Global Health Interventions and Artificial Intelligence

Global_Health_101_----_Chapter_14_Noncommunicable_Diseases_and_Mental_Disorders.pdf

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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023. Created from indianatech-ebooks on 2022-10-05 02:41:48.

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CHAPTER 14 Noncommunicable Diseases and Mental Disorders

LEARNING OBJECTIVES

By the end of this chapter, the reader will be able to do the following:

■ Describe the burden of noncommunicable diseases and mental disorders worldwide

■ Discuss the most important risk factors for the burden of these conditions

■ Outline the costs and consequences of selected noncommunicable diseases and mental disorders

■ Review measures that can be taken to address the burden of these conditions in cost-effective and fair ways

■ Describe some successful cases dealing with noncommunicable diseases and mental disorders in low- and middle-income countries

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R ▶ Vignettes

oberto was 45 years old and lived in Bogota, Colombia. He had a government desk job and had been affected by

overweight for most of his adult life. He got little exercise. He had read about increasing rates of diabetes in Colombia but still thought this was largely a disease of people in rich countries. Last year, Roberto started feeling thirsty all the time, had dry mouth, and felt weak after exertion. He went to his doctor and was diagnosed with type 2 diabetes.

Shalini was 35 years old and lived in Sri Lanka. She had grown up in a village, had worked hard on her family’s small farm, and had been healthy for all of her adult life. She had two children and had not had any problems during either pregnancy. During a recent visit to the local health center, however, the doctor discovered that Shalini had high blood pressure. The doctor talked with Shalini about changing her diet and also prescribed medication for her. The medicine she needs is not expensive but, unfortunately, Shalini has to take this medicine for the remainder of her life.

Alexei was 47 years old and lived in Moscow, Russia. Alexei had been smoking one pack of cigarettes a day since he was 16 years old. He heard on television and on the radio about the bad effects that cigarettes have on health. Urged by his children to stop smoking, he tried unsuccessfully on several occasions to quit. Over the last few months, Alexei developed a continuous cough and was often short of breath. Alexei had lung cancer.

Lai Ying was a factory worker who lived in Guandong Province, China. Until recently she had been a happy and healthy young woman. Lately, however, Lai Ying had felt very unhappy, did not feel like getting out of bed in the morning, did not want to go to work, and had no energy when she was at work. Lai Ying’s family

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noticed that she was not eating properly and that she was not herself. However, they thought she was having a difficult time at work or with a boyfriend and that she would soon be fine. After some months of this behavior, Lai Ying consumed an overdose of sleeping pills and died by suicide.

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▶ Key Definitions Communicable diseases are illnesses caused by an infectious agent that spreads from a person or an animal to another person or animal. Like noncommunicable diseases, they can be very disabling, can seriously impair the ability of people to engage in day-to-day activities, and often lead to death if they are not treated appropriately. However, noncommunicable diseases (NCDs) are, in some respects, the opposite of most communicable diseases. They cannot be spread from person to person by an infectious agent, even if they might be associated with one. In addition, they tend to last a long time.

In practice, however, the definition of noncommunicable diseases is not as clear as it might seem. First, the terms chronic disease and degenerative disease are often used interchangeably with noncommunicable disease. However, some would say that these are also imperfect terms because some communicable diseases, such as HIV/AIDS, can become “chronic” conditions when those affected receive appropriate treatment. Second, a number of noncommunicable diseases, such as some cancers, have infectious causes. Third, although mental health disorders are included, in principle, in noncommunicable diseases, they are excluded from many discussions of NCDs.

In this text, however, for the sake of simplicity and to conform to the generally used terminology, we shall consistently use the term noncommunicable disease. This will include all causes that are included in the Global Burden of Disease Study 2016 (GBD 2016) under the category of noncommunicable diseases, including mental disorders.

This chapter will focus on selected noncommunicable diseases of importance. This includes cardiovascular disease, cancers,

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chronic obstructive pulmonary disease, vision and hearing loss, and mental health disorders. Including mental disorders in the chapter title is intended to signal the coverage of the chapter and the importance of mental health.

You are already familiar with most of the terms used in this chapter; however, a few key terms with which you may be less familiar are defined in TABLE 14-1.

TABLE 14-1 Key Terms

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▶ The Importance of Noncommunicable Diseases

Noncommunicable diseases are of immense and growing importance worldwide. In fact, the burden of these conditions is greater than the burden of communicable diseases in low- and middle-income countries, as well as in high-income countries. Only in sub-Saharan Africa is the burden of communicable diseases higher than that of noncommunicable diseases. This contradicts some people’s continuing perception that low-income countries do not face a significant burden of noncommunicable disease and that these diseases are problems only for affluent countries.

Moreover, the burden of noncommunicable diseases will increase in low- and middle-income countries as they develop economically, become more integrated with the global economy, urbanize, and age. Among the most important of the noncommunicable health conditions that low- and middle- income countries face are ischemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, cancers, musculoskeletal disorders, and mental health disorders. The risk factors for several noncommunicable diseases relate in significant ways to lifestyle, much of which is modifiable. This chapter discusses, for example, the importance of diet, physical activity, tobacco use, and alcohol use for the onset and during the course of certain noncommunicable diseases. By engaging in appropriate health behaviors, it is possible for most people to considerably reduce the risk of getting heart disease, stroke, COPD, some cancers, or diabetes.

Some noncommunicable diseases can be prevented at relatively low cost, but these diseases are often very expensive to treat. It is possible, for example, to significantly reduce the chances of getting lung cancer by making a modest investment in smoking

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cessation therapy and by quitting smoking. By contrast, the cost of treating lung cancer through drugs and surgery is considerably more expensive.

TABLE 14-2 indicates some of the most important links between noncommunicable diseases and the Sustainable Development Goals (SDGs). The table highlights the importance of noncommunicable diseases in all countries, including low- and middle-income countries.

TABLE 14-2 Selected Links Between Noncommunicable Diseases and the SDG Health Targets

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The chapter first examines the burden of noncommunicable diseases and the risk factors for those diseases. Following that, it comments on some of the most important costs and consequences of those diseases. It then reviews what steps can be taken to address the burden of these diseases in cost-effective ways and discusses several examples of successful efforts to prevent and deal with noncommunicable diseases. The chapter concludes with comments on some of the future challenges that must be addressed if the burden of noncommunicable diseases is to be reduced.

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▶ A Note on Data This chapter includes data on both deaths and disability-adjusted life years (DALYs) for the most important noncommunicable diseases. An important part of the data in the chapter, therefore, is based on the Global Burden of Disease Study 2016 and its related publications and website. Much of the other data used in this chapter comes from the World Health Organization (WHO). The chapter also uses data from a number of studies of specific diseases, especially from Disease Control Priorities, Third Edition (DCP3).

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▶ The Burden of Noncommunicable Diseases

Cardiovascular Disease Ischemic heart disease caused almost 10 million deaths in 2016 and is the leading specific cause of death globally for all age groups and both sexes. Stroke was the second leading cause of death globally among all age groups and for both sexes in 2016 and was responsible for more than 6 million deaths. Together, ischemic heart disease and stroke, generally referred to in burden- of-disease studies as cardiovascular disease (CVD), made up almost 27 percent of all deaths globally in 2016.

Ischemic heart disease is the fifth leading cause of death in low- income countries. However, it is the leading cause of death for both sexes and all ages in lower middle-, upper middle-, and high- income countries. Stroke is the second leading cause of death in lower middle- and upper middle-income countries but is the third leading cause in high-income countries and the eighth leading cause in low-income countries.

Ischemic heart disease is the largest cause of death among all age groups for both sexes in all World Bank regions, except in East Asia and the Pacific, where stroke is a more common cause of death, and in sub-Saharan Africa, where communicable diseases still predominate and where ischemic heart disease is the seventh leading cause of death. Stroke is the leading cause of death in East Asia and the Pacific. It is the second leading cause of death in Europe and Central Asia, Latin America and the Caribbean, and the Middle East and North Africa. It is the third leading cause of death in South Asia, fourth in North America, and eighth in sub-Saharan Africa.

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Together, ischemic heart disease and stroke made up about 44 percent of all deaths in Europe and Central Asia in 2016 and about 37 percent of all deaths in East Asia and the Pacific. However, they were associated with only about 12 percent of the total deaths in sub-Saharan Africa. CVD rates are higher in Eastern Europe than in Western Europe, although the rates of CVD are falling in some Eastern European countries. The highest rates of CVD are in the former Soviet Union, where they earlier contributed to declines in life expectancy.

Ischemic heart disease was the 2nd leading cause of DALYs and stroke was the 3rd leading cause of DALYs among all age groups and both sexes in 2016. For low-income countries, ischemic heart disease was the 9th leading cause of DALYs and stroke was the 11th leading cause of DALYs. However, in the lower middle- income countries and upper middle-income countries, stroke was the leading cause and ischemic heart disease was the 2nd leading cause. In the high-income countries, ischemic heart disease was the leading cause of DALYs and stroke was the 3rd leading cause.

Given limited access to prevention programs or appropriate treatment, deaths from CVD generally occur earlier in life in low- and middle-income countries than in high-income countries. In India, for example, CVD occurs in people at younger ages more often than in high-income countries. Whereas in high- income countries only about 22 percent of CVD deaths occur in people under 70 years of age, in India, about 50 percent of the CVD deaths occur in people under 70.

To help get a better understanding of the importance of CVD to the burden of disease, TABLE 14-3 shows the burden of deaths and DALYs by World Bank regions that are associated with ischemic heart disease and stroke, compared to some of the other leading

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causes of deaths and DALYs. TABLE 14-4 does the same by World Bank country income group.

TABLE 14-3 Deaths and DALYs from Select Noncommunicable and Communicable Causes, by World Bank Region, 2016, as a

Percentage of Total Deaths and DALYs

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TABLE 14-4 Deaths and DALYs from Select Noncommunicable and Communicable Causes, by World Bank Country Income

Level, 2016, as a Percentage of Total Deaths and DALYs

Some of the risk factors for cardiovascular disease are modifiable while others are not. Men have a higher risk of heart disease than

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women who are premenopausal, but postmenopausal women have the same risk of cardiovascular disease as men. In addition, men and women have similar risks of stroke. The medical history of one’s family is also significant. If a male relative had coronary heart disease before 55 years of age or a female relative before 65 years of age, then one has a higher risk of heart disease. Ancestry is also relevant, as people of African or Asian descent have higher risks than other groups. Aging also increases risk, with the risk of a stroke doubling every 10 years after age 55.

Other risk factors are modifiable, meaning one can change them by changing behavior. These include hypertension, which is the biggest risk factor for stroke and a major risk factor for heart disease. Tobacco use is also a major risk factor for CVD, with higher risks for women and those who started smoking early and smoke a lot. High levels of cholesterol, which are linked to a diet high in saturated fats and the lack of physical activity, are also risks. The lack of physical activity is a risk for obesity that in turn is a risk for diabetes, which doubles one’s risk of CVD. Excess alcohol consumption is also associated with heart disease.

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PHOTO 14-1 A Chinese healthcare provider is shown here taking her patient’s blood pressure. Hypertension is a major risk factor for noncommunicable diseases. Better prevention and management of hypertension is central to improving health in many countries. In resource-poor settings, how could one make a start at improving the prevention, diagnosis, and management

of hypertension?

Social factors can be important risks for CVD. There is good evidence that higher risks of CVD are associated, for example, with poverty, stress, and being isolated socially. Depression is also an important risk factor for CVD.

Diabetes There are several types of diabetes. The two most common are called type 1 and type 2 diabetes. Type 1 diabetes is thought to be an autoimmune disorder that attacks and destroys the cells in the pancreas that produce insulin. Without insulin, the body is not able to use glucose (blood sugar) for energy. To treat the disease, a

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person must inject insulin, follow a diet plan, exercise daily, and test blood sugar several times a day.

Type 1 diabetes usually begins before the age of 30. This type of diabetes was previously known as insulin-dependent diabetes mellitus or juvenile diabetes. Type 2 diabetes was previously known as noninsulin-dependent diabetes mellitus or adult- onset diabetes. Type 2 diabetes is the most common form of diabetes mellitus, present in about 90 percent to 95 percent of all people with diabetes. People with type 2 diabetes are able to produce insulin; however, they either do not make enough insulin or their bodies do not efficiently use the insulin they do make.

