Chronic conditions policies: oral health, a felt absence

Abstract

The global health scenario shows an epidemic of non-communicable diseases that lead to long-term chronic conditions, some of which are incurable. Many infectious diseases, owing to their development and length, also generate chronic conditions. Similarly, non-morbid states, such as pregnancy, and some life cycles such as adolescence and ageing, follow the same logic. Among all these chronic conditions there is a significant interrelationship with oral health, both in parallel events and common risk factors. This article presents cross-sectional qualitative research into World Health Organisation recommended health policies to address chronic conditions. Several documents published by the organisation were analysed to verify the presence of references to oral health in relation to chronic conditions, particularly cardiovascular diseases and diabetes as these most frequently have oral manifestations. The analysis showed no significant references to oral health or its indicators within the published texts. The study recognises the value of the work developed by the World Health Organisation, as well as its worldwide leadership role in the development of health policies for chronic conditions. This article proposes a coalition of dentistry organisations that could, in a more forceful and collective way, advocate for a greater presence of oral health in drafting policies addressing chronic conditions.

INTRODUCTION

In May 2010, the United Nations (UN) General Assembly adopted a resolution on prevention and control of non-communicable diseases (NCDs) calling for:

• •A high-level NCDs meeting of the General Assembly in September 2011 to discuss NCDs at a high-level plenary meeting, scheduled for September 2010, for a review of the Millennium Development Goals (MDG)
• •A Secretary-General’s report on the global status of NCDs in preparation for the September 2011 meeting.

That resolution marked a special moment in addressing NCDs at the global level, which began nearly 20 years ago with the Global Burden of Disease Project (GBDP). Commissioned in 1991 by the World Bank, the GBDP provided the first standardised, data-driven evidence of the impact of NCDs not only in high-income countries but also in low and middle-income countries. Since then, GBDP updates have made clearer the toll of NCDs worldwide. Approximately 60% of the world’s mortality, or 35 million deaths in 2005, resulted from NCDs (cardiovascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes), including key risk factors such as tobacco and alcohol use, unhealthy diets (high in sugars, salt, and trans fats) and insufficient physical activity. While the proximate causes of these diseases are individual lifestyle behaviours mediated by socio-environmental factors, the globalisation of alcohol, food processing and tobacco marketing, as well as industrialisation and urbanisation, have contributed to the increase of NCDs, demanding improved global collective action in response¹.

That United Nations (UN) resolution was the second such resolution in the entire history of the World Health Organisation (WHO). A decade ago, at a similar meeting on human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), the Global Fund for HIV/AIDS, Tuberculosis and Malaria was created, this being a revolutionary new global health funding mechanism. Non-communicable diseases remain neglected despite their social parallels with HIV. As with HIV there have been misconceptions. Although NCDs have been thought of as diseases of the wealthy, this is not correct. Another common fallacy is that NCDs stem from a moral failure in that weakness of will leads to obesity or sedentary lifestyles. In many parts of the world people face major barriers to making healthy choices and face powerful pressures to adopt unhealthy ones. The MDGs did not include non-communicable diseases even though they account for 60% of global deaths. Most of the morbidity and mortality caused by chronic diseases are preventable. Because non-communicable diseases are not part of the goals, development agencies fail to prioritise them; health ministers in turn do not seek support for prevention and control because of the lack of available funding. As a result, little research can be done on how to prevent and treat these conditions, and this allows the argument that there is weak evidence for intervention. Currently, more than half of the world’s population lives in urban settings. Slums need corner food stores that sell fresh produce, not just packaged junk at cheap prices and a long shelf-life. Margaret Chan, WHO’s Director-General, stated that ‘Today, many of the threats to health that contribute to NCDs come from corporations that are big, rich and powerful, driven by commercial interests, and far less friendly to health’².

Non-communicable diseases are a low global health priority despite their economic and human burden on countries. The prioritisation of NCDs for UN institutional support can raise its visibility as a critical health and development challenge. Global initiatives on NCDs are fragmented. Although WHO has provided technical leadership on NCDs, it lacks the political authority and governance to motivate concerted action by the wide range of global stakeholders. Multisectoral collaboration is mandatory, although the private sector role in addressing NCDs is also absolutely critical. Partners must be selected cautiously, avoiding any suggestion of policy influence not based on evidence and ethical standards. Multisectoral collaboration should also be taken into consideration in private sector initiatives¹.

