In a chapter published in "Social Injustie and Public Health,”” Karen R. Siegel, K.M. Venkat Narayan and Derek Yach set out to explain the social injustice seen in chronic and non-communicable disease. This is particularly important because when one discusses health problems that affect countries globally, public health workers usually focus on infectious diseases, hunger and inadequate access to healthcare. This focus has led to a prioritization of the items mentioned and has guided spending patterns of international organizations and donors. Due to that, major chronic diseases/ non-communicable diseases (NCDs) that kill millions of people and cause the suffering of many more have largely been neglected.

Estimates put the number of deaths in 2008 at 57 million, with four NCDs accounting for 36 million of these deaths. The NCDs causing 63% of global deaths are cardiovascular disease (CVD) (17 million deaths), cancer (7.6 million deaths), chronic respiratory disease (4.2 million) and diabetes mellitus (1.3 million deaths). Although these diseases are often seen as diseases occurring mainly as countries develop and are no longer suffering from infectious diseases, 80% of deaths due to NCDs occurred in low- and middle- income countries, where they are usually seen in younger ages. One-fourth of NCD deaths worldwide have occurred in someone younger than 60. In low- and middle- income countries, 29% of NCD deaths occur prematurely, with 13% suffering the same in high-income countries (Source: Levy et al.).

Considering that NCDs mostly affect poorer communities and the availability of cost-effective treatment, the global neglect of NCDs is a great social injustice. A look into the gender, race and ethnicity, and socioeconomic status of people in a community shows us how NCDs disproportionately affect some people more than others. With that being said, policies and programs can mitigate these inequalities, and we must look into ways to address the suffering NCDs impose on many. The policy changes must address the major risk factors of NCDS, which include tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol. These factors are actually responsible for over half of the NCD burdens, since they directly result in increased blood pressure, physical inactivity, and overweight and obesity. Indeed, about nine of the top ten leading mortality risk factors are related to NCDs, and the authors emphasize that most of these risk factors can be modified with appropriate policy and clinical interventions. The burden we face today due to NCDs are the cumulative result of a lifetime of risk factors. Therefore, the interventions we put in place today will lessen the burden of NCDs in the future. This is particularly important because high-income countries may be able to keep up with the demands of a growing population, but middle- and low- income countries that are experiencing a decreasing fertility rate and a growing aging population may not be able to keep up with the demands that come with that demographic change. Unlike high-income countries, low- and middle- class incomes are not able to provide pension and social security for their citizens. This will continue to exacerbate the burden of NCDs (Source: Levy et al.).

“In high-income and some middle-income countries, where risk factors for NCDs have been established for decades,” writes the authors, “NCDs caused by these factors are a major reason for health disparities by social class, ethnicity, and gender.” In essence, educating the public will not do much to reduce risk factors, since countries who are already aware of the risks still experience disparities. “Socioeconomic disparities in the occurrence of CVD and cancer (and their major factors) are present from age 2, even in egalitarian countries with homogeneous populations, such as Iceland. Studies of risk factors for NCDs in high-income countries- such as smoking, obesity, hypertension, and physical inactivity- have demonstrated that almost all risk factors are higher among people from the lowest social classes, mirroring trends in morbidity and mortality.” Fourteen risk factors- with smoking being the main one- specifically account for about three-fourths of the socioeconomic disparities in the incidence and mortality for coronary heart disease. However, low-income countries manifest these disparities differently. This is because risks like tobacco use, physical inactivity and obesity are usually seen in people with the highest level of disposable income in low-income countries. Because commodities and consumption patterns become affordable to poor people before health preventative measures are implemented, something of a “social drift” occurs. Therefore, the authors recommend that in low- and middle- income countries policymakers cannot afford to wait for the appearance of a social class gradient in the occurrence of either NCDs risk factors or the incidence of NCDs before the implementation of disease prevention measures. Governments of low-income countries made exactly this point both during the meetings in 2003 for the Framework Convention on Tobacco Controland during the 2011 United Nations High-Level Meeting on NCDs.