There is also a third type of diabetes, generally referred to as gestational diabetes. A high blood glucose level—hyperglycemia —that is diagnosed first in pregnancy is referred to as hyperglycemia in pregnancy or gestational diabetes mellitus (GDM). Hormonal production by the placenta can lead to diminished action of insulin, called insulin resistance, and lead to GDM. Other risk factors for GDM include older age, obesity, excessive weight gain during pregnancy, a family history of diabetes, or having had a stillbirth or giving birth to a child with congenital anomalies. GDM usually resolves when the pregnancy is over. However, having had GDM is a risk factor for GDM in subsequent pregnancies and for having type 2 diabetes. GDM in the mother also increases her baby’s lifetime risk of obesity and diabetes. The International Diabetes Federation (IDF) estimates that about 16 percent of pregnancies are associated with GDM.

IDF estimated that 425 million people aged 20 to 79 years had diabetes in 2017. The corresponding prevalence in this age group is 8.8 percent. The prevalence in men was 9.1 percent and in women was 8.4 percent. Rates of diabetes rise as people

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age. IDF also estimates that there were 1.1 million children and adolescents aged 0 to 19 years in the world who suffered from type 1 diabetes in 2017, with more than 130,000 new cases a year in this age group. FIGURE 14-1 shows IDF estimates of the prevalence rates of diabetes in 2017 by IDF region. FIGURE 14-2 indicates the number of people estimated to have diabetes in 2017 by IDF region, as well as the number projected to have diabetes in 2045. This shows a significant increase in the number of people likely to be affected by diabetes between 2017 and 2045 in the lowest-income IDF regions, Africa and Southeast Asia. This increase will have important implications for people’s health and the costs of health care in the affected countries.

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FIGURE 14-1 Prevalence of Diabetes in People 20–79 Years Old by IDF Region, 2017

Data from International Diabetes Federation. (2017). IDF diabetes atlas (8th ed.).

Retrieved from

http://www.diabetesatlas.org/IDF_Diabetes_Atlas_8e_interactive_EN/

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http://www.diabetesatlas.org/IDF_Diabetes_Atlas_8e_interactive_EN/

FIGURE 14-2 Number of People 20-79 Years Old with Diabetes by IDF Region, in Millions, 2017 and 2045

Data from International Diabetes Federation. (2017). IDF diabetes atlas (8th ed.).

Retrieved from

http://www.diabetesatlas.org/IDF_Diabetes_Atlas_8e_interactive_EN/

As shown in Figure 14-1, the prevalence of diabetes varies across International Diabetes Federation regions, from a high of 11 percent of the population in North America and the Caribbean to a low of 4.4 percent in Africa. It is also very important to note that many people with diabetes are undiagnosed. IDF estimates that even in high-income countries, only about 63 percent of those with diabetes are actually diagnosed and that in low-income countries,

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http://www.diabetesatlas.org/IDF_Diabetes_Atlas_8e_interactive_EN/

only about 23 percent of those affected are diagnosed. The prevalence of diabetes also varies by country. The highest rates are found in the island nations of the Western Pacific, where around a quarter to a third of all adults 20 to 79 years of age have diabetes.

The Global Burden of Disease Study estimated that diabetes was the 9th leading cause of death worldwide in 2016 among all age groups and both sexes and that about 1.3 million people died of diabetes in 2016. Diabetes was the 14th leading cause of death in low-income countries, the 9th leading cause in lower middle- income countries, the 11th leading cause of death in upper middle- income countries, and the 11th leading cause in high-income countries. About 80 percent of all deaths from diabetes occur in low- and middle-income countries.

Diabetes has a number of important and costly complications. Among the most common are eye problems that can cause blindness, kidney problems, and circulatory problems that can result in amputation of the lower extremities, stroke, and coronary heart disease. About two-thirds of people with diabetes have some disability, compared to less than one-third of people without diabetes.

The risk factors for type 1 diabetes are still being studied. However, type 1 diabetes is associated with a family history of diabetes. In addition, environmental factors, increased weight and height development, increased maternal age at birth, and exposure to some viral infections have also been linked to developing type 1 diabetes. Type 2 diabetes is also associated with a family history of diabetes. In addition, it is associated with diet and physical inactivity, obesity, insulin resistance, ancestry, and increasing age. In high-income countries, less-educated

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and lower-income individuals have higher rates of diabetes than better-educated and wealthier people.

PHOTO 14-2 The number of people who have overweight and obesity continues to grow throughout the world. Yet there have been few successful efforts at addressing this problem at scale. Still, there is good evidence that food labeling, as shown here,

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can alter the choices people make about what and how much to eat. Can better food labeling make a difference in people’s diets

in low- and lower middle-income countries?

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Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) is a term used to refer to chronic lung diseases that cause limitations in lung airflow. The most common symptoms are shortness of breath, excessive sputum production, and a chronic cough. COPD is a life-threatening disease; it can progress to death.

The main risk factors for COPD are as follows :

■ Tobacco smoking ■ Household air pollution ■ Ambient particulate matter pollution ■ Occupational exposures to dust, chemicals, fumes, and other

irritants ■ Frequent lower respiratory infections as a child

Exposure to household air pollution as a child can also be a risk factor for developing COPD later in life. COPD cannot be cured. However, treatments can alleviate symptoms, reduce disability, and prolong life.

Males and females now have roughly equal risk of being affected by COPD. In 2016, it was estimated that there were about 250 million cases of COPD worldwide. In that same year, about 5.6 percent of all deaths, or about 3.1 million deaths in the world, were associated with COPD. About 90 percent of all of those deaths were in low- and middle-income countries, reflecting their disproportionate exposure to the risks of COPD.

In 2016, COPD was the 3rd leading cause of death globally and the 6th leading cause of DALYs globally. COPD was the 11th leading cause of death in low-income countries, the 4th leading cause in lower middle-income countries, the 3rd in upper middle- income countries, and the 4th in the high- income countries.

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Cancer Cancer poses a unique challenge because there are many forms of cancer and each may have different characteristics concerning who it affects, its risk factors, and how it can be prevented and treated.

All forms of cancer were associated with almost 16 percent of all deaths in 2016, or about 9.5 million deaths. This would make cancers the second leading cause of death after cardiovascular disease. However, all forms of cancer combined led to more deaths than either ischemic heart disease or stroke when considered separately. About 70 percent of all cancer deaths occur in low- and middle-income countries.

Globally, all forms of cancer made up 9.2 percent of all DALYs in 2016. This was the second leading cause of DALYs after CVD. However, as with deaths, all forms of cancer when taken together led to more DALYs than either ischemic heart disease or stroke.

WHO has estimated that the following are the most commonly occurring cancers worldwide :

■ Lung (2.09 million cases) ■ Breast (2.09 million cases) ■ Colorectal (1.80 million cases) ■ Prostate (1.28 million cases) ■ Skin cancer (non-melanoma) (1.04 million cases) ■ Stomach (1.03 million cases)

WHO has also estimated that the most common causes of cancer deaths are the following :

■ Lung (1.76 million deaths) ■ Colorectal (862,000 deaths) ■ Stomach (783,000 deaths) ■ Liver (782,000 deaths)

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■ Breast (627,000 deaths)

As noted earlier, there are a number of different types of cancer, and their prevalence varies across regions. FIGURE 14-3 shows data on the leading types of cancer by WHO region.

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FIGURE 14-3 Leading Types of Cancer by WHO Region, as a Percentage of Total, 2018

Data from International Agency for Research on Cancer. (2018). GLOBOCAN 2018:

Cancer today. Retrieved from https://gco.iarc.fr/today/explore

The distribution of deaths caused by different types of cancers in each region is shown in FIGURE 14-4.

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https://gco.iarc.fr/today/explore

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FIGURE 14-4 Leading Causes of Cancer Deaths by WHO Region, as a Percentage of Total, 2018

Data from International Agency for Research on Cancer. (2018). GLOBOCAN 2018:

Cancer today. Retrieved from https://gco.iarc.fr/today/explore

In the simplest of terms, there are a number of points that are striking about Figure 14-3:

■ Liver cancers are uniquely important in Africa.

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https://gco.iarc.fr/today/explore

■ Cervical cancer is a much larger share of all cancers in Africa than elsewhere.

■ Stomach cancers are uniquely important in the WHO Western Pacific region.

■ Bladder cancers are a larger share of the total cancers in Europe than elsewhere.

There are also a number of points that are striking about Figure 14-4:

■ Cervical cancer deaths as a share of all cancer deaths are much more important in Africa than in any other WHO region.

■ Deaths from cervical cancer are not among the top five leading causes of cancer deaths in several regions.

■ Lung cancer deaths are not an important share of total cancer deaths in Africa.

■ Bladder cancer deaths are the leading cause of cancer death only in Europe.

■ Stomach and esophageal cancer deaths are an important share of cancer deaths only in the Western Pacific.

The global burden of cancer has continued to grow as more people in more places continue to live longer and the burden of communicable diseases decreases in these populations. Although cancer is common everywhere, the types of cancer most prevalent in a region can depend on environmental factors and the standard of living. Generally, worldwide trends show that in low- and middle-income countries, the economic and societal shift toward lifestyles typical of high-income countries leads to a rising burden of cancers associated with reproductive, dietary, and hormonal risk factors. As income levels increase, cancers for which sedentary behavior or high fat consumption is a risk factor tend to increase as a proportion of all cancers. Increases in breast cancer in low- income countries will be largely due to changes in reproductive

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practices, with women choosing to have fewer children, have their first pregnancy later in life, and breastfeed for a shorter period.

Although cancer incidence has been increasing in most regions of the world, there are obvious differences and inequalities between low- and high-income countries in incidence and mortality rates. Incidence rates remain highest in higher-income regions due to longer average life spans, but mortality is relatively much higher in lower- and middle-income countries, likely due to a lack of early detection and access to treatment facilities. For example, breast cancer incidence has reached more than 90 new cases per 100,000 women annually in Western Europe, a high-income region, compared with 30 per 100,000 in Eastern Africa, a low- income region. However, breast cancer mortality rates in these two regions are almost identical, at about 15 per 100,000.

Moreover, many low- and middle-income countries face a double burden of cancer due to cancers caused by infectious agents combined with cancers associated with behavioral risks. The situation in high-income countries is more nuanced, depending on the country. Incidence for some cancer types, including prostate, colorectal, and female breast cancer, is increasing in several countries. Decreasing mortality trends in high-income countries can largely be attributed to decreases in risk factors, such as changing smoking habits, especially in men, plus better screening and early detection, and improved treatment.

In both low- and high-income countries, both men and women are affected by cancer. Certain cancers have higher incidence rates in women, like breast cancer, while others affect men and women equally. Certain cancers, such as cervical cancer or prostate cancer, are specific to women or men. Although men and women of all ages are at risk for developing cancer, this risk increases with age. Cancer has a higher incidence in older individuals above 65 years due to more prolonged exposure to environmental risk

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factors and the accumulation of genetic changes. Moreover, the incidence of cancer tends to be higher in urban regions because of the differences in lifestyle and increased risk of exposure to carcinogens.

There are many risk factors for cancer, and they vary by the type of cancer, as noted in TABLE 14-5. Some cancers are associated with tobacco use, such as lung and esophageal cancers. Tobacco use is one of the greatest risk factors for cancer in general. Tobacco is most directly linked to lung cancer, but using tobacco can also indirectly increase the risk of other cancers such as prostate and breast cancers. Alcohol is associated with liver, upper digestive tract, breast, and colorectal cancers, whereas diets high in red and processed meats and low in fiber have been associated with colorectal cancer. Obesity is a risk factor for breast (postmenopausal), colorectal, endometrial, kidney, esophageal, and pancreatic cancers. Similarly, low physical activity can be a major risk factor for colon, breast, and endometrial cancers.

TABLE 14-5 Leading Risk Factors by Cancer Type

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As noted, other cancers are associated with infectious agents. Liver cancer, for example, is associated with the hepatitis B virus, cervical cancer is associated with the human papillomavirus (HPV), and stomach cancer is associated with the bacteria Helicobacter pylori. Liver cancer is also associated with schistosomiasis, a parasitic worm that is also called “bilharzia,” which infects more than 200 million people worldwide. There are

also numerous environmental and occupational carcinogens, such as asbestos, which was the cause of lung cancer in many roofing workers in the United States, for example.

