Kerala Journal of Ophthalmology

PERSPECTIVE
Year
: 2020  |  Volume : 32  |  Issue : 3  |  Page : 224--231

Noncommunicable diseases and noncommunicable eye diseases: What is the way forward?


Meena Chakrabarti 
 Retina and Vitreous Services, Chakrabarti Eye Care Centre, Trivandrum, Kerala, India

Correspondence Address:
Dr. Meena Chakrabarti
Retina and Vitreous Services, Chakrabarti Eye Care Centre, Indian Oil Petrol Pump, Kanjirampara P.O., Trivandrum, Kerala
India

Abstract

As humans conquered indectious communicable diseases, nutritional deficiency as well as conditions responsible for maternal and perinatal mortality and lifespan increased, new problems such as diabetes, hypertension, cardiovascular, respiratory, and renal diseases, mental health, and drug abuse became significant health issues. Cloistered under a single umbrella term noncommunicable diseases (NCDs), these conditions as well as noncommunicable eye diseases are characterized by a course that is prolonged with multiple morbidities and an unequal distribution that puts the poor and the vulnerable at a disadvantage. Our country is going through the phase of communicable disease to noncommunicable disease (NCD) transition. And hence it is absolutely vital for us to plan and execute effective strategies to control these conditions.



How to cite this article:
Chakrabarti M. Noncommunicable diseases and noncommunicable eye diseases: What is the way forward?.Kerala J Ophthalmol 2020;32:224-231


How to cite this URL:
Chakrabarti M. Noncommunicable diseases and noncommunicable eye diseases: What is the way forward?. Kerala J Ophthalmol [serial online] 2020 [cited 2021 Apr 21 ];32:224-231
Available from: http://www.kjophthal.com/text.asp?2020/32/3/224/304539


Full Text



 Introduction



For the most part of our history, the main threats to a healthy life were natural calamities, communicable diseases, malnutrition, injuries, and complications of childbirth. After a prolonged and successful battle against these entities, our health-care system was able to streamline a very effective strategy for early recognition, prevention as well as effective management of these disease entities. As humans conquered these conditions and lifespan increased, new problems such as diabetes, hypertension, cardiovascular, respiratory, and renal diseases, mental health, and drug abuse became significant health issues. Cloistered under a single umbrella term noncommunicable diseases (NCDs), these conditions are characterized by a course that is prolonged with multiple morbidities and an unequal distribution that puts the poor and the vulnerable at a disadvantage [Figure 1] and [Table 1].{Figure 1}{Table 1}

The threat to a healthy life from these diseases is greater due to the lack of a proper health-care system response or an effectively planned strategy to contain them.

 Why are Noncommunicable Diseases a Serious Public Health Problem?



NCDs have become the most dominant global public health challenge of the 21st century. Sixty-three percent of the annual global death toll and untold morbidity and disability caused by NCDs makes this entity a real public health problem. In India, 62% of all deaths and 55% of all disability-adjusted life years (DALYs) in 2016 were attributable to NCDs. NCDs not only have a serious impact on human health but also exert a severely detrimental effect on the country's economic growth. NCDs and mental health conditions could cause the world $47 trillion in lost economic output from 2010 to 2030 if urgent actions are not enforced to prevent or treat these conditions.

NCDs account for:

62% of all deaths in India40% of all hospital stays35% of all recorded outpatient department (OPD) visits55% of DALYs26% probability of premature deathsIncreased out-of-pocket expenditure (OOPE) for hospitalization for NCDs (from 32% [1995–1996] to 47% in 2004).

Thus, it is estimated that NCDs reduce the gross domestic product of India by at least 1%, and hence, the economic consequences of NCDs cannot be overstated. NCDs push a large number of persons with fragile and unstable financial status into poverty with its high potential for incurring OOPE for hospitalization to manage the several chronic disease-related sequelae.[1],[2],[3],[4],[5]

NCDs exert a deleterious effect on the country's economic growth in several other diverse ways also. They account,for increased health-care expenditure for the health-care system, the family as well as the individual, and is responsible for the affected persons opting for early retirement, thereby reducing the available labor and reducing productivity. Productivity is further reduced when the afflicted employee (due to his chronic ill health) is unable to perform his duties satisfactorily.

