Non-communicable diseases in Pakistan

Interview

Muhammad Arshad

Non-communicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. Such diseases are of a long duration, have a prolonged course and usually have slow progression. It is rare to have a complete cure for such diseases. NCDs kill 38 million people every year across the world. Some three-fourths of these deaths occur in the low and middle-income countries. 16 million of these people are less than 70 years of age.
There are four main types of non-communicable diseases, also called chronic diseases, namely cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma) and diabetes. These are modifiable and nonmodifiable. Obesity is now also considered a proper disease and with DM, it comes second. Nonmodifiable risk factors include age, gender, family history, ethnicity and prior stroke or heart attack. One’s socioeconomic status plays an important role in NCDs.
They are more disastrous in the lower socio-economic group and, on the other hand, can be dealt in a better way if the socio-economic status is high as treatment is easily accessible.
Middle and low income countries should work to make their infrastructure stronger to tackle these modifiable factors by making drugs and proper healthcare more accessible, as this can have a dramatic impact on the general picture of the country, by following WHO guidelines made for such countries.
There is no particular age or region which is affected by NCDs in a country. It could be any age and any region. Children, adults and the elderly are all equally susceptible to risk factors that play a part in increasing the risk of non-communicable diseases.
These diseases are also accelerated by the age factor, fast and unplanned urbanization and the global acceptance of unhealthy lifestyles and life patterns. For example, globalization of unhealthy patterns of life like unhealthy diet (increased consumption of junk food and no exercise) patterns may cause individuals to have raised blood pressure, higher levels of blood glucose and excessive weight gain. These are called ‘intermediate risk factors’ which can cause cardiovascular disease.
NCDs in Pakistan are on the rise when compared to other Asian countries. 52.1% males and 53% females die of NCDs in Pakistan under the age of 70 as per research conducted by WHO in 2014. Compared to other countries, the death ratio of male to female in India was 62% and 52.2%, in China it was 39.7% and 31.9%, in Bangladesh 49% and 49.6%, in Sri Lanka 48.8% and 35.8% and in Thailand it was 45.5% and 38.7%, respectively. These figures indicate that Pakistan has a greater percentage of deaths due to NCDs. We can say that it is alarming and may be primarily because there is limited awareness and almost no efforts are made to prevent such diseases.
There is a rising trend seen in heart failure which means that the basic screening at primary health care level is needed and more resources are required to make it more efficient so that basic subtle signs of initial disease are not missed which will help in the long run to decrease the cost of hospitalization of heart failure management.
Pakistan is ranked in the top 10 countries globally for people with diabetes aged 20 to 79 years. There is a high prevalence of diabetes in Pakistan with 50% undiagnosed individuals. There is also a prevalence of Type 2 diabetes in Pakistan which is at a high at 7.6 % (5.2 million people) and is expected to increase to around 15% (14 million people) by 2030 as per research conducted in 2015 by WHO.
We also have the highest rate of breast cancer in South Asia with 60 to 70% patients in advanced stages. It is the most common cancer affecting the female population in Pakistan as it kills nearly 40,000 women every year. Its incidence in Pakistan is 2.5 times higher than in neighbouring countries like Iran and India.
The prevalence of hypertension is 50 percent in the adult population above 50 years of age, while 30 percent in people around 30 years of age and 5 to 7% among children. The prevalence of essential hypertension is increasing at an alarming rate in Pakistan which is about 3 to 4% in childhood and sharply rises when people are nearing middle age.
These figures illustrate an apparent lack of precautionary measures, appropriate treatment and a general lack of budget allocation to such health issues. NCDs are predicted to increase in the future and not much is being done to control these diseases even though there is a dire need to.
Pakistan is not really equipped or ready to deal with the NCDs that have dangerously hit the people. Currently, the provinces are responsible for structuring the policies for such diseases tailored to local needs. The allocation for the health sector has significantly risen from 4 to 6% of the budget in 2010 to 8 to11% of the budget in 2012. Unfortunately, this is not appropriate as most of it goes towards curative care and the health system does not have the ability for the prevention and control of NCDs.
There is a significant lack of understanding of the importance of tapping on early detection, early management and prevention and they are still not catered to as they should be. They are still not appropriately addressed and the available resources are not used to lessen the causes of NCDs. There is a need to review the health policy and health sector budgeting so that the needs of healthcare for NCDs can be met.
Though there is a department for NCDs in the Ministry of Health, but unfortunately there is no operational national policy. There are also no policies or action plans in place to reduce the use of alcohol and tobacco and to increase physical activity of people, nor any programs that encourage healthy diet patterns on a national level, though these exist very much in some private hospitals where they are doing a great job but are only accessible to those who can spend a hefty amount of money and are also very few in comparison to the general population.
Affordability is a big issue as the masses are unable to afford a proper quality drug but some MNCs have a good way to promote their drugs which need to be communicated well to the masses. Even though there is minimum support from the government, the MNCs are playing a positive role in developing such medicines. Initiatives must be taken to strengthen the promotion of public health and medicines. The sale of spurious medicines is on the rise and medicines are still smuggled. Lack of knowledge and resources among the patients causes them to buy fake medicines which increase the incidences of NCDs. The pharmaceutical industry can only support when there are strict rules and regulations imposed by the government to control such issues.
A very small percentage of structurally trained doctors are struggling to provide proper primary care but that needs to be done on a mass /national level by restructuring health care by making primary care accessible to people.
Our primary care is unfortunately done by completely untrained physicians or by quacks who are playing a horrendous role and jeopardizing important lives of people. Early detection of NCDs is limited and even the physicians in the urban areas can’t do much because the policies, programs and the budget do not support them so forget about rural areas!
The main risk factors of NCDs, if recognized and avoided, could cause a reduction of deaths by 600,000 between 2015 and 2025. Simple cost-effective measures can be taken to make visible changes in reducing NCDs. Basically, these include lifestyle modification strategies i.e. incorporating exercise in the daily routine, having a balanced diet by decreasing junk food consumption, including soft drinks and fruit juices, decreased intake of salt in everyday cooking and decreasing tobacco and alcohol use.
Pakistan is one of the first developing nations to devise a comprehensive National Action Plan to address NCDs. At the moment, the focus of policy and planning is only disease-related but it must be health-oriented, specifically focusing on primary care, preventive measures and the promotion of health. As of now, the best strategy that can be used to manage NCDs is focus and implementation of primary prevention.
Several interventions like taxation, law enforcement by government bodies and using a portion of philanthropic funding for primary care should be introduced. There should also be commissions at the provincial level to prevent and control NCDs where professional and public sector representatives could work together towards modifying NCD risk factors, take on legislation and set goals and targets in the public and private sector. The funds for the commission can come from tax levies on tobacco, sweetened drinks and fast food, besides joint funds from the philanthropic segment.
The government should establish strict rules and regulations so that such practices do not prevail. Seminars, workshops and public service messages can be used as tools to do so. This should be at the governmental level but due to the limited involvement of the government, the private sector can take such initiatives. At the same time, they can also positively influence the government to take such initiatives. Ethical practice is the key to reducing the spread of NCDs. The practitioners, the pharmaceutical industry and the government can together make a positive impact and really help in lowering the frequency of such diseases.
Dr. Ambreen Javed is a 3rd year resident in the Family Medicine department at Aga Khan Hospital, Karachi.

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