The Developing World & Non-Communicable Diseases: A Pandemic of Drug Shortages & Inequitable Access

Throughout the developing world, health demographics are rapidly shifting from communicable diseases to non-communicable diseases (NCDs) due to urbanization, lifestyle changes, and introduction of processed food. Although still retaining a significant portion of their communicable disease burden like tuberculosis and malaria, the prevalence of hypertension, diabetes, and cancer in developing countries has increased dramatically and is expected to cause every 7 out of 10 deaths by 2020. With the rise of these health ailments, the global health community has highlighted the importance and severity of these diseases through UN High-level meetings, incorporating relevant indicators in the Sustainable Development Goals (SDG’s), and forming interagency coalitions within countries to address the barriers of NCD prevention and treatment. However, NCD medication supplies have remained an underappreciated barrier that humans affected by global health inequalities confront each day. The complications of drug supplies range from common medications being out of stock to not having a vital class of medications available at the health facility. The medication shortages that plague developing nation states often have a more pronounced effect on underserved populations – essentially causing an impossible barrier to treating their chronic condition and preventing morbidity/mortality.

Last month on November 20thThe Lancet Diabetes & Endocrinology revealed predictions in the year 2030 regarding the world’s insulin supply that stunned health care professionals around the globe. From data gathered recently, the number of individuals diagnosed with Type 2 diabetes is estimated at 405 million people. Although some patients can be treated with oral or injectable diabetic medications like metformin or GLP1 inhibitors, there are approximately 63 million people on earth today that require the use of insulin to manage their diabetes. However, only 30 million individuals use insulin due to availability, affordability, and inequitable access to this essential class of medications. Although these numbers provide a clear indication of the necessity for change in regards to access to insulin globally, the scientists at Stanford that conducted the aforementioned study in The Lancet predicted that the number of individuals diagnosed with Type 2 diabetes will increase to 510 million in 2030 – 79 million of those will need insulin to proper manage their health disorder with only 38 million having equitable access to insulin. These statistics exhibit that, in 13 years, less than half of the people on this planet will be able to access insulin, a medication developed 97 years ago. Though over half of the world’s diagnosed Type 2 diabetics will reside in China, India, or the United States, the study continued and stated that the insulin supply shortage will distress those inhabiting Africa and Asia most significantly. The reasons formulated to explain this health disparity include the fact that three pharmaceutical industries control almost 100% of insulin being manufactured in the world, the complexity of insulin which is a hormone produced by living cells, and generic companies’ lack of interest in producing a biosimilar at an equitable price.   

Cardiovascular diseases (CVDs) pose an implausible health burden on the global society with 30% of all deaths worldwide being attributed to these ailments. Of this mortality caused by CVDs, it is estimated that 80% occurs in the developing world with projections suggesting a steady increase in this percentage. However, with equitable access to cardiovascular medications, approximately 75% of recurrent CVDs can be prevented causing a decrease in both mortality and morbidity for humanity. To determine the access to common cardiovascular medications like atenolol, captopril, hydrochlorothiazide, losartan, and nifedipine, the BMC Cardiovascular Disorders journal published findings in 2010 of a survey within 36 countries. The findings revealed that the drug shortages transcended more complex medications like insulin and affected the access of medications that are considered ubiquitous in the developed world. The analyzed data revealed that of the abovementioned medications in the 36 countries, only 26.3% was available in the public sector and 57.3% in the private sector. The study also stated that in several nations, the wages earned within one working day was insufficient to meet the cost of one day of purchasing treatment. When considering situations where monotherapy is inappropriate, this finding would disclose that treatment would be particularly unaffordable.

When considering access to NCD medications generally, wealth has been a substantial determinant of inequitable access to treatment of hypertension, asthma, cancer, and others classified as NCDs. In many low-income to middle-income countries (LMICs), a wealth gradient has even been observed. In order to gather information to disprove or support this theory, the BMJ Global Health Journal published a study conducted in Kenya in August 2018. The study administered surveys to patients prescribed hypertension, diabetes, and asthma medications and collected data on those medications available at their home, including location and cost of the service. When analyzing the data, the results clearly indicated a wealth gradient for each of the three diseases included in the study in terms of access. As household income increases, so does the likelihood that a family has an opportunity to obtain proper medication. In addition, the results showed that poorer patients had to travel further to obtain treatment than those with a higher income. Finally, and most meaningfully, poorer patients paid more for their medications than their fellow humans inhabiting other parts of the country.  

These global health inequalities are unjustifiable in a global society where the quantity and quality of medications on the market is incredible. The drug shortages and inequitable access differ between the developed world and developing world, but also by socioeconomic stratifications within countries themselves. In order to provide compassionate care to every human suffering from any of these ailments, governments need to begin initiatives to make insulin, losartan, albuterol, and every vital NCD medication available to every citizen in their country. Heads of states, pharmaceutical industries, ministries of health, and health care professionals need to accompany their citizens and patients with a health mindset moving away from health as a commodity to health as a right. Most urgently, universal health care coverage needs to be at the forefront of every national health agenda to properly address this pandemic of drug shortages and inequitable access.