As the impact of NCD increases, fuelled by the lack of a proper health-care system response and an increased aging population, deaths due to NCDs are expected to spiral skywards with the maximum increase in the middle- and low-income groups.

 Communicable Facts for the Community The Myths Surrounding Noncommunicable Diseases



Myth No 1 – Noncommunicable diseases are primarily urban diseases of the rich and the elderly

The myth that NCDs are seen only in urban India was busted as early as 2003, when the NCD mortality in rural India was shown to be comparable to the mortality due to communicable diseases, maternal and neonatal conditions, and nutritional disorders. This showed that our country was going through the phase of communicable disease-to-noncommunicable disease (NCD) transition. The rate of transition is directly related to the level of social development, education, and degree of urbanization and was seen to occur faster in the more developed metropolitan cities with the poorer states also racing to catch up. This transition is evident if we examine the DALY due to NCDs which increased by 65% (1990–2016) in the late transition states compared to the 36% increase in the early transition states during the same period of time. It is also disheartening to note that the NCD burden is increasing at a greater rate among the poor in India in whom the onset of these diseases is at an earlier age. The majority of the deaths due to NCDs in India are premature and preventable, and additionally, the years of productive life lost due to NCDs are greater than those due to communicable diseases.

Myth No 2 – Increase in noncommunicable diseases represents economic growth

Until a few years back, NCDs, especially diabetes and hypertension, were considered as signs of prosperity and wealth. This scenario has changed dramatically with the NCD burden increasing at an alarming rate among the poorer and marginalized sections of the society. The triad of reduced productivity during the most active phase of life, increasing OOPE to treat chronic sequelae of NCDs as well as the added burden on an already stressed health-care system in a highly populated country like India has created an awareness in governmental and nongovernmental agencies on the tremendous detrimental effect of NCDs on economic growth.

Myth No 3 – Noncommunicable diseases are incurable, self-inflicted with difficult-to-change behavioral risk factors and the state has no role in its prevention

Most of the NCDs are incurable, but the multiple morbidities, premature deaths, and disabilities sue to NCDs are preventable using evidence-based interventions. There is good quality evidence which suggests that lifestyle interventions and an emphasis on a daily physical activity are useful in delaying the onset and slowing the progression of diabetes, hypertension, and cardiovascular diseases.

The role of the state administration: Initiating changes in the society to trigger these behavioral modifications and providing incentives to make healthy choices on the responsibilities of the state. Smart urban life planning, affordable and accessible healthy foods, quality health education, and limitations on the advertising of unhealthy food products are strategies to reduce NCDs.

Low-cost solutions (“best buys” – actions) that should be enforced to accelerate results in terms of lives saved, disease prevented, and heavy costs avoided are as follows:

Banning smoking in public places, thereby protecting people from tobacco smokeCreating public awareness about the dangers of tobacco and alcohol use (using both the visual, digital, and print media)Enforcing bans on tobacco and alcoholic product advertising, promotion, and sponsorshipRestricting access to retailed alcoholPromoting public awareness on healthy diet and physical activityEnforcing drink-driving lawsRestriction on marketing food and beverages high in salts, fats, and sugar, especially to childrenPromoting school-, workplace-, and community-based physical activity programsEnforcing population-wide preventive interventions

Vaccination against hepatitis B, a major cause of liver cancerVaccination against human papillomavirus, the main cause of carcinoma cervixProtection against environmental and occupational hazards such as aflatoxins, asbestos, silica dust, and contaminants in potable waterScreening for breast, oral, colon, and cervical cancers.

The health-care system should combine population-based and individual interventions for primary prevention, early detection, treatment, and palliative care.