There is a dangerous cycle described by Gunnar Myrdal, a recipient of the Nobel Prize for Economics, to the World Health Assembly. Put simply, people become sick because they are poor, but being sick makes them even poorer. Although NCDs are often seen as the result of not taking care of our bodies as adults, many of the major risks of CVD, cancer, diabetes and chronic obstructive pulmonary disease (COPD) begin in childhood due to factors such as the early termination of breastfeeding, exposure to alcohol and tobacco, inadequate diets and multiple respiratory infections. All these risk factors lead to the eventual development of NCDs in adulthood. Studies have shown that the development of COPD and a worsening lung function is often the result from cumulative exposures that start in childhood and even earlier. Studies conducted in South Africa and Mexico by surveying 13- to 15- year olds in 2008 show that one-fourth currently smoke cigarettes and that there are almost as many girls as boys who engage in the behavior. Obesity is also a growing problem in many low-income countries. In 2004, for example, 9 percent of 5- to 11- year olds in Mexico were obese, 27 percent of children under 15 in China were obese, and 22 percent of children in schools in South Africa were overweight or obese (Source: Levy et al.).

It is important to note that in countries with low health literacy, behavior is strongly influenced by commercial messages. The low health literacy seen in low-income countries often undermines public health messaging and efforts to combat NCDs. Low levels of health literacy are often associated with no understanding of health risks of NCDs and how to reduce certain risk factors. Public health messages have been found to be effective with changing people’s behavior, but it has been difficult to have those messages reach communities with poor health literacy. On the other hand, the global marketing of things associated with NCDs- tobacco, alcohol, and salty, sugary and fatty foods and beverages- now reaches most countries and specifically targets vulnerable populations, such as low-income communities, minorities and young people. Marketers often ensure that their messages take advantage of inadequate or nonexistent regulations, using misleading advertising to reach their targets. Companies perceive emerging markets in low-income countries and perform research to reach specific populations that are especially vulnerable in those countries. International tobacco countries are known to have used images to describe some of their cigarettes as light and mild, while some fast food companies have used techniques to specifically lure children to eat at fast food restaurants and consume foods with high sugar contents (Source: Levy et al.).

Poor communities in low-income countries stand to suffer the most from the increase of people with chronic diseases. WHO estimates that low-income countries in sub-Saharan Africa, Latin America and the Eastern Mediterranean area will experience three- to four- fold increases in the next few decades with the number of people requiring long-term care, which is rudimentary in many of these countries. Inadequate access to quality medical care is probably the most worrisome aspect of the increasing number with NCDs. Poor people usually lack access to methods for the early detection of NCDs, such as hypertension, diabetes and cervical cancer. This results in many of them finding out about their disease when it has already progressed to dangerous stages. In the United States, for example, people that live in high-poverty areas are almost 2.5 times more likely to present with an advanced stage of malignant melanoma and about as twice as likely to have an advanced stage of prostate cancer and breast cancer once they finally seek medical assistance. Poorer patients from low social classes consistently have lower survival chances from diseases. In addition, even if early detection was possible, chemotherapeutic agents, which are most effective against the 10 leading cancers, are not accessible (Source: Levy et al.).

The chapter concludes by issuing an agenda for action, with a list of actions that people in power can take to mitigate the currently disproportionate and unjust NCDs problem. These recommendations include 1) promoting reviews of governmental spending, 2) developing partnerships between global organizations, such as nongovernmental organizations and community-based organizations, 3) investing in programs that target reducing risk factors for younger people, 4) targeting prevention and control measures for vulnerable populations and 5) providing financial help to ensure better access for poor people for early detection and long-term treatment (Source: Levy et al.).

Implementing these recommendations will help decrease the number of people suffering from NCDs in poor communities and decrease the global burden of the diseases. One of the recommendations was to increase global partnerships with global organizations, such as World Forgotten Children Foundation (WFCF). Help our mission today and become a part of ensuring a more equitable world.

Sources:

Levy, Barry S., et al. Social Injustice and Public Health, Oxford University Press, New York, NY, 2019, pp. 251–267.

United Nations. (n.d.). 2011, High Level Meeting, prevention, Control, non-communicable diseases, NCDS, United Nations, UN, General Assembly, GA. United Nations. Retrieved June 19, 2022, from https://www.un.org/en/ga/ncdmeeting2011/documents.shtml

World Health Organization. (1970, January 1). Who framework convention on tobacco control. World Health Organization. Retrieved June 19, 2022, from https://apps.who.int/iris/handle/10665/42811

Yach, Derek, et al. “Epidemiologic and Economic Consequences of the Global Epidemics of Obesity and Diabetes.” Nature Medicine, vol. 12, no. 1, 2006, pp. 62–66., https://doi.org/10.1038/nm0106-62.