In Uganda, a mother of five has been waiting all day to see a doctor, with no success. The story normally ends here. In delay. Frustration. But bolder than her peers, she takes matters into her own hands, and confronts a doctor in the hallway by ripping open her blouse. Exposed is a breast mostly ulcerated, eaten by cancer. Sadly, what shocks the doctor is her directness, not the late stage of the disease, which is common among the disadvantaged in the country. She received chemotherapy that same day.
Infectious diseases such as malaria and TB will continue to remain highly relevant for many years to come in countries such as Uganda, but there are already international organizations dedicated to combating these ailments. Less attention has been paid to non-communicable diseases (NCDs), which have been rising at an unprecedented rate, and are by far the leading causes of death in the world. For the first time in human history, more people live in countries where obesity kills more than starvation. 63% of us will die of one of the “big four”: cardiovascular disease, cancer, respiratory disease, and diabetes. These are not simply unavoidable deaths due to over-consumption and old age: 80% of people who die of NCD-caused deaths live in low- and middle-income countries (LMCs), and a large proportion strikes those under 60. We can even put a mortality rate on inequality: 20 million, or a third of all global deaths, are preventable. That’s the difference between death rates in high-income countries and all other regions of the world.
A cancer diagnosis does not necessitate a death sentence, but in an LMC, it can when the illness is exacerbated by the environment. The Ugandan case above helps us unpack the multitude of issues that contribute to the problem – inefficient health systems, replete with endless waits, shortages of everything, hidden fees and lost lab tests – that compound the stigma and poverty that prevent the sick from going to the clinic. The inequalities of access that have plagued efforts to address infections are only going to be more apparent when applied to the longer-term NCDs. And according to a report by the World Economic Forum and the Harvard School of Public Health, “the cumulative costs of NCDs will be at least $47 trillion from 2010 through 2030, with mental illnesses accounting for more than one-third of the cost. This is a low-end estimate.”
This is all fundamentally important because it necessitates a shift in global health governance, whose architecture has been designed to combat urgent and communicable disease. The annals of public health have a storied history in lepers, and smallpox, and the great killers – the Spanish flu and bubonic plague. Some of these continue to evade our efforts. However, NCDs will be a growing problem because the international response to address them will be more difficult, time-consuming, and costly than many of the other public health campaigns undertaken in the past. NCDs have longer timeframes, less direct causation, are less visible and will need to engage not only public, but private actors, as well as societal change.
Their cause goes beyond individual choices, with larger, structural forces at work, shaping our longevity. A poor national health care system is one such example. But on top of that, we must consider the impact that multinational systems of economics and trade have had upon the rise of NCDs. John Norris writes about an example in a recent Foreign Policy article: the saga of Samoa and the American turkey tail. These tidbits, at 40% fat, are a byproduct Americans do not want. After WWII, marketers for the poultry industry began dumping them in Samoa, where they became a local delicacy. By 2007, Samoans were eating more than 44 pounds of turkey tails every year, and obesity rates reached 56% by 2008, as the tails and other imported foods edged out the local diet. Many Samoans believe that foreign goods are superior to locally-produced items. Samoan officials tried to ban turkey butt imports in 2007, pleading with the WHO for help in combatting American poultry companies. Meanwhile, the WTO blocked Samoa’s application for membership. The debacle bogged down Samoa’s WTO application for years, until it agreed to open itself back up to the fatty imports in 2011. The president of the USA Poultry & Egg Export Council stated “we feel it’s the consumers’ right to determine what foods they wish to consume, not the government’s.” NCDs do not always have direct correlation with one specific food or product, but that does not discount that our international trade and corporate practices are having a definite impact on waistlines around the world.
Hope lies in the fact that there are spaces in which communicable and non-communicable diseases overlap, and best practices from one field can be applied to the other. There are direct correlations found between the two (see: the HPV virus and cervical cancer.) Regardless of whether we’re facing a case of river blindness or pre-diabetes, we will always need a robust health system, that is fully-staffed and sustainably financed, that individuals can access without barriers or stigma. Public health initiatives will need to target issues of prevention more than ever before, and we’ll need to better highlight the linkages between corporate, government, and personal entities that contribute towards our declining health, to find opportunities where programming such as support groups and other platforms can counter them.
P. S. If you fall on the same side as the USA Poultry & Egg Export Council, and paternalism holds you back from supporting more government initiatives against NCDs, I would insist that there is already paternalism in the choices that have been determined for us before we were born. Our work schedules. The costs of seeing a doctor. The costs of educating a doctor. Profit margins. Did you know that companies such as Kraft and Nestle have entire research wings dedicated to engineering a food’s “bliss point,” which is achieved when a consumer’s brain receptors will continue to crave that food without ever triggering the mechanism of feeling satiated? These are just examples of some larger barriers that limit our options in making healthy decisions. It wasn’t until my freshman year of college that I learned there were so many more varieties of apples than I’d seen in grocery stores, after we looked at an heirloom seed catalog in an honors class. For 17 years, those alternatives had been hidden behind a corporate curtain that limited my choices down to those types that are easiest to grow and ship. The Granny Smith. Fuji. Pink Lady. Those were all choices pre-determined for you. And because just a few corporations produce almost all personal consumer products we buy, this pre-selection matters because these goods go directly in or on your person. Public governance is in a unique position to counter corporate influence in a way that individuals alone cannot.