Deaths from NCDs are only a small fraction of the problem given that these diseases also inflict a major toll on quality of life and healthy and happy ageing. The growth in the incidence and mortality of NCDs is projected to disproportionately affect poor and disadvantaged populations, thereby contributing to the ever-widening health gaps between and within countries³.

A formal meeting of UN member states to conclude work on the comprehensive global monitoring framework, including indicators and a set of voluntary global targets for the prevention and control of non-communicable diseases, took place in Geneva on 5–7 November 2012. The session was attended by representatives from 119 member states, one regional economic integration organisation, one intergovernmental organisation and 17 non-governmental organisations (NGOs)⁴.

This meeting restated that cancer, diabetes and heart diseases are no longer diseases of the wealthy, they now hamper the people and the economies of the poorest people even more than infectious diseases. This represents a public health emergency in slow motion. NCDs are a major cause of poverty, a barrier to economic development and a neglected global emergency, which demand joint efforts to be overcome. In May 2009, the NCD Alliance was launched by the International Diabetes Federation, World Heart Federation and Union for International Cancer Control to represent the millions dying and affected by NCDs across both the developing and developed world, and prevent further spread of the NCD epidemics. In February 2010, the NCD Alliance was joined by the International Union against Tuberculosis and Lung Disease as a full partner. The NCD Alliance will drive forward five areas of work for presentation to the UN Summit by: leading a civil society movement for NCDs; producing evidence-based arguments to support the NCDs cause; acting as the global voice of its members and people with NCDs; creating a 2020 Roadmap for NCDs and sharing innovative solutions and best practice on NCDs; working with like-minded NGOs, governments and businesses to take forward NCD Alliance key ‘asks’ for and from the UN Summit⁵.

In recent decades several national and international guidelines have been produced on the management of chronic conditions, although they are too complex for application in primary care, especially in low-resource settings. The Global Status Report on Non-Communicable Diseases 2010 (http://www.who.int/nmh/publications/ncd_report2010/en/) highlights the need for countries to integrate NCD prevention and management into primary health care even in low-resource settings. The WHO has identified an essential package of cost-effective interventions with high impact, feasible for application in resource-poor settings⁶.

At the end of the 2011 Conference, 193 member states signed the Political Declaration on Prevention and Control of NCDs, which included Article 19 stating ‘that renal, oral and eye diseases pose a major health burden for many countries and that these diseases share common risk factors and can benefit from common responses to non-communicable diseases’. The President of Tanzania, H.E. Jakaya Kikwete, highlighted the importance of oral health in the context of the four main types of NCDs by hosting a side-event at the high-level UN meeting, called ‘Putting Teeth into NCDs’. At this meeting, many authorities advocated on the need to increase efforts to strengthen the prevention and control of oral diseases, which are often neglected despite their tremendous impact in most countries. They made persuasive cases for the inclusion of oral health in the decisions of the UN heads of state regarding national strategies to address NCD burdens⁷.

Dental caries is the most common chronic disease in the world, affecting more than 90% of the world’s population. All other mouth diseases, including oral cancer, periodontal disease, craniofacial trauma and disorders, and Noma (a deadly disfiguring disease of children in sub-Saharan Africa), have significant impacts on general health, wellbeing and productivity throughout life. Safe and affordable oral care is often not available for large parts of the population in low- and middle-income countries. In addition, there are also high-income societies where millions live without access to oral health-care⁷.

Both NCDs and oral diseases share common risk factors and are linked in reciprocal ways. The mouth can be a mirror for systemic diseases that manifest themselves there; similarly, oral diseases can have an impact on systemic conditions. Policies that address risk factors for oral illnesses, such as the intake of sugars, tobacco and alcohol, address the very same risk factors associated with cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Other factors, such as lack of clean water and sanitation, poor education, low socio-economic status and poor housing, are determinants of general health and oral health alike. In 2011 the WHO regional office for Africa convened 17 francophone chief dental officers in Ouidah, Benin, and produced a consensus statement conveying the importance of integrating oral health into NCD programmes addressing tobacco control, healthy diet and fluoride. Oral health staff at the Pan American Health Organisation, the WHO regional body responsible for the Americas, are working to integrate language and metrics into the regional targets and indicators as the global monitoring framework evolves. The World Dental Federation (FDI), representing the dental profession worldwide, has released support material that will assist national dental associations in their advocacy with national governments to incorporate oral health into their national NCD strategies⁷.

