Chronic Diseases in Resource Poor Settings: next steps to reduce global disparities in health.

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The health focus in developing countries has been on prevention and treatment of infectious diseases, like TB, malaria, HIV, diarrheal diseases.  Chronic disease risk is often assumed to be a problem for countries where economic transition has provided a higher standard of living and raised life expectancy.  However, diseases like asthma, diabetes, cancer, heart disease increasingly coexist with infectious diseases in poor countries and present a dilemma in the allocation of resources.  According to the Global Burden of Disease Study, “these conditions–often linked directly to poverty and infection–account for more than a quarter of the disease burden in the very poorest populations.”1  PIH physician Gene Bukhman states,  “For the bottom billion,  non-communicable diseases, NCDs, like rheumatic heart disease, type 1 diabetes, mental illnesses, epilepsy, and cervical cancer–are often the result of lack of access to food, shelter, education, and health care interventions readily available in developed countries.”2  More than 4 million of the 7.6 million cancer deaths in the world each year now occur in developing countries.  A global task force has been working for the last few years to propose, implement and evaluate strategies to reduce burden of cancer in poor countries.3 Many of the “reasoned” justifications citing cost effectiveness or inadequate infrastructure , once used to rationalize policies for withholding treatment of MDR-TB, or HIV in resource poor settings, also surface in discussion of chronic diseases.

Once again, Partners in Health is challenging this inequity by instituting programs and accumulating clinical research data to change thinking and policy. At a conference in March, 4 Paul Farmer proposed an extension of the community worker model to use efficiently scarce resources for both infectious and chronic diseases. Treatment of infectious diseases can contribute to reducing chronic disease risk and visa versa. For example, effective immunization programs not only protect against the specific infectious disease, but also improve overall health and in some cases, e.g. hepatitis B or HPV, can reduce risk for cancer.  Untreated Streptococcal infections can lead to chronic rheumatic heart disease and prompt diagnosis and antibiotic treatment has practically eliminated this risk in wealthy countries.  Improving the overall capacity for health services in a comprehensive manner provides the means for simultaneously addressing the infectious and chronic health needs, ultimately promoting better health outcomes long term. “In resource-constrained countries without specialized services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement.” 5 These efforts have prompted the U.N. General Assembly to hold discussions on global funding for chronic disease prevention and treatment in mid-September, 2011.

1 Christopher J L Murray, Alan D Lopez (1997)  Alternative projections of mortality and disability by cause.  1990–2020: Global Burden of Disease Study.   Lancet 349: 1498–1504.
2  Demanding action for non-communicable diseases, NCDs  3/01/11  news post.
3 Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries.
4 “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion,”  Harvard School of Public Health  Boston,  March 2- 3, 2011.  View presentations and read more at
5 Farmer, P. et al., Expansion of cancer care and control in countries of low and middle income: a call to action.

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