Currently, the health care for NCDs has its main focus on hospital-centered acute care which is a very expensive way of tackling NCDs and will not contribute to the reduction of NCD burden. To ensure primary prevention and early detection of NCDs, the integration of these diseases into the primary health-care package is mandatory. Cost-effective and sustainable health-care interventions should be offered to high-risk individuals such as:

Interventions for the prevention and management of diabetes ( which have definitely reduced costs while improving health) , include glycemic control, blood pressure control, foot care, diabetic retinopathy (DR) screening, screening for nephropathyInclusion of chronic respiratory diseases also in lung heath programs designed for prevention, treatment, and control of tuberculosis. This program should explore the procurement of quality-assured inhaled drugs at affordable costHigh-risk individuals and those with established cardiovascular disease can be treated with low-cost generic medicines (regimen of aspirin, statins, and blood pressure-lowering agents) that significantly reduce the risk of death or a major cardiac event. When coupled with cessation of smoking the therapeutic benefit can be doubledCreating access to pain-relieving agents (morphine) and staff trained in palliative care, by forming mobile palliative units for home visits and necessary care of the terminally ill patients.

Financing and strengthening the health-care system to deliver cost-effective individual interventions through a primary health-care approach is a pragmatic first step to achieving the long-term vision of universal care coverage for NCDs. Strengthening political commitments and according a high priority to NCD programs are also key steps in expanding the health-care system capacity to tackle NCDs. For this to occur, we need to improve our basic technologies, the health workforce, health information, funding, etc., to ensure that the primary care package delivers the abovementioned cost-effective interventions to the public.

 Noncommunicable Eye Diseases



Global efforts to address NCDs have largely excluded reference to the massive social and economic impacts of blinding conditions such as cataract, glaucoma, diabetes, and age-related macular degeneration (AMD). These efforts focused mainly on how mortality rates could be reduced, and hence, diseases such as cancer, respiratory illnesses, and those caused by tobacco and poor diet received all the attention in discussions on tackling the NCDs.

The World Health Organization's (WHO) most recent figures show that 285 million people globally are vision impaired, of whom nearly 40 million are blind. Around 50% of all blindness and vision impairment in developing countries is caused by cataract, and a further 10% of blindness is caused by glaucoma. Four percent of blindness and vision impairment is caused by diabetes, one of the primary diseases being addressed within the NCD framework.

There is growing evidence to support a relationship between blindness and mortality. Studies have shown that up to 60% of children who become blind die within 2 years. The DALY measure of time lived with a disability combined with time lost due to premature mortality for vision impairment (mostly caused by cataract, glaucoma, and refractive error) is the 6th largest cause of DALYs globally. Vision impairment has a 3% share of global DALYs – more than unhealthy diet (1%–2%) and physical inactivity (2.1%), and only fractionally less than those resulting from cancer (5.1%), respiratory disease (3.9%), and harmful use of alcohol (4.5%) and tobacco use (3.7%)

Although cataract and uncorrected refractive errors remain by far the leading causes of visual impairment, several other eye conditions have emerged as significant threats to people's vision – those which are noncommunicable (or chronic) and which become more prevalent with aging. They are:

DRglaucomaAMD.

In addition, the ocular adverse effects of abuse of tobacco, alcohol, and illicit drugs have also emerged as a social threat and health hazard. Drug and alcohol abuse can produce a variety of ocular and neuro-ophthalmic manifestations. Novel substances of abuse and novel routes of administration may surprise even the most astute physician if substance abuse is not suspected.

Unlike cataract or refractive error, for which surgery or a pair of spectacles can restore vision, these diseases all affect the back of the eye, are incurable, and require ongoing lifetime follow-up and management

Over the last two decades, these noncommunicable eye diseases (NCEDs) have become much more significant due to two main reasons:

The demographic transition (the fact that more people are living longer) is taking place due to better nutrition and accessibility to a more comprehensive health-care service. Since DR, glaucoma, and AMD mainly affect the elderly, demographic transition has resulted in an increase in the incidence of these conditionsThe epidemiological transition means a change in population health due to changes in lifestyle. NCDs, particularly cardiovascular disease and diabetes (with its complications, including DR), are increasing because of changes in lifestyle with urbanization. People are less active, eat more, and eat unhealthy junk food. Smoking is prevalent in many populations and is a known risk factor for AMD [Figure 2].{Figure 2}

Both demographic and epidemiological transition has already occurred in high-income and many of the middle-income countries and is starting to become noticeable in low-income countries also.

