Noncommunicable Diseases

What is the burden of non communicable disease?

Non communicable disease represents a wide range of diseases, from cardiovascular disease,
cancers, and depression, to Alzheimer’s and chronic arthritis. Together, they represent the
majority of causes of death and disability in most developed countries. Today, cardiovascular
diseases and cancer alone each represent nearly 25% of the causes of death as reflected on death
certificates in the United States. The impact of non communicable diseases on death only reflects
part of the influence of these diseases on people’s lives. Chronic disabilities, largely due to non
communicable diseases, are now the most rapidly growing component of morbidity in most
developing as well as developed countries. As populations age, non communicable diseases
increase in frequency. The presence of two or more chronic diseases makes progressive disability
particularly likely. The consequences of the rapidly growing pattern of disability due to
noncommunicable diseases have enormous economic implications. The great increase in direct
costs for health care is in part due to the increased burden of noncommunicable diseases. The
impact extends beyond healthcare costs, as it affects the quality of life and may limit the ability
of those who wish to work to continue to do so. Noncommunicable diseases have not always
dominated the types of diseases that impact a society. Box 6-1 discusses the epidemiological
transition and provides a perspective on where we stand today. There are a wide range of
preventive, curative, and rehabilitative approaches to noncommunicable diseases. However,
there are a limited number of basic strategies being used that are part of the population health
approach, including:
• Screening for early detection and treatment of disease
• Multiple risk factor interventions
• Identification of cost-effective treatments
• Genetics counseling and intervention
• Research
We will take a look at each of these approaches. Finally, we will see how many of these
approaches can be combined using the population health approach. Let us begin with what we
call screening for disease.
How Can Screening for Disease Address the Burden of Noncommunicable Diseases?
Screening for disease implies the use of tests on individuals who do not have symptoms of a
specific disease. These individuals are asymptomatic. This implies that they do not have
symptoms related to the disease being investigated. They may have symptoms of other diseases.
Screening for disease can result in detection of disease at an early stage under the assumption
that early detection will allow for treatment that will improve outcome. Screening has been
successful for a range of noncommunicable diseases, including breast cancer and colon cancer,
as well as childhood conditions, including vision and hearing impairments. In all of these
conditions, screening has resulted in reduced disability and/or deaths. Not all noncommunicable
diseases, however, are good candidates for screening, and in some cases, screening programs
have yet to be devised and studied for some noncommunicable diseases for which early detection
could be useful. Four criteria need to be fulfilled for an ideal screening program. While few, if
any, health conditions completely fulfill all four requirements, these criteria provide a standard
against which to judge the potential of a screening program. These criteria are :
1. The disease produces substantial death and/or disability.
2. Early detection is possible and improves outcome.
3. There is a feasible testing strategy for screening.
4. Screening is acceptable in terms of harms, costs, and patient acceptance.
The first criterion is perhaps the easiest to evaluate. Conditions such as breast and colon cancer
result in substantial death and disability rates. Breast cancer is the second most common cancer
in terms of causes of death and is the most common cancer-related cause of death among women
in their 50s. Colon cancer is among the most common causes of cancer death in both men and
women. Childhood conditions, such as hearing loss and visual impairment, are not always
obvious; however, they cause considerable disability. Determining whether early detection is
possible and will improve outcomes is not as easy as it may appear. Screening may result in early
detection, but if effective treatment is not available, it may merely alert the clinician and the
patient to the disease at an earlier point in time without offering hope of an improved outcome.