World Heart Day 2018

Today, September 29, marks World Heart Day (WHD) around the world. World Heart Day brings awareness to the prevention and control of cardiovascular diseases (CVDs) which plays a significant role in our daily lives contributing to our overall health and wellness.

What are Cardiovascular diseases?

Cardiovascular diseases are a group of disorders of the heart and blood vessels and they include:

  • Coronary heart disease – disease of the blood vessels supplying the heart muscle;
  • Cerebrovascular disease – disease of the blood vessels supplying the brain;
  • Peripheral arterial disease – disease of blood vessels supplying the arms and legs;
  • Rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
  • Congenital heart disease – malformations of heart structure existing at birth;
  • Deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

According to the World Health Organization (WHO), cardiovascular diseases take the lives of 17.7 million people every year, and accounts for 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke.

Projects around the world

The global fight against CVDs is happening throughout the world. Some examples include:

– Through the HEARTS project based in Manila, Philippines, WHO and partners like the United States Centers for Disease Control and Prevention (CDC), are supporting ways to fight cardiovascular disease through training, planning and implemention.

– A two-year Standardized Hypertension Treatment project launched in 2015 by the Pan American Health Organization (PAHO) and CDC on the Caribbean island of Barbados, enacted a mission to improve hypertension treatment and control among Barbadians with raised blood pressure through standardizing care for hypertensive patients, prescribing and making available the most effective medicines for treating each person’s condition. The principal investigator of the project highlighted, “It was also encouraging to see the cultural and behavioural change in the clinics among health workers who had to deliver a more focused form of care.” It is important to also note how cultural and social factors play a vital role to behavioral change when it came to seeing patients achieving satisfactory blood pressure control.

Specific intervention activities included: (1) Developing salt reduction and tobacco control plans, (2) Implementing simplified and standardized management protocols, (3) Improving access to medicines and technologies, and (4) Building capacities of health and other providers.

http://www.who.int/news-room/feature-stories/detail/treating-cardiovascular-disease-in-barbados

http://www.who.int/news-room/feature-stories/detail/philippines-embraces-efforts-to-step-up-cardiovascular-disease-care

Key messages to protect heart health

There are small, yet very impactful ways to make “heart health at the heart of all health”. Here are some facts/tips!

  • Tobacco use, an unhealthy diet, and physical inativity increase the risk of heart attacks and strokes.
  • Engaging in physical activity for at least 30 minutes every day of the week will help to prevent heart attacks and strokes.
  • Eating at least five servings of fruit and vegetables a day, and limiting your salt intake to less than one teaspoon a day, also helps to prevent heart attacks and strokes.

When it comes to reducing cardiovascular diseases and improving heart health, it is pivotal to identify those individuals with or at highest risk of CVDs due to risk factors such as hypertension, diabetes, hyperlipidaemia or an already established disease to ensure they receive appropriate treatment in order to prevent premature deaths. During 2015, 17 million premature deaths occurred from noncommunicable diseases (under the age of 70) with 82% of deaths reported in low- and middle-income countries, and 37% caused by CVDs (WHO, 2017). Although there has been great strides toward the prevention of cardiovascular diseases, inequalities including access to noncommunicable disease medicines, and basic health technologies in all primary health care facilities is essential to those in need of receiving treatment and education.

The epidemic of cardiovascular diseases has also impacted my life with my grandmother,mother, and all 4 of my aunts and uncles suffering from hypertension. In March 2018, my cousin at the age of 35 suffered from a massive stroke and is successfully recovering. I spent bringing awareness to this day by cooking popular caribbean dishes with a healthy spin and educating family and friends across the United States and Caribbean on the importance of having and maintaining a healthy heart. In addition, I took a 2 mile walk through my neighborhood taking in the beautiful Florida scenery and cool breeze.

How did you celebrate World Heart Day?

 

World No Tobacco Day 2018

The focus of this year’s World No Tobacco Day on May 31st is the impact of tobacco on cardiovascular health. In 1967 the Surgeon General’s report definitively linked smoking to lung cancer and presented evidence that it causes cardiovascular problems. Despite all the evidence and outcry from health professionals, it was not until the 1990s when many countries around the world banned smoking in public places. There have been several policies including those deterring tobacco companies from advertising to younger age groups and forcing them to add warning labels on tobacco products. Despite all these efforts, tobacco still kills 7 million people each year and tobacco use (and secondhand smoke) is responsible for nearly 12% of all deaths globally due to cardiovascular diseases (CVDs).

Tobacco1

Tobacco smoke contains more than 7000 chemicals and is divided into a) a particulate phase which contains nicotine and total aerosol residue or tar and b) gas phase which contains carbon monoxide and other gases. The image below depicts how chemicals in tobacco cause CVDs.

