|Year : 2020 | Volume
| Issue : 2 | Page : 43-49
Is the COVID-19 pandemic an opportunity to advance the global noncommunicable disease agenda?
Jacob Kumaresan1, Bolanle Bolaji2, Jennifer Prince Kingsley2, Nalini Sathiakumar2
1 Former WHO Executive Director, New York, USA
2 Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA
|Date of Submission||22-May-2020|
|Date of Decision||11-Jun-2020|
|Date of Acceptance||15-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Nalini Sathiakumar
Department of Epidemiology, University of Alabama at Birmingham, Birmingham
Source of Support: None, Conflict of Interest: None
More than 70% of the annual global deaths are due to noncommunicable diseases (NCDs), and 80% of these deaths occur in low- and middle-income countries. Most of these deaths are in people <70 years of age and can be prevented and controlled by addressing a set of modifiable risk factors, namely tobacco use, alcohol misuse, unhealthy diets, physical inactivity, and obesity. Recognizing the global burden of NCDs, the world's leaders adopted several policy instruments such as the NCD Global Action Plan, the Framework Convention on Tobacco Control, and the global monitoring framework on NCDs. In 2015, the UN General Assembly included reduction of premature mortality from NCDs by one-third by 2030 as target 3.4 of the Sustainable Development Goals (SDGs). Assessment of this target in 2018 found some progress with tobacco control, but the overall progress was inadequate. The global pandemic of coronavirus disease 2019 (COVID-19) has brought NCDs to the forefront. Preliminary data indicate that persons with NCDs are extremely susceptible to COVID-19 and its complications including death. Focus on controlling the pandemic has led to delays in the diagnosis, treatment, and management of NCDs. This pandemic has exposed the weaknesses of the health-care systems, exacerbated the inequalities within societies, and disproportionately affected the vulnerable groups. In the process of recovery and in future planning, governments and leaders need to take proactive actions toward the prevention and control of all avoidable deaths from NCDs if the SDG target 3.4 is to be achieved by 2030.
Keywords: COVID-19, noncommunicable diseases, Sustainable Development Goal 3.4
|How to cite this article:|
Kumaresan J, Bolaji B, Kingsley JP, Sathiakumar N. Is the COVID-19 pandemic an opportunity to advance the global noncommunicable disease agenda?. Int J Non-Commun Dis 2020;5:43-9
|How to cite this URL:|
Kumaresan J, Bolaji B, Kingsley JP, Sathiakumar N. Is the COVID-19 pandemic an opportunity to advance the global noncommunicable disease agenda?. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Sep 21];5:43-9. Available from: http://www.ijncd.org/text.asp?2020/5/2/43/288249
| Introduction|| |
Noncommunicable diseases (NCDs) have long been of concern in the developed countries and are of increasing concern in the developing countries in the past few decades. There have been global movements toward the early diagnosis and management of NCDs with an emphasis on both prevention and rehabilitation. The novel coronavirus disease 2019 (COVID-19) pandemic has affected the global population in unforeseen ways since originating in Wuhan China and has required a monumental health-care response worldwide. Besides persons with NCDs being particularly vulnerable, the prevention and control of NCDs has been compromised increasing the existing global burden of NCDs. This study aims to review the impact of COVID-19 on NCDs and to underscore the importance of advancing the global agenda on NCDs.
| Global NCD Burden and Global Action Plan|| |
NCDs are the leading cause of death and disease worldwide, with a disproportionately higher burden in low- and middle-income countries (LMICs). In 2016, 40.5 of the 56.9 million global deaths were due to NCDs, with 80% of these deaths occurring in LMICs; 46% were among the population below 70 years of age. Although NCDs primarily occur in middle and older age groups, the younger age groups are not exempt. The impact of NCDs is felt most among the poorest populations in the LMICs. Cardiovascular diseases, diabetes mellitus, cancers, and chronic respiratory diseases are four of the most common NCDs., Ironically, most of the premature deaths from these preceding NCDs are preventable by addressing a cluster of modifiable risk factors, namely tobacco use, alcohol misuse, unhealthy diet, and physical inactivity. Globally, in 2016, 1.1 billion people over the age of 15 years were current smokers, and about two billion adults (39%) 18 years and above were overweight and 13% were obese.
