be as dangerous, such as dengue fever and Chagas disease. Such evidence most likely informs the attention given to communicable diseases, especially in developing countries. Thus, the global community has refined strategies to address the health needs that arise from the scourge of infectious diseases and these are encapsulated in the Millennium Development Goals (MDGs). There is, however, a conspicuous absence of a goal directed at NCDs.

For many infectious diseases, the developing world, with Sub-Saharan Africa at the centre of the fray, is hardest hit. Many countries on the continent, despite some progress, lag behind the MDG targets. It could be that these targets are not as realistic as they should be, given the evident constraints and competing priorities.⁽⁷⁾ That said however, infectious diseases are still an unconquered challenge in developing countries within Africa. These illnesses are inextricably linked to conditions associated with poverty and, more precisely, socioeconomic inequality.⁽⁸⁾ For example, poor housing, inadequate nutrition, unsafe water, sanitation and hygiene, as well as unsafe sex link individuals with infectious agents. The aforementioned conditions are prevalent in societies where there is inequitable access to financial resources, information and basic services.

In recent times, a distinct pattern seems to be emerging in most parts of the developing world. In clinics, the physician is faced with increasing numbers of patients with chronic diseases on a daily basis. In many cases, these chronic diseases are non-communicable. There is an increasing proportion of the population ill with hypertension, stroke, diabetes mellitus, asthma, obesity and other NCDs. In the face of the infectious disease scourge, the developing world is thus confronted with a fresh challenge: the rise of NCDs. It is the co-existence of these burdens of communicable and non-communicable disease that is referred to as the ‘double burden of disease’. The WHO has noted a global increase in the contribution of NCDs to disease and deaths. In a recent report, the WHO states that the proportion of global deaths attributed to NCDs was 63%.⁽⁹⁾ At least 70% of these deaths occurred in developing countries.⁽¹⁰⁾ It is in fact predicted that this proportion will progressively increase such that by 2030, even in SSA, NCDs will be the leading cause of death.⁽¹¹⁾ The encouraging news is that this is currently only a projection.

The degree to which NCDs dominate death and disease differs by region of the world. In these differences lie clues as to the possible underlying determinants of the NCD burden of disease. In developing countries with certain characteristics, epidemiologists have noted what is now known as the ‘risk transition’. This term was first defined based on observations in developed country settings. Traditional risk factors, as noted above for infectious diseases, are gradually being overtaken by more modern risks.⁽¹²⁾ In developed countries, this process is much more advanced, with improvements in livelihoods drastically reducing the prevalence of disease due to infectious causes. This has been linked to national income growth and accompanying improvements in living standards that eliminate traditional risks.⁽¹³⁾ However, the emergence of modern risks - smoking, physical inactivity, alcohol abuse and unhealthy diets principally - are linked to the increasing prevalence of NCDs, hence the term risk transition. With the reduction of premature death due to infectious diseases, people live longer. Thus, in developed countries, the proportion of the aged in populations is generally progressively increasing. Consequently, with the increase in lifespan and modern risks, NCDs are predominantly an issue in the older segment of the population. Nevertheless, this still only partially accounts for the increased burden of NCDs.

To a large extent, globalisation and unregulated urbanisation contribute to the rise in prevalence of NCDs.⁽¹⁴⁾ With unregulated urbanisation, environments have become less conducive to physical activity and more conducive to unhealthy eating habits. Likewise, globalisation has encouraged international competition and overproduction of unhealthy products – especially fatty foods, tobacco and alcohol. In spite of the now obvious adverse effects of these factors on health, the economic incentive for their continued production is huge. Furthermore, with poverty and socioeconomic inequalities come increased exposure and vulnerability to these risks.⁽¹⁵⁾ It has been empirically demonstrated that poorer groups in societies with higher income disparities are more likely to fall ill with NCDs and are less likely to access adequate care for these illnesses.⁽¹⁶⁾ The result is an NCD epidemic.

With progressive economic growth, the risk transition is now being observed in developing countries. The large disparities in income, predominance of urban slums and dearth of regulatory oversight on food markets has led to an increase in NCDs. For example, a World Bank report notes that in 2010 in China 80% of deaths were due to NCDs and projects that by 2030, 60% of China will live in urban areas.⁽¹⁷⁾ Although many developing countries are further down the ladder with regard to risk transition, the same pattern is still obvious elsewhere. Several studies in the last decade in Africa⁽¹⁸⁾ clearly describe the emergence of NCDs as an important public health issue in population medicine. As previously stated, a crucial issue is that, unlike the developed world, Africa is simultaneously dealing with infectious disease on a massive scale. This has implications that extend far beyond the bounds of health.

