On Non-Communicable Diseases

In 2008, non-communicable diseases (NCDs) accounted for 63 percent of all deaths worldwide. According the World Health Organization’s (WHO) recent Global Status Report on Non-communicable Diseases, without an intervention, NCDs are “projected to kill 52 million people annually by 2030." By informing the public about their risk, encouraging them to make healthy lifestyle changes, and improving treatment for individuals with NCDs, it may help to reduce the incidence of these diseases globally.



NCDs, which include diabetes and cancer, are defined as chronic conditions or diseases which do not result from an acute infectious process. The Centers for Disease Control and Prevention (CDC) report that half of all deaths in the U.S. each year are due to heart disease, cancer, or stroke. In addition to the incidence of NCDs in developed nations, a reported 80 percent of the 36.1 million NCD-associated deaths in 2008 occurred in developing nations. While NCDs can present a burden for any nation’s healthcare infrastructure, Dr. Margaret Chan, WHO Director General, notes that “for some countries it is no exaggeration to describe the situation as an impending disaster.”

Reports indicate that cardiovascular diseases account for the majority of NCD-related deaths, or 17 million annually, followed by cancer (7.6 million annually), respiratory disease (4.2 million annually), and diabetes (1.3 million annually). These four groups of diseases account for nearly 80 percent of all NCD deaths, and share four common risk factors: tobacco use, inadequate physical activity, harmful alcohol use, and poor diet. Almost six million people die as a result of tobacco use each year, and 2.5 million die from alcohol-related causes. In addition, lack of exercise and poor diet contribute to obesity, increasing individual’s risk of heart disease, stroke, and diabetes.

To lessen the impact that NCDs have on global health, the WHO has suggested that a number of measures be taken, including banning smoking in public places and promoting public awareness about the importance of diet and exercise. Encouraging individuals to make healthy lifestyle choices and providing them with information about how to improve their health, it may be possible to reduce the number of NCD-related deaths worldwide.



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Inflammatory Bowel Disease

More than 1.5 million Americans – nearly one in every 250 people - are currently living with inflammatory bowel disease (IBD). IBD refers to two related but different diseases: Ulcerative Colitis and Crohn’s disease, which cause chronic inflammation of the intestinal tract. By increasing awareness about these conditions, research into new treatment options may be advanced, improving the lives of individuals with IBD.

Though the exact cause of the condition is not known, inflammatory bowel disease is thought to occur when the body’s immune cells attack the intestine. According to experts, there may be an initial trigger, such as an infection or something taken in from the diet or environment, that activates this immune response. IBD is frequently viewed a spectrum, as some patients exhibit symptoms associated with both UC and Crohn’s disease. The inflammation seen in Ulcerative Colitis (UC) occurs only in the large intestine (colon) and is limited to the inner lining of the intestinal wall. In contrast, Crohn’s disease can involve any portion of the intestinal tract from the mouth to the anus but is frequently confined to the terminal portion of the small intestine (ileum). While Crohn’s and UC affect different areas of the digestive system, both are marked by diarrhea, rectal bleeding, urgency to have bowel movements, abdominal cramps and pain, fever, and weight loss. In addition to painful and frequently debilitating symptoms, individuals with IBD can experience complications of their condition including bowel obstruction, ulcers, and malnutrition.
Treatment options for Crohn’s and UC are frequently limited to anti-inflammatory, immunosuppressant, and steroid-based medications. These medications are used to control acute attacks or “flare ups”, prevent repeated attacks, and help the colon and intestinal tract to heal. In addition, UC can sometimes be treated through surgical removal of the affected portion of the bowel, after which patients may require an ileostomy to allow waste to leave the body. Because Crohn’s disease frequently spreads deep into the layers of affected bowel and intestinal tissue, surgical removal of the affected regions is often not possible.
Experts continue to strive to identify new treatment options for individuals with IBD. New research suggests that while UC and Crohn’s affect a relatively high rate of individuals in the U.S., the conditions are extremely rare in the developing world. According to some experts, there may be a correlation between parasitic worm (helminth) infection – which is common in the developing world but not in the United States – and the number of patients presenting with UC. Though the practice is not recommended, Dr. Joel Weinstock, chief of gastroenterology at Tufts University Medical School, notes that some UC patients have seen relief from symptoms after ingesting the trichuris suis worm, a parasite that lives in the intestines of pigs. Researchers are also investigating the use of live bacterial cultures (probiotics), including a genetically altered version of the common bacteria Lactobacills acidophilus, which have been found to nearly eliminate colon inflammation in rodent studies.
While experts work to develop new treatments, individuals with IBD can manage their condition using medications and monitoring their diet to avoid foods that exacerbate their symptoms. Participating in support groups, either online or in person, can help some individuals with IBD learn more about their condition, ways to cope with it, and available treatment options.

