On March 2-3, our colleagues at Partners in Health hosted a conference on non-communicable diseases (NCDs) at Harvard Medical School. Ryan Schwarz, Bibhav Acharya and I attended from Nyaya Health. The conference’s title–”The Long Tail of Global Health Equity”–referred to the observation that while a small handful of conditions (HIV, malaria, maternal mortality, etc) each account for a large global burden of disease and disability, there is a large tail to the curve of diseases whereby an array of less common conditions together make up a tremendous burden of disease. In particular, this group of diseases–because of its diversity–has not received as much attention or concerted effort in the global health response. As Dean Julio Frank of Harvard School of Public Health remarked, “Just because there are diseases only of the poor, doesn’t mean they’re the only diseases of the poor.” The myth that infectious diseases are either the only health problems, or the only addressable health problems, of the global poor has constrained the global health movement.
We’ve seen this problem for years in our work in Nepal. There is tremendous financial support, political effort, evidence base, and detailed algorithms for managing conditions like HIV and TB in resource limited settings. Indeed, PIH published fantastic books on management of HIV and MDR TB dating back nearly a decade. These books hand wonderful management strategies for settings where advanced diagnostics were not available, and they were easy to translate into clinical practice across an array of settings (I relied on them in both Nepal and South Africa).
In contrast, when we’ve tried to bolster our programs for caring for other chronic conditions like chronic obstructive pulmonary disease (COPD)–one of the most common diagnoses at Bayalpata Hospital–we’ve found little in the way of helpful guidelines designed for resource-limited settings. With the example of COPD, there are guidelines from the Global Initiative for Chronic Obstructive Lung Disease (the GOLD guidelines). However, they state that COPD should be diagnosed by spirometry, and only provide a tiny footnote for settings that do not have spirometry, providing the vague advice that clinicians should then “use all available tools.” We do not have a spirometer at our hospital, nor is there one available anywhere in the district or any surrounding district. I’ve not seen one in any district hospital in Nepal. I would like to see us obtain a spirometer, but the present reality is that the vast majority of COPD patients in Nepal are diagnosed and cared for without spirometry, and we can provide them good care. Good clinical protocols are a necessary component.
Diabetes presents similar challenges. It has been unequivocally more difficult to manage diabetes than HIV in our setting. Insulin is ideally refrigerated, and few of our patients even have electricity. Little investment has been made in training staff or providing financial support to health centers to provide care for this common disease, which is often a source of impoverishment for families in Nepal as they struggle to get patients minimum diabetes care. As we heard from participants across the globe at this conference, this experience is common throughout resource-limited settings.
We, as providers caring for the poor across the world, have desperately needed good protocols for managing NCDs. Implementing these will be the first, immediate thing that will help us improve care for our patients. But we also need to see more commitment to resources and infrastructure, and we need to see political will at the top. The hope for this currently rests in the UN General Assembly meeting in September, which will convene a summit on Non-Communicable Diseases.
We will keep our ears to the ground to see how we might support our friends and colleagues who are advocating for more emphasis and resources for NCDs as this summit approaches. And for now, we look forward to reviewing the PIH NCD manual and incorporating its content into our health programs in Achham.
Jason Andrews, MD is the co-founder and Chief Medical Officer of Nyaya Health. He is currently a fellow in the Division of Infectious Diseases at Massachusetts General Hospital.