Screening cigarette smokers for lung cancer using X-rays would seem reasonable because lung
cancer is the number one cancer killer of both men and women. However, X-ray screening of
smokers has been beneficial only in terms of early detection. By the time lung cancer can be seen
via chest X-ray, it is already too late to cure. This early detection without improved outcome is
called lead-time bias. As indicated in the third criterion, in order to implement a successful
screening program, there must be a feasible testing strategy. This usually requires identification
of a high risk population. It also requires a strategy for using two or more tests to distinguish
what are called false positives and false negatives from those who truly have and do not have the
disease. False positives are individuals who have positive results on a screening test but do not
turn out to have the disease. Similarly, false negatives are those who have negative results on the
screening test but turn out to have the disease. Screening for asymptomatic disease usually
identifies more false positives than true positives. True positives are individuals who have a
positive test and also have the disease. This is true for most screening tests, as discussed in Box
6-2 on Bayes’ theorem. How can we develop feasible testing strategies To understand the need
for and use of feasible testing strategies, it is important to recognize that screening for diseases is
usually conducted on groups that are at an increased risk for the condition. For instance,
screening men and women for colon cancer and women for breast cancer is often conducted on
people aged 50 years and older. This type of group is considered high risk, usually with a chance
or risk of having the disease of 1% or more. Use of high-risk groups like these allows tests that
are less than perfect to serve as initial screening tests. As we have seen, screening for diseases
such as breast cancer almost always requires two or more tests. These tests need to be combined
using a testing strategy. The most commonly used testing strategy is called sequential testing, or
consecutive testing. This approach implies that an initial screening test is followed by one or
more definitive or diagnostic tests. Sequential testing is used in breast cancer, hearing, and vision
testing, and most other forms of screening for noncommunicable diseases. It is generally the
most cost-effective form of screening because only one negative test is needed to rule out the
disease. Sequential testing by definition misses those who have false negative results because
when a negative test occurs, the testing process is over, at least for the immediate future. Thus, a
testing strategy needs to consider how to detect those missed by screening. We need to ask: Is
there a need for repeat screening, and if so, when should it occurec Finally, an ideal screening
test should be acceptable in terms of harms, costs, and patient acceptance. Harms must be judged
by looking at the entire testing strategy—not just the initial test. Physical examination, blood
tests, and urine tests often are used as initial screening tests. These tests are virtually harmless.
The real question is: What needs to be done if the initial test is positive? If a large number of
invasive tests, such as catheterization or surgery, are required, the overall testing strategy may
present substantial potential harms. Screenings and diagnostic tests themselves can be quite
costly. In addition, costs are related to the length of time between testing. Testing every year will
be far more costly than testing every five or ten years. The frequency of testing depends on the
speed at which the disease develops and progresses, as well as the number of people who can be
expected to be missed on the initial test. Mammographic screening is traditionally conducted
every year because breast cancer can develop and spread rapidly. In the case of colon cancer,
however, longer periods between testing are acceptable because the disease is much slower to
develop. Thus, cost considerations may be taken into account when choosing between
technologies and when setting the interval between screenings. Finally, patient acceptance is key
to successful screening. Many screening strategies present little problem with patient acceptance.
However, colon cancer screening has had its challenges with patience acceptance because many
consider it an invasive and uncomfortable procedure. Fewer than half the people who qualify for
screening based upon current recommendations currently pursue and receive colon cancer
screening. This contrasts dramatically with mammography, where a substantial majority of
women over 50 now receive the recommended screening. The screening tests that completely
fulfill these ideal criteria are few, and many more are successfully used despite not fulfilling all
these criteria. Screening may still be useful as long as we are aware of its limitations and
prepared to accept its inherent problems. Table 6-1 illustrates how commonly used screening
tests for risk factors for cardiovascular disease and common cancers perform based upon the four
criteria we have outlined. These criteria also help identify types of screening that should not be
done. In general, we do not screen for disease when early detection does not improve outcome.
We do not screen for rare diseases, such as many types of cancers, especially when the available
tests are only moderately accurate. Finally, we do not screen for disease when the testing strategy
produces substantial harms. Screening for disease is not the only population health approach that
can be used to address the burden of noncommunicable disease. Multiple risk factor reduction is
a second strategy that we will examine.
How Can Identification and Treatment of Multiple Risk Factors Be Used To Address the
Burden of Noncommunicable Disease?
As we have seen, the concept of risk factors is fundamental to the work of public health. Risk
factors ranging from high levels of blood pressure and LDL cholesterol to multiple sexual
partners and anal intercourse help us identify groups that are most likely to develop a disease.
Evidence-based recommendations often focus on addressing risk factors, and implementation
efforts often address the best way(s) to target high-risk groups. Thus, identifying and reducing
risk actors is an inherent part of the population health approach to noncommunicable diseases. A
special form of intervention aimed at risk factors is called multiple risk factor reduction. As the
name implies, this strategy intervenes simultaneously in a series of risk factors, all of which
contribute to a particular outcome, such as cardiovascular disease or lung cancer. Multiple risk
factor reduction is most effective when there are constellations, or groups of risk factors that
cluster together in definable groups of people. It may also be useful when the presence of two or
more risk factors increases the risk more than would be expected by adding together the impact
of each risk factor. The success in the last half century in addressing coronary artery disease
exemplifies multiple risk factor reduction. Box 6-3 discusses the impact of this strategy on
coronary artery disease. Multiple risk factor reduction strategies are being attempted for a range
of diseases, from asthma to diabetes. Multiple risk factor reduction is most successful when a
number of risk factors are at work in the same individual. As we have seen with asthma, factors
like indoor and outdoor air pollution, cockroaches and other allergens, and a lack of adherence to
medications tend to occur together and may be most effectively addressed together. Similarly,
obesity and lack of exercise tend to reinforce each other, often requiring a comprehensive
multiple risk factor reduction approach.
