Future challenges of the double burden of disease in Greece
By: Disease In Greece, A Timeline
Tags: Double Burden Of Disease, Future, Diabetes, Greece, Malaria

We’ve finally come to the last part of the Disease in Greece timeline: the future!

If you followed all our blog posts, we hope you’ve gained some knowledge on malaria and diabetes, and the times that Greece has struggled with them. In our previous post about the present day, we discussed how the two diseases create a double burden on Greece.

For today’s story, we’re looking at the future. We’ll be discussing the factors that can worsen the negative consequences of malaria and diabetes in Greece. We also invite you to discuss your thoughts with each other in the comments: by now, we’ve hopefully given you enough information to build an informed opinion!

Health care system challenges

Although Greece functions under a version of universal healthcare, an increasing trend of spending on private out of pocket spending means that there are many inequalities in the health care they provide.

Out of pocket payments are payments which patients themselves pay for. They became more common after the Greek financial crisis, as the governmental spending cuts resulted in an unsatisfactory service for many. During the aftermath of the crisis there were reports of many medications being unavailable in governmentally funded healthcare institutes and many had no choice but to turn to private options.

This is something Greece is still dealing with and although the economy has improved since the late 2000’s, 36% of patients report an informal out of pocket payment. Many of these patients also stated the payments were due to a fear of inadequate service. This poses a serious threat to the future of Greek healthcare as the population is currently aging, which will incur the need for additional medication. This is because, as we age, the likelihood of falling ill or developing non-communicable diseases increases. The disparity between those who have the money to spend on private service and those who do not will also increase. This trend means that a high level of care will not be provided to those in Greece who cannot pay and this issue will increase in the future in line with an increasing age of the population.

Climate change

The fact that our climate is changing, is by now undeniable. For Europe, it means a generally higher temperature, which results in changes in geographical climate zones and in seasons. Low temperatures will become less common, and winters will be milder. Increased humidity and rainfall is also expected, which can result in flooding, and increase in the amount of marshes in Greece.

While this all has few effects for diabetes, it will influence the future of malaria. The circumstances in Greece will be more suitable for the Anopheles mosquitoes, which are the vectors for the malaria parasite. Warmer temperatures, a higher humidity and the increase in marshland (breeding grounds for mosquitoes) make Greece a more convenient country for them to live in. The “seasonality” for these mosquitoes will also increase, meaning that they can stay active for longer periods during the year. It has been predicted that for 2051–2080, the annual period of possible malaria transmissions could be up to 6 months.

This all results in more possible infections of malaria in the country, and the fact that malaria will not only be incidental, but could become endemic. Unless public health interventions are properly planned, implemented and maintained, malaria will pose a bigger and bigger problem. When malaria will constantly be present, its burden on Greece’s people and health system will increase vastly.

Geographical distribution of possible malaria resurgences in central Greece. High R0 density = high risk of malaria resurgence. (Source: Pergantas et al.)

Migration streams

There is a current trend of people moving around the world by traveling, migrating and fleeing to another country. This, together with the effects of climate change, has resulted in the comeback of malaria in Greece.

Especially in 2015 and 2016 there were a lot of refugees coming to Greece and this brought along both social and economical consequences which also affected health. This occurred while Greece was still recovering from its economic crisis. Because of the economic crisis, there was less money available for healthcare, as was already mentioned in our previous blog posts, and there were not enough health care workers to carry the double burden of disease.

In the meantime, Greece did not have a lot of knowledge on how to handle the high amount of refugees, which affected the Greek National Health Service (NHS) a lot. This resulted in low accessibility to healthcare, support and information, but also to more outbreaks of communicable diseases in refugee camps. There were also not enough healthcare workers present with the same cultural background as refugees or who spoke the same language which also resulted in less accessibility to healthcare. This poor situation of healthcare in refugee camps poses challenges for the future as well, since it lowers the health of refugees and surveillance of diseases such as malaria, leading to an increase of the burden of malaria across Greece.

It is important to make sure that there is a good surveillance system for diseases and that the NHS is expanded to a system which also includes the needs of refugees. In the near future, it is also important that there is enough money, that there are enough healthcare workers available and that the management is as efficient as possible to help overcome these present challenges in the future. These challenges will probably still exist in the future, since Greece is still suffering from the negative consequences of the economic crisis.

Controlling malaria

In order to control malaria, insecticides are often used to control the number of mosquitoes to reduce the amount of mosquito borne diseases. However, in some areas in Greece there is currently resistance to some insecticides which are being used, meaning that it is not effective anymore. This could be because of the use of pesticides in agriculture. Even though many pesticides are not used anymore because it is prohibited, there are still mosquitoes which are resistant to these because of exposure in the past.

In the future, it is very important to use surveillance systems to know which kind of mosquitoes are present and which are showing resistance to which insecticides. This knowledge can help with the development of new insecticides with new targets and lowering the resistance amongst the mosquitoes. If this is not done, and mosquitoes become increasingly resistant to possible preventions, the total number of mosquitoes will increase, which will in turn increase the number of malaria mosquitoes.

The aging population

A challenge that will enlarge the burden of diabetes is the aging population. There is currently an aging population in Greece, in which there are more older people than young people. The life expectancy at birth and the number of people over 65 years of age has increased and this is expected to increase in the future as well. As you can see in the first graph underneath, the life expectancy in 2019 is 82 years old and this has been increasing since 1960.

Life expectancy at birth in Greece between 1960 and 2019 (Source: World Bank)

In the second graph you see the percentage of the population in Greece which is 65 years or older. In 2020 this was 22.3% and as you can see in the graph, this also has increased since 1960. This while the number of people at a working age is expected to decrease even more in the future. However, more migrants and refugees could help with the economic situation of Greece by being part of the working age group and in this way contribute to the economy as well as to making the population consist of more younger people.

Percentage above 65 years old in Greece between 1960 and 2020 (Source: World Bank)

As mentioned, in our previous posts about the biological background of diabetes and in our last post about the present situation, one of the risk factors of diabetes is age above 45 years old. Since the percentage of people above 65 years old and the increase in life expectancy, this means that in the future the number of people with diabetes in Greece is likely to increase as well. This increase in diabetes will lead to more pressure on the healthcare system and will also bring along more financial costs, especially while the burden of infectious diseases such as malaria is also there. So it is important to strengthen the healthcare system in order to make it ready for the number of people with diabetes which will keep increasing.

Unhealthy lifestyle

Another challenge for the burden of diabetes is lifestyle. Greece has had a long history as the European country with the highest percentage of smokers and still currently holds that title with 42% of people 15 years old or older smoking. This is an unhealthy behaviour which adds to strain on the healthcare service. It is not the only negative title Greece holds: Greece is also leading in childhood obesity, with 44% of boys and 38% of girls being over a healthy weight. This is partly due to a decrease in consumption of fresh and healthy foods as poverty rose during the financial crisis. This meant there was an increase in processed, unhealthy but cheaper foods. These two factors present Greece with a serious threat, especially as the global trend of increasingly unhealthy lifestyles continues to increase. This becomes relevant when thinking about diabetes because smoking, obesity and a generally unhealthy lifestyle lead to an increase in the chance of developing diabetes. It is likely that we will see the results of this unhealthy lifestyle in the number of diabetes cases in the coming decades.

While this is mainly a challenge that has to do with diabetes, it also has an indirect effect on the burden of malaria. As stated in our previous “Diabetes type II — a quick lesson in biology” post, those who suffer from diabetes have a higher chance of contracting malaria. Therefore, an unhealthy lifestyle is a cause of concern for the burden of both diseases.