NCDs and Covid-19-Reciprocal burdens.
“Burden – a load – a typically heavy load”
by Sir George Alleyne, Director Emeritus, PAHO and HCC Patron.
I participated recently in a panel that dealt with the double burden of NCDs and Covid-19 and one interpretation was that both diseases individually represented a load-a heavy load for society. There is no doubt that each separately and individually represents a heavy burden. But on subsequent reflection, I wondered if it was not more appropriate to consider the reciprocal impact of the two problems one upon the other and vice versa. This reciprocity is not sequential but simultaneous.
There are numerous reports that persons with NCDs such as cardiovascular disease, diabetes, cancer and chronic respiratory illnesses as well as obesity have a poor outcome when infected with Covid 19. Mental health issues are not to be ignored as depression and suicide have been reported during or post Covid-19. Conversely, there are now very good data that NCD services and by extension patients with NCDs suffer because of Covid-19. Health and financial resources are deviated from attending to NCDs and directed towards addressing the pandemic. The data from WHO show that three quarters of countries surveyed showed considerable disruption to NCD services.
This interaction is unique in a temporal sense – all pandemics are time-limited so this interaction will dissolve. The challenge is to make use of this unique experience to address the future pandemics that will inevitably arise and from an NCD perspective ensure that they and their attendant comorbidities do not present the same threat again. It is not often appreciated that the current demographic situation is such that unless corrective prevention steps are taken NCDs will again compromise health outcomes in future pandemics. The association between NCDs and viral pandemics is not new. The NCDs and particularly obesity increase the risk of being hospitalized and dying from influenza virus infections. In the SARS and MERS epidemics – both caused by Corona viruses, comorbidities especially from NCDs also contributed to adverse outcomes.
As part of the preparedness for future pandemics it behooves society to address prevention and control of NCDs.
There is widespread belief that as humans invade new ecological niches, zoonotic infections may reach pandemic status. There is also prediction of a novel influenza pandemic superimposed on the seasonal influenza outbreaks. As part of the preparedness for future pandemics it behooves society to address prevention and control of NCDs. I do not claim that this will eliminate the possibility of the pandemic, but it should serve to reduce hospitalization and mortality. Among the lessons from Covid-19 that have salience for NCDs is that the effort made to increase preparedness for the pandemic should not wane post-Covid but should continue to be applied vigorously, especially to NCDs. As a Lancet editorial of September 5, 2020 states “Covid 19 has shown that many of the tools required for fighting a pandemic are also those required to fight NCDs: disease surveillance, a strong civil society, robust public health, clear communication, and equitable access to resilient universal health-care systems”.
But the effort to reduce the impact of NCDs on Covid-19 should not be restricted to avoiding the decrease in NCD resources and improving the treatment of persons already suffering from NCDs. The effort must include a life course approach to prevention of NCDs. This includes attention to maternal and newborn care and also attention to the health and practices of children and adolescents. The global increase in childhood obesity does not augur well for future NCDs and in my view is nothing short of a scandal. It is particularly galling, since the responsibility rests predominantly on society given the reduced agency of the child and while there may be arguments about the relative role of epigenetics there is enough solid evidence of the efficacy of interventions such as increased taxes on sugary beverages and nutrition behavioral modification. This problem is acute in the Caribbean and represents an area of intense work by the Healthy Caribbean Coalition.
Among the lessons from Covid-19 that have salience for NCDs is that the effort made to increase preparedness for the pandemic should not wane post-Covid but should continue to be applied vigorously, especially to NCDs.
Specific reference is made to resilient health systems as being applicable to both Covid-19 and NCDs. Such systems should be aware, agile, adaptable and articulated and although all of these are critical, I would stress the awareness aspect. This will be achieved through efficient data capture as part of the basic information systems that must be the bedrock of universal health coverage. The Caribbean is relatively well served in this area, given the mandate of CARPHA.
It is customary and natural to look for approaches that will seize the moment when the hysteria surrounding Covid-19 is highest to make the case for the reciprocity of burden and say almost ritualistically that the basis of action must be intersectoral. I will not deny this truth but would add that much more attention has to be paid to those who are currently suffering from NCDs and therefore at highest risk. The NCD epistemic community must be widened to include the billions of people living with NCDs whose aggressive advocacy should be loud during Covid and perhaps at a higher volume post Covid. One of the roles of civil society is the amplification of these voices and I congratulate the Healthy Caribbean Coalition for paying special attention to that group of persons.
Luckily there is no talk of laying down the burden of NCDs by any Caribbean riverside. The task is to prevent citizens from taking it up or to try to lighten the load of those who already are burdened.