Mental Disorders Parallel with its definition of health, the World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”

One of the major categories of noncommunicable diseases in the Global Burden of Disease Study 2016 is “mental disorders.” This includes depressive disorders, anxiety disorders, bipolar disorder, and schizophrenia. The category also includes conduct disorders, autism spectrum disorders, eating disorders, attention deficit hyperactivity disorder, and idiopathic developmental disability disorder. In earlier studies of the burden of disease, alcohol and drug use disorders were included in mental disorders, but they are now categorized separately as “substance use disorders.” In addition, some of the writing on mental disorders globally discusses neurological and substance abuse disorders and self- harm. This chapter does contain comments on alcohol use and a case study on dementia. However, self-harm is treated in the

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chapter on adolescents and young adults and the chapter on injuries. In addition, this chapter does not discuss mental health issues in complex emergencies, which are discussed in the chapter on such emergencies.

Four mental disorders contribute the largest share to the burden of mental disorders and are the main focus of comments on mental disorders in this chapter. These are unipolar depressive disorders, which will be referred to here as depression; schizophrenia; anxiety disorders; and bipolar affective disorder. These conditions are defined briefly in TABLE 14-6.

TABLE 14-6 Key Mental Health Terms and Definitions

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Mental disorders have generally been thought to be associated overwhelmingly with disability, rather than with deaths. However, a recent study for the first time estimated the number of deaths associated with mental disorders. It suggested that more than 2.2 million deaths may have been associated in 2010 with depression, 1.3 million with bipolar disorder, and about 110,000 with autism spectrum disorder. The deaths from depression would be linked with suicide and comorbid conditions such as cardiovascular disease and infectious conditions. Those associated with bipolar disorder would be linked with comorbid causes such as cardiovascular disease, plus intentional injuries and suicide. Those associated with autism spectrum disorder would be linked with accidents, respiratory diseases, intellectual disability, epilepsy, and seizures.

Estimates of the Global Burden of Disease Study 2016 indicate that mental disorders contributed 4.8 percent of the total DALYs globally. This is more, for example, than the DALYs associated with unintentional injuries, chronic respiratory diseases, or HIV and sexually transmitted diseases. Depression alone is estimated to have been associated with 1.7 percent of the DALYs globally for both sexes and all age groups.

The Global Burden of Disease Study 2016 suggests that there is a significant difference between the burden of mental disorders in females and males. Globally, they are associated with 5.6 percent of DALYs for females and 4.1 percent for males. The 2016 study also suggests that DALYs associated with mental disorders as a share of total DALYs for both sexes and all age groups rise as country income levels rise. Mental disorders are associated with 2.7 percent of DALYs in low-income countries, 4.1 percent in lower

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middle-income countries, 5.8 percent in upper middle-income countries, and 7.1 percent in high-income countries.

It is also essential to examine how the burden of disease from mental disorders varies by age group. Mental disorders are the largest cause of DALYs for the 15- to 49-year-old age group, globally and in high-income, upper middle-income, and low- income countries. Only cardiovascular disorders cause more DALYs than mental disorders in this age group in lower middle- income countries. In fact, looking at specific causes for this age group globally, major depressive disorder is the 7th leading cause of DALYs and anxiety disorder is the 14th. Mental disorders (including suicide) take a particular toll on older adolescents aged 15 to 19 years. Major depressive disorders are the 4th leading cause of DALYs in this age group and anxiety disorders are the 9th leading cause of DALYs in this age group globally for both sexes.

One reason for the large disability burden of these conditions is the substantial number of people who suffer mental disorders. Other reasons are that mental disorders often start at relatively young ages, they go on for a long time, they are often not cured, and they, therefore, produce large amounts of disability.

The determinants of mental disorders are complex, not very well understood, and appear to be both genetic and nongenetic. The recent Lancet Commission on Global Mental Health and Sustainable Development suggests that the causes of mental disorders relate to “the complex interplay of psychosocial, environmental, biological, and genetic factors across the life course, but in particular during the sensitive developmental periods of childhood and adolescence.”

Studies have also suggested that a number of social determinants have an especially important impact on mental health :

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■ Demographic factors: age, gender, and ethnicity ■ Socioeconomic status: low income, unemployment, income

inequality, low education, and low social support ■ Neighborhood factors: inadequate housing, overcrowding,

neighborhood violence ■ Environmental events: natural disasters, war, conflict, climate

change, and migration ■ Social change associated with changes in income,

urbanization, and environmental degradation

It is also clear that there is a “vicious cycle” between social determinants and mental disorders, because having a mental disorder can cause disability, constrain one’s ability to function and earn income, and further immiserate the affected person.

WHO suggests that:

Determinants of mental health and mental disorders include not only individual attributes such as the ability to manage one’s thoughts, emotions, behaviors and interactions with others, but also social, cultural, economic, political and environmental factors such as national policies, social protection, standards of living, working conditions, and community support.

Stress, genetics, nutrition, perinatal infections and exposure to environmental hazards are also contributing factors to mental disorders.

Vision and Hearing Loss Vision Loss Vision loss is a major cause of disability. In addition, the aging of populations globally and continued improvements in life

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expectancy will increase the importance of vision loss as a burden of disease. These factors will also shift the types of problems that cause visual impairment toward those suffered by older populations.

The latest estimates suggest that almost 190 million people in the world suffer mild vision impairment. It has also been estimated that there were almost 217 million people in the world in 2015 who suffered moderate to severe impairment of their vision. The major reasons for moderate to severe impairment were the following :

■ Refractive errors such as near- and farsightedness and astigmatism: 53 percent

■ Cataract: 24 percent ■ Age-related macular degeneration: 4 percent ■ Glaucoma: 1 percent

The same study suggested that about 36 million people suffered from blindness in 2015. The following were the major reasons for blindness :

■ Cataract: 35 percent ■ Uncorrected refractive errors: 21 percent ■ Glaucoma: less than 1 percent

Besides the causes noted, blindness can also be caused by, among other things, glaucoma, vitamin A deficiency, and rubella. Some blindness also has parasitic and infectious causes, such as trachoma and onchocerciasis, although the number of people who are blind because of these causes has declined as progress has been made against these diseases. Diabetes-related eye disease can also cause blindness. Over 80 percent of vision loss can be prevented or cured.

The main risk factors for visual impairment are poverty, gender, age, and a lack of access to health services. Cigarette smoking is

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also a risk factor for cataracts and glaucoma.

The causes of vision loss and blindness also vary by age and country income group. In young children, the leading cause of blindness in low-income countries is congenital cataracts, whereas in high-income countries it is eye problems associated with prematurity. In adults in low-income countries, a substantial burden of vision loss and blindness is associated with conditions that could be treated but are not, such as refractive errors and cataracts. In high-income countries, adult vision loss is much more often associated with macular degeneration.

WHO has estimated that about 90 percent of those who suffer visual impairment live in low- and middle-income countries. About 65 percent of those who suffer visual impairment are over 50 years of age. About 19 million children also suffer such impairment, and 12 million have refractive errors that could be corrected with appropriate services.

Females are more likely than males to suffer blindness and visual impairment from diabetic retinopathy and cataracts. Males are more likely to suffer visual impairment and blindness due to glaucoma and corneal opacity than females.

The Global Burden of Disease Study 2016 suggests that visual impairment and blindness were responsible for about 1.2 percent of all DALYs in 2016, for both sexes and all ages. This was more than the burden for any individual cancer, except lung cancer, and about the same as the DALYs associated with anxiety disorder. The study also indicated that visual impairment and blindness were responsible for 0.6 percent of DALYs in low-income countries, 1.3 percent in lower middle-income countries, 1.4 percent in upper middle-income countries, and 0.8 percent in high- income countries.

Hearing Loss

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WHO estimates that about 432 million adults and 34 million children worldwide have disabling hearing loss. This means that more than 5 percent of the world’s population suffers disabling hearing loss. About 80 percent of them had adult-onset hearing loss and about 20 percent had childhood-onset hearing loss. About one-third of people over 65 years of age are affected by disabling hearing loss. More males have suffered hearing loss than females, probably as a result of exposure to noise.

The 2016 Global Burden of Disease Study indicated that 1.3 percent of DALYs globally, for all ages and both sexes, could be attributed to hearing loss. This was greater than the burden globally of vision loss and more than any of the individual mental health disorders, except depression. The proportion of DALYs from hearing loss varied by country income group :

■ Low-income: 0.6 percent ■ Lower middle-income: 1.0 percent ■ Upper middle-income: 1.8 percent ■ High-income: 2.1 percent

There are a range of factors in lower-income countries that affect hearing loss. These countries are also less able to treat hearing loss than higher-income countries. However, population aging is probably the most significant factor that will propel an increase in the number of people globally who suffer hearing loss.

Childhood-onset hearing loss is primarily related to congenital conditions, infection of the ear, or complications of other diseases, such as meningitis. Adult-onset hearing loss is largely related to exposure to noise and chemicals, as well as to aging. Poverty, poor hygiene, a failure to get vaccinated, and other causes that contribute to children getting infections are also risk factors for hearing loss. Some medicines and recreational exposures can also cause hearing loss.

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Tobacco Use Tobacco is such an important risk factor for cardiovascular disease, COPD, cancer, and diabetes that it bears specific mention of its own. Globally and for all ages and both sexes, tobacco is the third leading attributable risk factor for death. Tobacco is also the third leading risk factor for death in high- income and upper middle-income countries, the fourth in lower middle-income countries, and the eighth in low- income countries. Tobacco is the fourth leading risk factor globally for DALYs.

It is estimated that about 7 million deaths annually are associated with the use of tobacco. More than 80 percent of these deaths are the result of direct tobacco use, and almost all of the remainder are due to the effects of secondhand smoke. It is also estimated that 1 in 5 males over the age of 30 and 1 in 20 females over the age of 30 who die worldwide die of tobacco- related causes. Ultimately, one-half to two-thirds of those who smoke will die of causes related to tobacco. In addition, half of all tobacco-related deaths occur among people ages 35 to 69. The

most common tobacco-related deaths are from CVD; diseases of the respiratory system, such as emphysema; and cancers. Tobacco use can also increase the risk of getting tuberculosis (TB) or dying from it, as well as substantially increase the risk of developing diabetes.

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PHOTO 14-3 Reducing tobacco consumption is the single most important investment in reducing the burden of

noncommunicable diseases. There is a well-known and evidence-based package of interventions to accomplish this. Especially in low- and lower middle-income countries, what

forces impede the implementation of this package?

Most tobacco is used through smoking either cigarettes or bidis, which are hand-rolled cigarettes used largely in South Asia. It is estimated that about 1.1 billion people smoke worldwide. Of countries that participated in a review of tobacco prevalence by WHO, Russia had the highest rate of smoking prevalence at about

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39 percent of all adults. Indonesia was the second highest with 34.8 percent of adults smoking. The lowest rate of the countries surveyed was in Nigeria, with 3.9 percent prevalence.

In all regions of the world, men smoke more than women do (see TABLE 14-7). This is most pronounced in low-income countries, in which relatively small shares of women smoke. Prevalence for men was estimated earlier to vary from 18 percent in sub-Saharan Africa to 49 percent in East Asia and the Pacific. The rates for women were estimated to vary from 2 percent in a number of regions, including the Middle East and North Africa, South Asia, and sub-Saharan Africa, to 9 percent in Latin America and the Caribbean. The highest rate of smoking prevalence among males is 76 percent in Indonesia. The highest rate of smoking among women was 44 percent in Montenegro.

TABLE 14-7 Smoking Prevalence by Sex, by World Bank

Regions and Country Income Groups, 2016

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The extent to which people take up smoking varies not only by sex but also by socioeconomic status and level of educational attainment. The higher the socioeconomic status and the higher the level of education, the less likely a person is to smoke. Most people who smoke start when they are teenagers. In addition, it is important to note that tobacco is physically addictive and that once one starts to smoke, it is difficult to stop.

In some countries, such as Canada, Poland, Thailand, the United Kingdom, the United States, and Uruguay, the use of tobacco has been declining. However, usage is increasing among men in low- and middle- income countries and among women in all regions. Unless steps are taken to stop the spread of tobacco use, we are likely to see continued growth in CVD, COPD, and cancers related to smoking. CVD, COPD, and cancers related to smoking are often avoidable, and the overwhelming majority will occur in today’s low- and middle-income countries.

