Introduction to NCDs in Eastern Europe
Non-communicable diseases in Eastern Europe: a region hit hard
Von Nicole Probst-Hensch / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
The world population is faced with a dramatic increase in the prevalence of non-communicable diseases (NCDs). Within 20 years between 1990 and 2010, the contribution of NCDs to the global burden of disease increased from 43% to 54%. (Murray C et al, 2012) This is the result of increased life expectancy and alterations in our lifestyle and the environment. Globalized markets and an increasing number of people living in urban contexts contribute importantly to the chronic disease epidemic.
NCDs are a major source of poverty for regional and national economies, for health systems and for households and individuals. They diminish the active work force and cause severe gaps in productivity. They strain health and welfare expenditure. Their costly and often lifelong treatment also overwhelms house hold budgets. Most importantly they diminish well-being in those suffering from one or more chronic conditions. (The World Bank 2011)
The cultural and economic diversity of countries in Eastern Europe makes it difficult to summarize the NCD problem in the region. Yet, the political history of 20th century Europe in the region contributed to some important commonalities such as the failing of communist systems in implementing effective health policies. Health care was primarily focusing on the treatment of acute, mostly infectious diseases. The marks of these systems are still evident today and leave national health care systems unprepared for the cost-effective NCD control, but of course broad differences exist in how rapidly the gaps are closing. (Mackenbach JP, Karanikolos M, McKee M, 2013)
Overall and healthy life expectancy in Eastern Europe is generally lagging far behind Western Europe. In countries like Russia or Ukraine, life expectancy has even decreased compared to the 70s and 80s. (Mackenbach JP, Karanikolos M, McKee M, 2013; Salomon JA et al, 2012) According to the most recent global burden of disease estimates Eastern Europe has by far the highest death rates of all the regions in the world, mostly due to the very high death rates from cardiovascular causes (Figure 1).
Figure 1: Death rates in 2010, by cause and region (http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-cause-patterns)
In looking at the risk factors contributing to disease, disability and deaths, alcohol is ranking number 1 in Eastern Europe. (Lozano R et al, 2012) The excessive alcohol consumption in the region affects the population as a whole, but the problem is particularly strong in young and middle aged men. Disability and years of life lost as a result of alcohol are not only attributable to cardiovascular diseases and different cancer types. The excessive alcohol consumption also takes its toll in the form of injuries, accidents and violence. Even among boys and girls aged 5-14 years alcohol ranks as second most important cause of disability adjusted life years (DALYs), mostly due accidents, injuries and violence and as a result of the drinking behaviour in these childrens’ social network. Excessive alcohol use also increases the risk for chronic infections, most importantly HIV due to risky behaviour (e.g. promiscuity, unsafe sex), AIDS (e.g. inadequate treatment, poor compliance with treatment), and tuberculosis (e.g. increased risk of infection; poor living conditions). (Rehm J et al, 2009) The rates of HIV infections are undergoing dramatic increases in some countries in the region. Eastern Europe and Central Asia belong to the regions with a particularly prominent problem of multidrug resistant TB.
Figure 2: Disability Adjusted Life Years, Men, Age 15-49, Eastern Europe (http://viz.healthmetricsandevaluation.org/gbd-compare/) (green bars: traffic-related and non-traffic-related injuries as well as self-harm and inter-personal violence; blue bars: NCDs; red bars: infections).
Ukraine is among the countries where the problem of cardiovascular diseases and its risk factors including hypertension, alcohol consumption and smoking is very severe and threatening the lives of young people, particularly men. (The World Bank 2010) According to a recent survey, non-smokers make up less than 30% of the male population aged 18 to 65. More than 30% of men below age 50 report heavy or binge drinking (having one or more days in a month with more than five drinks), a behaviour which by now is also not uncommon in young women. Already at the age of twenty, the rate of hypertension is reportedly 20% and increases to over 60% by the age 60.
Figure 3: Age-standardized death rates due to cardiovascular disease, ischemic heart disease, and cerebrovascular disease, Ukraine vs. EU 1990-20047
Awareness, prevention and treatment of cardiovascular diseases and their risk factors remain poor in the region. While several countries have passed laws towards controlling alcohol abuse, the prices and taxes on alcohol remain comparatively low in Eastern Europe. Governments’ reluctance to increase prices relates to the fear of increased smuggled and home-produced alcohol as well as to concern about negative public attitudes. Yet a recent survey indicated that women, but not men would be in favour and supportive of more stringent control measures. (Roberts B et al 2012)
The health care system and especially the primary care setting needs to be re-oriented from a focus on the episodic treatment of acute diseases towards the prevention and treatment of chronic diseases. According to a recent survey in several Eastern European and Central Asian countries, more than a quarter of persons diagnosed for hypertension are not taking regular medication, although the importance of taking medicine on a daily basis for decreasing disability and mortality is well established (Roberts B. et al, 2012). An USAID survey conducted by Hill and colleagues among 269 primary care providers in Georgia, Albania, Armenia and Russia, revealed that only 70-80% felt confident enough to treat hypertension (Hills K. et al, Chitashivili T. 2012). This percentage dropped to less than 50% for treating diabetes, and to less than 10 % for treating alcohol abuse. Only 52% of the providers provided correct answers to questions about knowledge on hypertension and its treatment. Access to resources for improving the know-how (literature; guidelines) was reported as very poor.
Efforts to ameliorate the health of people in Eastern Europe are urgently needed. A whole generation of especially young and middle aged men is a risk of being lost to the NCD epidemic. In the area of prevention the excessive alcohol use is a priority. Young and middle aged men, and increasingly also women are central target groups for prevention efforts, which must also consider the very poor fruit intake, obesity and tobacco smoking. Stricter alcohol laws and their enforcement are needed. Diagnosis and treatment of NCDs must be improved by strengthening primary care and re-orienting it towards NCDs. Training of health care professionals is a high priority. Patient involvement and self-management needs must be improved.
* Nicole Probst-Hensch is Professor of Public Health at the University of Basel and heading the unit of Chronic Disease Epidemiology at the Swiss Tropical and Public Health Institute, Basel, Switzerland. Contact: Nicole.firstname.lastname@example.org
- Hills K et al. Chitashvili T. Non-communicable disease burden in Eastern Europe: quality gaps and opportunities. USAID Health Care Improvement Project. International Forum for Quality & Safety in Health Care April 19 2012.
- Lozano R et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380: 2095-128.
- Mackenbach JP, Karanikolos M, McKee M. The unequal health of Europeans: successes and failures of policies. Lancet 2013;381: 1125-34.
- Murray C et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2197-223
- Rehm J et al. The association between alcohol use, alcohol use disorders and tuberculosis (TB). A systematic review. BMC Public Health 2009, 9:450 doi:10.1186/1471-2458-9-450
- Roberts B, Stickley A, Balabanova D, Haerpfer C, McKee M. The persistence of irregular treatment of hypertension in the former Soviet Union. J Epidemiol Community Health 2012 doi:10.1136/jech-2011-200645
- Salomon JA et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2129-43.
- The World Bank 2010 and Verso 04, 2010. Report Series Health and Demogaphy. What underlies Ukraine’s mortality crisis?
- The World Bank 2011. The growing danger of non-communicable diseases. Acting now to reverse course. Conference Edition September 2011.