Substantial reduction of NCD mortality requires policies that considerably reduce the modifiable risk factors and blood pressure and offer equitable access to efficacious and evidence-based preventive and treatment care for all NCDs. In 2003, the Framework Convention on Tobacco Control was unanimously adopted at the World Health Assembly. It now covers about 90% of the world's population in 181 countries. This milestone in the promotion of public health is a fundamental instrument in enabling governments to introduce and implement public policies for tobacco control in the interest of peoples' rights and their health. In 2011, the United Nations General Assembly adopted a Political Declaration in New York and highlighted the need to implement proven cost-effective measures to reduce the four modifiable risk factors. A “NCD Global Action Plan” of 25 indicators and 9 voluntary targets was developed and agreed upon by 194 countries to be attained by 2025. [Table 1] provides the definition of the nine voluntary targets. To track the implementation, the World Health Organization (WHO) developed the “global monitoring framework on NCDs” through monitoring and reporting on the attainment of the nine global targets by 2025, against a baseline in 2010. Accordingly, governments were urged to: (i) set national NCD targets for 2025 based on national circumstances; (ii) develop multisectoral national NCD plans to reduce exposure to risk factors and enable health systems to respond in order to reach these national targets in 2025; and (iii) measure results, taking into account the Global Action Plan. The facilitation of multisectoral and integrated actions at country level through multi-stakeholder partnerships led by national governments was considered to be crucial in addressing the social and economic challenges due to NCDs.
In 2015, recognizing that the prevention and control of NCDs is central to global health and international development, Heads of State and Governments included the reduction of premature mortality from NCDs by one-third by 2030 as target 3.4 of the Sustainable Development Goals (SDGs). Member states forged a consensus to act in unity toward a just and prosperous world free of the avoidable burden of NCDs.
| Progress Toward Achieving Sustainable Development Goal 3.4 or Noncommunicable Disease Targets|| |
In 2018, the United Nations General Assembly noted that global progress toward achieving the SDG target 3.4 was inadequate and the investment was insufficient. Overall, the risk of death caused by any of the four main NCDs among those aged 30–69 years of age reduced from 22% in 2000 to 18% in 2016. The risk of death was disproportionately higher in adults in LMICs (23%) than adults in high-income countries (HICs) (12%). The rate of decline in NCD deaths from 2000 to 2010 was 14%. It is projected that with moderate acceleration in the 2000–2010 decline, the 2030 target of one-third reduction may be achieved. However, the trends of behavioral risk factors were found to vary by regions. The consumption level of alcohol increased in Southeast Asia by 30% between 2000 and 2016 in contrast to a decrease in alcohol intake by 12% in the European Region during the same period. Europe had the highest level of alcohol consumption despite this decline. Tobacco use reduced from 27% in 2000 to 20% in 2016, and it is expected that the global target may be achieved with a more rapid decline. The levels of physical inactivity have not declined in the last 25 years and are unlikely to meet the 2025 target. Data on trends of salt intake are scarce, but data in 2010 found a high level of salt intake. There is a 10-year interval remaining for NCD targets to be accomplished, and it is critical for countries to keep on track with the 2030 goals.
| COVID-19 Crisis and Noncommunicable Diseases|| |
This year is unique in the history of the world, with an unprecedented event overtaking the lives of all global citizens. COVID-19, an infectious disease caused by severe acute respiratory syndrome (SARS) coronavirus 2, has spread globally, resulting in the ongoing 2019–2020 pandemic. Being a novel virus among the corona group, no person in the world is immune and people of all ages are vulnerable to exposure. As of May 20, 2020, COVID-19 has resulted in over five million confirmed cases and 325,000 deaths [Figure 1] and [Figure 2].,
|Figure 1: Total number of global coronavirus cases, January 22 to May 16, 2020|
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|Figure 2: Total number of global coronavirus deaths, January 22 to May 16, 2020|
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The COVID-19 pandemic has brought to the forefront the global burden of NCDs. Based on the available data from different countries, it is evident that people with underlying NCDs are extremely vulnerable to COVID-19 with severe disease and complications resulting in death. Data from the New York City Health in the United States (US) as of April 30, 2020, indicate that 95.8% of the 13,000 deaths occurred in persons more than 44 years of age (22.4% in persons aged 45–64 years and 73.5% in those older than 65 years). Of these deaths, 73.4% had a history of one more underlying NCDs, namely diabetes, asthma and lung disease, cancer and immunodeficiency, hypertension and heart disease, and kidney, gastrointestinal, and liver diseases. Data from the Centers for Disease Control and Prevention based on COVID-19 case report forms submitted from February 12 to March 28 indicate that approximately one-third (37.6%) of COVID-19 cases had at least one underlying NCD; 11% had diabetes, 9.2% had chronic lung disease, and 9% had cardiovascular disease. Data from Italy on 1591 intensive care unit COVID-19 patients found that most (96.2%) had one or more NCDs (hypertension, 69.2%; type 2 diabetes, 31.8%; ischemic heart disease, 28.2%; chronic obstructive pulmonary disease, 16.8%; and cancer, 16.3%). Similarly, an association between COVID-19 severity and NCD has been reported from Spain  and China. Typically, COVID-19 deaths occur in older people who have existing NCDs. The study from Italy noted a median age of 63 years, with only 13% of patients below 51 years of age. Smoking  and obesity,, two of the major risk factors for NCDs, were found to be independent risk factors for severe COVID-19 infection and death. The distribution of these factors primarily in younger and middle age groups places these subgroups of the population at high risk. Kass et al. in their analysis of data from six university hospitals in the US found that obesity could shift severe COVID-19 disease to younger ages; this pattern is more evident in the US where the prevalence of obesity is 40%. In China, patients with severe disease and deaths from COVID-19 typically had a high body mass index of >25 kg/m 2. Obesity can restrict respiratory function by impeding diaphragmatic movements, impair immune responses to viral infection, and induce diabetes mellitus and oxidant stress leading to cardiovascular dysfunction.,
COVID-19 has also exacerbated the inequalities within societies, with vulnerable groups affected the most. For example, the New York City Health data from hospitalized COVID-19 patients found that COVID-19 deaths were higher in black/African American (92.3 deaths per 100,000 population) and Hispanics/Latino patients (74.3) than white (45.2) or Asian (34.5) patients. The burden of NCDs among black/African American population is higher than other races.
