New Responses to Non-Communicable Diseases

by Alphee September - TGJ Staff November 1, 2012

In an interview with The Global Journal at the Economist Conferences NCD Summit held in
Geneva on 29 October 2012, Ama de-Graft Aikins discusses NCDs in emerging markets and
the need for coordinated action. Ama de-Graft Aikins is Visiting Fellow at LSE Health and
Associate Professor of Social Psychology at the University of Ghana.

Developing countries are facing a double burden of infectious and chronic diseases.
Prevention there seems to focus much more on infectious diseases such as HIV or
tuberculosis than on NCDs. Do you see new initiatives focusing on the prevention of
NCDs in African countries?
There are at least four countries that have done something about prevention and have
published their research: Cameroon, Ghana, South Africa and Tanzania. A lot of what is done

in other countries as far as prevention is concerned focuses on educating the population, for
example using the mass media. But chronic diseases are complex lifestyle diseases as well as
diseases of social conditions, such as poverty. So education is a good start but it is not
enough. Communities need to be involved in understanding what their health problem is and
how they can contribute to the development of relevant solutions. That's where I think South
Africa has led in terms of an early coronary heart disease intervention project that mixed
education, community-level activities, mass media and so on. Community-based approaches
are considered best practice because they tend to have longer term impact.
A few years ago, then President Thabo Mbeki's AIDS denialism caused some uproar in
South Africa and among the international community. Did you notice differences and
specificities with regards to representations of chronic diseases in African countries?
A lot of the work in Africa has been epidemiological. A number of surveys provide numbers
in terms of prevalence of risk and complications, but very few studies try to explore how
people make sense of these conditions. Take diabetes for instance, qualitative research on
experiences has been conducted in about six countries: Botswana, Cameroon, Ghana, South
Africa, Tanzania, Uganda. What has emerged out of these studies is that in almost all these
countries people see diabetes as a 'sugar disease'. But people also attribute diabetes to
supernatural causes. In between, there are other ideas that relate to what doctors tell their
patients, about physical inactivity or smoking or alcohol overconsumption, but those are few
and far between. Overall, people either attribute diabetes to their diet or they draw on
traditional belief systems about health and illness to make sense of diabetes. A similar
thinking process exists for hypertension, in some of these countries, although the dominant
belief is that hypertension is stress-related or linked to daily hassles of poverty.
What is the response from the healthcare sector?
NCD research, intervention and policy is far advanced in high income countries. In contrast,
very few African countries have managed to develop responses that address the needs of
ordinary people. Many basic things that are routine in high income countries, such as taking
blood pressure, are not done at health centre level. Doctors and senior nurses might be
knowledgeable about general aspects of common NCDs, but health workers with lower levels
of training struggle to understand NCDs. This group is often no more knowledgeable about
NCDs than lay communities.
That is where the shifting of competencies from highly skilled healthcare professionals
to community health workers you mentioned comes in. Can you elaborate on this?
It is a very simple idea. There are many basic things that can be done in NCD care which do
not involve complex knowledge and technical skills. For instance, you can teach an educated
health worker to be able to take someone's blood pressure or to know that there are three or
four types of drugs that work for hypertension in a particular locality. You can teach them to
teach somebody with hypertension what to eat, what to avoid eating, how much exercise and
what kind they can do. The task-shifting strategy has worked for the care of some neglected
tropical diseases and common mental disorders in Asia, Latin America and Africa, and has
now been piloted in Africa for diabetes and hypertension. As a matter of fact, highly skilled
health professionals in Africa are scarce so you need to figure out how to devolve healthcare
for a vast range of healthcare services in order to make healthcare accessible and effective.

Can you tell us more about the West African Health Organisation?
WAHO has been around since 1987 and is based in Bobo-Dioulasso, Burkina Faso. It is a
Specialised Agency of ECOWAS and works with West African governments at the health
level. They have the power to convene meetings with member states and to mediate the
relationship between the global health community and national policymakers. However, there
is not much communication between the organization and researchers and they have only just
recently developed a programme on NCDs when NCDs have been a public health problem in
Africa for a long time. These are some of the things we need to consider if we want important
ideas discussed in Geneva or New York to get operationalised in a rural village in Ghana or
an urban slum in Kenya. Usually governments will sign up to agreements at the global stage,
but somebody has to make sure governments actually do what they pledged they were going
to do for their citizens. I think organisations like WAHO have that power to push
policymakers to action. So it is really about how researchers, policy makers and regional
organisations work together so that everybody gets plugged into the global system. But global
ideas only work if they are implemented locally. It has to be a two-way system, top-down and
bottom-up. Communities must be at the centre.