Screening for disease and multiple risk factor reduction are key approaches to using testing as
part of secondary intervention. The enormous burden of noncommunicable disease cannot be
totally prevented, even by maximizing the use of these strategies. It is important to couple them
with costeffective treatment. Thus, a third population health strategy for addressing the burden of
noncommunicable disease is to develop cost-effective interventions to treat common diseases.
How Can Cost-Effective Interventions Help Us Address the Burden of Noncommunicable
Diseases? Clinicians today have a wide range of interventions to treat disease. Many of these
interventions have some impact on the course of a disease. The proliferation of interventions
means that it is especially important to identify which provide the greatest benefits at the lowest
cost. In order to understand how cost-effective interventions can help address the burden of
noncommunicable disease, we need to understand what we mean by “cost-effective.” Cost-
effectiveness is a concept that combines issues of benefits and harms with issues of financial
costs. It starts by considering the benefits and harms of an intervention to determine its net-
effectiveness or net benefit. Net-effectiveness implies that the benefits are substantially greater
than the harms, even after the value (or utility), as well as the timing of the harms and benefits,
are taken into account. Only after establishing net-effectiveness do we take into account the
financial costs. Cost-effectiveness compares a new intervention to the current or standard
intervention. It usually asks: Is the additional net-effectiveness of an intervention worth the
additional cost? At times, it may also require us to ask: Is a small loss of net-effectiveness worth
the considerable savings in cost? Figure 6-1 is a tool for categorizing interventions in order to
analyze their costs and net-effectiveness. Box 6-4 provides more details on the use of cost-
effectiveness analysis.7 Preventive interventions often undergo cost-effectiveness analysis. Many
interventions, ranging from mammography to most childhood vaccinations to cigarette cessation
programs, get high or at least passing grades on cost-effectiveness. However, many widely used
treatment interventions do not or would not meet the current standards of costeffectiveness. The
application of cost-effectiveness criteria to common clinical interventions is considered a
population health intervention aimed at getting maximum value for the dollars spent. The results
of cost-effectiveness analysis have already had an impact on a number of common clinical
procedures. For instance, cost-effective treatments include the use of minimally invasive
orthopedic surgery, such as knee surgery; the reduced length of intensive care and hospitalization
for coronary artery disease; and the use of home health care for intravenous administration of
antibiotics and other medications. These efforts to increase the cost-effectiveness of routine
healthcare procedures are becoming key to maximizing the benefits obtained from the vast
amount of money spent on health care in the United States. Applying cost-effectiveness analysis
to routine clinical interventions is often coupled with efforts to better predict the outcome of
disease and treatment. Improving the ability to predict the outcome of diseases and interventions
can help us know when, how, and if to intervene. Improved prediction or prognosis using
prediction rules developed based on large amounts of clinical data holds out the hope of
increased effectiveness, as well as reduced costs by tailoring the treatment to the individual
patient. In addition to screening, multiple risk factor reduction, and cost-effective interventions
using prediction rules, the revolution in genetics has opened up another possible strategy for
addressing the burden of noncommunicable diseases.
How Can Genetic Counseling and Intervention Be Used To Address the Burden of Chronic
Diseases?
Interventions based upon genetics have been part of medical and public health practice since at
least the 1960s, when it was recognized that abnormalities of single genes for such conditions as
Tay-Sachs disease (found among Ashkenazi Jews) and sickle-cell anemia (found among African
Americans) could be detected by testing potential parents who could then be counseled on the
risks associated with childbearing. It was also recognized that chromosomal abnormalities that
produce Down syndrome, the most commonly recognized cause of mental retardation, could be
detected at an early stage in pregnancy. In addition, certain genetic defects, such as
phenylketonuria (PKU), can be recognized at birth, and in the case of phenylketonuria, relatively
simple dietary interventions can prevent the severe retardation of mental development that would
otherwise occur. In light of all this valuable knowledge, today, genetic testing and counseling are
often offered to prospective parents. Testing for Down syndrome is a standard part of prenatal
care, and testing for a wide range of rare, but serious, disorders is a population health
intervention. In fact, in most states, these tests are legally required soon after birth.