The impact of COVID-19 response measures on the diagnosis and management of NCDs is of great concern. For example, cancer diagnosis and treatment was severely disrupted in the United Kingdom both due to staff shortages and to restrict patient exposure to COVID-19. A study in Austria found that there was a 40% decrease in admissions for acute coronary syndrome since the COVID-19 pandemic. In an online US Gallup Panel Survey, 42% with cardiac disease reported that they would be very concerned seeking immediate care in an emergency for fear of exposure to coronavirus. Several factors disrupt the continuity of care for NCD patients and management of NCD risk factors such as physical distancing, quarantine measures, limited access to primary health-care units, discontinuity in the supply chain of essential medications, and essential community services. In addition, in most LMICs, the total suspension of public transportation services has disabled access to health-care services. Such disruptions of routine health services, diagnostic tests for NCDs including cancer, and medical supplies will increase the morbidity of NCD patients and avoidable NCD mortality over time.
As with all disasters/pandemics, a mental illness crisis related to COVID-19 is inevitable and impending. The SARS epidemic in 2002–2003 was linked with increases in anxiety, depression, and posttraumatic stress disorder. The mental health effects due to COVID-19 is expected to reach gigantic proportions, more than any other disaster/pandemic in the current era. The UN cautions policymakers to prepare for the looming mental illness crisis due to COVID-19. The pandemic has enormously increased psychological suffering stemming from factors such as fear of infection, grief at the loss of loved ones, shock at the loss of jobs, isolation and restrictions on movement, difficult family dynamics, uncertainty, and fear for the future; health-care workers have added factors of lack of adequate personal protection, physically demanding long working hours, and psychological trauma from caring for COVID patients.,, According to a recent Kaiser Family Foundation poll, more than half of Americans (56%) reported that worry or stress related to the COVID-19 outbreak has led to at least one negative mental health effect. Higher-than-usual levels of symptoms of depression and anxiety have been reported from different countries. The extreme and ongoing stress may also lead to greater reliance on addictive substances such as alcohol and drugs. Canada's national statistical agency reported that one-fifth of people aged 15–49 years had increased their alcohol consumption. A report from the Well Being Trust and the Robert Graham Center estimates that there would be 75,000 additional “deaths of despair” from drug and alcohol misuse and suicide due to unemployment, social isolation, and fears about the virus in the US. The short- and long-term consequences of mental illness due to COVID-19 will significantly compound the existing burden of the NCDs.
| Opportunities for Noncommunicable Disease Prevention and Control during and Beyond COVID-19|| |
The COVID-19 pandemic has burgeoned into a global economic and social crisis. Consequently, a response at the global and country levels is needed to control the virus and to revert the global economy back on track to achieve the SDGs. While HICs have begun the financial recovery process with emergency funding mechanisms such as stimulus packages, developing countries lack such backup options. The latter countries have exceeded their available financial resources toward COVID-19 response programs. Such a situation of escalating national debt impedes plans and progress toward meeting the SDGs. More than 80 countries have sought support from the International Monetary Fund for financial support. While restructuring their economies and responding to the COVID crisis and planning the recovery process, it is crucial that countries steer their economies toward the SDGs.