Burden of disease: Implications for human development in Sub-Saharan Africa

The definition of the burden of disease, as defined by the WHO, incorporates the effects of disease on premature death and disability.⁽¹⁹⁾ The connotation of the term burden can however be extended to describe the effects of disease on the livelihoods of households and on society. Infectious diseases have ravaged Sub-Saharan Africa. Sixty eight per cent of people that live with HIV & AIDS globally live on the African continent.⁽²⁰⁾ They are, in many cases, at the most productive phases of their lives and require expensive medical care. The accompanying discrimination and stigma has additional costs to the individual that are intangible. The aggregate effect of these factors on national budgets for health and on national image is large.⁽²¹⁾ Similar to the case of HIV & AIDS, malaria was estimated by the Roll Back Malaria Programme to cost the African continent annually on average 1.3 % of gross domestic product (GDP).⁽²²⁾ The current development framework based on the MDGs implies that as long as it continues to struggle with malnutrition, infectious diseases and poverty, Africa shall be considered underdeveloped, irrespective of macro-economic growth rates. These examples serve to illustrate that the effects of health problems at household, community and overall societal levels can be detrimental to overall human development.

In defining non-communicable disease, the World Bank uses terms that reflect its long latent phase, protracted duration and debilitating consequences.⁽²³⁾ These characteristics of NCDs make the effects thereof particularly damaging. In developing countries experiencing rapid economic growth, the WHO estimates an annual fall in GDP of between one and five per cent due to heart disease, stroke and diabetes alone.⁽²⁴⁾ The high annual costs of health care and loss of productive man-hours due to ill health has economic impacts on the sick individual, his/her dependants and the whole nation. Although the lag in the economic development of SSA has been partially attributed to infectious diseases, there is a disheartening possibility of a future where this impact is worsened by a coincident burden of NCDs. Given the situation, remaining passive about NCDs and refusing to double efforts with regard to infectious diseases has far-reaching implications for SSA. Poor health is just one of them.

The current understanding of the risk factors leading to the emergence of the NCD crises provides the opportunity for action. Smoking, alcohol abuse, unhealthy diets and physical inactivity are risk factors that can be modified. Although there is some contribution from genetic factors, gender and ageing, attributable proportions independent of modifiable risk factors are not considerable.⁽²⁵⁾ The individual cannot however take full responsibility for the modification of these factors for several reasons. Evidence shows that these risk factors act cumulatively over the life course of individuals.⁽²⁶⁾ This starts in the intra-uterine stage of life, with maternal under-nutrition for example. At this point, the individual has no control over his/her exposure or vulnerability to risk. Beyond this phase, unhealthy environments encourage the individual to make daily choices that increase his/her risk for disease. Unhealthy foods are cheaper, tobacco is accessible and exercise is often either inaccessible or unsafe. Many times, the individual may be a victim of the wrong choices of others, for example in the case of second hand smoke leading to lung cancer or drunken driving that kills pedestrians. In addition, individuals may not have sufficient information to make rational decisions with regard to healthy foods and lifestyles.⁽²⁷⁾

With regard to infectious diseases, the fall in prevalence in developed countries as stated above, has been linked to improvements in standards of living, encouraged by national income growth and provision of social amenities. The role of external regulation is therefore critical to the management and control of both infectious and non-communicable diseases. With the established potential impact of the double burden of disease on SSA, action is imperative to halt the continuation of current trends. Considering the benefits for human development, coordinated evidence-based efforts in this direction will be well worth it.

Halting the evolution of the double burden of disease in Sub-Saharan Africa

With globalisation, the level of control that nation-state governments have over the affairs of their territories is gradually being eroded.⁽²⁸⁾ The domains that affect the double disease burden extend beyond health care to the food industry, agricultural production, the tobacco and alcohol industries, urban planning, pharmaceutical industries, water and sanitation, among others. Over the past decades, there have been several calls for action from the WHO and other multilateral agencies. Evidence supports the promotion of primary health care for integrated care delivery in both communicable and non-communicable diseases.⁽²⁹⁾ Efforts are being made by governments to increase financial access to care by encouraging pre-payment and pooling of funds. However, action must extend to general health promotion in domains listed above. Policies aimed at improving water, sanitation and housing could be immensely effective if enforced. In addition, governments must seek to reduce income disparities and absolute poverty through job creation and social safety nets.