Indian Journal of Community Medicine

All Medical Journals Issues Contents Editorial Board
& Information
Vol. 30, No. 4 (2005-10 - 2005-12)
Editorial
Emerging Epidemic of Non Communicable Diseases-An Urgent Need for
Control Initiative

The increasing burden of Non Communicable Diseases (NCD), particularly in developing

countries including India, threaten to overwhelm already stretched health services.The
disease patterns of India can be classified into three categories-communicable disease, noncommunicable disease and injuries. At the onset of 20th century, communicable diseases
including maternal and perinatal causes were the leading killers.The scenario at the onset of
21st century has changed drastically, making NCDs the major killer all over the world. This
whole process of shift in disease pattern is leveled as epidemiological transition. Earlier
NCDs were thought to be diseases of rich but the NCD epidemics are observed in developing
countries also. In recent times, the life expectancy has increased with several undesirable
alterations in lifestyle. Hence there is increase in both the dose and duration of risk factors,
leading to an increase in lifestyle diseases/non-communicable diseases and their
consequences.
It is projected by Murray and Lopez that the overall NCD burden will rise sharply by 2020 in
India. About two fifth (40.4%) of deaths were attributable to NCDs in 1990 and it was
projected that this will increase to 66% in year 2020. The age group involved in India is
mainly between 30-69 yrs, which is a matter of great concern to the society. It is estimated
that there are about 25 million cases of cardiovascular diseases, similar number of cases of
diabetes, 2.4 million cases of cancer and one million cases of cerebrovascular disease/stroke
in our country. The world health report 1999, estimates that in 1998, 78% of the burden of
NCDs and 85% of the cardiovascular disease burden arose from low and middle-income
countries. However the existing health system in the country is focused on communicable
diseases.
Several diseases come under the umbrella of NCD and more common are Cardiovascular
diseases, Cancer, Diabetes, and COPD etc. When closely examined, the NCDs have got four
common risk factors like tobacco, unhealthy diet, physical inactivity and alcohol.The list of
NCDs to be addressed should not be limited but priority should be given to those with
common risk factors. And in addressing the risk factors the mentioned criteria should be
taken into consideration i.e. the risk factor should be connected to several NCDs, should be
important and methods should exist to intervene and to assess the changes.
For prevention of NCDs, a paradigm shift is required from the treatment of risk factor in
isolation to a comprehensive risk factors management approach. There are two strategies

available for prevention of NCDs-high risk and population strategy. The high risk preventive
strategy is a targeted approach for vulnerable individuals hence caters to the tip of iceberg.
However, primary prevention based on comprehensive population based programme is the
most cost effective approach and seeks to shift the distribution of risk factors in a favourable
direction. These two strategies are not mutually exclusive; instead they should be used in
combination to address the problem of NCDs. Another important component is to promote
evidence based non-pharmacological treatment, operationalizing prevention aided by
counseling protocols and promotion of cost effective generic drugs. The patient and the
family members should be empowered to cope with a long-term illness through selfmanagement tools.
Unlike communicable diseases, which have multiple individual control programmes, NCD
have to be addressed under a common programme as most of the intervention are
overlapping. Differences in CD and NCD have to be kept in mind. NCD are having a gradual
onset, multiple etiology, long natural history, prolonged treatment and follow up, a
multidisciplinary care approach affecting quality of life as compared to sudden onset, single
cause, short natural history, treatment and follow up in cases of CDs. Already there is
National cancer, Blindness and Mental health programmes functioning in the country. There
is a need to include CVDs, Diabetes Mellitus, and COPD etc. Other closely related
programme is on oral health, nutrition and health care for the elderly.
Keeping in view current and rising trend on NCDs, there is an urgent need to start NCD
programme in India. There could be different models. It could be achieved either by
integrating the existing programme on cancer, diabetes, blindness and mental health or as a
new policy initiative. However, former would be more cost effective. Interventions should
include primary prevention by focusing on risk prevention and risk reduction through policy,
implementation of available legislations and health promotion and secondary prevention by
early detection with the availability of diagnostic facilities, management and referral services.
Implementation strategy could be devised with clear role at central level for guidelines and
funding, at state level to monitor and provide technical support and district level for
implementation. District NCD Control Programme model need to developed with the
objective of surveillance of NCD risk factors, integrated primary prevention of common risk
factors and early identification and management of common NCDs at various health
facilities. Organizational set up could be a district level committee or society or expanding
the scope of the District Blindness Control Society. Surveillance strategy could be linked with
recently launched Integrated Disease Surveillance Project (IDSP) or based on WHO STEPS
instrument after local adaptatioon. Training and IEC strategy could be an integral part of the
routine district health set up. Evaluation of the programme could be done at the national; state
and district level with help of programmatic indicators by a designated nodal agency. It is
high time to join hands to impress upon the government to start NCD control programme
through advocacy and to work for a model, which is feasible, cost effective and sustainable
for our country.

Dr. JS Thakur,
Assistant Professor School of Public Health,
PGIMER, Chandigarh-160012
E-mail: jsthakur_in@yahoo.co.in