Getting Ahead of the Curve

During a recent trip to sub-Saharan Africa, I was vividly reminded of a major challenge for low- and middle-income countries: the double burden of disease. While still dealing with undernutrition, acute infections, and reproductive health problems, these countries face the additional burden of noncommunicable diseases, including cardiovascular diseases, cancer and diabetes, as well as neglected problems related to mental health, oral health and injuries. 

To be clear, progress in improving the world’s health has been remarkable, and there is great cause for optimism. (See Bill Moss’s conversation with Matshidiso Moeti, WHO’s regional director for Africa.) People in LMICs have benefited from a marked increase in life expectancy due to sizable investments in evidence-driven maternal and child health programs. Worldwide, childhood mortality was cut in half between 1990 and 2015, and maternal mortality decreased by 44 percent. This extraordinary success has resulted in a larger proportion of the population surviving into the prime ages when NCDs begin to take their heaviest toll. But increased life expectancy is not the sole explanation for the meteoric rise in NCDs: Unhealthy behaviors such as smoking, unhealthy diets, harmful use of alcohol and increasingly sedentary lives play a critical role. These behaviors, in turn, are due to an array of social and economic factors, including rapid urbanization as well as the globalization of the food, tobacco and alcohol industries. More recently, early malnutrition has been linked to the onset of chronic diseases. The Bloomberg School’s Center on the Early Life Origins of Disease has shown that maternal health and fetal exposures in utero can affect a child’s future NCD risks, demonstrating the intergenerational link of NCDs. Their findings raise both challenges and opportunities for bridging maternal and child health with adult health to prevent and manage NCDs across the life span and generations.    

More than 30 years ago, the late Drs. Ernest Gruenberg and Morton Kramer, professors at the Bloomberg School, were warning us about the evolving pandemic of NCDs. I remember the passion with which they spoke about the “failures of success” as people increasingly survived childhood only to struggle with diabetes, heart disease, cancer or mental disorders as adults. They admonished the global health community to get ahead of the curve by emphasizing NCD prevention and rethinking how health systems are organized to manage these diseases. Today it has become increasingly clear that NCDs may well exact a greater toll from LMICs than from higher income countries because their rise has been more rapid, while policies and infrastructure that ensure that today’s children can thrive into late adulthood are often lacking. 

The UN has taken encouraging steps against NCDs: Three of its 2015 Sustainable Development Goals are specific to NCDs, injuries and mental health. Importantly, the WHO has emphasized the value of prevention: For every $1 invested in their 16 “best buys” for NCD interventions, the return would be at least $7 by 2030. But national and local governments and international agencies are not yet investing with the intensity needed to move the needle. 

While the challenges seem insurmountable, my visit to Tanzania left me hopeful about the future. It started with a visit to one of our alums. Frank Manase, MD, MPH ’12, recognized the need to aggressively address the growing epidemic of NCDs and established the Community Center for Preventive Medicine on the outskirts of Dar es Salaam in 2013. This community-based social and health services organization advocates for prevention and primary health care designed to address NCDs. Frank shared startling statistics with us. In a survey of the more than 5,000 adults attending CCPmedicine, 42 percent were obese, 29 percent didn’t engage in adequate physical activity, 29 percent smoked, and 40 percent were hypertensive. But he has a vision. Partnering with volunteer health professionals as well as leaders from the community, government, schools, corporations and religious groups, he uses a family-centered approach to empower individuals to take a leading role in promoting their own health. His program emphasizes integrated preventive and curative services; health promotion where people live, work, play and worship; early detection of disease; timely intervention; and high-quality health services that will ameliorate NCDs’ disabling consequences. CCPmedicine also engages policymakers and communities themselves in its programmatic efforts. Their vibrant support was evident upon our arrival to the village of Kinyerezi, where more than 300 guests had gathered to celebrate CCPmedicine’s fifth anniversary. Inspired, we left convinced more than ever of the power of public health through education, science, partnerships, people and advocacy. 

My hope was further buoyed by a meeting later that day with the Honorable Ummy Mwalimu, Minister of Health of Tanzania. She spoke eloquently of the need to expand efforts to prevent and treat NCDs while continuing to address ongoing “first burden” challenges. She also reminded us that Tanzania and other LMICs are actually facing a “triple burden.” The third burden is the direct effects of globalization on health, such as the emergence of new infectious diseases with pandemic potential and the impacts of climate change. Tackling this third burden will require new investments in systems to address the health and livelihood effects of globalization for the common good of the planet and its people.

Addressing these interconnected problems will require learning and action at individual, community and policy levels as well as building bridges across sectors and siloed institutions. The new, 21st-century public health approach is primed to do just that, as I argued in last spring’s column on Public Health 3.0. We look forward to working with our colleagues in Tanzania and other countries around the world to confront the evolving “triple burden” with an expanded arsenal of public health strategies.