Covid-19 and Pakistan's raging NCD crisis

Covid-19 has reminded us of the potentially devastating interlinkages between NCDs and infectious diseases.
Published July 31, 2020

As the world scrambles to contain the Covid-19 pandemic, the most devastating infectious disease outbreak to hit the world in decades, the crisis has revealed a great deal about the gaps in our economic and health systems. At the same time, in the choice of its victims, the virus has also revealed another health crisis raging world over — that of non-communicable diseases (NCDs).

The evidence emerging from the pandemic makes one thing clear — people living with or affected by noncommunicable or chronic diseases are at higher risk and far more vulnerable to becoming severely ill from the virus.

What are NCDs? According to the WHO, these are long-duration diseases that result from a combination of genetic, physiological, environmental and behavioural factors. The major types of NCDs include cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes.

While previously thought of as a problem for developed countries, NCDs have risen world over in the past 30 years — driven by urbanisation, globalisation and associated lifestyle changes — and now kill 41 million people every year (more than 71 per cent of all global deaths). More than three quarters of NCD-related deaths now occur in low- and middle-income countries like Pakistan.

While public health debates in Pakistan have focused more on continuing battles with communicable disease like polio, NCDs, such as heart disease, diabetes and hypertension now contribute significantly to adult mortality and morbidity in Pakistan — they are amongst the top 10 causes of mortality and morbidity within the country, and WHO estimates indicate that they account for approximately 58 per cent of total deaths in Pakistan. In addition, they impose a heavy and increasing economic burden on individuals, families, communities, and health systems in the country. Over 45 per cent of Pakistani households spend far more on treating NCDs than they do on communicable diseases. Many of these expenses end up being catastrophic, pushing people into deprivation.

NCDs have a lot to do with a set of inter-related behavioural, metabolic and environmental risk factors, which greatly increase chances of contracting these diseases. These risk factors include tobacco use, unhealthy diet, physical inactivity, and obesity, as well as problems like air pollution and food systems.

Prior research has already focused on the dangerous convergence between NCDs and infectious disease. Studies have demonstrated how diabetes patients are more susceptible to diseases like tuberculosis and malaria. As is becoming clear from the emerging clinical evidence on Covid-19, these NCD risk factors can make people more vulnerable to becoming severely ill with Covid-19 as well. For example, smokers are likely to be more vulnerable to Covid-19 as they already have reduced lung capacity or lung disease. Similarly, obesity has been identified as one of the risk factors for severe illness from Covid-19 and mortality in younger individuals is higher among those that are obese.

Many of these risk factors are increasingly prevalent in Pakistan. Around 24 million Pakistanis smoke tobacco, which kills around 160,000 people a year. Twenty-six per cent of our population is diabetic, one of the highest rates in the world, and obesity is on the rise, with 20 per cent of men and 25 per cent of women in Pakistan being either overweight or obese.

A major reason behind these unhealthy indicators is our increasingly unhealthy diet. Consumption of vegetables and fruits in Pakistan has been decreasing amid high consumption of salt and sugar and rising intake of unhealthy processed food products. Another nutritional challenge in Pakistan relates to dangerously high consumption of industrially produced trans-fatty acids (iTFA), a harmful fat found in processed vanaspati ghee, margarines and some cooking oils that greatly increases the risk of heart disease. The excessive intake of TFA in a culture of deep-frying has created a generation of patients suffering from hypertension and heart disease.

NCDs are a growing problem and as the coronavirus pandemic has shown, can have devastating mortality consequences if left unchecked. Pakistan’s NCD burden is worsening and puts a large proportion of the population at risk, both from the chronic diseases themselves and from vulnerability to severe illness from infectious diseases like Covid-19.

Fortunately, NCDs are largely preventable. Through tobacco use cessation, fruit and vegetable intake, physical activity, healthy body weight and avoidance of stress, these diseases can be prevented to a large extent, and in the event of disease, suffering and deaths can be reduced.

However, this will require concerted policy efforts from the federal and provincial governments as well as cooperation from society. Smart policies can help create a healthier environment for people, including a healthier food environment. This must include policy and regulatory measures to reduce the consumption of excessive salt and sugar and eliminate the use of TFA from our food supply (something the WHO has also called for and our successive governments have also committed to). This must also include efforts to adequately tax the tobacco industry and unhealthy beverages and earmark those funds for investing in public health. This will create healthier populations less susceptible to NCDs.

In addition, there is a need to integrate treatment and prevention of NCDs in the system of primary healthcare (rather than costly late-stage treatment at tertiary care hospitals). Early detection and management of diabetes, hypertension and other NCDs at the primary healthcare level is cost effective and with early treatment, the needless strokes, blindness, heart failure, end stage renal disease, gangrenous legs, and amputations can be avoided. This must be accompanied by efforts to raise public awareness about risk factors behind NCDs and promote healthy behaviours and lifestyle choices among the population that can prevent the development of these illnesses.

In public health, we have always kept infectious and non-communicable diseases in separate silos. Covid-19 has reminded us of the potentially devastating interlinkages between the two. Therefore, the redesign of our health systems in response in a post-Covid-19 context must also include an integration of the battle against NCDs, which has been neglected in public health planning to-date. As we resume the fight for quality universal health coverage in the aftermath of the pandemic, NCDs must be placed at the centre of the debate in order to adapt our health systems to contemporary health challenges so we can make our societies secure and less vulnerable to being ravaged by future outbreaks.