Non-communicable diseases in the developed world
Infectious diseases are now under control almost everywhere. But growing incomes and lives that last longer, but demand less, have replaced germ-borne diseases with those which have no single cause: cancer, cardiovascular disease, chronic lung diseases and diabetes, to pick the four leading horsemen of the modern apocalypse.
In 2012, non-communicable diseases were responsible for 68 per cent of all deaths globally, according to statistics from the World Health Organization (WHO). Almost three quarters of these deaths occur in low and middle-income countries. Cardiovascular diseases, which include heart disease and stroke, are by far the largest killers, claiming 17.5 million lives in 2012, followed by cancer (8.2 million) respiratory diseases (4 million) and diabetes (1.5 million).
Margaret Chan, director-general of the WHO, warned last year of a lack of capacity to act, especially in the developing world. “Our latest data show that 85 per cent of premature deaths from non-communicable diseases occur in developing countries,” she told a meeting in New York. “The challenges presented by these diseases are enormous. They demand some fundamental changes in the way social progress is measured, the way governments work, the way responsibilities are assigned and the way the boundaries of different government sectors are defined.”
What good choices can do is to improve the odds: immortality is not yet on offer
The common factor is lifestyle. People live longer but do less, spending their lives in sedentary occupations that require little physical exertion. Diseases that favour the elderly have a much larger canvas upon which to work. Food has never been cheaper or more plentiful, but overeating and under-exercising is a toxic cocktail, leading to obesity and increasing the risks, especially of diabetes. Tobacco is a causative factor in three of the top four non-communicable diseases. Alcohol, too, plays a role.
Good choices can reduce the risks for individuals, but not eliminate them. While life expectancy has risen, the maximum age reached by exceptional individuals has changed little. There are many more centenarians than there were, but none of them reaches the age of 120. Cancer, a disease driven by multiplying errors in the copying of DNA, will eventually account even for the most abstemious. What good choices can do is to improve the odds: immortality is not yet on offer.
Knowledge alone is not enough. Anyone who has not been living in a cave must by now be familiar with the advice about diet and lifestyle that is pressed upon them from every side. Yet progress is slow and the statistics suggest that emerging economies have failed to learn from the developed world and are condemned to retrace the same evolutionary path. While death rates from heart disease fell rapidly in Western Europe, the United States and Australasia between 1980 and 2010, they rose in most of Asia.
How to respond divides policy-makers. Apart from the single issue of tobacco, around which all can rally, opinions differ. Should the role of governments be limited to providing advice and information, or should legislation be used to enforce changes in food composition and availability? It depends on whether you believe consumers are sovereign and entitled to make their own mistakes, or are the dupes of producers who care little for the consequences of their actions. This is a philosophical rather than a medical question, and the answers provided by politicians reveal how difficult it is to walk the tightrope between nannying and neglect.
The responsibility deals on food and alcohol introduced in the UK by the Coalition Government bring out these disagreements. The aim is to move food and drink producers towards healthier products and promotions by voluntary agreement. They have achieved some success, according to Professor Susan Jebb, the Oxford nutritionist who chairs the Department of Health’s Public Health Responsibility Deal Food Network.
She says 70 per cent of high-street chains are now committed to calorie labelling, half of food producers are committed to reductions in saturated fats and two thirds to salt reductions. “A good start had been made in reducing sugar in soft drinks and in portion sizes in confectionery,” she told a London conference recently. But she admitted that efforts to come up with a code on responsible promotion had so far failed.
For her efforts, Professor Jebb has been portrayed as the pawn of the food industry. At the same meeting where she made her claims, Professor Graham McGregor, a long-term campaigner for salt reduction who has now also turned his attention to sugar, dismissed the responsibility deal and accused the food industry of “slowly poisoning us”. He called for a ban on the marketing of unhealthy food. “Jeremy Hunt [Health Secretary] doesn’t want to do it,” he said. “We have got to force him.” Food policy is not an arena for the faint-hearted.
Similar disagreements have arisen in healthcare. The National Institute for Health and Care Excellence has recommended a lowering of the threshold for prescribing statins, cholesterol-lowering drugs shown to reduce deaths from heart disease. Some doctors object that this risks medicalising millions of healthy people to achieve benefits, which at the individual level would be small, even if collectively they saved many lives.
“The benefits in a low-risk population do not justify putting approximately five million more people on drugs that will then have to be taken lifelong,” wrote a group of doctors that included the President of the Royal College of Physicians, Sir Richard Thompson, and the former chairwoman of the Royal College of General Practitioners, Dr Clare Gerada, in a letter to The Times. According to another signatory, Professor Simon Capewell, an expert in clinical epidemiology at Liverpool University, the recommendations “are deeply worrying, effectively condemning all middle-aged adults to lifelong medications of questionable value”.
GPs were also enraged by the suggestion that people worried about cancer should be able to refer themselves for specialist tests, bypassing the GP altogether. Cancer is frequently diagnosed late in the UK, one cause of which may be GPs’ reluctance to refer suspicious cases for further tests. In other healthcare systems, with better reported outcomes, it is possible to go directly to a specialist.
In treating non-communicable diseases, doctors often find themselves playing catch-up. By the time the condition is diagnosed, the pattern of behaviour that contributed to it is firmly established. What many people need is less a doctor, more a life-coach. As the WHO’s Dr Chan observed, what is missing is not so much knowledge as a capacity to act.