Strategic planning and availability of services for the prevention, early detection, and management of DR, glaucoma, and AMD has been enforced in many high-income countries by providing comprehensive eye care services that are integrated into their national health systems.

In addition, to enhance the quality of life of people with permanent, severe vision loss, the provision of low vision services as well as vision and occupational rehabilitation services have been made available. Most low-income countries, and some middle-income countries, however, are not able to provide adequate services to prevent and manage these diseases as there is a shortage of skilled eye care professionals with the competence to effectively handle these eye conditions. The eye health services in these countries also lack an interdisciplinary, patient-centered approach, which is critical for the successful management of NCEDs.

What are the priorities for action?

Major contributions to eye care development in India have come from the ophthalmologists (mass cataract surgery in the early 1900s; major participation of nongovernment organizations), policymakers (National Program for Control of Blindness and Visual Impairment, 1976; systematic development under the World Bank-assisted India Cataract Project, 1995–2002), and the industry (manufacturing of affordable surgical instruments and medicines). Although the country can boast of higher cataract surgical coverage and near-total elimination of trachoma, there is an increasing prevalence of DR and undetected glaucoma.

India is presently at the crossroads of adherence to the old successful model of service delivery and adoption of new innovative methods of teaching and training (workforce development and skill-based training) relevant medical research and product development. In the absence of these new approaches, the initial gains in eye care cannot be furthered in India. A new approach combining the best of “old” tradition and the “new” technology is required to further the future of eye care in our country.[6],[7],[8] Thus, the future of eye care in our country is dependent on:

Availability of committed, trained eye care professionals who have the equipment they need and are working within an adequate infrastructure and are trained to provide comprehensive eye examinations. They should be confident in managing NCEDs, including the competency, to perform patient counseling.

There is a huge disparity in the quality of training available to the ophthalmic assistants and optometrists in our country. The duration of training varies from 6 months to 4 years, with a similar variation in the quality of training. These variations in training are reflected in the quality of eye care services available in our country. On the one hand, we have well-equipped and staffed tertiary eye care referral centers while on the other end of the spectrum are centers lacking appropriately trained professionals and basic infrastructure. Rural–urban disparities of eye care services make easy availability of eye care facilities difficult for the rural population. More than 70% of the Indian population reside in rural areas where only 25% of ophthalmologists practice. Eye surgeon–population ratio varies from 1:20,000 in urban areas to 1 in 2, 50,000 in rural areas.

Necessary equipment and infrastructure (including good record-keeping processes) need to be put in place so that, once trained, eye care providers can examine, manage, and follow up patients. Nonavailability of proper equipment is one of the main obstacles hampering appropriate eye care delivery. In addition, there are centers where equipment are available, but lack of maintenance results in suboptimal utilization of the equipment. Inadequate ophthalmologic equipment management training also acts as a barrier in utilization of equipment. High maintenance costs and location of the eye care facility in remote areas again pose challenges for maintenance of equipment.Adequate and realistic patient counseling: As these conditions require often lifelong follow-up, they will have a major long-term impact on patients, both in terms of their time and compliance with the treatment regimen and in terms of the lifelong costs of managing their condition. An awareness drive should be started, and at all contact points (OPD, camps, schools, offices, etc.), trained counselors should explain about the importance of early detection, periodic checkup, compliance to therapy as well as long-term follow-up. In a study of the predictors of and barriers associated with poor follow-up in glaucoma patients, lack of knowledge about the blinding sequelae and perceptional barriers were responsible in 40% of patients with poor compliance to follow-up. If this is the level of awareness regarding the disease and the need for follow-up in patients with established disease, the awareness levels in those without established disease will definitely be worse.Establishing health insurance-based financing of health care, which includes eye care, appears to be the optimal way to prevent vision loss in those individuals who may not be able to afford out-of-pocket payments. There are about 16 government health insurance schemes in India such as the Ayushman Bharat, Rashtriya Swasthya Bima Yojana, or the Kerala government-sponsored Karunya Health Scheme. A Government Health Insurance Scheme is a state or central government-powered health insurance initiative for its citizens, directed toward enhancing the health-care quotient of the region by offering low-priced insurance policies with a sizeable sum insured. Such policies are usually offered on an annual basis at a low price to encourage people below the poverty line to avail insurance.

