Non-communicable diseases and COVID-19: A perfect storm
For decades academics and policy makers have warned of the risks of a viral pandemic with effects as devastating as the Spanish Flu in 1918. What they did not anticipate, however, was its interaction with a co-existing pandemic of non-communicable diseases (NCDs). Covid-19 is that perfect storm, particularly for poorer communities, where NCDs and their risk factors are disproportionally high among all age groups.
While NCDs are more common among older people, for younger people, NCDs and underlying metabolic conditions—obesity, hypertension, kidney disease, and diabetes—are all associated with higher risk of severe illness, hospitalisation, and death from covid-19. Of particular worry is the association with obesity, which in the US and many parts of the world is associated with poverty. In the US and Mexico, more than one third of people 15 years and older are obese and more than 20% in South Africa, Costa Rica, Colombia, Brazil, Hungary, and Chile.
The global response has been to treat covid-19 as a vertical disease rather than addressing the full ecosystem of our response to covid-19 or its interaction with NCDs and poverty. This is particularly urgent given that poverty is now both a driver of covid related mortality and an outcome of the response. From Mexico City to New York City to the Western Cape, covid-19 has both targeted and amplified poverty as a powerful determinant of health and hit hardest in communities that also lack access to care. In the US, for example, where poverty intersects with structural marginalization, people from non-Hispanic black communities make up 33% of the covid related deaths, though represent only 18% of the population.
Measures including lockdown and social distancing have caused health service disruptions affecting access to medicines, diagnostics, and treatment, including for NCDs. The result is an overall worsening of health outcomes in particular for poorer communities, further exacerbated by food insecurity and reduced social services access that predate the pandemic. With nearly half a billion people projected to fall into extreme poverty due to the covid response, loss of income, high out-of-pocket costs for healthcare, food insecurity, increased unemployment levels, and lower educational attainment. These will all have a direct effect on morbidity and mortality worldwide in the longer term.
The Sustainable Development Goals, which called out the need to address universal health coverage, pandemic preparedness, and NCDs, were built with the rationale that complex social problems, including health, need complex multisectoral interventions—there are no magic bullets—and the context and the strength of health systems matter. The WHO Independent High-Level Commission on NCDs similarly called for integration of NCDs and mental health into national SDG and universal health coverage implementation. These goals and recommendations should be brought to bear in the face of covid-19.
Given the interaction between covid-19 and NCDs, we must urgently address the underlying drivers of the NCD pandemic that are fueling covid-19 mortality. First, this requires adhering to the tenants of “precision public health:” focusing interventions on risk reduction for those most susceptible. This cannot be accomplished without better data sharing. While the signals are clear that NCDs are a risk factor for covid-19, the granular data from the more than 400,000 deaths worldwide are not freely available to global health researchers to analyze the role of competing risk factors, disease history, medicine interactions, or other potential socioeconomic or demographic associations. Where available, it is either for purchase or researchers must sign restrictive data sharing agreements.
However, even without these data, we know enough about the risk factors to do better. It is time to move from a vertical approach to applying the techniques of population health to assess risks, target prevention, and engage communities in the response, and to build synergies across care platforms, in particular between NCDs and infectious diseases. Rather than applying blunt tools such as lockdowns to the entire population, we must target those at risk, with more localised interventions. At the same time, we must provide support to those who are socioeconomically vulnerable with the means to mitigate the pandemic response effects on poverty, which is a direct determinant of health. An example of such a strategy is underway in Pakistan, where the government has provided over 80 million people with emergency cash transfers.
To date, the global response to covid-19 has focused on covid-19 only and targeted the entire population rather than those most at risk. The result has been mass fear and confusion and, arguably, a tremendous misallocation of resources. However, as covid-19 continues to spread and there are concerns of a second wave, it is not too late to apply the tools of precision, evidence-based public health and move from a sole focus on covid-19 deaths to addressing the underlying drivers of morbidity and mortality. This means focusing prevention efforts on people suffering from NCDs and applying a Sustainable Development Goal agenda 2030 lens which looks past a single public health endpoint to address the multiple factors affecting population health.