The common risk factor approach addresses risk factors common to many chronic conditions, including oral health, within the context of the wider social environment. As causes are common to a number of other chronic diseases, adopting a collaborative approach is more rational than one that is disease specific. The immediate causes of major dental diseases, caries and periodontal disease are diet, plaque and smoking. Oral mucosal lesions, oral cancer, temporomandibular joint dysfunction and pain are related to tobacco, alcohol and stress, trauma to teeth and other injuries. As these causes are common to a number of other chronic diseases such as heart disease, cancer, diabetes and strokes, it is rational to use a common risk factor approach that can be implemented in a variety of ways. Oral diseases are the most common of the chronic diseases and are important public health problems because of their prevalence and their impact on individuals and society, as well as the cost of their treatment. Chronic diseases such as obesity, diabetes and caries are increasing in developing countries, with the implication that quality of life related to oral health, as well as general quality of life, may deteriorate8., 9., 10..

In the interconnected treatment of oral health and chronic diseases there is evidence about how fewer hospitalisations of diabetic patients could be achieved through periodontal therapy, and further studies are analysing other chronic diseases and conditions such as heart attacks, strokes and pregnancy with preterm birth. Periodontal treatment has been associated with a significant decrease in hospital admissions, physician visits and overall cost of medical care in diabetics. Referring to this approach, a study showed average savings of US$1,814 per patient in a single year and a 33% decrease in hospital admissions¹¹.

Based on these facts, our research intended to identify how much oral health is considered in the elaboration of public health policies aimed at improving care for chronic conditions, especially those related to cardiovascular diseases and diabetes.

METHOD

This research used a cross-sectional qualitative approach. Data were collected between 5 December 2012 and 10 December 2012 from the ‘media centre’ section of the WHO website (http://www.who.int), searching with the expression ‘non-communicable diseases’. This resulted in 12,000 publications being found. This was reduced to 45 publications by filtering in the advanced search mode and asking for ‘Find results with all of the words, 100 results, Language English, File Format.pdf, Occurrences in the title of the page, Domain who.int, Sort by date’. These documents were reports, conference abstracts, plans of action, manuals and guidelines. All of these are stored in public and open Internet archives. Two were unavailable. The analysis of the remaining 43 documents occurred from 12 October 2012 to 15 December 2012, using the Windows 7 ‘find’ tool to identify the following keywords: oral health, dental caries, periodontal disease.

RESULTS AND DISCUSSION

In the 43 publications analysed, ‘oral health’ appears seven times, ‘dental caries’ four times and ‘periodontal disease’ does not appear. The inexpressive presence of ‘oral health’ could be attributed to a broad approach to health with no compartmentalisation. What became of the most prevalent oral chronic conditions: ‘dental caries’ and ‘periodontal disease’? The NCDs issue has become globalised beyond the capacity of any single country or organisation and multisectoral collaboration should be taken into consideration. Private sector initiatives such as the Global Alliance on Chronic Diseases, formed in June 2009 to mobilise resources for NCDs research in developing countries, have demonstrated efficacy¹.

Misunderstanding of non-communicable diseases, with people facing barriers to making healthy choices and facing powerful pressures to adopt unhealthy ones leads to similar causality in oral health. Similar to the HIV meeting, the UN high-level meeting on non-communicable diseases is a battleground, pitting public interests against powerful private ones. However, unlike the HIV activism of the past, the voices of people affected by NCDs are mostly quiet. Whether or not the UN meeting encourages the emergence of a global social movement for change will shape the future of our health for years to come².

The inclusion of oral health in the Political Declaration issued by the UN heads of state and sponsored by WHO is a collaborative effort of many players and organisations. Many of the same, and other participants will support national planning, implementation and evaluation of integrated NCD strategies. These efforts involve clinicians and their representatives, dental educators, researchers, public sector administrators, policy-makers and industrial leaders, as well as NGOs working with disadvantaged populations nationally and globally⁷.

It is well established that partnerships and collaborations are essential to success in the international fight against non-communicable diseases. Therefore, the American Cancer Society, the American Diabetes Association and the American Heart Association have joined forces to support the UN effort. This work is being conducted under the banner of the Preventive Health Partnership, a joint initiative founded in 2004 to work together to reduce the burden of cancer, diabetes mellitus, cardiovascular disease and strokes. The international goal is to raise awareness about the burden of NCDs globally by providing key policy and media stakeholders with technical assistance to inform policy discussions, along with resources that highlight the global burden of NCDs and the need for coordinated interventions³.

A global monitoring framework, including 25 indicators and a set of voluntary global targets for the prevention and control of non-communicable diseases, were integrated to develop a draft WHO global action plan for the prevention and control of non-communicable diseases. This plan, covering the period 2013–2020 was submitted to the 66th World Health Assembly, through the Executive Board, and approved. Among the 25 indicators there are none related to oral health⁴.

