A patron poses outside one of Accra’s many thriving fast food establishments / Photo by Olivier Asselin
Fries in Fresno, Burgers in Batu, Soda in Soweto
Lifestyle diseases are on the march across the planet. Can we contain them, or are they irresistible?Kwesi and his brother, Yawo, finish off their third bottle of soda of the day and start to think about dinner. A large pie at Pizza Inn? Fried chicken or a hamburger at Papaye? They settle on a visit to Papaye, a popular fast-food joint, and hop on a crowded city bus to get there.
Nothing about this scenario sounds surprising, except for this: Kwesi and Yawo live in Accra, Ghana—a city where, just a decade ago, food choices were limited to local fare like rice, yams and simple stews.
Today, Ghana has seen a boom in fast food chains. It’s a change that has come with increased economic prosperity, but it’s also come with a cost. Ghana—and countless other developing countries around the world—is now grappling with what has become a global pandemic: chronic disease.
Long viewed as a healthcare burden that affects only people in wealthy countries, chronic disease is now threatening lower-income countries that are already battling infectious disease and woeful healthcare standards. In Ghana, which struggles against HIV and malaria, diabetes is now a growing concern, affecting more than 2 million people. “It’s not just the cost of care, or the lack of promotion about the disease that is causing this,” says Kwamena Beecham, President of the Ghana Diabetes Association. “It’s unhealthy eating, lack of physical activity, and obesity.”
A new estimate by the Global Burden of Disease reports that chronic illnesses already cause almost half the disease burden in low-to middle-income countries, and are on the rise.
“There is a very pervasive misunderstanding that chronic diseases affect only wealthy people in wealthy countries,” says Robert Beaglehole, former director of the WHO’s department of chronic disease and health promotion and Emeritus Professor at the University of Auckland, New Zealand. “Chronic diseases are a major, and neglected, cause of poverty, economic stress and premature death around the world.”
That neglect is waning: international organizations are beginning to sound the alarm bell, calling for changes to the global health paradigm. In 2005, the WHO vowed a major assault on chronic disease—with the goal of reducing it by two percent a year through 2015. If that goal is reached, according to the organization, it would prevent the deaths of 36 million people in the next decade, nearly all of whom would be under the age of 70. However, while the numbers aren’t yet in, estimates point to substantial increases, not decreases, in chronic diseases.
In addition to the health toll, there’s a pressing economic one: half of those who contract chronic diseases are in their most productive years, resulting in high rates of disability, unplanned absences and accidents on the job.
The Good Life?
What’s causing chronic disease in developing countries?
First, there’s increased lifespan—when people live longer, they are more likely to reach the age when chronic illnesses worsen and become more difficult to manage.
Then, there’s the globalization of lifestyle. The same lifestyle choices that plague the health of citizens of developed countries have become the scourge of people in the developing world too. The exact causes of chronic disease vary from one country to the next and include sedentary habits, diets of processed foods high in salt, sugar and fat, environmental pollutants and tobacco use. Add in stress, insufficient sleep, an absence of screening for chronic diseases to catch them early, a general failure to follow medical advice, and the stage is set.
Many countries are following in the footsteps of the United States. In the next decade, it’s projected that 43 percent of Americans will be obese (30 pounds or more over a healthy weight level), putting them at risk for at least three major chronic diseases: diabetes, heart disease and cancer. The U.S. spends over $1.8 trillion a year in healthcare costs for these diseases, and it’s a price tag that will continue to rise with the rate of obesity.
We have to look at how to slow the growth of healthcare costs, and one of the costs we need to look at is chronic disease,” says Kevin Volpp, MD, Director of the Center for Health Incentives at the University of Pennsylvania. “The question is: what are the behaviors that contribute to these diseases that are modifiable? The lion’s share of our healthcare costs goes to treating diseases that involve many office visits, so we need to focus the ingenuity of providers on keeping people healthy and out of doctors’ offices and hospitals.”
The scourge of these diseases is emerging more gradually in lower-income countries than in the U.S. as complex environmental, social, economic and behavioral factors start to converge. In some parts of the world, like Africa, the development has come as a surprise; in China and India, less so.
A shift in lifestyle has brought the burden of chronic disease to China, where heart disease, diabetes and cancer now account for more than three-quarters of all deaths. Managing these diseases, according to WHO estimates, could cost China more than $500 billion over the next decade.
“The Chinese way of living has changed significantly,” says Wu Yangfeng, Director of The George Institute for International Health in Beijing. “Among these changes, the most surprising is an increasingly sedentary lifestyle—even in rural areas. With the popularity of computers and television, and access to modern transportation, people are spending more inactive hours than ever before.” Studies show that poor nutrition is also a problem in China with an increase in the consumption of fatty foods.
In India, too, the increasing popularity of foods high in fat—particularly those cooked in oils filled with transfats—has contributed to a rise in chronic disease. In rural parts of the country, cardiovascular diseases are now a leading cause of death. India is also home to the largest population of diabetics in the world, at 30 million, and that number is expected to grow to 57 million by 2025.
Rohina Joshi, a senior research fellow at the George Institute in Sydney, says efforts to combat chronic disease in India have been complicated by its spread to the more remote parts of the country. “The majority of the Indian population resides in rural villages where physicians and hospitals are not readily available,” she says. “To tackle chronic disease, a well-functioning, accessible and affordable primary healthcare system is required.”