Alcohol Alcohol is a major public health problem. Alcohol use is associated with 0.7 percent of all DALYs globally. This varies by country income group:

■ Low-income: 0.3 percent ■ Lower middle-income: 0.5 percent ■ Upper middle-income: 1 percent ■ High-income: 1 percent

Globally, this is similar to the burden of breast and colorectal cancers. In addition, alcohol use disorders are the 9th leading attributable risk factor for deaths globally, the 9th leading risk factor in low- and middle-income countries, and the 6th leading risk factor in high-income countries. In 2016, alcohol was the 9th

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leading attributable risk factor for deaths and the 8th leading attributable risk factor for DALYs globally, for both sexes and all ages. This ranking did not vary much by country income group. However, there is substantial difference in ranking for males compared to females. It was the 5th leading risk factor for DALYs for males globally, but the 13th for females. There is also a substantial difference across regions in the importance of alcohol. It was the 6th leading attributable risk factor in Europe and Central Asia but the 15th in the Middle East and North Africa.

High-risk drinking is defined as drinking 20 grams or more per day of pure alcohol for a woman and 40 grams a day for a man. This is equal to about one-quarter of a bottle of wine for a woman and one-half a bottle of wine for a man. High-risk drinking may also be defined to include the total amount that is consumed, the frequency with which it is consumed, and the extent to which one engages in binge drinking.

High-risk drinking has a negative effect on people’s health in a number of ways. Among other things, it increases the risks for hypertension, liver damage, pancreatic damage, hormonal problems, and heart disease. In addition, alcohol intoxication is associated with accidents, injuries, accidental death, and a variety of social problems, including the first sexual encounters of teenagers, unprotected sex, and intimate partner violence. It is also possible to become dependent on alcohol, which has a number of negative psychological and physical consequences. Moreover, fetal alcohol syndrome is associated with low birthweight babies who are at risk of developmental disabilities.

The prevalence of high-risk drinking varies by region. It has been estimated that men in Europe and Central Asia have the highest prevalence of high-risk drinking: about 21 percent between ages 45 to 59. People in the Middle East and North Africa have the lowest prevalence, which is reported to be very low. South Asia

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also has a very low prevalence of high-risk drinking. The prevalence rate of high-risk drinking also varies by age, with fewer people engaging in high-risk drinking after age 60 than at younger ages. In each region, high-risk drinking is higher among men than women, except in South Asia.

There is very little evidence on the determinants of high-risk drinking, especially in low-income settings. Studies done in high- income countries suggest that lower socioeconomic status and lower educational attainment are risk factors for drinking to the level of intoxication.

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▶ The Costs and Consequences of Noncommunicable Diseases, Mental Health Disorders, Tobacco Use, and Alcohol Use

Overview The economic costs of noncommunicable diseases are substantial and are growing, given the increasing burden of cardiovascular disease and diabetes, as well as a number of other conditions, such as vision and hearing loss. These costs include the direct costs of treating noncommunicable diseases, which by their nature often require many years of treatment. They also include indirect costs that result from lost productivity. These are also very substantial, given that noncommunicable diseases often start at relatively younger ages, often cause substantial disability, and can persist for many years.

In addition, many actors in the global health arena previously carried out their work as if high-income countries faced the burden and costs of noncommunicable diseases and low- and middle- income countries faced only the burden and costs of communicable diseases. However, in light of the increasing amount of noncommunicable diseases in low- and middle- income countries, it is clear that these countries do not have the luxury of facing either communicable or noncommunicable diseases. Rather, even low-income countries now simultaneously face the burden and costs of communicable diseases, noncommunicable diseases, and injuries. Some additional comments follow on the costs and consequences of noncommunicable diseases.

A study conducted in 2007 estimated the economic costs of selected noncommunicable diseases in 23 low- and middle-

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income countries. In those countries, the selected diseases make up 80 percent of the noncommunicable disease burden. This study noted that men in low- and middle-income countries are 56 percent more likely to die at the same age of such causes than men in high-income countries, and women are 86 percent more likely to die at the same age than women in high-income countries of these causes. The study further concluded that these countries would lose $84 billion in economic production between 2006 and 2015 alone as a result of the large and growing burden of noncommunicable diseases.

The World Economic Forum commissioned a study in 2011 on noncommunicable diseases in low- and middle-income countries. That study concluded that the cumulative output lost due to these conditions in low- and middle-income countries over the next 2 decades would be $47 trillion. The study also suggested that low- and middle-income countries would bear an increasing share of the costs of these diseases in the future.

A more recent study examined the costs of noncommunicable diseases in China and India from 2012 to 2030. This study concluded that China would face costs of $27.8 trillion and India, $6.2 trillion. These costs would largely be driven in both countries by the costs of CVD, mental health, and respiratory diseases. The costs in China would be substantially greater than in India largely because of the much larger share of the population in China that would be older and because China is further along the epidemiological transition than India.

Another study done recently suggested that, especially for populations without insurance, as many as 60 percent of the families affected by NCDs faced catastrophic out-of-pocket healthcare expenditures. A study done on the costs of NCDs in the Eastern Caribbean island states found that patients suffering from noncommunicable diseases spent on average 36 percent of

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their annual household income on care for the management and treatment of these diseases.

WHO has also estimated that implementing a package of “best buys” to address NCDs, which is discussed later, could generate $350 billion in additional economic activity between 2018 and 2030.

Cardiovascular Disease Only a small number of studies have been done on the direct and indirect costs of CVD in low- and middle-income countries. A study conducted in South Africa suggested that the direct costs of treating cardiovascular disease were about 25 percent of all healthcare expenditures, which was equal to between 2 percent and 3 percent of the gross domestic product (GDP) in that country. The indirect costs of cardiovascular disease on the economy are likely to be substantial, given the relatively low age at which such diseases affect people in many countries.

Chronic Obstructive Pulmonary Disease There is a limited amount of data on the costs of COPD in low- and middle-income countries. However, a small number of studies have been done on those costs in high-income countries. One study in Canada and Sweden, with data from the last decade, suggested that the annual indirect plus direct costs of COPD varied by severity of the illness and ranged, as noted here, from the least to the most severe illness :

■ Canada: $2,462 to $5,520 ■ Sweden: $696 to $20,260

These numbers suggest that the trajectory for treating COPD as populations age will be a challenging one, especially in resource- poor countries.

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Diabetes It is estimated that the direct costs of treating diabetes vary between 2.5 percent and 15 percent of health expenditures in different countries, depending on the prevalence of disease and the extent and costs of the treatment available. Given the level of development of different low- and middle-income regions, it is likely that the Latin America and Caribbean region has the highest expenditure on diabetes per capita and sub-Saharan Africa the lowest such expenditures.

Moreover, the International Diabetes Federation has estimated that expenditure by people with diabetes on this condition has risen from $232 billion in 2006 to $727 billion in 2017. Given the increasing numbers of people with diabetes, these numbers should be expected to increase. In addition, the 10 countries spending the most on diabetes care spend from $5,700 a year per affected person to almost $12,000. The International Diabetes Federation also estimates that countries in the different IDF regions are already spending between 6 percent and almost 17 percent of their annual healthcare expenditures on diabetes.

The indirect costs of diabetes in low- and middle- income countries are substantial, partly reflecting the fact that many people in those countries live with diabetes without proper treatment and, therefore, suffer from disability and related losses in productivity. In fact, the direct and indirect costs of diabetes are likely to grow in all regions as the number of people with diabetes increases, as noted earlier.

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Mental Disorders There are relatively few reliable data on the direct and indirect costs of mental disorders. In addition, the studies that have been done largely refer to high- income countries. Nonetheless, they are indicative of the large and usually unappreciated costs of mental illness in all countries. A study done in the United States estimated that the direct and indirect costs of mental illness were equal to about 2.5 percent of gross national product (GNP), and a similar study done in Europe estimated that the costs of mental illness there were between 3 percent and 4 percent of GNP. Studies

done in Canada, the United Kingdom, and the United States showed that about half of the total costs of mental illness were direct costs and about half were indirect costs. These indirect costs are so substantial for mental illness that one study done in the United States estimated almost 60 percent of the productivity losses that come from illness, accidents, or injuries are linked with mental illness. Studies done in the United States and the United

Kingdom showed, in addition, that workers suffering from depression lost 40 to 45 days of work in a year as a result of their illness.

The most comprehensive study done on the costs of noncommunicable diseases suggested that annual economic losses due to mental, neurological, and substance abuse disorders combined was about $8.5 trillion per year. The study also suggested that such costs are rising. The Lancet Commission on Global Mental Health and Sustainable Development estimates that the economic losses to the global economy from mental health disorders will be about $16 trillion from 2010 to 2030.

Hearing and Vision Loss

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Unfortunately, very little information is available about the economic costs of vision and hearing loss, especially in low- and middle-income countries. This is despite the large number of DALYs attributed to them now and the growing number of DALYs that will be associated with them as populations age.

Some of the limited information that is available refers to the United States. A study done in 1995, for example, suggested that the economic cost to the United States from vision loss was almost $40 billion annually, of which about 60 percent was direct costs and 40 percent indirect costs. Another study, published in 2006, estimated that the annual economic loss from major vision disorders in the United States was about $35 billion, of which about $16 billion was direct medical costs, about $11 billion other direct costs, and about $8 billion in productivity losses.

A study of tea pickers in India confirmed the important economic consequences to individuals of vision loss, as well as the low cost of preventing some of those losses. This study sought to identify the economic impact of offering eyeglasses to treat presbyopia, the age-related decline in near vision, on individuals who picked tea and on the tea company for which they worked. Those tea pickers who were given eyeglasses were able to substantially increase the amount they picked per day, which increased their income and the income of the company. Compliance with the intervention was high, as was the benefit-to-cost ratio of the intervention. At the end of the study, those in the control group also received eyeglasses.

A comprehensive review of the existing literature on hearing loss in low- and middle-income countries was published in 2010. It did not indicate either country or global estimates of the economic costs of hearing loss; however, it did indicate some of the costs that would be associated with hearing loss, for which economic costs could be calculated :

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■ Constraints to the formal education of children with hearing loss, with its attendant consequences on their employment and earning prospects

■ The number of school days missed by children with disabilities ■ The costs of additional medical visits associated with children

with disabilities ■ The high cost of education for students with hearing loss ■ The difficulties faced by adults with hearing loss in finding and

keeping employment ■ Income levels for people with hearing loss, which can be 45

percent of the levels of people without hearing loss, even in high-income countries

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Tobacco Use Calculating the costs of smoking to an economy can be very complicated. The simplest way to do so is to calculate gross costs, which include all the costs associated with smoking-related diseases. Studies on the costs of smoking have largely focused on the costs of smoking in high-income countries. These studies suggested that the gross costs of smoking to various high-income economies range from 0.1 percent to 1.1 percent of GDP and that the costs to low- and middle-income countries might be just as high.

However, a recent report by the National Cancer Institute of the United States, in collaboration with WHO, cited a study that concluded that the total economic costs of smoking to the world economy in 2012 were $1.4 trillion, or 1.8 percent of the world’s GDP. The direct healthcare costs of smoking in 2012 were $422 billion, or about 5.7 percent of all healthcare expenditures that year.

The prevalence rates of smoking are increasing among women everywhere and among men in low- income countries. We should expect, therefore, that the economic costs of smoking in those countries will increase for some time. In fact, it is estimated that 70 million people died of smoking-related causes between 1950 and 2000 and that, if present trends in tobacco use continue, an additional 150 million people will die of smoking-related causes between 2000 and 2025. Of course, the economic costs of this will be great.

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Alcohol Use Disorders For the economic costs of alcohol use disorders, as for many other issues, there are relatively few data for low- and middle-income countries. Excessive alcohol use, as discussed earlier, is linked with health problems of the drinker. In addition, it is linked with violence and injuries caused by the drinker, such as when driving while intoxicated. When calculating the economic costs of excessive alcohol drinking, therefore, one has to take account of the costs of health care for the user and for others whose injuries or health conditions were caused by the user. The indirect costs of excessive alcohol drinking will include the productivity losses of the drinker and people hurt by the drinker because of excessive drinking.

The limited studies that have been done on the costs of alcohol abuse can only be considered indicative because they did not follow any standard methodology. However, they all reveal substantial costs of alcohol abuse, as a share of GDP :

■ Canada: 1.1 percent ■ France: 1.4 percent ■ Italy: 5.6 percent ■ New Zealand: 4.0 percent ■ South Africa: 2.0 percent

A 2009 study examined the economic costs attributable to alcohol in four high-income countries and two middle-income countries. The costs were greater than 1 percent of GDP in all countries. The highest costs were found in the United States, at 2.7 percent of GDP, and South Korea, at 3.3 percent of GDP. In another estimate, the United States Centers for Disease Control and Prevention (CDC) estimated that excessive alcohol consumption costs the United States $290 billion annually.