A coordinated and resourced programme of work by civil society in the lead up to and immediately after the UN summit will be essential to its success. The four leading NCD federations – International Diabetes Federation (IDF), World Heart Federation (WHF), Union for International Cancer Control (UICC) and The International Union Against Tuberculosis and Lung Disease (The Union) – have coordinated the global civil society response through the creation of an NCD Alliance that has worked alongside NGOs, the WHO, health professionals, academia, the private sector and other stakeholders to form a powerful and united voice⁵.

The WHO guideline objectives stated that the primary goal is to improve the quality of care and outcomes in people mainly in low-resource settings. This guideline provides a basis for the development of simple algorithms for NCD management with essential medicines and technology available in first-contact health services in low-resource settings. It recommends a set of basic interventions to integrate NCD management into primary health care. The recommendations are limited to patients with certain chronic conditions, as the more complex management of other conditions requires more specialised care. The target users are health-care professionals responsible for developing NCD treatment protocols, which will be used by health-care staff in primary care units in low-resource settings. A guideline development group was created and included external experts and WHO staff. In one specific case it resulted in a 72-page guideline for cancer, heart disease and stroke, diabetes, and chronic respiratory disease. Surprisingly, there is no mention of oral health, dental caries, periodontal disease or dentists⁶.

Since 2000 there has been evidence that further improvements in oral health and a reduction in oral health inequalities will only be secured through the adoption of oral health promotion policies based upon the common risk factor approach. Individually focused oral health education interventions are ineffective, wasteful of limited resources and may increase inequalities. The same applies to policies on NCDs, which must address risk factors common to many chronic conditions within their context. The potential benefits of such an approach are far greater than isolated interventions. To be effective in this style of working oral health professionals need to develop a range of networking and communication skills to enable them to work collaboratively with other agencies and professionals8., 9..

In October 2012, the FDI called upon its member national dental associations to contact their minister of health and chief dental officer: the goal was to ensure that concrete measures to integrate oral health into NCD strategies were debated during the WHO consultations. For its part, the FDI has submitted detailed comments on the WHO ‘Zero Draft’ document, which, without strategies and policies to ‘maximise opportunities and efficiencies for mutual benefit’ measures for monitoring progress, consigns oral health to the realm of good intentions rather than solid actions. The FDI noted that what is most important is non-communicable disease policies through effective prevention and early diagnosis by primary health-care and multi-stakeholder interventions, to reduce the cost of NCDs to the public, governments and national health-care systems. In its submission, the FDI pays due regard to current constraints within the WHO. It emphasises, nonetheless, that it is essential ‘to recognise the important role of the WHO in the global health leadership by retaining the Oral Health in the Work Programme proposal and among the priorities in the fight against NCDs’¹².

According to these concepts, Curitiba, in southern Brazil, has been innovating in dealing with chronic conditions, using a chronic conditions care model developed for the Unified Health System (SUS). Family health teams are formed by individuals from different disciplines such as the family doctor and community nursing staff, the oral health team, social worker, pharmacist, psychologist, nutritionist, physiotherapist, physical education teachers and community health agents. They work together, interconnected by health-care networks, providing health care for a specific community¹³.

The WHO Global Action Plan for Prevention and Control of Non-communicable Diseases 2013–2020 contains specific mention of oral diseases. The plan was adopted by WHO member states on 27 May at the 66th World Health Assembly (Geneva, May 20–28, 2013). The reference to oral diseases reflects government commitment in the 2011 UN Political Declaration on NCDs, which recognises that oral diseases share risk factors with the four major chronic diseases: cancer, diabetes, cardiovascular and respiratory disease, and thus benefits from a common approach. However, there are only two mentions of oral diseases in the 55-page document¹⁴.

CONCLUSION

The WHO has played an undisputed leadership role in combating chronic conditions around the world through largely efficient health policies. These actions have already brought many benefits to millions of people. Partnerships with several organisations in different areas seem highly positive. Nevertheless, it is undeniable that oral health has been overlooked in policies aimed at combating chronic conditions, particularly cardiovascular diseases and diabetes where there are more interactions and oral manifestations. In addition, oral health associations should establish partnerships and/or alliances to advocate with the WHO for multisectoral policies geared primarily for those professionals who work in primary care. Health-care networks should fulfil their role of interconnecting teams, leveraging what is offered by established policies developed in consensus with the various sectors involved.

Conflict of interest

None declared.