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Tobacco Use Worldwide

Currently, approximately one third of the global population over the age of 15 - about 1.1 billion people - smoke cigarettes. Tobacco use continues to be the leading preventable cause of death worldwide, killing at least five million people each year. Trends from illness and death related to tobacco use indicate that by 2030, tobacco use will contribute to the deaths of more than 10 million people worldwide each year, 70 percent of whom live in the developing world. Though various strategies are in place, including bans on smoking in public areas, restrictions on advertisements for tobacco products, and increased taxes on cigarettes, the number of people who use tobacco has not significantly decreased. A recently released report from the World Health Organization (WHO) details cigarette and smokeless tobacco consumption and seeks to find an approach that may lessen the use of these products.

The WHO report indicates that though 22 of the world’s most populous 100 cities are now “smoke-free,” this only accounts for 5.4 percent of the world’s population. In 2008, the WHO established a set of guidelines aimed at helping nations to reduce smoking, which include:

1. Monitoring tobacco use and the policies to prevent it,
2. Protecting people from tobacco smoke,
3. Offering people help to quit using tobacco,
4. Warning people about the dangers of tobacco,
5. Enforcing bans on tobacco advertising, promotion, and sponsorship, and
6. Raising taxes on tobacco.

However, reports indicate that less than 10 percent of the world’s population is covered by any one of these measures. Additionally, only two percent of individuals live in nations that have comprehensive and widely-accepted smoke-free laws, and 94 percent are not protected by any laws against smoking.

Laws banning smoking - including the use of cigarettes, cigars, and hookahs - in public places will come into force in 2010 in many areas of the world. According the Syrian Society for Countering Cancer, 60 percent of adult men and 23 percent of women in Syria smoke, and 98 percent of Syrians are affected by second-hand smoke exposure. Other nations face similarly high rates of tobacco use and smoking-related illness and death. The high incidence of tobacco-related deaths in the Philippines (90,000 per year), Malaysia (10,000 per year), and Vietnam (40,000 per year) has caused concern in these regions, but fully effective smoking bans are not yet in place. Reports indicate that the majority of smokers in some Southeast Asian countries are men, and that as many as 75 percent of men smoke, compared to fewer than 20 percent of women who do. In Cambodia, for example, roughly half of the older women do use tobacco, but favor smokeless chewing tobacco, which many women begin during pregnancy to help lessen prenatal nausea.

Over the past four years, smoking rates have decreased in developed nations including the United States, Japan, and Western Europe as anti-smoking laws gain momentum. However, the World Lung Foundation (WLF) indicates that “More than 80 percent of those with premature deaths [from smoking] would occur in low- and middle-income countries.” Since 1960, according to the WLF, “the global production of tobacco has increased 300 percent in low- and middle-resource countries while dropping more than 50 percent in high-resource countries.” In China and India, over half a billion men consume tobacco, and other nations are facing similar problems of mass consumption of tobacco use. Tobacco is a contributing cause to heart attacks, strokes, diabetes, cancers and asthma worldwide, regardless of how it is consumed (smoked, chewed, etc.). According to Ala Alwan, the WHO non-communicable diseases expert, more than 80 percent of the WHO’s projected cancer deaths are likely to occur in the poorest regions of Africa. To increase awareness and provide education about the dangers of smoking, the WHO is planning to establish a regional hub there in 2010.

It remains to be seen how much impact the efforts of the WHO and other organizations will have with regard to decreasing the number of individuals who use tobacco. Through newly established laws, increased taxation, and outreach and education about the dangers of cigarettes and smokeless tobacco products, it may be possible to urge individuals to quit smoking or not to start at all.

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The Flu Vaccine

As new cases and concerns about seasonal flu and swine flu (H1N1) continue to spread worldwide, two vaccines have recently been made available. Both the nasal spray vaccine and injectable vaccine for seasonal flu have proven effective for specific portions of the population, however distribution is still slow. For the H1N1 (swine flu) virus, The Baltimore Sun reports, availability is still an issue and many areas have not yet received enough doses to meet the demand. While many in the developed world do not yet have access to the H1N1 vaccine, Dr. Bernadine Healy notes that the problem is even greater in the developing world. To help these nations fight the pandemic, the United States has agreed to donate 10 percent of its vaccination supply to the World Health Organization (WHO) – eight other nations will make similar donations.