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▶ Addressing the Burden of Noncommunicable Diseases

The global community has focused much more attention on NCDs in the last decade than ever before. The United Nations, for example, convened a high-level meeting on noncommunicable diseases in September 2011. This meeting resulted in an international political commitment to trying to reduce the burden of NCDs by 25 percent by the year 2025. This meeting highlighted the idea that all countries, including today’s low- and middle- income countries, must take measures now to reduce the burden of noncommunicable diseases. This includes efforts that can reduce the burden of NCDs for those already afflicted by them, as well as efforts to prevent the burden of NCDs from growing.

The final declaration of the meeting indicated a number of steps that countries could take to address their burden of NCDs :

■ Focusing on prevention and the main risk factors of tobacco, alcohol, dietary risks, and the lack of physical activity

■ Engaging all government parties in the battle against NCDs ■ Increasing funding to address NCDs

The declaration further noted that countries should focus on the following actions :

■ Take multisectoral, cost-effective approaches to addressing NCDs

■ Speed action on the measures indicated in the Framework Convention on Tobacco

■ Implement WHO-recommended approaches to diet, physical activity, alcohol, and the marketing of unhealthy foods to children

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■ Promote cost-effective measures to reduce salt, sugar, and saturated fats in foods and eliminate trans fats in food

■ Promote vaccination against the infectious causes of NCDs, including the vaccines against hepatitis B and HPV

PHOTO 14-4 A young woman is shown here being the first in rural areas of China to get a vaccine against 9 strains of HPV. This vaccine and the one against hepatitis B are, in effect, “cancer vaccines.” While there has been good progress in increasing their uptake, additional progress is needed. What

measures can be taken globally and locally to increase the use of these vaccines, especially in low- and middle-income

countries?

The declaration from the meeting also highlighted a number of measures that should be taken to strengthen the ability of health systems to monitor NCDs and to act on them effectively, such as

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enhancing universal health coverage and improving access to affordable medicines.

As a follow-up to the high-level meeting, the World Health Assembly, the governing body of WHO, endorsed in May 2013 the Global NCD Action Plan 2013–2020. The action plan includes a number of voluntary global targets as noted in TABLE 14-8. The action plan also contains a number of indicators for each of the targets.

TABLE 14-8 Global NCD Action Plan Voluntary Global Targets

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The Global NCD Action Plan also lays out a series of evidence- based, cost-effective measures that are “best buys” in addressing the burden of some of the most important NCDs, other than mental disorders. The most significant of these measures are shown in TABLE 14-9.

TABLE 14-9 Selected Policy Measures in the Global NCD Action Plan

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More recently, a WHO report of a high-level commission on NCDs recommended a number of updated best buys for the control of NCDs that focused on CVD, COPD, and diabetes. These are shown in TABLE 14-10.

TABLE 14-10 WHO Best Buys for the Prevention and Control of

Noncommunicable Diseases

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The DCP3 has recently suggested that countries adopt what it calls “essential packages” of interventions to prevent and address CVD, COPD, and diabetes in low- and middle-income countries. TABLE 14-11 summarizes the DCP3 recommendations. The package recommended by DCP3 goes somewhat beyond the best buys suggested by WHO. One important advance of the DCP3 report was that it organized recommended interventions by platforms for their delivery. TABLE 14-11 shows the package that DCP3 has recommended and where such interventions could be delivered.

TABLE 14-11 Essential Interventions for the Prevention or Management of Risk Factors and Selected NCDs

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▶ Additional Comments on Addressing Key Risk Factors for CVD, COPD, and Diabetes

Some additional comments follow on steps that countries can take to address some of the key risk factors for CVD, COPD, and diabetes—tobacco, alcohol, hypertension, high cholesterol, and obesity.

Tobacco Use The Framework Convention on Tobacco, agreed upon in 2003, outlines the measures that countries have agreed to undertake to reduce both the demand for and the supply of tobacco. WHO then elaborated on these measures by outlining the MPOWER program for tobacco control, which consists of six elements :

■ Monitor tobacco use and prevention policies ■ Protect people from tobacco smoke ■ Offer help to quit tobacco use ■ Warn about the dangers of tobacco use ■ Enforce bans on tobacco advertising, promotion, and

sponsorship ■ Raise taxes on tobacco

The following comments elaborate on these points.

Evidence suggests a number of steps can be taken to reduce the use of tobacco. Almost all countries tax cigarettes; however, low- and middle-income countries tend to tax cigarettes at lower rates than do high-income countries. Public demand for cigarettes is sensitive to price, and the lower the country income level, the more price increases will affect demand. Studies conducted in low- and middle-income countries indicate that a 10 percent increase in cigarette taxes can lead to an 8 percent reduction in the demand for cigarettes. Under these circumstances, taxing cigarettes would

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be an effective policy for reducing cigarette consumption. Smuggling is a significant issue when countries raise tobacco taxes. However, there is evidence that 10 percent greater expenditure on efforts to reduce smuggling can lower smuggling by 5 percent and tobacco consumption by 2 percent.

For countries where there is weak government enforcement of laws, it will be more difficult to enforce restrictions on smoking; however, an increasing number of countries are undertaking these measures. Studies suggest that countries that can enforce legal restrictions can reduce the number of cigarettes smoked between 5 percent and 25 percent and can reduce smoking uptake by about 25 percent. The effectiveness of these actions is likely to be enhanced in settings in which there are also strong social norms against smoking.

There is also evidence from high-income countries that consumption of cigarettes can be reduced by about 6 percent through a total ban on cigarette advertising, which is another step that low- and middle-income countries should consider. Countries should also provide the public with information about the negative effects of smoking tobacco. There is evidence from high- income countries that such efforts led to short-term reduction in cigarette consumption of between 4 percent and 9 percent and long-term declines of between 15 percent and 30 percent.

High-income settings that have had the biggest impact on reducing tobacco consumption have undertaken comprehensive tobacco control programs that generally included efforts to prevent young people from starting smoking, encouraging all smokers to quit smoking, reducing exposure to passive smoking, and eliminating disparities in smoking among different population groups by helping those most at risk to reduce tobacco consumption. It remains critically important to stop people from

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taking up smoking; however, in order to reduce tobacco-related deaths in the near future, it is essential to reduce consumption among those already smoking. Preventing young people from taking up smoking will have an impact on tobacco-related deaths only in the more distant future. There is evidence that brief counseling sessions by medical providers can double quit rates to about 4 percent to 8 percent. Medications that aid quitting tobacco smoking can triple the rates of quitting to 8 percent to 12 percent.

Alcohol Despite the high burden of disease and economic costs that are related to excessive drinking of alcoholic beverages, very few countries have embarked on coherent efforts to reduce alcohol consumption. Those that have done so generally focused their attention on policy and legislative actions, such as taxation, laws on drunk driving, and restricting alcohol sales to selected places, times, and age limits. Controlled advertising and tightened law enforcement, such as through more widespread breath testing of drivers, have also been imposed. Another successful part of such programs was to encourage counseling by healthcare providers through “brief interventions with individual high risk drinkers.”

Just as is the case for cigarette taxation, increased taxation on alcohol will likely lead to a decrease in the purchase and consumption of alcohol. Whereas in the case of tobacco increased taxation can lead to the smuggling of untaxed cigarettes, in the case of alcohol increased taxation can lead to a rise in the consumption of illicit alcohol. This is an issue that countries must take into account when considering raising taxes on alcohol.

In selected high-income countries, studies suggest that reducing the number of hours during which alcohol can be sold can lead to

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a 1.5 percent to 3 percent decrease in high-risk drinking and a 1.5 percent to 4 percent decrease in alcohol-related traffic deaths. Government authorities have to assess the extent to which such measures could be implemented effectively, especially in low- and middle-income countries with weak governance, as well as the extent to which such measures might also drive people to seek illicit alcohol.

Bans on alcohol advertising can be put into effect, as discussed for tobacco; however, it appears that such bans have had relatively little effect on the consumption of alcohol. In healthcare settings in a number of countries, efforts have been made to engage high-risk drinkers in brief but specific education and counseling about the risks of excessive drinking. Even when taking relapses into account, it appears that such counseling is effective in reducing excessive consumption by 14 percent to 18 percent, compared to no treatment at all. Although this approach might be effective in middle-income countries, it is unlikely to be effective in many low-income countries, given the scarcity of effective health services, the lack of health providers, and the already excessive demands on their weak health systems.

A study that was part of a broader major review of alcohol and health suggested that countries should take a stepwise approach to reducing alcohol consumption. Such an approach would allow countries to implement an increasing number of and levels of policies on alcohol as their capacity to legislate and enforce such approaches grew. The study recommended, at a minimum, that all countries make alcohol more expensive through excise taxes; reduce availability through regulation, licensing, and controlled sales to minors; check sobriety of drivers; and engage in the brief treatment approach noted above. As countries move to the next level of addressing alcohol abuse, they can, for example, ban sales and drinking in public places, regulate discounts on alcohol,

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and do random breath testing. At the last level, countries could set high minimum prices for alcohol, ban all forms of product marketing and restrict the design of packaging, and provide mandatory treatment for drunk driving, as well as treatment options for alcoholism.

High Blood Pressure, High Cholesterol, and Obesity The majority of risks associated with cardiovascular disease relate to a combination of high blood pressure, high cholesterol, high body mass index, low intake of fruits and vegetables, physical inactivity, and tobacco and alcohol use. The single most important risk factor for type 2 diabetes is obesity. This section comments on measures that can be taken to improve diet and to reduce obesity.

To reduce the burden of CVD and diabetes, healthy eating and maintaining a healthy weight are key. Generally, this requires eating more fruits and vegetables and decreasing the intake of salt and foods that are high in saturated fats and trans fats. It also entails limiting the intake of sugar and replacing refined grains with whole grains. People with overweight generally need to consume fewer calories each day and need to become more active physically. Tax policies can be used to subsidize healthier foods and tax those that are less healthy.

The lack of regular physical activity, in fact, is associated, among other things, with CVD, stroke, type 2 diabetes, and colon and breast cancer. Urbanization, motorization, and television watching all reduce physical activity. Countries can use public policies to try to limit the role of automobiles, promote walking and biking, and design communities in ways that encourage healthy lifestyles. In Singapore and London, for example, taxes are levied on cars that enter the center of the city to reduce the use of vehicles and their attendant traffic and pollution. Many cities promote the use of

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bicycles and have bicycle lanes, as one can see in a number of European cities, such as Amsterdam. By contrast, other places have features that may encourage the use of automobiles over other types of transport. Some communities in the United States, for example, have limited or no sidewalks, little public transport, and services that are very spread out, all of which provide an incentive for people to use automobiles to get from place to place, rather than to walk or bike.

One way to promote healthier diets is through population-based health education. Large-scale education efforts of this type, often through the mass media, have had mixed results because it is difficult to successfully promote the reduction of obesity on a large scale. Generally, mass programs are more effective when they are combined with direct communication with individuals.

Few efforts to undertake population-based education measures have been studied. However, a study on a project to reduce salt intake among men in one part of China found a reduction in both hypertension and obesity after 5 years. In another effort, the government of Mauritius encouraged the population to switch from cooking with palm oil, which is high in saturated fat, to soybean oil, which has less saturated fat. Over a 5-year period, the intake of saturated fat decreased and the total cholesterol intake levels in the population fell. Regulations and legislation on labeling food products and the reduction of unhealthy ingredients in commercial food products can also contribute to reducing obesity. New York City, for example, banned the use of trans fats in its restaurants.

