The Convergence of Infectious Diseases and Noncommunicable Diseases Proceedings of a Workshop (2019) / Chapter Skim
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2 An Overview of Colliding Epidemics and Syndemics
2 An Overview of Colliding Epidemics and Syndemics
Pages 7-22
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From page 7... ...
CONVERGENT ACTION FOR COLLIDING EPIDEMICS OF INFECTIOUS AND NONCOMMUNICABLE DISEASES To establish the rationale for taking an integrated approach to address the colliding epidemics of infectious diseases and NCDs, Tolullah Oni, clinical senior research associate in the MRC Epidemiology Unit at the University of Cambridge, first described how mortality and morbidity trends have shifted in recent decades, with the contribution of NCDs to both of those burdens increasing relative to infectious diseases. She followed with a discussion of the role of false dichotomies in delaying convergent action, the range of interventions that exist for convergent action, and lessons to apply 7
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In order of magnitude, the top 10 contributors to the global CDR in 2015 were ischemic heart disease, stroke, lower respiratory infections, chronic obstructive pulmonary disease, lung cancers, diabetes mellitus, dementias, diarrheal diseases, tuberculosis (TB) , and road injuries (Jamison et al., 2018)
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High-income countries Ischemic heart disease Ischemic heart disease Stroke Stroke COPD Dementias Lung cancers Lung cancers Lower respiratory infections COPD Diabetes mellitus Lower respiratory infections Dementias Colon and rectum cancers Road injuries Diabetes mellitus Liver cancer Kidney diseases Stomach cancer Breast cancers 0 50 100 150 200 0 50 100 150 200 CDR per 100,000 population CDR per 100,000 population FIGURE 2-1 Crude death rate by country income status, 2015. NOTES: The colors of the bars indicate causes for which overall death rates are increasing (red)
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. Dispelling False Dichotomies to Move Toward Convergence Moving toward convergence will require dispelling myths and false dichotomies about the chronicity, interactions, and risk factors related to infectious diseases and NCDs, said Oni.
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Rapid patterns of urbanization create an additional layer of complexity to shared risk factors, because many settings with emerging epidemics of NCDs coupled with high rates of mortality and morbidity are also experiencing rapid urbanization (Ezeh et al., 2017)
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shared between infectious diseases and NCDs. The spectrum extends to secondary prevention, such as screening and integrated services, through to tertiary prevention with integrated treatment and care.
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AN OVERVIEW OF COLLIDING EPIDEMICS AND SYNDEMICS 13 TABLE 2-1 Spectrum of Exposures, Health Services, and Potential Outcomes Health Services Exposures Intermediate Outcomes Long-Term Outcomes Food Sugar Eating behavior Diabetes Salt Obesity Hypertension/CVD/ Greenhouse emissions stroke Cognitive function Cancer Climate change Water and Pest/vectors Physical activity Infectious disease Waste Poisoning Obesity Injury Physical activity Health care episodes Cerebrovascular opportunities Health care admissions disease Air pollution Acute respiratory Greenhouse emissions disease Chronic respiratory disease Climate change Transport Noise pollution Physical activity Diabetes Social cohesion Obesity Hypertension/CVD/ opportunities Social cohesion stroke Physical activity Mental ill-health opportunities Chronic respiratory Air pollution disease Greenhouse emissions Climate change Habitation (and Damp Physical activity Acute respiratory planning) Thermal comfort Obesity disease Ventilation Sleep and stress Chronic respiratory Social cohesion Social cohesion disease opportunities Health care episodes Hypertension/CVD/ Physical activity Health care admissions stroke opportunities Mental ill-health Air pollution Infectious disease Health Care Availability Health care episodes Mortality (prophylaxis, Accommodation Health care admissions Morbidity treatment, Affordable Disease control palliation)
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• HIV has a high and growing prevalence in regions and states with significant population growth and urbanization rates, such as China, India, and countries in Africa. Oni reflected that the same characteristics apply to NCDs such as hypertension, yet global action has not been spurred for NCDs as it has been for infectious disease epidemics.
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Oni maintained that progress can be driven by fostering collaboration and building relationships to support and promote equitable population health outcomes by leveraging the beliefs, practices, and self-efficacy of individuals and civil society as well as harnessing the potential of economic and environmental drivers. In that context, she made the case for four approaches to convergent prevention and control.
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Oni concluded her presentation by saying the following: We need to be bolder in the ways we build and strengthen our systems for health, by thinking beyond just treatment and secondary prevention to research that addresses long-term and delayed co-occurrence in order to improve our health outcomes. SYNDEMICS OF INFECTIOUS AND NONCOMMUNICABLE DISEASES In her keynote address, Emily Mendenhall, Provost's Distinguished Associate Professor at Georgetown University, explored how syndemics of infectious diseases and NCDs can inform new approaches to tackling the global burdens.
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. Syndemics of Diabetes, Depression, and Infectious Disease Syndemic research provides opportunities to consider the convergence of infectious diseases and NCDs.
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. These trends are driven by high lifetime levels of social stress, the interface with depression, the interface with chronic infections such as HIV and TB, and unreliable access to quality, affordable care (Reddy et al., 2007; Mendenhall et al., 2012)
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AN OVERVIEW OF COLLIDING EPIDEMICS AND SYNDEMICS 19 BOX 2-1 Esther's Narrative Mendenhall described meeting Esther, a woman in her 50s living with HIV and diabetes, at a public diabetes clinic. Esther had to travel a long distance from her home to access the clinic, where she was exposed to people with tuberculosis being treated in other parts of the hospital.
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Syndemics can shift how diseases are studied, moving from ethnography to epidemiology then back to ethnography, with complex biological, psychological, and social interactions assessed using quantitative analyses to better understand illnesses. DISCUSSION During the discussion, Marcos Espinal, director of communicable diseases and health analysis at the Pan American Health Organization, highlighted the importance of thinking about syndemics because it may help find
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While there is value in drawing best practices and learning from efforts to integrate HIV and TB care, some of these approaches may not be taken up as the health workers may become fatigued with all of the different practices promoted to them. Espinal questioned, "How can we make sure health workers do their part and those simple measures are available in the community, because if we get too complex, then we might not be adopting those approaches." Oni suggested differentiating between complexity and complicatedness to avoid the risk of being paralyzed by complexity.
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