Volume 10 Issue 1
Peer reviewed article
Non-Communicable Diseases (NCDs) stand as one of the world’s most challenging health, social and economic issues.  The speed at which NCDs have risen has created a mammoth global problem, and it is predicted that by 2030 they will overtake infectious diseases as the leading contributor to dis- ability adjusted life years in LMICs.  Astonishingly, almost three quarters (28 million) of NCD deaths globally now occur in low- and middle-income countries each year . Fighting NCDs is intrinsic to im- proving the lives of all people, however, it is also an incredibly complex issue that is entrenched within a country’s social, economic and physical environments. Kenya is one such low-income country that is experiencing rapid NCD growth. Throughout this piece, I draw upon some personal experiences I had during a 4 week elective in Kenya to highlight the complex issues at play and identify some barriers against improvements being made.
Non-Communicable Diseases (NCDs) stand as one of the world’s most challenging health, social and economic issues.  The speed at which NCDs have risen has created a mammoth global problem, and it is predicted that by 2030 they will overtake infectious diseases as the leading contributor to disability adjusted life years in LMICs.  During a 4 week elective in Kenya
in December 2014, I was prompted to reflect
on my own perception of NCDs in the global context. This short exposure, although neither extensive nor comprehensive, inspired me to learn more about the issue of NCDs in low to middle income countries (LMIC) and has helped me understand the many factors complicating the global fight against NCDs. Throughout this piece, I will draw upon some experiences I had in Kenya to highlight the complex issues at play and identify some barriers against improvements being made.
What are NCDs?
NCDs can be defined as chronic diseases that are not transmissible. They constitute a large group of diseases that are of long duration,
and generally slow to progress, with the 4 main types of noncommunicable diseases being cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.  Common risk factors for developing these chronic diseases such as poor diet, a sedentary lifestyle, exposure to tobacco and harmful use of alcohol are near ubiquitous, contributing to the rapid rise of NCDs globally and impacting on many other areas of human and economic development. While the traditional understanding of NCDs portrays it as a problem of the old and wealthy, the new reality is that the burden of diseases from NCDs lies disproportionately in LMICs.  Contrary to popular opinion, available data demonstrate that nearly 80% of NCD deaths occur in LMICs.  Since the landmark 2011 UN Summit,  there has been a greater appreciation of the emerging burden of NCDs in LMICS. However, despite repeat calls for action, the NCD burden is increasing unchecked.
Social Determinants of Health
The social, economic and physical environments in developing countries afford their populations much lower levels of protection from the risks and consequences of NCDs than in high income countries (HIC).  In many countries, harmful drinking and unhealthy diet and lifestyles occur both in higher and lower income groups. However, high-income groups can access services and products that protect them from the greatest risks while lower-income groups can often not afford such products and services.  A recent report identified four broad reasons chronic disease are on the rise in the African region. These were rapid unplanned urbanization, little understanding of the risks that come with a chronic condition like heart disease, lack of access to healthcare and cost of treatment. 
In Kenya, health expenditure remains less than 5% of gross domestic product (GDP) , with curative rather than preventative health continuing to receive the highest share of the total health sector budget.  As a comparison, Australia spent 9.67% of GDP on health in 2012 – 2013.  Importantly, Kenya’s figure sits significantly less than the 15% goal set out in the Abuja Declaration of 1989.  A 10 year review of the Abuja Declaration, which was signed by heads of state of African Union countries to improve the health sector, revealed that there has not been appreciable progress in terms of the commitments that African Union governments, including Kenya, make to health, or in terms of the proportion of gross national income the rich countries devote to official Development Assistance.  This disproportionate economic commitment to tackling health, and subsequently NCDs, is disparaging and highlights the lack of action in this key area.
The transformation of the food sector is another example of how the economic environment has perpetuated the rise of NCDs. Studies have shown how food environments and access to convenience foods in developed countries have contributed to higher rates of obesity, diabetes and cardiovascular disease.  What is concerning is that the harmful habits that stubbornly resist public health measures in HICs are shared between all countries, shaped in part by national and global food production and a variety of marketing forces that drive global epidemics of NCDs. The sale and promotion of tobacco, alcohol, and ultra-processed food and drink (unhealthy commodities), transnational corporations  are all driving factors. In Kenya, the fight against these diseases is further complicated by cultural factors, including the perception of overweight and obesity as signs of prosperity.  Whilst the transformation of the food sector and concurrent growth of supermarkets has shown to provide some financial benefits to rural farmers,  ready access to cheaper, higher calorie but not necessarily healthy food options presents a growing challenge.