Inoculating individuals for both viruses is complicated by the time frame in which the vaccinations can occur. If one chooses nasal spray for both seasonal and swine flu, they must wait four weeks between doses, while if one is injected for one virus and uses nasal spray for the other, they can be administered together. Discovery Health reports that doctors recommend annual flu shots to lessen the chances of becoming ill. Individuals as young as six months can be inoculated, according to the Centers for Disease Control and Prevention (CDC) and side effects are reported to be minor. Because the virus used to make the seasonal flu vaccine is dead, it is not possible to contract flu from a flu shot, however one may expect a low-grade fever 8 to 24 hours following injection, a swollen or tender area around the injection site, a slight headache or chills within 24 hours.

The seasonal flu shot is an inactivated vaccine, and contains three influenza viruses – one A(H3N2) virus, one regular seasonal A(H1N1) virus (which differs from the 2009 H1N1 virus), and one B virus. The viruses used change annually based on international surveillance which track infection trends and scientists estimations about which strains will circulate during the year. In contrast to the flu shot, the nasal-spray flu vaccine contains a weakened but still living flu virus, sometimes called LAIV (live attenuated influenza vaccine). These nasal mists are approved for use in healthy individuals ages two to 49 who are not pregnant. In addition to nasal sprays, Discovery Health reports that researchers at Stanford University and the University of Alabama at Birmingham have been working with naked DNA in an effort to develop a vaccine that could be delivered via shampoo or dermal patch.

Three recent large-scale studies, including a study led by Dr. Arnold S. Monto of the University of Michigan, indicate that while the seasonal flu shot is more effective for adults and safe for women who are pregnant, the intranasal vaccine (nasal spray) is more effective at preventing flu in children. These studies showed 35 to 53 percent fewer cases of flu in children who were given the nasal spray vaccine than those who received injected vaccines. The Los Angeles Times reports that injectable vaccines prevent roughly 50 percent more seasonal flu in healthy adults than the nasal spray vaccines.

Due to the relative newness of the H1N1 vaccine, health authorities have implemented a number of tracking measures to ensure its safety. The Associated Press reports that Harvard Medical School scientists are working to link insurance databases covering 50 million people with vaccination registries to allow them to determine if people visit a doctor after being vaccination as well as the reason for the visit. Johns Hopkins University and the CDC are also working to ensure that any side effects are noted and addressed quickly. These efforts include emailing individuals who have been vaccinated recently to see how they are feeling (Johns Hopkins), and preparing take-home cards asking vaccine recipients to report any side effects to the nation’s Vaccine Adverse Event Reporting system (CDC). These measures are being undertaken as in the Internet-age, the Associated Press notes, one person updating their Facebook status to say that they got a flu shot and feel sick could cause a wave of similar reports.

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Associated Press on the Nasal Spray Flu Vaccine - The New York Times on CDC Side Effect Tracking Measures

Using Telemedicine to Treat Chronic Disease

Chronic diseases pose a threat worldwide, particularly in the developing world. Heart disease, cancer, diabetes, and other chronic diseases account for over half of all deaths each year - double the number of deaths caused by infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined. Developing nations are facing an epidemic of non-communicable chronic diseases as risk factors such as obesity, lack of physical activity, and tobacco use continue to increase. Contrary to the popularly held belief that infectious diseases are the leading cause of death in the developing world, 80 percent of chronic disease deaths occur in low and middle income countries.

International attention and funding has primarily focused on communicable disease, and as a result the healthcare systems of developing nations are not well equipped to manage chronic conditions. For example, the World Health Organization spends only 50 cents per person on chronic disease (excluding mental health) per year, compared with $7.50 for the major infectious diseases. Regular doctor visits are necessary for proper treatment and management of chronic diseases, but most low- and middle-income countries have not developed the necessary infrastructure or network of specialty physicians to provide this type of care.

Telemedicine and teleconsultation programs offer a cost-effective solution to this problem. Through initiatives like iConsult, healthcare providers in remote or medically underserved areas can consult with specialty physicians over the Internet to gain access to their clinical expertise. By utilizing iConsult, an Endrocrinologist in New York City or Cardiologist in Portland would be able to offer assistance to a provider in a clinic in Chad, and ensure that a patient with diabetes or high blood pressure receives the highest quality of care.

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Reports indicate a nutritious diet, physical activity, avoiding alcohol and tobacco use, and regular medical exams help decrease the risk of developing a chronic disease.

CDC Report on Chronic Disease - WHO Report on Chronic Disease - Report from SciDev Net

See also:
Nugent, R. (2008). Chronic diseases: a growing problem in developing countries. DiabetesVoice, 53, 17-20.