The burden of disease among the global poor

Abstract

The analyses of comparative burdens of communicable and non-communicable diseases between the world's poorest 20% and richest 20% that Davidson R Gwatkin and colleagues (Aug 14, p 586)1Gwatkin DR Guillot M Heuveline P The burden of disease among the global poor.Lancet. 1999; 354: 586-589Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar report raise several questions related to the policy implications of such a polarised comparison for less-developed countries. First, the analyses ignore 60% of the population distribution and only focus on 20% at each end. Since most of this 60% live in less-developed countries, the burden of disease and its effect on health-care resources are of relevance to policymakers in less-developed countries. Conversely, the more-developed countries, where the richest 20% reside, would continue to invest in control of non-communicable diseases, irrespective of what Gwatkin and colleagues state, and will continue to gain in health benefits. Is the recommendation to neglect non-communicable disease meant only for the less-developed countries? The world health report 19992WHOThe world health report 1999: making a difference. WHO, Geneva1999Google Scholar shows that in 1998 non-communicable diseases accounted for 77% of global mortality and 85% of the global burden of disease accrued from low and middle income countries. Even within these regions, which have double the burden of disease, non-communicable diseases contributed to 53·8% total mortality and 39·8% total disease burden. Clearly, we cannot delay action in this area. Second, whereas communicable diseases will remain the predominant problem of the poorest sections in less-developed countries, this factor should not mean that prevention of non-communicable diseases should be sequential to complete control of communicable diseases. Epidemics of non-communicable diseases will increasingly burden the poor, and more importantly, the rising costs of clinical care for those with non-communicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases. The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneously. Third, the message that recommendations for control of non-communicable diseases will be detrimental to the world's poor subverts the efforts of less-developed countries to address important policy issues related to global determinants of non-communicable diseases. Transnational tobacco and food traders, and international pharmaceutical and medical-technology industries, will be major beneficiaries of such attitudes that allow non-communicable diseases to proliferate, without challenge, in less-developed countries. A life-span approach to health promotion and disease prevention has to recognise that even as we strive to consolidate the gains in health for children below age 15 years (by controlling communicable diseases more effectively) we should not allow those gains to be frittered away in midlife (by failing to prevent non-communicable diseases). The only way to bridge the rich-poor gap in health is to ensure equitable global development and speedy redressal of poverty in less-developed countries (including release from the debt trap), and not through an artificial moratorium on public-health efforts to contain non-communicable diseases. Will the World Bank help to address these real priorities?