On the international stage, there is a need for a development framework post-2015 that takes cognisance of the impact of NCDs and calls for policy coherence with regard to health. At present, the framework convention for tobacco control calls for policy that limits access to tobacco with similar recommendations for alcohol.⁽³⁰⁾ Moreover, the World Trade Organisation is looked upon to legislate on issues that affect unhealthy food, tobacco and alcohol supply and limit the exposure of populations to these dangerous products. The lobbying power of the private sector involved in tobacco, alcohol and food production has however stalled these efforts globally. Sadly, they are increasingly permeating developing country markets. The creation of incentives for alternative production such as differential taxation for healthy and unhealthy foods with checks to prevent cost shifting to consumers is an option for governments.

There is also an important role for civil society organisations in reaching vulnerable and underserved populations with health care, advocating for policy and monitoring policy implementation. With the creation of environments conducive to good health, populations should be educated on healthy choices. Thus in the final analysis, there is a role for everyone to play. These efforts will need to be concerted, sustained and adequately funded. Understanding the implications of ill health for development, the benefits of action far exceed the costs.

Conclusion

The modifiability of the risk factors that create the double burden of disease offers Sub-Saharan Africa the opportunity for prevention. In nations and as a region, with the support of the rest of the global community, we must act. The gains made in the last decade with regard to infectious diseases will soon be overshadowed if we do not. What is at stake is our health as populations, our wealth as nations and our development as a region.

Written by Adanna Chukwuma ⁽¹⁾

NOTES:

(1) Contact Adanna Chukwuma through Consultancy Africa Intelligence’s Public Health Unit (public.health@consultancyafrica.com).
(2) ‘Package of essential non-communicable disease (PEN) interventions for primary health care in low-resource settings’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(3) Boutayeb, A., 2006. The double burden of communicable and non-communicable diseases in developing
Countries. Transaction Royal Society of Tropical Medicine and Hygiene,100(3), pp. 191—199.
(4) ‘Declaration of Alma Ata’. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, http://www.who.int.
(5) ‘The global burden of disease 2004 update’, World Health Organisation Report, 2008, http://www.who.int.
(6) Ibid.
(7) Dodd, R. and Cassels, A., (2006). Health, development and the Millennium Development Goals. Annals of Tropical Medicine & Parasitology, 100, (5/6), pp. 379–387.
(8) ‘Equity, social determinants and public health programmes’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(9) ‘Package of essential non-communicable disease (PEN) interventions for primary health care in low-resource settings’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(10) Ibid.
(11) Ibid.
(12) ‘Global health risks: Mortality and burden of disease attributable to selected major risks’, World Health Organisation Report, 2009, http://www.who.int.
(13) Ibid.
(14) Equity, social determinants and public health programmes’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(15) Ibid.
(16) Ibid.
(17) ‘Toward a healthy and harmonious life in China: Stemming the rising tide of non-communicable diseases’. World Bank Human Development Unit, East Asia and Pacific Region, Report Number: 63426, 2011, http://www-wds.worldbank.org.
(18) ‘Package of essential non-communicable disease (PEN) interventions for primary health care in low-resource settings’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(19) ‘The global burden of disease 2004 update’, World Health Organisation Report, 2008, http://www.who.int.
(20) ‘Global health sector strategy on HIV/AIDS 2011-2015’, World Health Organisation Report, 2011, http://whqlibdoc.who.int.
(21) Reynolds, L., (2011). HIV as a chronic disease considerations for service planning in resource-poor settings. Globalization and health, 7(35).
(22) ‘Key malaria facts’, Roll Back Malaria Report, 2010, http://www.rollbackmalaria.org.
(23) ‘Toward a healthy and harmonious life in China: Stemming the rising tide of non-communicable diseases’. World Bank Human Development Unit, East Asia and Pacific Region, Report Number: 63426, 2011, http://www-wds.worldbank.org
(24) Ibid.
(25) ‘Equity, social determinants and public health programmes’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(26) Ibid.
(27) Sassi, F. and Hurst, J., ‘The prevention of lifestyle-related chronic diseases: an economic framework’, OECD health working paper No. 32, 2008, http://www.oecd.org.
(28) Jessop, B., ‘Globalization and the national state’, published by the Department of Sociology, Lancaster University, Lancaster LA1 4YN, 2000, http://www.lancs.ac.uk.
(29) ‘Package of essential non-communicable disease (PEN) interventions for primary health care in low-resource settings’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.
(30) ‘Equity, social determinants and public health programmes’, World Health Organisation Report, 2010, http://whqlibdoc.who.int.