Catalysing the response to NCDI Poverty at a time of COVID-19

Nelson Mandela wrote ”Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right to dignity and decent life.”¹ In a world where there are increasing numbers of super-wealthy individuals, some with a personal wealth larger than the gross domestic product of entire countries, a catastrophic level of poverty affects the lives of about a billion people.² Over 90% of the poorest billion live in low-income and lower-middle-income countries (LLMICs) in sub-Saharan Africa and south Asia, and about 80% of them are younger than 40 years.³ What can be done about this injustice?

The Lancet NCDI Poverty Commission⁴ presents a novel approach, with a strong equity framing, to non-communicable diseases and injuries (NCDIs) of the global poor. The findings and recommendations of this Commission advance our knowledge and framing of these multifactorial conditions. This comprehensive report makes us listen to the voices of our poorest patients and brings into context data on what has been achieved and where the global health community and governments have failed in the past decade. The Commission's new analyses highlight the importance of moving from individual responsibility to multisectoral responsibility to address NCDI Poverty. Led by Gene Bukhman and Ana Mocumbi, the Commissioners' report proposes a fundamental shift from the prevailing global framing of NCDs, which focuses on five diseases and five risk factors,⁵ to a broader set of conditions and risk factors among younger populations. The Commission challenges the current narrow framing of NCDs based on an outdated concept of epidemiological transition,⁶ whereby these diseases only emerge with advancing age, increasing affluence, and urbanisation. As the global poor are mainly younger than age 40 years, many NCDs, such as rheumatic heart disease, congenital heart disease, and peripartum and other cardiomyopathies, lead to heart failure and premature death in young populations.⁷ The authors call for Sustainable Developmental Goal (SDG) targets 3.1 on maternal mortality and 3.2 on under-5 mortality to be separated by causes of death to identify the role of specific underlying NCDs. Furthermore, SDG 3.4, which tracks deaths from cardiovascular disease, cancer, diabetes, mental ill-health, and chronic respiratory diseases only in individuals aged 30–70 years, needs to be expanded to encompass all ages, and other NCD causes.

The Commission highlights inadequate development assistance for NCDIs. An important role has been assumed by the UN system, with WHO alone responsible for 20% ($164 million) of NCDI development financing in 2017, showing technical leadership in this field.⁸ A key message of the report is that “international development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care”.⁴

The Commission's recommendations are addressed to national governments, ministries of finance, national civil societies, and research institutions, among others. Some of the key recommendations are aimed at making NCDI Poverty a global priority in the SDG area through national governments adjusting priorities-based approaches to best available local data on NCDIs, and the specific needs of the poor. Structural reforms for quality and innovations in integrated service delivery, including prevention, medical management, surgery, and palliative care at primary, secondary, and tertiary levels, are identified as one of the key priority areas for cost-effective intervention.

Efforts to tackle NCDI Poverty also need to address the social determinants of health, such as improved housing, household energy, food security, education, and transportation. To facilitate these key recommendations, international development assistance for health should be substantially augmented with a focus on poor populations.

The Commission highlights some progress made in the past few years in delineating NCDI burden, catalysing financing, and developing partnerships, such as the Disease Control Priorities Project 3rd edition⁹ and the Commission launching an NCDI Poverty Network to focus on integrated delivery strategies for locally prioritised interventions.

© 2020 Tommy Trenchard/Panos Pictures

Crucially, the Commissioners call for global solidarity to tackle NCDI Poverty and bridge a gap in universal health coverage, including access to surgery. There is increased awareness of the lack of access to cardiothoracic surgery in LLMICs. The formation of the Cardiac Surgery Intersociety Alliance, supported by global cardiothoracic societies, with the goal of consolidation of cardiac surgical efforts within LLMICs, is a promising move.10, 11

Multisectoral action against NCDIs will be crucial, involving ministries of health, finance, energy, transportation, and social protection, as well as civil society groups, research institutions, and professional organisations. An example of the part that professional groups can play is the 2020 joint statement of the World Heart Federation and the World Stroke Organization that called on governments to deliver radical shifts in public health policy to deliver progress on cardiovascular disease and stroke prevention.¹² The two organisations urged governments to move away from the approach of individual clinical risk factor screening towards investment in primary prevention at the population level. By placing all our bets on identifying and treating diseases of the circulatory system, we are missing the opportunity to intervene on their shared causes much earlier in the prevention timeline where the costs are lowest.

In 2020, the global response to the COVID-19 pandemic could hold some lessons for tackling NCDIs. Many LLMICs responded swiftly to the pandemic and implemented measures, such as lockdowns, physical distancing, and use of face masks, much faster than some high-income countries.¹³ The importance of community-appropriate advocacy to communicate public health measures became clear.¹⁴ One example of swift government action is how South Africa implemented novel approaches, including a ban on the sale of tobacco and alcohol for some months followed by restricted access.¹⁵ Although these measures led to reductions in road traffic crashes and crime, allowing the reprogramming of hospital beds to accommodate COVID-19 patients, they impacted negatively on the economy and the broader COVID-19 response disrupted some routine health services.¹⁵

Importantly, the pandemic has exposed deep inequalities in our societies and the world's poorest are among those most severely impacted. As the Commission describes, projections of extreme poverty have increased because of the pandemic and about 71–100 million people, most in sub-Saharan Africa and Asia, are likely to be pushed into extreme poverty because of the COVID-19 pandemic. Action to address economic inequalities and improve the lives and wellbeing of the poorest billion must be at the heart of efforts to rebuild our societies. It is in all our interests to improve the world we share in terms of the prevention of disease and access to health care. The Commission's report provides a much-needed, comprehensive analysis of NCDI Poverty and the achievable key interventions to make a substantial change. It calls on all of us to build global solidarity. Overcoming NCDIs linked to poverty is not a gesture of charity. It is an act of justice.