Studies suggest the following goals for large-scale health education efforts if they are to succeed in changing what people eat :

■ Have a realistic time frame that takes account of the time it takes to change deeply ingrained behaviors

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■ Be carried out by a respected organization and headed by a competent manager, with clear responsibility

■ Encourage different organizations and agencies to work together to maximize the reach of the program and ensure that messages get disseminated in appropriate ways

■ Involve the food industry and enhance food labeling

Even as countries undertake the steps noted, they will still need to treat those who already have CVD or who have some of the key risk factors for CVD, including hypertension. Most low-income countries and some middle-income countries do not have the level of health system or the financial resources needed to carry out sophisticated medical procedures. In such settings, however, an important reduction in risks and in the burden of disease can be realized through preventive interventions, such as getting people with high cholesterol and hypertension to take inexpensive medicines to lower blood pressure and cholesterol.44

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▶ Additional Comments on Addressing Diabetes, Cancer, Mental Health, and Vision and Hearing Loss

Given the growing importance of diabetes, the increasing amount of vision and hearing loss to be expected in aging populations, and the relative neglect historically of mental health issues, the following section offers additional comments on these topics. The section also includes additional comments on cancer, given that many lower-income countries are paying additional attention to preventing certain cancers and treating others.

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Further Addressing Diabetes Avoiding overweight and obesity is the single most important way to prevent type 2 diabetes. Although large-scale efforts to reduce obesity have generally not been very successful, a pilot project that used intensive personal counseling to promote weight loss through healthier eating and more physical activity was successfully carried out in China, Finland, Sweden, and the United States. The average weight loss after almost 3 years of participation in this study was about 10 pounds more than in the control group. In addition, the study group had a 58 percent lower rate of type 2 diabetes than the control group.

Treatment for people with diabetes is needed in all countries. Treating people with type 1 diabetes with insulin is a cost-effective investment, although difficult to afford or manage in the poorest countries, especially for people living outside of the main cities. For all people with diabetes, it is cost-effective to control hypertension because the combination of the two diseases can produce major vascular complications. People with diabetes are also subject to foot problems from circulation difficulties associated with their diabetes, so appropriate foot care is another cost- effective investment. The cost of not doing this can be ulcers and eventual amputation of the foot. Those countries with greater resources and a health system that can deliver additional interventions can also consider other cost-effective measures for treating diabetes, including vaccination against influenza and pneumococcal infections, diagnosis and treatment of retinal problems associated with diabetes, and treating hypertension with ACE inhibitors to prevent kidney problems from getting worse.

Cancer DCP3 recently recommended a package of interventions that are cost-effective and that low-resource countries should be able to

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carry out effectively to reduce the burden of cancers. This

package is shown in TABLE 14-12.

TABLE 14-12 Essential Cancer Intervention Package

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Tobacco control is overwhelmingly the first priority for preventing cancer, as noted earlier. Countries should also try to reduce the burden of cancer by vaccinating against infectious agents that are associated with cancers, such as hepatitis B and HPV. An increasing number of countries are adding the hepatitis B vaccine and the HPV vaccine to their national immunization programs. This is especially important in countries where a relatively large share of the population carries hepatitis B. However, additional progress is needed in ensuring that the first dose of the hepatitis B vaccine is given at birth to reduce mother-to-child transmission.

The prevention and treatment of cancer face many challenges due to the fact that each type of cancer has its own risk factors and the most appropriate form of treatment depends on the type of cancer and the level of resources available. Prevention is the most cost- effective method to reduce the economic burden of cancer because cancer treatment can require very advanced and expensive interventions over a long period of time. The importance of prevention and early detection in low- and middle-income countries is highlighted by the fact that the stage of cancer at the time of detection in these countries is, on average, substantially further advanced than in wealthier countries. In some countries, in fact, as much as 80 percent of cancers may already be incurable when first diagnosed. Patients in low- and middle-income countries also tend to have additional health conditions that make their recovery from cancer less likely than patients in high-income countries.

Although screening is possible for a number of cancers, DCP3 has suggested that only opportunistic screening for cervical cancer is generally cost- effective and manageable in low-income settings. However, that study also suggested that screening for some other

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cancers, such as oral cancers in places with a high prevalence rate of such cancers, might also be warranted.

To be effective, cancer treatment programs in most low-income countries and many middle-income countries will require considerable strengthening of a range of health services:

■ Laboratory services ■ Pathology ■ Surgery ■ Chemotherapy ■ Radiotherapy

In addition, substantial training of health providers will be needed. It will also be very important that cancer treatment be of appropriate quality. This means, among other things, that all of the inputs needed to treat a particular cancer must be in place and must be delivered appropriately if desired cure rates are to be achieved. Collective global effort could be very important for helping countries to reduce the costs of and improve procurement of cancer-related drugs, including drugs for palliative care. Collective efforts could also help countries address the key constraints to providing appropriate detection and treatment of cancer that are noted here.

Even considering the present limitations on cancer treatment in a number of settings, DCP3 has suggested that it is cost-effective in low-resource settings to treat precancerous lesions of the cervix and to treat early stage cervical, breast, and colorectal cancers. DCP3 also suggests that low-resource countries should seek to treat those childhood cancers that have high cure rates, a recommendation that goes beyond those of WHO.

Another aspect of cancer treatment is palliative care. There exists a substantial need to limit suffering and discomfort for the many individuals who will die from cancer each year. Unfortunately, low-

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and middle-income countries generally have only limited access to palliative care. This is despite the fact that two-thirds of cancer patients will suffer from moderate to severe pain and the majority of them will have no access to pain relief. Palliative care comprises both medical interventions and psychosocial support, but oral morphine is underused on a global level and there is a shortage of qualified counselors and therapists for such care.

In addition to preventive measures, improved early detection methods are also critical to reducing the global burden of cancer. The world must continue to devise low-cost, effective screening tests for detecting cancer in low-resource settings. For example, cervical cancer screening is traditionally done via a Papanicolaou (Pap) smear in higher-income countries. However, Pap smear programs can be unfeasible where there is little infrastructure, so a direct visualization method, using visual inspection of the cervix with acetic acid, was developed that allows for testing and treatment of precancerous lesions in a single visit.

Mental Health There has been little progress until relatively recently in most low- income countries and many middle- income countries in addressing mental disorders. Unfortunately, despite the enormous and growing importance of mental disorders, there is generally an inadequate understanding of the importance of mental health, a lack of funds for mental health, a shortage of people who understand mental health issues, and stigma around mental disorders.

In addition, the more limited the resources of a country, the wider the gaps are likely to be between what is needed to address mental disorders and what is available to do so. In fact, estimates suggest that in low- and middle-income countries, only between 15 percent to 24 percent of people in need of mental health services

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receive them; even in high-income countries, it is estimated that only 35 percent to 50 percent of the people in need of mental health services receive them. There is also an exceptional lack of human resources in most low- and middle-income countries to help address mental disorders. High- income countries have 170 times the number of psychiatrists and 70 times the number of nurses per capita as in low-income countries.

Moreover, a significant amount of the mental health care in low- and middle-income countries is offered in large psychiatric hospitals that consume an overwhelming share of the mental health budget in those countries. Yet, a range of mental disorders can be prevented and treated effectively outside such settings. In fact, the evidence is growing that for $3 to $4 per person per year, countries could provide more community-based approaches to care that would offer drug therapy combined with psychosocial support for bipolar disorder, depression, and schizophrenia, as well as drug therapy for panic disorder.

It is also clear that low- and middle-income countries have scarce financial resources and a limited number of mental health professionals. Thus, they are very unlikely to be able to take an approach to mental health that is medically oriented and depends on psychiatrists and psychiatric nurses, as is the case in most high-income countries. Rather, approaches that are cost-effective, scalable, and sustainable will have to depend on the community and on family-based efforts.

In this light, and with increasing attention to mental disorders, in 2013 WHO published the Mental Health Action Plan, 2013– 2020. This plan takes a comprehensive view of both needed actions and the various actors who must be involved in improving action on mental disorders, from stakeholders to government to the global community. Some of the key recommended actions in the plan are noted here:

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■ Countries should have national plans for mental health that are consistent with international human rights instruments.

■ Countries should have updated their laws on mental health, and those laws should also be consistent with international human rights instruments.

■ Services for people with severe mental disorders should be increased by 20 percent by 2020.

■ Countries should implement multisectoral promotion and prevention programs for mental health.

■ Steps should be taken to reduce suicides by 10 percent by 2020.

■ Countries should take steps to improve their collection of and reporting on key mental health indicators.

The plan also recommended that countries should do the following:

■ Involve a broader range of stakeholders in their work on mental health and involve those affected by mental disorders in the planning, implementation, and monitoring of mental health programs

■ Shift services away from long-stay mental hospitals and toward non-specialized community- based approaches, evidence- based approaches, and community support

■ Provide integrated and responsive care that brings together promotion, prevention, care, and support

■ Reduce disparities by paying particular attention to groups most in need

As noted earlier, The Lancet Commission on Global Mental Health and Sustainable Development issued a comprehensive report in late 2018. The Commission strongly recommended dealing with mental health as an issue of sustainable development and of human rights, if progress in this field is to be enhanced. It also

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recommended that it be addressed as an essential component of universal health coverage.

TABLE 14-13 outlines the specific interventions the Commission recommended for addressing mental disorders in low-, medium-, and high-resource settings. It is important to remember as one considers this table that the services suggested for high-income countries are a long-run goal for all countries. Clearly, countries will need to take a stepwise approach to achieving such comprehensive services.

TABLE 14-13 Mental Health Service Components Relevant to Low-Resource, Medium-Resource, and High-Resource Settings

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The Commission also put forward a number of other suggestions that could be important to health services beyond mental health :

■ Moving care away from hospitals and toward the community ■ Involving patients and family members in planning and

providing care ■ Using multidisciplinary teams to provide social interventions

alongside clinical and pharmacological interventions ■ Focusing on comorbidities, while dealing with mental health

conditions

There have been few mental health success stories in low- and middle-income countries. Uganda was one low-income country that sought before most others to improve mental health services through a model of community-based care that was truly integrated into the national health system. There have also been some instructive efforts to provide community-based care for schizophrenia in India. This has been coupled with shifting of tasks to community-based health workers, given the absence of trained mental health professionals in much of India. In addition, although Chile is now considered a high-income country, it will be important to follow the progress of mental health services for depression in Chile, which has become a model for a national effort to address depression. A community-based intervention in Zimbabwe called the Friendship Bench has tackled common mental disorders by training lay health workers to deliver problem-solving therapy over the course of 6 weeks on benches outside of public clinics. This is an example of a success story in which a program utilizing community members has been scaled up in many districts across the country. Another evidence-based intervention delivered through community health workers originated in Rawalpindi, Pakistan. The Thinking Healthy Program (THP) has since been

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implemented in other parts of Pakistan and has been adopted by WHO’s Mental Health Gap Action Program. THP has reduced rates of perinatal depression among mothers by using cognitive and behavioral therapy to improve mental well-being and social support. This is an example of a successful intervention in a low- resource setting that has been integrated with existing maternal and child health programs to facilitate scaling up.

Vision Loss In 2013, the World Health Assembly approved a global action plan for universal eye health. The plan has three objectives: generate evidence to enhance understanding and commitment; develop coherent national policies, plans, and programs on eye health; and enhance multisectoral collaboration and partnerships to improve eye health.

The plan sets a target of reducing preventable blindness globally by 2019, from the 2010 baseline. The plan encourages countries to establish comprehensive eye care programs that are well integrated into their health systems and that focus on cost- effective interventions to address refractive errors and the burden of unoperated cataracts. The plan also encourages countries to continue to work across sectors to help address the infectious and parasitic causes of blindness, as well as the growing threat of blindness related to diabetes. Eye care is an area in which there has been considerable success with task shifting, and the plan also comments on the training of personnel for eye care, including allied healthcare personnel. This could include, for eye care, for example, ophthalmic assistants who are trained to do cataract surgeries, especially in places where there are an insufficient number of ophthalmologists.

Hearing Loss

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Despite the substantial burden of disease and economic costs related to hearing loss, the world has not yet adopted any coherent plan or targets to address this problem. WHO suggests, however, that about half of all cases of hearing loss can be addressed by primary prevention:

■ Immunizing children against childhood diseases, including measles, meningitis, rubella, and mumps

■ Immunizing adolescent girls and women of reproductive age against rubella before pregnancy

■ Screening for and treating syphilis and other infections in pregnant women

■ Improving antenatal and perinatal care, including promotion of safe childbirth

■ Avoiding the use of ototoxic drugs, unless prescribed and monitored by a qualified physician

■ Referring babies with high risk factors (such as those with a family history of deafness or those born with low birthweight, birth asphyxia, jaundice, or meningitis) for early assessment of hearing, prompt diagnosis, and appropriate management, as required

■ Reducing exposure (both occupational and recreational) to loud noises by creating awareness, using personal protective devices, and developing and implementing suitable legislation

WHO also suggests that attention be paid to early diagnosis and appropriate medical or surgical intervention for middle ear infections that can lead to hearing loss.

