Measuring mortality from non-communicable diseases: broadening the band
Authors: K Srinath Reddy
Journal: The Lancet Global Health (2020)

Despite inexplicable exclusion from the Millennium Development Goals of 2000, non-communicable diseases (NCDs) were recognised as a major global public health threat by the UN in 2011 and found a place in the Sustainable Development Goals (SDGs) of 2015. Periodically updated estimates of NCD-related death and disability, from the Global Burden of Disease Study, and associated economic losses, make a compelling case for a determined response.1Roth GA Abate D Abate KH et al.Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1736-1788Summary Full Text Full Text PDF PubMed Scopus (3479) Google Scholar, 2Bloom DE Cafiero ET Jané-Llopis E et al.The global economic burden of noncommunicable diseases. 2011. Geneva.http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdfDate accessed: February 12, 2020Google Scholar, 3James SL Abate D Abate KH et al.Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1789-1858Summary Full Text Full Text PDF PubMed Scopus (5908) Google Scholar The four NCDs initially targeted were cardiovascular diseases, diabetes, cancer, and chronic respiratory disease. Major risk factors selected for quantified reductions in population prevalence were unhealthy diets, physical inactivity, tobacco, and alcohol.4WHOGlobal Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. 2013. World Health Organization: Geneva.https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1Date accessed: February 12, 2020Google Scholar Mental health has now been added by WHO to the targeted NCDs and air pollution has joined the list of major risk factors.5UN General AssemblyPolitical declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. 2018. United Nations: New York.https://www.un.org/ga/search/view_doc.asp?symbol=A%2F73%2FL.2&Submit=Search&Lang=EDate accessed: February 12, 2020Google Scholar SDG targets specify a 30% reduction in mortality by 2030 from the four major NCDs in those aged 30–70 years. Such restrictions elicited objections both with respect to the specified age range5UN General AssemblyPolitical declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. 2018. United Nations: New York.https://www.un.org/ga/search/view_doc.asp?symbol=A%2F73%2FL.2&Submit=Search&Lang=EDate accessed: February 12, 2020Google Scholar, 6Binagwaho A Muhimpundu MA Bukhman G 80 under 40 by 2020: an equity agenda for NCDs and injuries.Lancet. 2014; 383: 3-4Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar and the limitation to four NCDs only. Concern was voiced that a substantial proportion of NCD deaths in Africa occurred below 40 years of age and an additional under-40 NCD mortality target was proposed.6Binagwaho A Muhimpundu MA Bukhman G 80 under 40 by 2020: an equity agenda for NCDs and injuries.Lancet. 2014; 383: 3-4Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar Others questioned why avertable deaths over 70 years were ignored by a so-called ageist approach.7Lloyd-Sherlock P Ebrahim S McKee M Prince M A premature mortality target for the SDG for health is ageist.Lancet. 2015; 385: 2147-2148Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar The exclusion of other NCDs—especially non-neoplastic liver and kidney diseases—drew protest from health professionals advocating their importance. The age and disease category restrictions also appeared to run counter to the broad remit of universal health coverage. Would universal health coverage resources flow equitably to unlisted NCDs? In The Lancet Global Health, Ramon Martinez and colleagues make the case for estimating premature avertable mortality from a broader range of NCDs, without arbitrary age restrictions.8Martinez R Lloyd-Sherlock P Soliz P et al.Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990–2017: a population-based study.Lancet Glob Health. 2020; 8: e511-e523Summary Full Text Full Text PDF PubMed Scopus (83) Google Scholar They define avertable mortality as deaths that can be prevented by public policies and preventive health interventions as well as deaths which can be avoided or postponed by good quality personal health care. They quantify avertable mortality from eight disease clusters covering 43 fatal NCDs and estimate that, globally, premature avertable mortality from these NCDs has declined from 12 855 years of life lost (YLL) per 100 000 population (95% UI 11 809–14 051) in 1990 to 9008 (95% UI 8329–9756) in 2017. The inclusion of more NCDs, with a large component of potentially avertable mortality enhances the value of the indicator in tracking progress. The inclusion and exclusion criteria are, however, not clear. Are ovarian, brain, and pancreatic cancers excluded because they are considered beyond the reach of prevention or effective treatment? The vagaries of the NCD label are visible when diseases of infectious cause are considered. Acute viral hepatitis is not included, whereas chronic sequelae of hepatitis viruses B and C are included. Cervical cancer and peptic ulcer are included despite established viral and bacterial causes. Rheumatic heart disease is an autoimmune response to streptococcal infection. The overlap between NCDs and infectious diseases will become wider as our knowledge of microbiome-associated NCDs grows. How long will the NCD label continue to brand a curious mix of conditions? Martinez and colleagues predict that the Eastern Mediterranean Region, Africa, and southeast Asia, from among WHO's regional groupings, will not reach the SDG target by 2030. There is wide variation in indicators of economic development, disease burden, and life expectancy within and between WHO regional groupings. Epidemiological transition is evident in all of them but at varied stages.9Olshansky SJ Ault AB The fourth stage of the epidemiologic transition: the age of delayed degenerative diseases.Milbank Q. 1986; 64: 355-391Crossref PubMed Scopus (491) Google Scholar Several of these countries are at earlier stages of transition than those in Europe or the Americas. Some of them are still striving to reduce the high burdens of avertable mortality from infectious diseases as well as maternal and child deaths. As they succeed and gain in life expectancy, they will have higher amounts of premature avertable mortality due to NCDs from middle-age mortality. Over time, they will succeed in reducing age-adjusted mortality rates related to NCDs, with more deaths occurring at older ages. Every attempt must be made to abbreviate the phase of midlife NCD deaths in these countries. However, their progress in achieving SDG target 3.4, by 2030, ought not to be compared with others who are far more advanced in their epidemiological transition and have crossed the hump of high mid-life mortality due to NCDs.10Reddy KS The health transition. The Indian Express. Oct 18, 2018.https://indianexpress.com/article/opinion/columns/united-nation-sustainable-development-goals-non-communicable-diseases-5398178/Date accessed: February 12, 2020Google Scholar Targets set for NCD mortality reduction, whether by the WHO metric or the new avertable mortality metric, ignore morbidity, which is an important contributor to disease burden and places high demands on the health system. Public health and medical interventions which reduce NCD mortality do not always reduce morbidity, as evidenced by stroke disability and congestive heart failure. The high burden of disability from mental health disorders is missed by a mortality indicator. Should we move to an NCD indicator based on avertable disability-adjusted life-year (DALY) loss due to NCDs which quantifies both mortality and morbidity? Given the growing overlap between infectious and non-communicable diseases, as well as the varied health system demands at different stages of epidemiological transition, should we have overarching all-cause avertable mortality and DALY indicators as trackers of progress? Perhaps these are questions for the post-2030 development goals. I declare no competing interests. Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990–2017: a population-based studyWorldwide, there has been a substantial reduction in premature avertable mortality from NCDs, but progress has been uneven across populations. Countries vary substantially in current levels and trends and, hence, the extent to which they are on track to achieve SDG 3.4. By accounting for premature avertable mortality while avoiding arbitrary age cutoffs, premature avertable mortality from NCDs is a robust, comprehensive, and actionable indicator for quantifying and monitoring global and national progress towards NCD prevention and control. Full-Text PDF Open Access