A problem the world over

International health experts are examining how lessons learned in combating infectious disease in developing countries can be applied to what is emerging as an even greater threat to global public health—the rising rates of chronic diseases.

This shift presents new challenges for health systems in developing countries that have traditionally viewed disease in terms of infectious disease outbreaks, where the goal has been isolating the source to prevent it from spreading to the rest of the population.

The strategies that governmental and nongovernmental organizations are using resemble, and in some cases borrow from, public health approaches to chronic disease being used in the U.S.

One approach to addressing the growing burden of chronic disease in the developing world is the continued use of an infectious disease paradigm. The World Health Organization has implemented an integrated approach toward fighting infectious diseases in children that calls for improving case-management skills of health staff, improving the overall health system, and improving family and community health practices.

The WHO's strategy on chronic disease has been to work with governments on improving environmental factors related to the particular disease, including poverty and health literacy. Its recommendations call for governments to establish national policies on chronic disease prevention and management that include tougher regulations on the availability of tobacco and promoting better nutrition and greater physical activity, similar to the “Let's Move” campaign led by first lady Michelle Obama.

Paul Madden, senior adviser for noncommunicable diseases with the not-for-profit Project HOPE, said the change in many developing countries from an agrarian to an industrial society has caused many people to adopt more-affluent Western lifestyles, including poorer diets, higher tobacco and alcohol use, and less physical activity. Also, a rise in the demand for Western fast food and processed foods has led to an increase in health-related issues such as diabetes and heart disease.

Some experts say the rise in noncommunicable diseases, caused mostly by adoption of unhealthy lifestyle behaviors as countries get wealthier, should be addressed in some of the same ways as infectious diseases.

“These lifestyle contagions actually spread from person to person. People who are around other individuals within their network of family and friends who eat unhealthy foods are more likely to eat unhealthy foods,” said Daniel Zoughbie, founder, president and CEO of the not-for-profit organization Microclinic International.

Worldwide, conditions such as diabetes, cancer, and heart and lung disease have outpaced infectious disease as the leading cause of morbidity and the No. 1 financial burden on health systems and governments in terms of treatment and lost productivity. Some countries' health systems are not adequately prepared to address the onset of chronic illness, leaving nongovernmental organizations to lead the intervention efforts in many areas.

The rapid pace of economic growth in Asia and South America in particular over the past two decades has brought with it a rise in what experts call “lifestyle” diseases once thought to be limited to the U.S. and other Western nations. The WHO has estimated that in China, the rate of diabetes in adults is currently about 12%, compared with the 4% rate seen during the 1990s.

While smoking has declined in most Western countries, it has been on the rise in other parts of the world. The WHO estimates that about 80% of the world's 1 billion smokers reside in low- and middle-income countries. For instance, nearly 70% of all men over the age of 15 in Indonesia smoke, which costs about $1.7 billion a year in treatment of tobacco-related diseases.

Preventable diseases are responsible for 36 million deaths worldwide, making up 63% of all deaths, according to the WHO. The majority of chronic disease-related deaths—between 80% and 90%—occur in low- and middle-income countries. Nearly half of all noncommunicable deaths in these countries occur in people under age 70, compared with about 29% in the U.S.

Over the next 20 to 30 years, the most rapid growth in diabetes will be in Africa and Asia, Madden said. “In India, 51% of the people we believe to have diabetes have never been diagnosed. In the bulk of the African countries, 50% of the people have not been properly screened to even know that they have Type 2 diabetes, and frankly a few of the countries are as high as 65% to 70%.”

One of the biggest factors in the rise of chronic disease has been the steady rise in the obesity rate throughout the world, which has nearly doubled since 1980, according to the WHO. A 2013 United Nations report found that about 1.4 billion people were considered overweight, or 20% of the world population. Of that number, 500 million are obese. Especially worrisome has been the rise in childhood obesity in recent years.

The transition in developing countries and regions, including sub-Saharan Africa, from addressing infectious diseases to chronic illness is called the “double disease burden,” said Dr. Adam Slote, a senior health adviser at the U.S. Agency for International Development. Advanced countries have been able to turn their sole attention to chronic diseases since infectious diseases have been mostly eradicated or are more easily managed. Yet many developing countries have to fight both types of illnesses simultaneously.

Zoughbie launched Microclinic International in 2005 based on the concept of “social contagions.” His organization trains small groups of people who form a human network he calls a microclinic, which provides support to members to engage in healthier behavior and act as agents to promote better health throughout their communities.

The organization began its work with a microclinic project in southeastern Kentucky. It received support from local health departments to implement its model that focused on increasing access to healthy food and promoting greater physical activity among residents. Since that time, the group has set up similar projects in Africa, India and the Middle East.

“As an organization, we're trying to break down the old paradigms and establish a new one in global public health by refocusing on behaviors, whether the disease is biologically infectious or noninfectious,” Zoughbie said.

The potential health and economic burdens of chronic disease have garnered attention from government and nongovernmental health entities, which have taken steps to address noncommunicable disease in much the same way they did for the increase of infectious diseases such as HIV/AIDS. In recent years, those efforts have yielded declines in the number of new cases of HIV/AIDS as well as in the number of deaths.

“One of the victories has been that HIV, for instance, is now a chronic condition, and it's not a certain death sentence, so there are lessons back and forth (in treatment of infectious disease and chronic disease),” said Jimmy Kolker, a former U.S. ambassador and currently principal deputy assistant secretary for global affairs at HHS. He said public health workers have learned lessons from HIV programs for addressing chronic conditions. One of the lessons, Kolker said, is that prevention is the most cost-effective way of reducing the spread of both chronic and infectious disease.

Combating the increase in chronic diseases in the developing world also means addressing discriminatory attitudes toward people with chronic conditions, Madden said. “In the African and Asian countries where there is no healthcare insurance, they fear absenteeism from work will be higher so they tend not to hire those who may have a chronic condition like diabetes.”

A 2011 study by the World Economic Forum estimated the global financial cost related to the five leading noncommunicable diseases—which include cardiovascular disease, lung disease, cancer and mental illness—at about $47 trillion over the next 20 years in treatment and lost productivity.

Follow Steven Ross Johnson on Twitter: @MHSjohnson