Patients must be able to comply with the treatment regimens, which means that the medicines they need have to be available and affordable. This means that the procurement and distribution logistics of eye medicines using bulk purchasing to drive prices down and to ensure quality control and standardization have to be strictly enforced.

Availability of low vision services which are affordable. Even in high-income countries, there may be uneven coverage of the population, and most low vision services are provided in urban areas, resulting in limited access. Adequate low vision and rehabilitation services should, therefore, be an integral part of comprehensive eye care. Once people have lost their sight due to an NCED, there is usually no way to restore vision, so rehabilitation and low vision are currently the only remaining intervention.

The Kerala Model “VISION REHABILITATION CENTERS:” To ensure provision for adequate accessibility to low visual aid facilities, the Kerala Society of Ophthalmic Surgeons (KSOS) have started a pilot project to train optometrists and facilitate setting up of vision rehabilitation centers within our state.

The participating institutes sign a MoU with KSOS to run low vision centers with commitment for a minimum period of 3 years without looking at the financial viability of the project. The institutions provide (a) space – minimum of 100–150 sq ft, (b) service of trained personal in low vision, and (c) consultant in medical retina (full time/part-time) and should have easy access to optical coherence tomography and Humphrey Field Analyser (HFA). The management personnel of the selected institutions/hospitals are trained regarding the functioning of low vision centers. The trained optometrists serve the designated center for a period of 12 months after completion of training. They will, in turn, train other optometrists deputed by KSOS MoU-signed institutions in low vision service. The service provider should also take the initiative to conduct outreach programs for case detection. This program may be considered as our first step toward ensuring provision for adequate accessibility to low visual aid facilities in our state.

A “bottom-up” pyramid represents a model of holistic eye care for creation of sustainable permanent facilities within communities, staffed and managed by locally trained human resources, and linked effectively with successively higher levels of care. This is the model adopted by one of the major tertiary eye care centers in South Indian and is an easily replicable model [Table 2] and [Figure 3].{Table 2}{Figure 3}

At the base of the pyramid are VISION GUARDIANS that represent community involvement and comprise trained young people who keep a close vigil on the eye health of about 5,000 persons within communities through door-to-door surveys and other informal meansVISION CENTERS form the next level and serve the primary eye health needs of the community and are staffed by persons from the local community, catering to a cluster of villages, individually servicing a target of around 50,000 peopleSECONDARY EYE CARE CENTERS are networked to the vision centers, and each serves a population of 500,000 persons. These centers provide care that can diagnose the complete range of ophthalmological diseases and offer high-quality surgical care for cataract – the most common cause of blindness. These centers draw upon local talent too, with team members recruited from the local community and trained at an advanced tertiary centersTERTIARY CARE HOSPITALS/TRAINING CENTERS are linked to secondary centers, and each serves a population of 5 million persons. These centers provide a comprehensive range of services and also serve as training centers to the secondary centers.CENTERS OF EXCELLENCE are linked to tertiary centers, and each serves a population of 50 million persons. These centers treat complex diseases, train the trainers in subspecialties and rehabilitation, and engage in advocacy.

