At NCD summit, a push to address ignored disease burden

MANILA — More than two-thirds of global deaths each year can be traced to noncommunicable diseases, a new study by The Lancet has found. But while much of the talk on NCDs has revolved around reducing premature deaths from just four major illnesses, millions of lives are claimed each year by diseases that aren’t even mentioned in the Sustainable Development Goals.

Ahead of this week’s high-level meeting on NCDs, at the United Nations General Assembly, health experts are urging immediate action and warn that focusing only on the “big four” could skew data and provide false optimism.

NCDs caused the death of 40.5 million people — or 71 percent of worldwide mortality — in 2016, according to the study published by The Lancet as part of NCD Countdown 2030, an independent annual monitor on NCDs in collaboration with the World Health Organization, the Imperial College London, and the NCD Alliance. Of this number, an estimated 32.2 million deaths were due to the four major diseases. The other 8.3 million were due to other NCDs, such as congenital heart disease, sickle cell disorders, kidney disease, and liver cirrhosis, and they affect all age groups, including those below 30 and above 70.

These other NCDs and age groups, however, are not included in the SDG target 3.4.

“Exclusion of these diseases from the global target could alter intervention choices and policy priorities, and their effects on overall NCD mortality and population health,” according to the report. It adds that measuring progress based on the four major NCDs alone could give a “more optimistic picture of progress than is warranted.”

Case in point: There are 35 countries on track to reduce NCD deaths by one-third among women in 2030, and 30 countries for men — if progress only considers the four major NCDs. But with all NCDs considered, only a handful of countries — 17 for women, and five for men — are on track to reduce NCD deaths by 2030.

In both datasets, most countries are still far off from significantly reducing the burden of NCD deaths among their population, given current rates of decline.

There are a few bright spots, countries such as South Korea and New Zealand show continuous declines in NCD mortality. They provide evidence countries can further reduce their NCD mortality with the right conditions and policies in place, even with an extremely low level of NCD mortality in the first place, said Majid Ezzati, an author of The Lancet report. There were also declines in NCD mortality in countries in Eastern and Central Europe that historically had high NCD mortality rates. And some low- and middle-income countries, such as Brazil and Iran, have also shown improvements in NCD incidence and mortality.

Still, there is much work to do, Ezzati said.

“Bottom line is, we’re just not doing enough, and I would say that part of this goes to national governments, certainly in high-income countries. But the major part of it should be around the aid and donor community. In all but 20 countries … there is a high risk of dying from NCDs than infections. Even in some of the poorest parts of the world, this is the biggest cause of death. Why then isn’t the donor community investing in [addressing them],” Ezzati told Devex.

The professor underscored the key role of data in shedding light on the overall burden of NCDs, strengthening accountability, but also in helping countries understand and set priorities.

“The main motivation should be that you gather good data because it would tell you what’s happening in your own country and what your priorities should be,” he said.

As government leaders and the global health community prepare for the third high-level meeting on NCDs this week, here are a few important data points we picked up from the report, as well as from the recently published 2018 global cancer statistics by the International Agency for Research on Cancer.

1. More people are likely to die from NCDs in LMICs

Women in low-income countries had the highest probability of dying (25-32.6 percent) from one of the four major NCDs versus women in high-income countries (below 10 percent), based on country-level data provided in the report.

Countries where men had a higher likelihood of dying (25-38 percent) from one of the four major NCDs, were also from LMICs.

The result is the same even with other NCDs combined, only larger. The probability of women dying from NCDs in six countries in sub-Saharan Africa, plus Afghanistan and Yemen in Asia was at more than 60 percent. In Sierra Leone, it reaches 72.3 percent. For men, those living in Mongolia (75.5 percent), North Korea (73.7 percent), Turkmenistan (73.5 percent), and Moldova (73.1 percent) had the highest probability of dying from NCDs.

2. NCDs are increasing in the United States, except for cancer

While most countries had declining NCD deaths, albeit, at different levels, there were 15 countries where NCD deaths had stagnated or increased among women — and 24 countries for men.

The report is not able to pinpoint the exact reasons for this, but the authors suspect it could be due to a worsening or lack of improvement on risk factors associated to the major NCDs, or due to weak health systems.

In the case of the United States, it’s possible that premature deaths from NCDs, except for cancer, have “slowed down or reversed,” a phenomenon common in low-income rural communities, according to report authors.

Declining cancer deaths in the U.S. have been linked to early diagnosis and improved treatment, as in the case of prostate cancer, one of the most commonly diagnosed cancer among men worldwide, according to the IARC report. There could be variations depending on sex, age, ethnicity, and cancer type, but details of which are not immediately available.

3. Men more likely to die from NCDs 

While men in LMICs had the highest probability of dying (25-38 percent) from one of the four major NCDs, there’s only one country — Iceland — where men had a less than 10 percent probability.

Even when combining other NCDs, there were still more countries — 15 in total — where men had a 70 percent and above likelihood of dying from one of the diseases. For women, only Sierra Leone registered a probability above 70 percent.

4. Men also had higher suicide rates

Men also had higher suicide rates in most countries than women, according to The Lancet. A mapping of suicide rates in the report showed the difference between male and female, with Kiribati showing one of the highest at 20-40 per 100,000 people for males.

Suicide is classified by the International Classification of Disease system as an injury, not an NCD — but it is used as an indicator for mental health in the SDGs. Mental health is part of the discussion in this week’s NCD summit, and it has garnered several mentions in the draft political declaration, including a standalone paragraph:

5. Three drivers of NCD decline across regions

Cancer and cardiovascular diseases have contributed to large declines of NCDs mortality in high-income countries, but not exclusively. In fact, in Central and Western Europe, huge reductions in premature deaths from NCDs since 2010 were largely credited to a decline in cardiovascular diseases. Meanwhile in a number of LMICs, including China and India, reductions in chronic respiratory diseases contributed to declines there on premature NCD mortality.

These should provide indications to national governments and the international aid community on where to focus their efforts and investments. Ezzati himself underlined the need for stakeholders to “focus.”

“We all have our favorite topics,” he said, but noted based on data in the report, stakeholders should make sure to focus their attention on four things: Tobacco control, alcohol, hypertension management, and universal health coverage, in which NCDs care and management is included in the essential package of interventions in every country.

6. The burden of cancer underscores access inequality

Cancer incidence is high in most developed economies, but gaps between incidence and mortality rates are smaller in low and middle-income economies. Take Australia and New Zealand versus West Africa, the two areas compared in the report. Cancer incidence rates among men in Australia and New Zealand were at 571.2 per 100,000 versus 95.6 per 100,000 in Western Africa. But in terms of mortality, the rates were 109.8 (Australia and New Zealand) versus 72.1 (Western Africa) per 100,000.

The reasons, according to the IARC report, have to do with access to timely diagnosis and treatment, but could also be the prevalence of certain cancer types, such as cervical cancer, associated with poor prognosis and higher mortality rates in the region.

Population size in Asia has also been considered as a factor in the high cancer mortality rates in the continent, which is close to 60 percent of global cancer deaths.

NCDs. Climate change. Financing. Read more of Devex's coverage from the 73rd U.N. General Assembly here.

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