For that part of hearing loss that cannot be addressed through primary prevention, or for which it is too late, WHO also recommends that countries focus on early detection of hearing loss, accompanied by appropriate management of the problem. In principle, screening and diagnosis can be done in preschools, schools, and the community. However, WHO acknowledges that

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both diagnosis and appropriate management of hearing loss requires greater attention and resources in most low- and middle- income settings. WHO estimates, for example, that only about 1 in 40 people in low- and middle-income countries who need a hearing aid have one. In addition, the resources available in these settings for speech therapy, training in sign language, cochlear implants, and related efforts are limited.30

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▶ Case Studies Three case studies follow. The first brief deals with mental health, specifically on the growing costs of dementia. Few countries and few actors in global health have paid much attention to oral health, so the second study deals with that topic. The third study examines Poland’s efforts to reduce tobacco consumption.

Dementia Dementia is a syndrome—usually of a chronic or progressive nature—in which there is deterioration in cognitive function beyond what might be expected from normal aging. The number of people living with dementia in 2013 was estimated to be about 44 million.

Dementia mainly affects older people, and the likelihood of developing dementia after age 65 roughly doubles every 5 years. However, there is a growing awareness of cases with an onset before the age of 65. The most important risk factors for dementia are age, family history, and heredity. Other risk factors include alcohol use, atherosclerosis, obesity, smoking, diabetes, and high cholesterol. Some evidence suggests an association between decreased blood flow conditions and the onset of vascular dementia.

Dementia is a global problem on the rise. The number of people living with dementia is predicted to reach 115 million by 2050. Population aging is the main driver of projected increases in the prevalence of dementia. Low- and middle-income countries going through the demographic transition are predicted to see the largest increase in prevalence, and it is projected that by 2050, 71 percent of dementia patients will live in today’s low- and middle-income

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countries, an increase from 68 percent in 2013. The largest increases are projected in East Asia and sub-Saharan Africa.

The social and economic costs of dementia are great. In 2010, the total global societal cost of dementia was estimated to be $604 billion annually. This corresponded to 1 percent of worldwide GDP. The total cost of dementia as a proportion of GDP varied from 0.24 percent in low-income countries to 1.24 percent in high-income countries. Costs of informal care provided by families and friends accounted for about 42 percent of worldwide total costs associated with dementia and the direct costs of care provided by professionals accounted for 42 percent of costs, as well. Direct medical care costs were much lower and were about 16 percent of worldwide total costs. People with dementia and their families face a significant financial impact from the cost of providing health and social care and from the reduction or loss of income.

Little is known on how to treat dementia, and there is no cure. However, there are many prospective treatments in clinical trials. In the absence of a cure or a treatment to reverse any cognitive loss, emphasis is put on supporting and comforting dementia patients and their families. A high proportion of people with dementia need some care, ranging from support with activities of daily living to full personal care and round-the-clock supervision.

In some high-income countries, between one-third and one-half of all people with dementia live in resource- and cost-intensive residential or nursing home care facilities. In the Netherlands, care facilities have reached a new level. Self-contained villages for those experiencing late-stage dementia allow patients to enhance their quality of life by living in a surrogate environment. These villages are set up to allow residents to go about their daily lives of going to the grocery store, shopping, or restaurants safely because everyone working in the village, from the storekeeper to

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the neighbors, is trained to be a dementia caregiver. It is known that with appropriate care and support, dementia patients can live many years after the onset of symptoms and can maintain a good quality of life.

Special challenges arise in meeting the needs of dementia patients in low- and middle- income countries. In these settings, there are few social protection programs for the elderly and sick and also fewer overall services for their support and care. In low- resource settings, it is recognized that primary care physicians or community-based workers will be the primary case managers, compared to specialists in more developed settings. With this in mind, primary care physicians and community-based personnel must be properly trained to handle dementia cases in these settings with a focus on continuing care and support rather than curative interventions.

There is an urgent need to develop cost-effective packages for medical and social care that meet the needs of people with dementia and their caregivers across the course of the illness and a need to develop evidence-based prevention strategies. Only by investing now in research and cost-effective approaches to care can future societal costs be anticipated and managed. Moreover, universal social support through pensions and insurance schemes could provide protection to this vulnerable group. Governments and health and social care systems need to be adequately prepared for the future and must seek ways now to improve the lives of the growing number of people with dementia and their caregivers.

Oral Health The Burden of Disease

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Seven oral diseases and conditions account for most of the oral disease burden globally:

■ Dental caries (tooth decay) ■ Periodontal (gum) diseases ■ Oral cancers ■ Oral manifestations of HIV ■ Oro-dental trauma ■ Cleft lip and palate ■ Noma

Yet, these diseases and conditions are either largely preventable or can be treated in their early stages.

Oral diseases were estimated by GBD 2016 to have affected at least 3.58 billion people worldwide in 2016. Caries of the permanent teeth were the most prevalent of all conditions assessed. It was also estimated that 2.4 billion people suffered from caries of permanent teeth and that almost 500 million children suffered from caries of primary teeth.

In fact, “oral disorders,” as they are called in GBD 2016, are among the most common of the noncommunicable diseases. Oral diseases were the 15th leading cause of years of life lived with disability (YLD) globally, for all ages and both sexes, in 2016. The ranking of such disorders by country income group in 2016 was as follows :

■ Low-income: 23rd ■ Lower middle-income: 24th ■ Upper middle-income: 14th ■ High-income: 13th

This ranking reflects, among other things, the interaction among changing diets, access to oral health services, and population aging. In fact, oral disorders were the 11th leading cause of YLD

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globally for people 50 to 69 years of age and over 70 years of age. Yet, despite the enormous amount of disability related to oral disorders, such disorders have never been part of mainstream discussions of global health.

Dental caries and periodontal disease are two prominent but often neglected burdens of disease in low- and middle-income countries. Dental caries, commonly known as tooth decay or cavities, are present in 90 percent of the global population, including an estimated 60 percent to 90 percent of all school-aged children worldwide. Caries result when naturally occurring oral bacteria break down foods, particularly those containing sugars and starches, into acidic by-products. These acids combine with saliva and food remnants to form plaque, a substance that builds up and adheres to teeth. Without removal, the plaque acids will either degrade the enamel of teeth and create cavities or turn into tartar, which can be removed only with a professional dental cleaning.

Together, plaque and tartar cause gingivitis, or inflammation of the gums. When left untreated, gingivitis advances to periodontitis, a disease characterized by inflammation around the teeth and also gums that retract from teeth to form spaces that are prone to oral infection. Once infection occurs, the body’s immune system responds with bacterial toxins that break down the bone and connective tissue, resulting in tooth loss. Severe forms of periodontal disease affect 5 percent to 15 percent of most populations, including about 2 percent of youth worldwide who suffer from juvenile or early-onset aggressive periodontitis. In addition, dental caries and periodontal disease can lead to tooth loss, including the loss of all natural teeth. This is a very important cause of years of life lived with disability in countries with a large share of older people in their population.

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Moreover, many people fail to understand or underestimate the importance of oral health to child health. Both dental caries and periodontal disease contribute to childhood morbidity and have a negative impact on their quality of life. Research suggests that the discomfort associated with biting and chewing for children who suffer from problems of oral health contributes to school absenteeism. It has been estimated, for example, that 50 million school hours are lost annually due to oral health issues. Malnutrition prevalence rates also increase if children are too pained to eat. A child’s psychosocial well-being and ability to smile and speak may also be impaired.

Another oral health disease of importance is noma. This condition originates as an untreated gingival inflammation, which then evolves into a gangrenous lesion that causes necrosis of the lips, chin, and facial tissues. Noma has generally been reported in children ages 2 to 6 who reside in low-income communities with poor sanitation in sub-Saharan Africa. However, it has also been reported in Asia and Latin America. The progression of noma can be halted when it is detected at an early stage and treated appropriately. Such treatment would include good hygiene, antibiotics, and nutritional rehabilitation. Yet, it has been estimated that 90 percent of children who are exposed to this illness die as a result of receiving no medical care, and survivors in those settings must often cope with severe facial disfigurement.

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Risk Factors for Dental Caries, Periodontal Disease, and Noma There are a number of risk factors for dental caries, periodontal disease, and noma in low- and middle- income countries. These include low education levels, low socioeconomic status, poor oral hygiene practices, alcohol and tobacco use, and excessive intake of dietary sugars. These often occur in settings with limited access to safe water and modern sanitary facilities, insufficient community infrastructure, and the presence of cultural beliefs that do not support preventive oral health efforts. Diabetes is also thought to be linked with periodontitis in reciprocal ways.

Current epidemiological data indicate that the oral health burden for children is most prominent in the Americas and has least affected Africa. However, the prevalence of these diseases is expected to rise in low- and middle-income countries due to increased sugar consumption that accompanies economic growth and globalization of the food industry. Illustratively, Dr. Karen Sokal-Gutierrez, a pediatrician working with the Children’s Oral Health Nutrition Project in Latin America and Asia, has noted an “explosion in the availability of soda, chips and other junk food.” These products are low-priced and contain large amounts of sugars and starches. Unfortunately, children are often exposed to these products without nutrition education to inform them of the potential negative health effects of consuming such food. The result is a pandemic of tooth decay, and Dr. Sokal-Gutierrez estimates that between one-third and one-half of the children she works with in El Salvador, Ecuador, Nepal, Peru, and Vietnam have baby teeth that are black, rotten, and decayed.

Barriers to Treatment and Prevention In addition to risk factors, there are several barriers to treatment that are prominent in resource-poor countries. In these countries,

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almost all tooth decay goes untreated. The dental healthcare

workforce in these countries is insufficient to satisfy service needs or demands. In high-income countries such as the United States

and Germany, for example, the dentist-to-patient ratio is 1 per 1,000 population. In low- and middle-income countries, the ratio decreases to 1 per 50,000 population. In some extreme cases in sub-Saharan Africa, the figure is as low as 1 dentist per 900,000 population. To further exacerbate this crisis, dentists in low- resource settings tend to practice in urban settings, neglecting rural populations, as families in these areas are more likely to be of low socioeconomic status and unable to afford dental care.

Another barrier to treatment is the high cost of dental services. In high-income countries, oral diseases rank as the fourth most expensive health condition to treat, yet insurance coverage for oral health is insufficient, even in many high-income countries. For instance, in the United States, about 130 million Americans lack dental coverage under their insurance plan. This includes 22 percent of children ages 1 to 17. Estimates suggest that, in low- income countries, the cost of treating dental caries in children alone would exceed the total current budget for child health activities.

Some prevention efforts are also hindered by the limited infrastructure in many low- and middle- income countries, as well as constrained family incomes. There is strong evidence that long- term, low exposure to fluoride reduces the prevalence of dental caries in children. Dispersing fluoride treatment in salt and public water systems has proven to be an effective prevention method in many countries. However, successful implementation is largely contingent on the capacity of infrastructure of the affected population, and most low- and middle-income countries lack the resources to accomplish this. With the world population now over 7 billion, estimates from the British Fluoridation Society’s

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most recent global report suggest that only about 435 million people have access to fluoridated water sources. Moreover, even on a household level in the lowest-income countries, fluoridated toothpaste can exceed a family’s budget. In the United Kingdom, for example, only 0.02 percent of a household’s annual expenditure is accounted for by toothpaste; in Zambia this percentage rises to 4 percent of annual household expenses.90

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Addressing Oral Health Issues Interventions focused on cost-effective prevention methods that combine social policy and individual action will have the most impact in low- and middle-income countries. It will be important to include oral health within the scope of comprehensive chronic disease prevention programs. Oral diseases share many risk factors with the four most prominent chronic conditions—CVD, diabetes, cancer, and COPD. Using a shared risk factor approach has the potential to address several health issues simultaneously, benefiting resource-poor countries by reducing the required amount of physical and financial resources. Government programs supporting subsidy and taxation relief of fluoridated toothpaste can also help to address financial barriers. The U.S. Centers for Disease Control and Prevention suggests that every dollar spent on community-based fluoridation interventions saves $38 on dental treatment.