Across Africa the spreading epidemic of chronic diseases including heart disease, cancer, diabetes and obesity was unanticipated. Indeed, The United Nations Millennium Development Goals (established in 2000) does not include any mention of reducing chronic diseases. According to Falu Njie, Deputy Director for Policy at the UN Millennium Campaign, that’s because they were not ranked as the greatest threat at the start of the century. “At the time these goals were formulated, we were looking at the most pressing diseases affecting poor people in developing countries—malaria, HIV and TB,” Njie says. Ironically, malnutrition and chronic disease occur side-by-side in many countries.
Like Ghana, Uganda—a country where, for decades, healthcare efforts have focused on HIV and malaria—has seen a surge in diabetes. The number of Ugandans with diabetes is now thought to have passed a million, in a population of 28 million, which doctors and government officials attribute to changes in lifestyle and rising obesity.
“It’s not just fast food chains that are contributing to this problem, but also the fact that people are developing their own fast foods as they shift from agrarian lifestyles to more urban ones,” says Michelle Holmes, associate professor in the Department of Epidemiology, Harvard School of Public Health. “In places where there are few resources, this is a huge problem.”
Since 2007, Holmes and her colleagues have visited several African countries to try and establish large-scale, long-term population studies of chronic disease. In Mbarara, a university town in southwestern Uganda, Holmes says one of the major diabetes clinics operates with skeletal resources —treating patients on benches under the trees.
Diabetes is also on the rise in South Africa, which has seen an alarming increase in the primary risk factor for the illness: obesity. According to the International Diabetes Federation (IDF), the estimated number of people with diabetes in South Africa is around 840,000—a number the WHO predicts will increase to more than 1 million in the next 25 years. Those at highest-risk, IDF reports, are lower -income black communities, which are undergoing rapid lifestyle and cultural changes.
Jumpstarting a Healthy Life
How can we get ahead of these diseases?
Most healthcare experts agree that low-cost, population-based interventions are effective—but they don’t always agree on what, exactly, those interventions are. And in developing countries, particularly in rural, hard-to-reach areas, they can be difficult to implement.
A patchwork of measures has been introduced, which vary from country to country. Most nations are focusing on some combination of changing diets, reducing salt, fat and sugar in processed foods, improving school meals, recommending more exercise and discouraging the use of tobacco.
By contrast, efforts to combat chronic disease on a global scale have been limited.
The WHO has been active, making recommendations to more than 190 of its member countries on how to address chronic disease. And in 2005, The Framework Convention on Tobacco Control (FCTC)—the world’s first global public health treaty—was signed by 168 of the 192 WHO member states.
The treaty bans tobacco advertising and sponsorship, and advocates tobacco taxes and legislation to make public places smoke-free.
In California, for example, a tax on tobacco has been credited with significantly reducing the rate of lung cancer and other respiratory ailments; and it is predicted that a tobacco tax in Turkey will reduce the number deaths from cigarette-related illness by several hundred thousand this year.
Since the FCTC was put into effect, more than 20 countries have levied high taxes (over 75 percent of the retail cost) on tobacco products. Yet tobacco use continues to kill more than five million people per year—an average of one person every six seconds—and accounts for one in 10 adult deaths worldwide. Experts say it’s the leading preventable cause of chronic disease worldwide.
The treaty has not been popular with the tobacco industry, which argues the taxes unfairly burden smokers and fail to increase revenue. And some experts have argued that a tobacco tax will have little effect on chronic disease, and will instead increase smuggling and unfairly impact poor consumers.
These arguments are echoed by the salt and soda industries, both targets of tax plans and proposals worldwide by governments trying to control the chronic diseases related to their consumption.
In the U.S., two dozen states have imposed taxes on soft drinks, with healthcare experts arguing for more. In a 2009 paper in the New England Journal of Medicine, several prominent nutritionists made the case for a one-penny per ounce soda tax to reduce obesity and related chronic diseases.
“There’s very compelling science linking sugary beverages to weight gain and to increased risk for diabetes and heart disease,” says co-author David Ludwig, director of the Optimal Weight for Life Program at Children’s Hospital, Boston, and Associate Professor of Pediatrics at Harvard. “Taxing soda is a rare win in public health—it would improve health through decreased consumption, lower the cost of health to the government of obesity-related diseases, and generate billions in revenue.”
The response from the soda industry? Coca-Cola Co. chairman and CEO Muhtar Kent has publicly decried the idea of a soda tax. In an opinion piece published in the Wall Street Journal (2009), Kent argued soda was not the cause of obesity, or related chronic illness. Instead, he pointed the finger at inactivity, and the consumption of sugary foods.
While the debate over taxation rages, there’s one strategy for preventing chronic disease that’s almost unanimously embraced: national and local campaigns to increase awareness of these diseases, and their risk factors, and to change lifestyles accordingly.
“We have a lot of evidence-based programs that we know are effective,” says Kenneth Thorpe, Executive Director of the Partnership to Fight Chronic Disease. “I think we should focus our work in identifying, and implementing, these best-practice programs.”
In Poland, for example, the death rate for adults under the age of 45 has been reduced by 10 percent a year for several years because health officials have made fruits and vegetables more available, and waged a campaign to lower the consumption of butter.
In Brazil, the government has promoted exercise by building bike trails and hiking parks, and pushed for companies to lower the amount of saturated fat, sugar and salt in processed foods.
And in Australia, the government has made chronic disease a priority, launching a national strategy to combat it in 2006, which included high-profile education campaigns and task forces aimed at tackling specific diseases.
No matter the strategy, experts say one thing is clear: if more countries don’t pay attention to chronic disease, the cost—both financial and human—could be devastating, particularly to emerging economies. “This is a preventable epidemic,” says Beaglehole. “We know what to do and how to do it, but we have to take action now.”
Photo: A patron poses outside one of Accra’s many thriving fast food establishments / Photo by Olivier Asselin
