The theory of epidemiological transition (or the changing patterns of population age distributions, mortality, fertility, life expectancy, and causes of death) offers a valuable framework for understanding how different types of diseases can occur simultaneously in a population. However, it can also put too much focus on non-communicable diseases (NCDs), when what is needed is a systemic approach to the social determinants of health.
The same warning applies in the opposite direction; the COVID-19 pandemic cannot disrupt efforts or distract us from the need to ensure access to health and well-being, including promoting, preventing, and treating chronic diseases.
According to the World Health Organization, 41 million people die every year from NCDs, the equivalent of 71% of the world’s total deaths. The four NCDs that cause the highest mortality are:
- cardiovascular diseases (17.9 million people a year)
- cancers (9.3 million people)
- respiratory diseases (4.1 million)
- diabetes (1.5 million)
As the COVID-19 pandemic has revealed, the global health picture can no longer be characterized simplistically as NCDs impacting developed countries and communicable diseases impacting developing countries. NCDs seriously affect people in low and middle-income countries (LMICs), where 77% of global NCD deaths (31.4 million) occur. These diseases are usually associated with older age groups, but more than 15 million of all deaths attributed to NCDs occur between the ages of 30 and 69. An estimated 85% of these deaths occur in LMICs.
NCDs are a problem worldwide, affecting countries of different development levels, as made explicit in target 3.4 of the Sustainable Development Goals (SDGs): “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.”
Reducing deaths from NCDs
Some of the actions needed to achieve target 3.4 are sectoral in nature, such as efforts to increase access to new generations of medicines in LMICs. For example, in many countries, including Brazil, the cost of immunotherapies for cancer treatment is prohibitive, directly affecting access. Policymakers must recognize this link between price and access and work strategically with the healthcare sector to enable treatments to be scaled up at lower prices, making universal access feasible. Through public–private cooperation, the cost of access can be reduced while increasing opportunities for investment, improving returns on research and development spending, and generating sectorial jobs and income. Cooperation is essential to tackling NDCs, as the case of cancer shows. Without it, innovation will limit treatment to those people and countries who can afford it, leaving many behind.
It is therefore vital that governments and the private sector deal directly and transparently with the issues of price and access by establishing relationships of trust and institutional stability. Nation states can use both carrot and stick, mixing incentives with appropriate regulation, in a process of negotiation with the pharmaceutical industry. This should involve mutual procurement commitments with public and international organizations to enable universal access worldwide.
Current data reveal that, so far, efforts made by countries to face the urgencies posed by the 2030 Agenda have had little effect. Add to this the fact that some of the conditions that contribute to the prevalence of NCDs are linked to the very ways societies are structured, and we have an extremely complex scenario. These diseases are driven by forces that include increasing inequity within countries and globally, rapid unplanned urbanization, globalization of unhealthy lifestyles, and population ageing. Unbalanced diets and lack of physical activity can lead to raised metabolic risk factors such as increased blood pressure, blood glucose and blood lipids, and obesity. All these can lead to cancer, cardiovascular, and other chronic diseases, strongly contributing to premature deaths.
In addition to all the arguments regarding chronic diseases, it should be noted that these conditions do not occur in isolation. The term ‘syndemics’ describes an epidemiological situation in which multiple diseases coexist and progress in synergy. The reality of the threat to life goes beyond the compartmentalized view to which we are accustomed, reinforcing the need to propose solutions from a systemic perspective. COVID-19, for example, is more dangerous among carriers of comorbidities, such as many NCDs.
The set of transformations needed to address NCDs goes beyond the field of health. A systemic approach is needed, one that relates well-being to the economy. In the classical sustainable development view, three worlds need to engage in dialogue: the world of economics, the world of social welfare, and the world of environmental sustainability. We emphasize that health incorporates these three dimensions in an interdependent way. Health is, at the same time, a constituent part of the Welfare State, an essential vector of economic development based on innovation capabilities and an integral part of environmental sustainability. It is not just an externality to development or complementary to development. Health is development! It strongly involves science, technology and innovation, local and regional production capability, general conditions of social welfare, and sustainability. All of these determinants conditioned the access to health and the global and national preparedness to face NCDs challenges.
According to the World Intellectual Property Organization’s Global Innovation Index 2019, just 15 global companies hold 60% of the patents in biotechnology for the treatment of cancer and other chronic diseases. Patents are indicators of current and, critically, future technological production profiles. Such patent concentration today means more concentration and asymmetry from a production and technology standpoint in years to come. This is not consistent with the 2030 Agenda. It will reproduce inequities in health and in economic development. The SDGs represent a positive global initiative that must involve political decision-making at national and global levels to face these international knowledge asymmetries.
We must address, at the same time, sustainability and access to technologies, as two sides of the same coin. This includes a global effort to foster a generation of innovation in less developed countries and link science, technology, and innovation with universal access needs. We need game-changers in incentivizing and regulating innovation, including in the field of intellectual property. The sustainable development agenda can only be achieved if there is a commitment to reduce global asymmetries in knowledge and health production.
This perspective involves a paradigm shift in public policies. We must integrate the world of economics and innovation with the world of well-being and environmental sustainability.
The authors would like to thank Marco Nascimento and Karla Montenegro for their help in gathering and organizing information for this article.