Tobacco2

While the effects of tobacco on heart health are well known, knowledge among the public that tobacco is one of the leading causes of CVD is very low. The figure below from WHO’s brochure shows the percentage of adults who do not believe or do not know that smoking causes stroke and heart attacks.

Tobacco3

The goals of World No Tobacco Day 2018 are to:

  • Emphasize the links between use of tobacco products and CVDs
  • Increase awareness among the broader public about the impact of tobacco and exposure to secondhand smoke on heart health
  • Provide opportunities to make commitments to promote heart health
  • Encourage countries to strengthen implementation of MPOWER

WHO and the US Centers for Disease Control and Prevention launched the Global Hearts initiative in September 2016. The initiative aims to support governments in bolstering prevention and control of CVD. Global Hearts comprises of three technical packages: a) MPOWER for tobacco control b) SHAKE for salt reduction and c) HEARTS to strengthen management of CVD in primary health care settings.

Hopefully, on this World No Tobacco Day, the governments will commit to protect their citizens from tobacco use. The truth of the matter remains: prevention and control are not sole responsibilities of governments. Health care professionals, public health agencies/staff, national/state/local governments, educational institutions, business leaders/businesses, community based organizations and community leaders all have a role in making everyday a “No Tobacco Day”.

Beat Diabetes: WHO call to action

It’s World Health Day today and the WHO has issued a call to action to “Beat Diabetes”.

World Health Day 2016 poster: Halt the rise in diabetes

Source: World health day

Diabetes is  a set of diseases that result in excessive amounts of sugar in the blood a.k.a high blood glucose. Type 2 diabetes is among the most common types of diabetes and it occurs when the body stops using insulin properly ultimately leading to “insulin resistance”. The other common types are

  1. Type 1 diabetes
  • occurs due to lack of insulin production
  • poorly understood form of diabetes

2. Gestational diabetes

  • occurs during pregnancy
  • risk factor for pregnancy related complications
  • increased risk of Type 2 diabetes for both the mothers and their children.

Diabetes is a metabolic disorder and its long term complications include heart disease, strokes, diabetic retinopathies, kidney failure  and poor blood flow to the limbs that could result in amputations. It is also among the leading cause of death. In 2012 nearly 1.5 million deaths were directly attributed to diabetes. Early diagnosis, management of blood glucose levels through diet, physical activity and medication when necessary and routine screenings are not only cost-effective but are effective interventions to prevent diabetes-related complications from occurring or worsening.

A new study published in The Lancet this month has raised the alarm by showing that there has been quadrupling of the number of people with diabetes since 1980. The pooled analysis of 751 population-based studies involving nearly 4.4 million participants from 146 countries shows increasing burden of diabetes, more so in low and middle income countries than in high-income countries. This number is startling and is  a wake up call to public health and health care professionals.

World Health Day 2016 banner

Image Source: World health day

 

Diabetes is a treatable disease and efforts to prevent/treat it, will help achieve MDG 3 target of preventing premature mortality from noncommunicable diseases by one-third by 2030. We should be working together to raise awareness about diabetes with a particular focus on low and middle income countries, scale up prevention strategies that are specific, effective and affordable.

For this campaign, WHO has created a quiz-take it to test your knowledge!

Together we can Beat Diabetes!

Note: This was cross-posted to my blog

PRI’s The World: Mysterious Kidney Disease Now Found in South Asia

I found this story particularly interesting, since I did a one-year fellowship with CDC-NIOSH on pesticide poisoning surveillance. The story examines a high incidence of kidney disease in Sri Lanka and discusses how farmers, medical professionals and government authorities have been dealing with it. The full story can be viewed here; a summary of the story, and a video, can be found below.


A form of chronic kidney disease (CKD), similar to one that has been killing sugarcane field workers in Central America, has now been observed in South Asia. The World‘s Rhitu Chatterjee reports from Sri Lanka, where thousands of rice farmers and their families are affected. Her story is part of a series, Mystery in the Fields, produced in collaboration with The Center for Public Integrity.

The afflicted show no signs of high blood pressure or diabetes – the most common causes of CKD elsewhere in the world – and yet their kidneys are failing. There is no known cure. Authorities are trying to find a cause, but their preliminary findings have not reached the people whose lives are threatened.

A new study by the World Health Organization and the Sri Lankan Ministry of Health suggests that Sri Lanka’s CKD sufferers may have been poisoned by chronic, low-level exposure to the heavy metals cadmium and arsenic. Researchers think the toxins may be coming from farm chemicals, such as pesticides and fertilizers. But while the study points to a possible cause, the study’s results have not been widely publicized.

Chatterjee speaks with rice farmers, doctors, government officials, and a representative from Sri Lanka’s farm chemicals industry. Her report examines the results of the WHO study, the secrecy that surrounds it, and the frustration of Sri Lankans who see little being done to prevent more people from falling ill.

The full report can be found here: http://bit.ly/Q9Gv1g