Ending the Chronic Liver Disease Public Health Threat: Systemic Challenges Through the Patient Lens

For those with lived-experience, liver disease is not encountered as a set of discrete conditions—viral, metabolic, or alcohol-related—but through fragmented and often inaccessible systems of care. Individuals often move through multiple entry points such as primary care, emergency settings, and/or specialty clinics without clear next steps, continuity, or coordination.

What is described as “disease burden” is experienced in navigating siloed systems that are poorly designed to recognise risk early, engage people equitably, or support them across the continuum of prevention, diagnosis, and care. While the Lancet Regional Health–Europe Series brings together more than 50 co-authors to present evidence on the challenges associated with major chronic liver diseases (CLDs), the patient voice is integral. Without this, science and advocacy become not patient-centric, but merely patient-decorated.

The disconnect for chronic liver disease persists despite the availability of highly effective tools. For example, viral hepatitis can be prevented, treated, and, in the case of hepatitis C, cured. Alcohol-related harm can be reduced through well-established population-level policies. Metabolic dysfunction-associated steatotic liver disease (MASLD) can be identified and managed through risk stratification, lifestyle intervention, and approved therapies. Still, outcomes lag behind what is achievable, reflecting a failure of implementation, policy alignment, and system design.¹ A recent meta-analysis found the pooled global prevalence of steatotic liver disease (SLD) to be approximately 37.5%² with prevalence in Europe as high as 40.3%.²

A central feature of this failure is fragmentation. Patients do not experience liver disease within specialty defined silos. Individuals still experience liver care divided across hepatology, endocrinology, cardiology, and addiction services, with limited integration. This structural divide leads to missed opportunities for timely detection, inconsistent messaging, and delayed intervention, particularly for individuals living with overlapping risk factors.^3,4 The result is a system that is reactive rather than preventive, often identifying disease only at advanced stages. This is also reflected in global and national policy frameworks where CLD is unacknowledged in the presence of other conditions, including type 2 diabetes (T2D) and obesity, where the prevalence of MASLD and MASH is very high.

Stigma further compounds these barriers. Across liver diseases, individuals frequently encounter assumptions, judgment, and language that frames disease as a consequence of personal choices rather than as the outcome of complex biological, social, and environmental factors. This stigma directly influences care-seeking, engagement, and health outcomes, while also shaping policy priorities and contributing to the persistent under-recognition of liver disease.^4,5 People-first, non-stigmatising language is not just a matter of preference, but a necessary component of both clinical practice and policy reform. Addressing this pervasive stigma requires intentional framing of how diagnoses, diseases, etiologies and circumstances are viewed, starting with the language used to name and describe them.⁶

Access to care and lifestyle support programmes are also structured by policy decisions rather than individual choice. Populations most affected by liver disease—including migrants, people who use drugs, and those experiencing incarceration or socioeconomic disadvantage—face systemic barriers to testing, treatment, and continuity of care. These groups are often described as “hard to reach”, although they are more accurately understood as populations excluded by design.¹

Patients navigate environments that actively shape disease risk. Alcohol-related liver disease reflects not only individual consumption but also the availability, affordability, and marketing of alcohol, alongside policy environments influenced by industry interference, as noted in the Lancet Europe series on chronic liver disease.⁵ MASLD, now the most prevalent liver disease in Europe, is driven by food systems characterised by widespread availability of ultra-processed foods, limited regulatory protections, and built environments that constrain opportunities for physical activity.^7,8 Despite this, MASLD remains largely absent from national and regional policy frameworks, highlighting a striking misalignment between disease burden and policy response.⁷

And while there has been some progress in some European countries in combating viral hepatitis,¹ across these conditions, a consistent pattern emerges: CLD is highly prevalent, largely preventable, and increasingly treatable—yet insufficiently prioritised. This reflects a broader systems failure in which prevention is undervalued, stigma is embedded, and commercial determinants of health are inadequately addressed. The persistence of liver disease in the face of effective tools reflects not a failure of medicine, but a failure of policy, systems, and political will.

Addressing liver disease therefore requires more than advances in therapeutics. Multi-disciplinary approaches and coordination across specialties and policy are no longer optional. Integrating SLD into existing T2D, obesity, and cardiovascular policy frameworks and healthcare services should be prioritised as set forth by the draft resolution of the WHO Executive Board that recommends integrating SLD (including MASLD) into the global NCD agenda. This would integrate prevention, early detection, management, surveillance and research within national health systems, universal health coverage, and multidisciplinary action on common cardiometabolic and alcohol-related risk factors.⁹ It requires a shift toward integrated, people-centred systems of care that reflect how people actually experience disease; policy coherence across infectious, metabolic, and alcohol-related conditions; and sustained action on stigma and the commercial and social determinants that shape risk.

Contributors

JM led with conceptualisation and the initial drafting, with writing and editing from GB and RP. All authors approved the version for publication.

Declaration of interests

JM acknowledges Madrigal Pharmaceuticals for support for meeting attendance, Boehringer Ingelheim for support for meeting attendance and participation on Advisory Boards, and Novo Nordisk for participation on Advisory Boards, all outside of this work and paid to former institution. GB acknowledges GSK honoraria for advisory board meeting paid to former institution and Madrigal Pharmaceuticals support for travel to meetings outside of this work also paid to former institution. RQ acknowledges Clarion I has a consulting contract with Roche and AstraZeneca is a funder of the International Liver Cancer Patient Movement outside of this work.