Noncommunicable Diseases

Noncommunicable diseases: The new epidemic?

Noncommunicable diseases (NCDs) increasingly contribute to total worldwide mortality (65% in 2010) with 80% of deaths occurring in low- and middleincome countries (LMICs); these are often premature deaths i.e. before 60 years of age. NCDs are now appearing everywhere in major articles and editorials of leading journals and are on the agenda of most research institutes and funding agencies. In 2011, the second meeting ever organized by the United Nations at the level of Heads of State, was on NCDs (the first one in 2001 was on HIV/AIDS). The UN and WHO, not be deterred from the somewhat embarrassing omission of NCDs from the Millennium Development Goals, have not unexpectedly come up with another slogan: ’25 by 25’ meaning a 25% reduction in mortality from NCDs among persons between 30-70 years of age, compared to 2010 NCD mortality levels. Well, it is about time. However, one cannot ignore the feeling that all this prioritizing and media attention is driven by the impact that NCDs have in high income-countries. All tropical doctors know that NCDs in LMICs are part of everyday practice and that there has been an astonishing denial, or inactivity if you will, with regard to NCDs. Hypertension, diabetes, cardiovascular disease, respiratory disease and cancer have always been common. While some of the risk factors are the same (alcohol, tobacco), there are specific risk factors such as rheumatic heart disease, domestic exposure to smoke and common biological agents that can cause cancer such as Epstein-Barr virus (nasopharyngeal carcinoma, malignant lymphoma), hepatitis B virus (hepatocellular carcinoma) and schistosomiasis (bladder cancer). On top of this, compounded by rapid urbanisation, the adoption of an unhealthy (western) life style is alarming, noted by rapidly increasing levels of obesity that is seen as a sign of good health (so not ‘slim’ as in AIDS) and high economic status (‘healthy and wealthy’). More recently introduced tropical diseases increase the risk of NCDs; for example stroke may be caused by infection in HIV disease. Another complex issue is the effect of HIV infection and subsequent treatment with antiretrovirals that both may cause atherosclerosis. Managing conditions such as diabetes mellitus or hypertension in a LMIC context first requires understanding of underlying mechanisms and collection of essential data. All these are discussed in this issue. Snake bite is somewhat peculiar as it is ‘communicable’ but not from person to person and not infectious; nevertheless we feel it deserves a place here. There is limited information on how to treat these conditions in a tropical context taking into account the availability of drugs, response to treatment in genetically different populations, lack of patient education, etc. Prevention and public health measures need more attention in most LMICs. A tailor-made approach based on epidemiological and clinical studies is needed. What does this mean for us? We should realize that the field of Tropical Medicine is perhaps wider than we often assume; it includes the practice of Medicine (read: Surgery, O&G etc. as appropriate) in a tropical environment and encompasses (among other) infectious diseases, including HIV medicine, community health as well as travel medicine. We should educate ourselves and the public in general about the importance of NCDs and give it a firm place. It would be good to review our teaching in various courses with regard to NCDs such as the training for Doctor in International Health and Tropical medicine (AIGT) as well as our teaching capacity: do we have enough expertise in this field? THE ERA OF NCDS HAS ARRIVED; NOW WE NEED TO FORMULATE A RESPONSE.

Ed Zijlstra, e.e.zijlstra@roctm.com