CHRONIC noncommunicable diseases (NCDs) are the number one cause of death and disability in the world.

The term NCDs refers to a group of conditions that are not mainly caused by an acute infection, result in long-term health consequences and often create a need for long-term treatment and care.

The top three causes of death in the country from January to November of 2023 were ischaemic heart diseases, neoplasms, and cerebrovascular diseases. These were also the leading causes of death in the same period in 2022. ( Philippine Statistics Authority ).

WHO alarmed over the surge

Noncommunicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression.

The four main types – cardiovascular diseases, cancer, diabetes and chronic respiratory diseases – impose a major and growing burden on health and development.

In the Western Pacific Region, 12 million people died from NCDs in 2019.

Despite progress in reducing premature deaths due to NCDs from 2000 to 2010, new risk factors and changing environments have reversed progress in some countries over the past decade.

The main types of NCDs share modifiable behavioural risk factors such as tobacco use, unhealthy diet, lack of physical activity and harmful use of alcohol, which lead to four metabolic/physiologic changes – raised blood pressure, overweight and obesity, raised blood glucose and raised cholesterol, and ultimately disease.

They continue to be an important public health challenge in all countries, including low- and middle-income countries where more than three quarters of NCD deaths occur.

Why is it important to prevent communicable diseases?

Because communicable diseases can have so much impact on the population, their surveillance and control is an important part of protecting the public’s health.

Unhealthy lifestyles are propagated in families and in low-income communities. In addition and as a result of lack of appropriate policies, this may have greater long-term consequences for an individual than the transmission of an acute infection. These medical problems are common the poor and young population which makes the problem more complicated because they can’t have access to medical check ups and medications.

Globalization and behavioral change

In the current context of rapid globalization, and “Macdonaldization,” commercial determinants and social determinants of NCDs are spreading rapidly and contributing to the increasing prevalence of NCDs globally (Mendenhall et al. 2017).

At the local level, urbanization is associated with poverty, food deserts, and consumption of highly processed food, as daily access to affordable healthy food is challenging and thus obesity and diabetes are on the rise (Ghosh-Dastidar et al. 2014).

Rates of risk factors such as smoking are often highest among those of lowest socioeconomic status because of poor health literacy, prevailing pressures to conform, stress, addiction, exposure in the home, and cheap tobacco in many countries (Di Cesare et al. 2013; Cappelen and Norheim 2005).

Lobbyists and advertising push for increasing tobacco, alcohol, salt, sugar, and fat consumption, which all could be considered vectors for NCDs (Whitaker et al. 2018; Kickbusch et al. 2016).

A common argument emphasizes that despite these “vectors,” individuals with NCDs are in control of the “contagiousness” (Gostin 2014). An individual for example can simply choose not to smoke. This may be true in theory, but in practice, peer pressure, social conditioning, social stresses, and subsequent addiction may make smoking very hard to avoid in certain environments (Cappelen and Norheim 2005).

Similarly, individuals can reduce their risks of developing CDs ( Communicable Diseases ) by being vaccinated, washing their hands, or not engaging in high-risk activities. As these activities are generally supported by public health measures, they may be easier for an individual to achieve than personal choices required to reduce NCD risk.

Perceived Cost of Treatment

Another strong argument points out that treatment of an acute infection with a single short course of a generic antibiotic is generally cheap and cost-effective. On one hand, most acute infections do not require long-term treatment and most individuals who survive return to their previous state of health. Access to medicines for infections is therefore only required intermittently and weaknesses in the health system may be less evident when treatment is required. Vertical programs directed at individual high burden infections, e.g., malaria, have circumvented the weaknesses in health systems and have successfully reduced disease burdens2 (World Health Organization 2015, 2018b, 2018i).

However, the long-term success of treatment for acute infections also requires universal access to essential and good quality medicines and requires good medication stewardship to curb antimicrobial resistance (Morehead and Scarbrough 2018).

Better infrastructure such as access to safe water, sanitation, vector control, and improved health literacy are needed if CDs are to be prevented. Thus, tackling CDs comprehensively may not be as simple as it appears.

On the other hand, treatment for NCDs is highly dependent on UHC Universal Health Care ) , consistent availability of essential medicines, evidence-based clinical algorithms being in place, and access to ongoing quality primary care. Many NCDs arise as complications of other untreated NCDs, e.g., kidney disease may be a consequence of uncontrolled high blood pressure, and is in turn a strong risk factor for hypertension and cardiovascular disease. Kidney disease and cardiovascular disease are more complex and more costly to treat than hypertension alone.

NCDs therefore often belong to a vicious cycle of augmentation of disease burden and resource requirements if early windows of opportunity for diagnosis and intervention are missed (Luyckx et al. 2018; Tonelli et al. 2012).

NCDs such as rheumatic heart disease, cervical cancer, and cirrhosis also arise from untreated infections, illustrating the necessity to address CDs and NCDs simultaneously. Besides strengthening prevention of NCDs, most NCDs are manageable even in low resource settings, as many can be diagnosed early with simple tests, and generic treatments are effective and cheap (Maher et al. 2009; Mani 2006; Lin et al. 2019).

Strategies such as the WHO Hearts Packages (World Health Organization 2018a) highlight simple resource-adapted approaches to comprehensive care for cardiovascular disease for example. The knowledge therefore exists.

There is no justification, even in low resource settings not to embark on systematic implementation of simple strategies to detect and treat NCDs early (World Health Organization 2018f; 2017b; Nishtar et al. 2018).

Both CDs and NCDs present challenges—even if at first glance it appears CDs are simpler and cheaper to tackle—and both need systematic strengthening of health systems. Prioritization of one over the other on the single basis of cost-effectiveness is not justifiable and is to the detriment of the whole. An implicit nihilistic argument is that treatment of NCDs requires sustainability and weak health systems cannot provide this, and also that medication is too expensive. Sustainable chronic treatment for HIV for example is possible in low-income settings (World Health Organization 2018b; UNAIDS 2016).

Pressure is mounting for improved access to treatment for Hepatitis C (Douglass et al. 2018). This can and should therefore be possible for NCDs, building upon the infrastructure and lessons learned from scaling-up treatment for HIV (Garrib et al. 2018).

Hence, following this first set of arguments, it can be concluded that the characteristics of CDs which appear to have led to their prioritization over NCDs are not ethically acceptable or conclusive: NCDs may be acute and reversible, CDs may be chronic, both may be preventable and contagious, and both may not be simple or cheap to treat.

Prevention and treatment of NCDs have recently been demonstrated to be highly cost-effective, and even cost-saving in the long run, especially when the current costs of no action are considered

(World Health Organization 2018) We therefore conclude that there are no morally relevant factors supporting the differential approaches to CDs and NCDs.

We now turn to examine whether there may be other arguments supporting lack of prioritization of NCDs. There’s no clear blueprint for control of NCDs, no specific timelines and accountable leaders assigned to these chronic debilitating illnesses hurting the ordinary Filipino.

We need to act now with sense of urgency. Now or never.

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“Pleasure in the job puts perfection in the work.” – Aristotle.

Seek purpose over distraction.

Anthony C. Leachon, M. D.

Independent Health Reform Advocate

Past President,
Philippine College of Physicians

Department of Internal Medicine
Manila Doctors Hospital