The triumph of the human genome project in the early years of the 2000s has sparked interest in
expanding the applicability of genetic interventions in medicine and public health. For instance,
the gene for cystic fibrosis, the most common genetic disorder among whites in the United
States, has been identified, and screening of large numbers of couples is now possible. Even
among whites without a history of cystic fibrosis, the chance of carrying the gene is about 3%. If
both the mother and the father carry the gene, the chance of having a child with cystic fibrosis is
25% with each pregnancy. The fetus can be tested for the disease early in pregnancy. There are a
wide range of current and developing applications of genetics, including
• Genetic prevention—This approach incorporates efforts to prevent the occurrence of single
genes or multiple gene combinations that are likely to produce disease. This includes expanded
use of genetic counseling, prenatal testing, and early abortion or fetal therapies. Knowledge of
the human genome holds promise for expanding this approach beyond diseases caused by single-
gene defects to diseases that depend on multiple genes. It is important to recognize that diseases
that are dependent on multiple genes will be more difficult to predict than those resulting from a
single gene.
• Genetic detection prior to disease—This approach includes efforts aimed at the detection of
genetic defects and the implementation of early intervention to prevent what is called the
phenotypic expression of genes. Building on the success of treatment of PKU and other inborn
errors of metabolism, risk factors for common diseases, such as high cholesterol, high blood
sugar, or obesity, may be detected early and aggressively managed during childhood.
• Gene-environmental protection—Genetic testing holds out the possibility of defining
combinations of genes that identify individuals who are especially likely to develop disease
when they experience specific environmental exposures, such as those interactions that occur in
occupational settings where workers are exposed to specific chemicals often at low doses.
Identification of gene-environment interactions may lead to identification of those who are at
high risk if they work in certain occupational settings.
• Genotypic-based screening for early disease— Combinations of genes may identify groups that
are at high risk of common diseases and that can be targeted for screening. For instance, studies
suggest that for certain common cancers, such as those of the breast, prostate, and colon, genetic
factors are associated with 30–40% of these diseases. Finding predisposing genetic patterns early
in life may be useful for identifying those who need earlier or more intensive screening for early
detection.
Each of these potential uses of genetics in public health present ethical as well as technological
issues. Questions to consider include: Should we identify diseases when little can be done to
prevent or treat them? How can we identify genetic risk factors without stigmatizing or putting
those with the genes at a disadvantage?
Will screening programs be improved by identifying groups at genetic risk of disease, or will
high-risk groups without genetic risk factors unfairly be passed over for screenings? These and
other approaches based on the rapidly accumulating knowledge of genetics are likely to become
routine medical and public health strategies for primary, secondary, and tertiary interventions for
noncommunicable disease in the coming years. Their successful adoption, however, will require
careful attention by those in the fields of public health and medicine to ensure that benefits are
gained and harms minimized. Despite the enormous advances that have occurred in public health
and medicine in recent decades, there is still much to be learned. A final strategy for
noncommunicable diseases addresses the question: What can we do when highly effective
interventions do not exist?
What can we do when highly effective interventions do not exist?
Alzheimer’s is among the most rapidly increasing conditions among those that we classify as
noncommunicable diseases. The aging of the population has been and is expected to be
associated with many more cases of Alzheimer’s, which primarily affects the quality of life with
its progressive damage to memory—especially short-term memory. Today, we have limited
treatment options for those afflicted with Alzheimer’s. Several drugs are available that have
modest positive impacts on memory. Efforts to stimulate mental activity through keeping active
mentally and physically have also been shown to have positive, yet modest, impacts. Public
health efforts have encouraged the use of these existing interventions, especially when there is
evidence that they allow individuals to function on their own or with limited assistance for
longer periods of time. The population health approach to Alzheimer’s disease, however, also
stresses the need for additional research. Epidemiological research has helped produce the
modest advances in preventing progression and treating the symptoms of the disease. A
population health approach, however, needs to acknowledge the need for a basic biological
understanding of what causes Alzheimer’s. Fortunately, the cause and treatment of Alzheimer’s
disease is being aggressively researched, and evidence for contributory cause(s) is accumulating,
as discussed in Box 6-5.
We have now explored the major population health strategies for addressing noncommunicable
diseases. These include screening, multiple risk factor reduction, cost-effective treatments,
genetic counseling, and more research. A complex problem often requires us to combine many of
these approaches.
How Can We Combine Strategies To Address Complex Problems of Noncommunicable
Diseases? Multiple interventions combining health care, traditional public health approaches,
and social interventions are often needed to address the complex problems presented by
noncommunicable diseases. The combined and integrated use of multiple interventions is central
to the population health approach. Box 6-6 looks at what we can learn about the population
health approach to noncommunicable diseases from the long history of alcohol use and abuse, as
well as the substantial recent success in addressing disease due to alcohol.10 We have now taken
a look at strategies to control noncommunicable diseases, which are currently the most common
reason for disability and death in most developed countries. Now, let us look at a second
category that has been central to the history of public health and threatens to become central to
its future: communicable disease.