The effect of this food environment transformation can be seen in the modern paradox that many developing countries suffer from undernourishment on the one hand, and obesity and diet-related diseases on the other. The lack of investment in nutrition  has also created a burgeoning challenge that complicates an already difficult issue. A UN taskforce mission in 2014 revealed that, alarmingly, 18% of Kenyan pre-school children are now obese, with around 30% of Kenyan adults overweight and around 9% obese,  while malnutrition statistics from 2009 showed 35% of children under five years were still stunted (defined as being less than -2 standard deviations from the height-for-age of the WHO Child Growth Standards median), 16% were underweight, and 7% were wasted.  In the African region, the rate of stunting remained at 39% in 2013.
NCDs in Kenya
In Kenya, NCDs account for 27% of deaths suffered by those aged between 30 and 70 years, with the potential to reduce productivity, curtail economic growth and trap the poorest people in chronic poverty. Prevalence and mortality data is either unavailable or have a high degree of uncertainty due to lack of national NCD information. [17, 18] However, 50% of all hospital admissions and 55% of hospital deaths in Kenya are estimated to be due to NCDs.  As with many developing countries, medical care is not readily accessible to the majority of the citizens, with primary health care implementation since the Alma-Ata Declaration in 1978 lagging behind despite government level commitments.  On top of the pervasive economic factors at play, the impacts of this are broad, as inability to access affordable and safe primary care services leaves little opportunity for health promotion and preventative medicine which are cornerstones in the fight against NCDs.
Many aspects of the underfunded and under- resourced healthcare system that struggles to deal with NCDs became apparent during
my stay. The multitude of barriers stacked up against the provision of basic healthcare, not just NCDs were apparent. Immersed in the hospital’s organised chaos, I watched on with admiration as the staff worked tirelessly without complaint and access to basic equipment (including CT machines and reliable supply of blood for transfusions). Day to day, as doctors worked within the constraints of a system stretched to its limits, it seemed that NCDs had fallen
on the wayside of their priorities. However, the devastating effects of NCDs though could not be denied and were a frequent encounter during my 4-weeks there.
The case of cervical cancer, a noncommunicable disease with an infectious origin, is just one example of health disparity resulting from inequitable access to life saving technology, such as vaccines. In sub-Saharan Africa, cervical cancer remains the leading cause of cancer death among women.  Encounters with patients suffering from cervical cancer were unfortunately not rare during my elective. In a system where receiving palliative care involves paying steeply out of your own pocket, and travelling 300 km to the national hospital, management of cancer was a helplessness- inducing experience for all. A sobering fact is that 80% of the women affected by cervical cancer live in developing countries.  This reality, and the numbers of women dying all over the world due to this potentially vaccine preventable disease is simply unacceptable.
Since it’s introduction in Australia through the HPV school vaccination program in 2007 there has been a 77% reduction in the HPV types responsible for cervical cancer.  Although we will not expect to see reduction in cervical cancer for a few more years, since cervical cancer usually develops over 10 years or more, health experts are confident of a decline and all current evidence is supportive of this.  Despite its effectiveness, cost remains one of the greatest barriers against introducing
this vaccine, among others, in developing countries including Kenya.  Other barriers include the underlying weakness of the health system in developing countries, lack of political commitment, weak information system, severe shortage of adequately trained health workers, lack of information about vaccines and the fear of vaccines.  It is clear that the issues at play at complex, but the injustice of not taking action against this is clear: with every 5-year delay in bringing vaccination to developing countries, 1.5 million to 2 million more women will die. 
In the face of a highly complex issue incorporating multiple diseases, there is a definite need for stronger health investment and public health programs to address awareness of the broad range of disease represented by NCDs. Resources, dedicated government bodies and funding are all necessary to improve knowledge of their risk factors, enable the implementation of programs to support prevention and initiate early management. These are all essential elements in the mitigation of NCDs.
Action Against NCDs
There are signs that awareness of NCDs is translating into action. The great levels of illness and death associated with NCDs has lead the Kenyan government to prioritise NCD prevention and control in its National Medium Term Plan 2014-2018; the United Nations Development Assisted Framework 2014-2018 for Kenya;  and the Kenya third generation WHO Country Cooperation Strategy (2014-2019).  The need for a ground-up approach has also been recognised. A few groups involving Kenyan young professionals (including medical students) have been developed to help change the mindset of the population through free health screening initiatives and school based educational programs.  Their experience in Kenya highlights how such a network can empower the youth to have a substantive impact on the prevention and mitigation of NCDs in their local context.
It is clear that that fighting NCDs is intrinsic to improving the lives of all people, but it is also clear that the issue of NCDs in LMICs is incredibly complex. While some countries are making progress, the majority are off course to meet the global NCD targets.  The role of policy change, taxation, mass media and 25. African Development Bank Group. Country Strategic Paper regulation of foods in targeting NCDs and their risk factors are all pivotal when NCDs are seen as part of an industrial epidemic.  As such, only by addressing the issues through a multi-sectorial response against NCDs and their risk factors can we make any real progress towards reducing or attenuating the occurrence of NCDs.
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