The intersection between NCDs and infectious diseases has not been central in the planning of the NCD global health agenda. The current COVID crisis has underscored the importance of addressing this gap. Amid the COVID-19 pandemic, it is crucial for governments to formulate and implement a framework for policies to implement a robust response for the prevention, diagnosis, and management of NCDs building on their existing programs. Health systems and communities need to be adaptive to support and manage the large population with NCD or with a NCD risk factor. Adapting the WHO's Innovative Care for Chronic Conditions framework would mean working across disease continuum with partnership triad between patients and families, health-care teams (primary, secondary, and tertiary care), and community members within a positive policy environment. Some areas to be strengthened would be: (1) expand mass COVID communication to include information and guidance on NCD control and prevention measures. It is important to allay public apprehension in seeking NCD-related health care during the pandemic and information on such resources. (2) Ensure continued supply chain of essential medications to enable control of NCDs. Maintaining the supply chain will reduce the risk of complications of NCDs as well as reduce the vulnerability and complications from COVID-19 infection. (3) Strengthen the self-management of NCDs by ensuring continuous supply of medications and easy access to resources including remote technology or services that provide monitoring and follow-up advice. (4) Prevent delays in NCD diagnosis and treatment. (5) Provide support for mitigation of NCD risk factors such as remote or virtual access to guidance on smoking cessation, weight management, and physical activity. Concurrently, ensure access to smoking cessation products and healthy food.
In the aftermath of the COVID-19 pandemic, governments will be developing programs to strengthen population and system resilience against future infectious disease outbreaks and pandemics. The negative impact COVID-19 on NCD morbidity and mortality would have regressed progress in these indicators achieved globally thus far. Governments should recognize that NCDs are a global emergency necessitating a comprehensive and strong response similar to pandemics. Optimal prevention and control of the NCDs should be an essential strategy that would strengthen and build resilience for future pandemics. Thus, action plans for NCDs should be integral in pandemic preparedness programs. Lessons learned from the current COVID pandemic should be applied to ensure continuity of care, particularly in the primary health-care systems. Mental health services should be a part of the NCD agenda with stepping up of services to tackle the increased demands and integrated into primary health care. A comprehensive primary health-care system is paramount to optimizing population health with inclusion of vulnerable and marginalized populations.
Developing countries are in different stages of progress in moving from a traditional provider-centered, disease-oriented approach to a patient-centered, health-management model. While governments are striving to provide health care that is accessible, affordable, and equitable, it is important to consider innovative models of care to bridge gaps in service. The COVID-19 pandemic has shown the key role of telehealth in mass communications, increasing traceability of people, movement tracking, temperature monitoring, and data sharing. Telehealth involves the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities. For example, mobile health entails using mobile communication devices help in patient education, health promotion, disease self-management, decreasing health-care costs, and to reach populations in remote areas. Telehealth has influenced several aspects of health care in improving access and reducing cost of care. Despite evidence on the demonstrated success of the telehealth, it has been underused, particularly in developing countries. Barriers impeding implementation in LMICs are problems with policy and accreditation, lack of trained teams, technological issues and keeping pace with rapidly evolving technology, legal and ethical issues, financing, and social factors (literacy and acceptance). In planning forward, countries should consider incorporating telemedicine in the mainstream health service delivery systems and in the context of management of NCDs including mental health.
Finally, the economic burden on households of NCDs is very high involving catastrophic out-of-pocket costs. Thus, in planning and implementing NCD programs, eliminating financial barriers for essential medications and adherence to interventions that are cost-effective and are designed to help the poor should be of high priority., In concert with programs to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's SDGs.
| Conclusions|| |
The COVID-19 pandemic has shown that health systems in developed and developing countries alike are ill-equipped to respond. COVID-19 has not only exposed the weaknesses of the public health infrastructure but also has clearly brought to the forefront the global NCD crisis that has taken a significant physical, psychological, social, and economic toll in families and communities. While some progress has been made in global tobacco control, much more needs to be done to modify the remaining risk factors for NCDs, namely alcohol abuse, unhealthy diets, physical inactivity, obesity, and hypertension. Will the commitments made at the 2015 UN General Assembly to adequately address NCDs be achieved by 2030? Only time will tell! Can the lessons learned on implementing stringent measures to curb transmission and treat COVID-19 be applied with the same rigor to the prevention and control of NCDs? According to WHO's projections, the total annual number of deaths from NCDs will increase to 55 million by 2030 if “business as usual” continues. As of now, we need to be optimistic and hope that as life returns, discussions during the recovery phase should advocate for more investments and resources to reduce avoidable deaths from NCDs, thus increasing productivity and economic growth and addressing social challenges in the global society.
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Conflicts of interest
There are no conflicts of interest.
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