This innovative approach ensures eye care delivery that

Combines excellence with equity: Quality eye care for allSustainability: Each center becomes self-supporting through income-generating activities and cross-subsidization of servicesTeam approach: Complementary roles for each team member for an efficient and cost-effective systemCommunity participation: Strong community ownership at the primary and secondary levels, with over 50% of staff recruited locally and contributions from the community in cash and kind.

This replicable model is appropriate for developing countries, as it does not depend on external funding or expertise in the long term.

While India is waking up to the need for eye care with the government making policy initiatives at both the state and center levels, a lot still needs to be done. The entry of several service providers and active participation from NGOs through various initiatives has also slightly assisted in raising the awareness of eye care in India. One such initiative is VISION 2020 that was launched by the WHO together with more than 20 international nongovernmental organizations that aim to provide technical support and advocacy to the prevention of blindness activities worldwide by the year 2020.

Another initiative that has seen some success is the Global Action Plan (GAP) which is a commitment endorsed by all WHO Member States to improve eye health for everyone (“Universal Eye Health”) by 2018. GAP is now the most important strategic document in eye health. This initiative represents a significant step forward toward achieving “universal access” to eye health. Approximately 25 VISION 2020 workshops take place every year at local and international levels, tackling specific national or regional priorities for the GAP. These workshops help to align GAP's objectives in tandem with the specific region.

 Conclusion



NCDs kill 41 million people each year, equivalent to 71% of all deaths globallyEach year, 15 million people die from a NCD between the ages of 30 and 69 years; over 85% of these “premature” deaths occur in low- and middle-income countriesCardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million)These four groups of diseases account for over 80% of all premature NCD deathsTobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets all increase the risk of dying from a NCDDetection, screening, and treatment of NCDs, as well as palliative care, are key components of the response to NCDs.

The “causes of the causes” of NCDs make them difficult to address; proximal causes include raised cholesterol, blood pressure, and glucose; intermediate causes include tobacco, poor diet, physical inactivity, and harmful use of alcohol. These risks are largely human-made and relate to how we live, age, work, and play. Distal causes include urbanization, population aging, and trade. Premature death and disability due to NCDs can, therefore, be viewed as failures of a broader socioeconomic system.

Thus, for providing a permanent solution to prevention and effective management of avoidable morbidity due to NCDs and NCEDs, the following factors should be integrated into the existing health-care facilities.

Effective strategies for disease prevention and controlTraining of required personnelInfrastructure developmentStrengthening existing health careDevelopment of affordable technologyAdvocacy and resource mobilizationRevamping of medical education for improved knowledge and skills.

A large part of the population whom we are targeting are illiterate and underprivileged, largely in rural and also in urban areas. These subsets of our population are lacking in awareness of health issues and have not yet adopted a health-seeking behavior. There is a strong need for an advocacy to create awareness and bring about behavioral change using multiple mediums ranging from folk theater to community radio, panchayat, and peer group influence. All medium of communication should be utilized to achieve this.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Available from: http://www.globalburden.org/.
2Available from: http://www.vision2020.org/documents/IAPB%20Documents/Briefing%20papers%20etc/Health%20 Systems%20and%20Eye%20Health-BP.pdf.
3World Health Organization. The World Health Report 2003 p160-165; WHO, Global Status Report on NCDs. p. 56, 89.
4Serge Resnikoff, et al. Non – Communicable Eye Disease: Facing the Future. Comm Eye Health 2014;27:87. Published online 10 December, 2014.
5Universal Eye Health: A Global Action Plan 2014–2019. Available from: http://www.who.int/blindness/actionplan/en/.
6Prevalence and Attributable Health Burden of chronic Respiratory Diseases, 1990–2017: A Systematic Analysis for the Global Burden of Disease Study 2017. GBD Chronic Respiratory Disease Collaborators The Lancet Respiratory Medicine 2020;8:6.
7Das T, Panda L. Imagining eye care in India (2018 Lalit Prakash Agarwal lecture). 2018;66 (11):1532-8.
8Vijaya L, George R. Prevalence of angle-closure disease in a rural South Indian population. Arch Ophthalmol 2006;124:403-9.