“The long tails of disease, of rheumatic fever as well as of cancer, are terrible afflictions among the poor — and have been too long neglected.”
Dr. Paul Farmer, co-Founder and Chief Strategist
Partners In Health
Epilogue, The PIH Guide to Chronic Care Integration for Endemic NCDs
Current momentum to address the global noncommunicable and injury burden has been predominantly focused on modifiable lifestyle risk factors, including unhealthy diets, sedentary lifestyles, alcohol and tobacco use. Yet, the very poor often live with diseases and risk factors that are neglected or misunderstood.
National planners and implementers in low-income countries lack data to clearly understand the burden of disease specific to their poorest populations, which is critical to developing practical, effective solutions to expanding care. The very poorest cannot be ignored as we work to tackle the endemic NCDs and injuries burden in low and middle-income countries worldwide.
Risk factors of poverty
In settings of extreme poverty, most NCDs cannot be prevented by dieting, exercise, or reducing tobacco and alcohol use. Death and suffering due to NCDs and injuries in low-income countries is instead impacted deeply by risk factors related to poverty, such as:
- Environmental toxins, including household air pollution
- Unsafe environments, including poor working conditions, road traffic safety, violence, and conflict
- Lack of access to health care
- Infectious diseases, including tuberculosis, malaria, hepatitis B, HPV, HIV, and streptococcal infections
- Complications of childbirth
- Malnutrition and food insecurity
While international attention has been primarily focused elsewhere, health care workers in low-income countries continue to see a more complex story. For instance, asthma and respiratory diseases often result from exposure to indoor cooking stoves. Rheumatic heart disease, one of the most common cardiovascular diseases among children and young adults in low-income countries, develops due to streptococcal infection. Many forms of cancer result from infectious disease risks, such as cervical cancer due to HPV or schistosomiasis-associated bladder cancer. Poor working conditions and traffic accidents can lead to a high burden of injuries and disabilities.
It is critical that national planning and implementation strategies to address NCDs and injuries in low-income countries take into account the risks faced by the very poorest.
Understanding the local burden of disease
In developing a more nuanced understanding of the risk factors prevalent in settings of extreme poverty, it is important that the global NCD community also considers the full disease burden present in these countries.
While cardiovascular disease, diabetes, respiratory diseases, and cancer are the most commonly discussed NCDs, they do not exist in isolation, and their manifestations in the poorest populations often require different treatment approaches. Diseases and conditions that clinicians in settings of extreme poverty might see include, but are certainly not limited to:
- Cardiovascular diseases, such as malignant hypertension, cardiomyopathies, rheumatic heart disease, congenital heart disease, and stroke
- Diabetes, including Type I diabetes
- Chronic respiratory diseases, including asthma
- Cancers, such as cervical cancer, breast cancer, and lymphoma
- Hemoglobinopathies, such as sickle cell anemia
- Liver disease
- Chronic and acute kidney disease
- Gastrointestinal conditions, such as appendicitis and hernias
- Musculoskeletal disorders, such as rheumatoid arthritis
- Neurological disorders, such as epilepsy
- Mental health disorders, including schizophrenia, anxiety, and psychosis
- Congenital disorders
- Oral and eye disorders
- Injuries and disabilities
All patients, regardless of income level or location, deserve access to equitable care. In order to achieve these goals, more research is needed to understand the NCD and injuries burden specific to the very poor, especially in children and young adults. In assessing how NCDs and injuries impact local populations, ministries of health will be able to better design healthcare delivery platforms that reach their poorest and most remote patients.