Emphasis also needs to be placed on strengthening oral health education and promotional methods in community settings. With an estimated 1 billion children attending primary and secondary schools globally, public schools are an optimal venue for health promotion and education among this population. Oral health education reinforced in this environment can foster productive health attitudes and good oral health habits early in life. Pilot studies conducted in the United States and Ireland have shown that school-based interventions improve knowledge related to oral cleanliness and gingival health among school-age children. The World Health Organization also strongly supports similar efforts on a global scale.

The Challenge of Curbing Tobacco Use in Poland

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Background More than three-quarters of the world’s smokers live in low- and middle-income countries, where smoking is on the rise. In the late 1970s, Poland had the highest rate of smoking in the world, with the average Pole smoking 3,500 cigarettes a year and nearly three-quarters of Polish men smoking daily. The impact on the nation’s health was staggering. In 1990, the probability of a 15- year-old boy in Poland reaching his 60th birthday was lower than in most countries, including China and India. Lung cancer rates were among the highest in the world. But because tobacco production, run by the state, provided a significant source of revenue, the government did not fully disclose to the population the negative consequences of smoking. The fall of communism further exacerbated smoking because tobacco, the first industry to be privatized, was taken over by powerful multinational corporations who flooded the market with international brands, spent vast sums on advertising, and kept prices so low that cigarettes cost less than a loaf of bread.

The Intervention As the tobacco epidemic escalated, Poland’s scientific community laid the foundation of the anti- tobacco movement. Research in the 1980s by the Marie Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology contributed to the first Polish report on smoking, highlighting the link between tobacco and the country’s alarming rise in cancer. A series of international workshops and scientific conferences in Poland further strengthened these findings. Civil society was experiencing a renewal at the time, with the formation of anti-tobacco groups such as the Polish Anti- Tobacco Society, which began to interact with international bodies, such as WHO and the International Union Against Cancer. In addition, the Health Promotion Foundation was established to lead public efforts on health issues and anti-tobacco education efforts.

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With the fall of the Berlin Wall, the media became free to cover health topics and played an important role in disseminating information, raising awareness about the dangers of smoking, and shaping public opinion. When tobacco control legislation was introduced in 1991, a heated public debate ensued between health advocates and the powerful tobacco lobby, increasingly viewed by the public as a contest between David and Goliath. In 1995, groundbreaking legislation was finally passed, requiring sweeping measures such as large health warnings on cigarette packs and bans on smoking in enclosed workspaces and health centers, on electronic media advertising, and on tobacco sales to minors. A 30 percent increase in taxes levied on cigarettes was subsequently passed in 1999 and 2000, and advertising was completely banned. In parallel, the Health Promotion Foundation also launched extensive health education and consumer awareness efforts. These included an annual “Great Polish Smoke-Out” competition to encourage smokers to quit, with incentives like winning a weeklong stay in Rome and a chance to meet the Polish-born Pope John Paul II. Since the first smoke-out in 1991, more than 2.5 million Poles have permanently snuffed out their cigarettes because of the campaign.

The Impact Cigarette consumption dropped 10 percent between 1990 and 1998, and the number of smokers declined from 14 million in the 1980s to under 10 million by the end of the 1990s. The reduction in smoking led to 10,000 fewer deaths each year, a 30 percent decline in lung cancer among men ages 20 to 44, a nearly 7 percent decline in CVD, and a reduction in infant mortality and low birthweight. Life expectancy in the 1990s increased by 4 years.

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Lessons Learned Poland’s experience shows that once smoking is seen for what it is—the leading cause of preventable deaths among adults worldwide—governments do act. Working in concert with civil society and using state-of-the-art communication strategies, the Polish government succeeded in countering the powerful economic influence of the tobacco industry and inducing major shifts in smoking, an addictive behavior that was also then an ingrained social norm. Poland’s sweeping legislative measures came to serve as a model for other countries. The experience of South Africa provides an interesting parallel: once the African National Congress came to power in 1994, the antismoking movement gained a powerful ally in Nelson Mandela and his first health minister, ultimately leading to the passage of strict tobacco control legislation and dramatic price control measures that increased the real value of cigarette taxes by 215 percent. As a result, cigarette consumption fell by more than 30 percent, from 1.9 billion packs in 1991 to 1.3 billion packs in 2002. As a South African researcher noted, “You need the right combination of science, evidence, and politics to succeed. If you have one without the other, you don’t see action.” For a more detailed discussion of the Polish efforts, see Case Studies in Global Health: Millions Saved.

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▶ Future Challenges of Preventing and Addressing NCDs and Mental Disorders

The world must face a number of challenges if it is to reduce the burden of noncommunicable diseases in low- and middle-income countries. First, the number of people with new cases of noncommunicable diseases will grow in low- and middle-income countries as a result of the aging of the population, urbanization, globalization, and lifestyle changes. In addition, because noncommunicable diseases are chronic, the number of people with these diseases will also rise. The increasing number of people who will be at risk of and living with chronic diseases in low- and middle-income countries will pose a huge challenge to the health of these countries, their health systems, and their national finances.

Related to this, a number of low-income countries will have to deal with the challenge of addressing increasing amounts of noncommunicable disease simultaneously with having to address substantial burdens of communicable diseases and injury. This will severely tax the managerial, technical, and financial capacity of many low- and middle-income countries. It will also require greater attention by low-income countries to noncommunicable diseases and to improved surveillance of these diseases. Low- and middle- income countries will need to strengthen primary care and integrate the prevention and control of noncommunicable diseases into it.

In addition, it will be important to spread as rapidly as possible to low- and middle-income countries the lessons that high-income countries have already learned about how to address noncommunicable diseases in cost-effective ways. It will also be critical to generate much greater evidence about what works in

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low- and middle-income countries. This body of evidence, especially for low-cost interventions that have a high payback, needs to be disseminated in low- and middle-income countries as rapidly as possible. Ongoing mechanisms need to be established to ensure that cost-effective diagnostics and drugs get used as early as possible after their development in low- and middle- income countries and not just in high-income countries.

Even as they continue to learn from the experience of the high- income countries, the low- and middle-income countries need to take the measures that are known to prevent noncommunicable diseases, as discussed earlier in the chapter. However, many countries have limited administrative capacity, insufficient financial resources, and major gaps in human resources for health. Thus, lessons will also need to be generated and disseminated on the operational efforts needed to put effective NCD programs in place in low-resource settings. In addition, such countries will almost certainly need to take a stepwise approach to strengthening their NCD programs, starting with those efforts that will have the highest return.

Most low- and lower middle-income countries have little experience in dealing with NCDs in a major way. In addition, many of these countries have health systems with major structural weaknesses that are not ready to address NCD prevention and control more broadly, effectively, or efficiently. Thus, many countries will have to substantially strengthen their health systems if they are to meet the challenges of a growing burden of NCDs. They will also have to strengthen their ability to act across agencies to tackle measures such as taxation policies that are needed to reduce the consumption of tobacco, alcohol, and sugar.

A major goal of public health policy is to try to help people live longer lives that are as healthy as possible. The epidemiologic and demographic changes that are occurring globally suggest this goal

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can be achieved only if countries take measures now to prevent as much noncommunicable disease as possible. To achieve this aim, countries need to increasingly prepare their health systems to deal with the prevention and treatment of noncommunicable diseases in cost-effective and efficient ways. The failure to address these aims effectively will result in older but unhealthy populations, whose needs for care and cost of care will overwhelm the health systems of a number of countries.

TABLE 14-14 portrays a number of measures that low- and middle-income countries could take to strengthen their health systems to address CVD, COPD, and diabetes. It is also clear that some of these measures can be extrapolated to what is needed for health systems to better address mental health disorders. Of course, in addition to the specific measures noted in the table, moving as rapidly as possible toward universal health coverage will allow for more services to be provided to a larger share of the population, with less financial risk than they face now. As countries do this, achieving services of appropriate quality will also be essential.

TABLE 14-14 Recommendations for Health Systems Improvements that Enable Implementation of the Recommended

Interventions

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▶ Main Messages Noncommunicable diseases constitute the largest burden of disease worldwide. In all regions of the world, except sub-Saharan Africa, the burden of these diseases is greater than the burden of communicable diseases and other Group I causes, including maternal, perinatal, and nutritional conditions. Cardiovascular disease is the single largest cause of death worldwide. Diabetes, some forms of cancer, and mental disorders are also major causes of disability and death from noncommunicable diseases. In fact, about 14 percent of the DALYs in 2016 were attributable to CVD, almost 9 percent to cancer, about 5 percent to the four mental disorders discussed earlier, about 3 percent to COPD, and almost 3 percent to diabetes. Moreover, economic development, globalization, urbanization, and aging will encourage the growth of noncommunicable diseases globally as a share of the total burden of disease.

The leading risk factors for cardiovascular disease are hypertension, obesity, high cholesterol, and tobacco use. Tobacco use is also the leading risk factor for COPD. A lack of physical activity contributes to CVD and obesity, and the main risk factor for diabetes is obesity. Some cancers are associated with an infectious agent, such as hepatitis B, H. pylori, or the human papillomavirus. Other cancers are linked with tobacco use. The nongenetic risk factors that are associated with mental disorders are not well understood. However, the recent Lancet Commission on Global Mental Health and Sustainable Development suggested that mental health disorders relate to a “complex interplay of psychosocial, environmental, biological, and genetic factors across the life course, but in particular during the sensitive developmental periods of childhood and adolescence.”

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The costs of noncommunicable diseases and the use of tobacco and alcohol abuse are substantial. They have a considerable impact on people in their productive years of life. In addition, mental disorders and diabetes are associated with very large amounts of disability. The costs of trying to prevent the burden of noncommunicable diseases include efforts to promote healthier lifestyles, including a healthy diet, maintaining an appropriate weight, and increasing physical activity, while trying to reduce obesity, cigarette smoking, and excessive drinking. The costs of treating noncommunicable diseases can be high, both because of the high cost of some medical treatments for specific episodes of illness and the need to treat some diseases and conditions for many years. Mental disorders, for example, frequently start early in life and often continue throughout life. Nonetheless, some medicines used for hypertension and high cholesterol, for example, are highly cost-effective in dealing with CVD, even in low- and middle-income settings, as are some medicines and treatment for mental health disorders.

The single most important step that low- and middle-income countries can take now to reduce the burden of noncommunicable diseases is to reduce the consumption of tobacco. There is good evidence from high-income and some lower- and middle- income countries that taxing cigarettes more heavily, banning smoking from public places, and trying to educate the population about the impact of tobacco on health can all contribute to reducing tobacco consumption.

Reducing the burden of noncommunicable diseases will also require that alcohol-related harm be reduced, which can be done in cost-effective ways by taking measures analogous to those taken for dealing with tobacco. In addition, it is critical that obesity be reduced through healthier diets, consumption of fewer calories, increased intake of fruits and green leafy vegetables, and more

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physical activity. Tax policies can also be used to subsidize healthy foods and tax unhealthy foods. Other measures to reduce obesity can be complemented with food labeling legislation and legislation to encourage the use of healthier ingredients in food products. The intake of salt must also be reduced.

Low-resource countries will need to embed approaches to mental health in their communities and at the family level. This can be coupled with better training of primary healthcare staff at all levels to deal with mental health, improved access to low-cost drugs, and enhanced financing by deconcentrating the budgets so that they are not disproportionately allocated to large psychiatric hospitals.

A number of countries are making important progress in addressing vision loss by reducing the loss from infectious and parasitic causes and taking steps to address unoperated cataracts. To meet the global goals of reducing preventable blindness, countries will need to take additional measures to establish more comprehensive eye care programs at all levels of their healthcare systems.

There are substantial gaps in attention to hearing loss. However, about 50 percent of all hearing loss can be addressed through primary prevention, including better maternal nutrition and care, enhanced vaccination, and reduction in syphilis. Increasing the attention of resource-poor health systems to the remaining burden of hearing loss will require increases in financial, human, and health system resources with greater attention to early screening and appropriate management.

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Study Questions 1. How important are noncommunicable diseases to the global

burden of disease? 2. Why are noncommunicable diseases less important to the

burden of disease in sub- Saharan Africa than in other regions?

3. What are the leading risk factors for cardiovascular disease?

4. What are the most important cancers that affect low-income countries?

5. What are the most important risk factors for cancers? 6. What factors are causing the epidemic of diabetes that is

occurring worldwide? 7. Why are mental disorders so important to the burden of

disease? 8. What measures have proven effective in reducing the use of

tobacco? 9. What evidence is developing about community-based

mental health programs? 10. What measures have been effective in reducing the abuse

of alcohol?

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