This essay investigates social determinants of health, specifically looking at non-communicable diseases, and argues that structural interventions in the economy and society are necessary to reduce the prevalence of non-communicable diseases (NCDs). Sociologists study health demographics because patterns of health change across classes, cultures, genders and countries. Disease does not have solely biological causes, but is also determined by factors such as the socio-cultural environment, economic status, living and working conditions and government legislation. Many NCDs, defined as diseases which cannot be passed from person to person, have such characteristics. Cardiovascular diseases, chronic respiratory diseases, cancers and diabetes are the four most prevalent NCDs, and the four biggest risk factors are alcohol use, tobacco use, unhealthy diets and a less active lifestyle. When looking at the causes of NCDs, this essay argues that people engage in unhealthy activities not because they lack the willpower to abstain, but because they are placed in a social and economic construct which constrains the choices that they are able to make, encourages unhealthy behaviour and prevents them from disengaging from those activities. Governmental and civil society organisations are therefore placed with the responsibility to intervene. Obesity will be looked at as an example of a risk factor for NCDs and a brief discussion on legislation for smoking in public will be included.
Firstly, let us consider of the prevalence, and environmental causes of, NCDs. NCDs account for a large and growing proportion of deaths across the world (World Health Organisation [WHO], 2013), and thus should be the focus for disease prevention policies. Indeed, 68% of deaths worldwide are the result of NCDs (WHO, 2014a). The distribution of NCDs reflects socioeconomic disparities, with the urban poor being the most affected (Schaay, Sanders & Kruger, 2011: 5). 80% of NCD deaths occur in low- and middle-income countries (WHO, 2013). A well-known report on inequalities in health, the Black Report, found material possessions to be a strong indicator of health (Townsend & Davidson, 1982, as cited in Coulson, Goldstein & Ntuli, 1998: 3). NCDs present a particular challenge to poor people due to the high cost and duration of treatment required, a factor that forces millions into poverty and undermines poverty reduction initiatives (WHO, 2013). Vulnerable and socially disadvantaged people are affected more often because they are exposed to greater levels of risk factors associated with NCDs when compared to people of higher social standing (WHO, 2013; WHO, 2014b). For example, low-income and marginalized communities face a lack of access to affordable, healthy food in the neighbourhood (Centres for Disease Control and Prevention [CDC], 2010: 2); less safe communities, a lack of park facilities and a lack of pavements which reduces physical activity (Meyers, 2008: 25; CDC, 2010: 2); exposure to hazardous chemicals in the community environment and workplace (Meyers, 2008: 23-24); and a lack of community resources and awareness to help abusers of alcohol (Maring & Braun, 2006: 1). The first two points are examples of risk factors which lead to overweight and obesity.
Let us define ‘obesity’ more clearly. Obesity is a disease which has a prevalence that is significantly large and increasing, and is a major risk factor for NCDs (WHO, 2014c; ‘disease’ is a term attributed to obesity in e.g. Goedecke, Jennings & Lambert, 2006: 67). An estimated 1.3 billion people globally are obese or overweight, with the proportion of the overweight population in some developing countries having tripled during the last 40 years (Goedecke, Jennings & Lambert, 2006: 65-66). Although obesity has not always been an area of concern, indeed it was a body shape “to be aimed at” in African and Pacific cultures (Moore, Aiken & Chapman, 2008: 250). Obesity, defined as a Body Mass Index[1] (BMI) of 30 or greater, increases the risk of developing NCDs such as diabetes, coronary heart disease (CHD), hypertension, cancer, psychological diseases and osteoarthritis (Goedecke, Jennings & Lambert, 2006: 69-70). A successful NCD prevention programme that targeted obesity and CHD will be presented later on.
The problem of NCDs can be viewed either from the perspective of the individual (who does not live a healthy lifestyle), or from the perspective of society (one that does not offer a satisfactory means of living a healthy lifestyle). The environmental causes mentioned above indicate that there are factors outside of the locus of control of the individual which contribute to NCD, and leads one to task the community and government with NCD prevention. Another perspective is that addiction to smoking, eating fatty foods or drinking alcohol could lead to NCD contraction. This perspective could view addiction as a moral deficit, the result of socio-cultural influences or as a psychological susceptibility (Fisher & Harrison, 2009), resulting in responses ranging from stigmatization to community-based prevention strategies to therapy and rehabilitation respectively.
Recognising the necessity of NCD prevention, one is led to ask how strategies are formulated and implemented. NCD prevention requires a national and community response, characterized by collaboration between public and private sectors. National health policies need to include NCD prevention strategies, and (preferably) an NCD directorate should be set up in order to manage and implement that policy (WHO, 2008: 16; Goedecke, Jennings & Lambert, 2006: 74). A multi-sectoral approach is required, as departments dealing with trade, taxation, education, food & agriculture and urban development have a significant influence on the success on prevention strategies (WHO, 2008: 13).
What are the important elements of national NCD prevention policies? Firstly, there should be a focus on building capacity in primary health care (PHC) to deal with NCDs. A focus on PHC is important in order to target the causes of NCD and prevent cases from progressing (until secondary health care treatment is needed). A PHC model of intervention focuses on strengthening the district health care system, delivering community-based services and promoting good health. As an example, physical activity can be promoted through ensuring that physical environments are safe and through community-led initiatives to promote exercise. A second element to NCD prevention policies is enforcing legislation. Protecting people from unnecessary exposure to harmful risk factors is essential, such as laws against smoking in public places, bans or restrictions on advertising for cigarettes and alcohol and restrictions on unhealthy food and sugary beverages. As an example, governments across the world regulate smoking, banning it indoors and in public spaces with moderate traffic, such as workplaces, alfresco dining settings, beaches, parks and sports stadia (Chapman, 2007: 160-162). Lastly, behaviour can be changed through awareness and education for the public, and the continuing education of medical personnel, about how to manage one’s lifestyle in a healthy way (WHO, 2008: 16). Throughout these intervention strategies, monitoring is essential.
A successful NCD prevention program can be found in North Karelia, Finland. The North Karelia Project was launched in 1972 in response to a local petition concerned with the high mortality rate due to coronary heart disease (CHD), of which obesity is a risk factor. In collaboration with local and national authorities, experts and the WHO, the ‘North Karelia Project’ was formulated. Over the next few decades, community organizations and individuals implemented strategies in the health sector, schools, NGOs, media, supermarkets and the food industry. The results show that major changes have taken place, with “the annual mortality rate of coronary heart disease in the middle-aged male population decreasing by 73% from the pre-program years (1967-71)” (Puska, 2002: 2) and with a similar reduction of cardiovascular disease mortality rates amongst women. Results also showed a reduction in smoking and lung cancer mortality rates (Puska, 2002: 2). Success factors included: (a) a sound theoretical framework; (b) strong community organization, with continuous monitoring and feedback; (c) the systematic involvement of the PHC system; (d) collaboration with the food industry; and (e) policy changes. This case shows that intervention programmes can successfully control NCD epidemics.
This essay has examined the social and economic causes of NCDs, and has recommended strategies for NCD prevention. We have found that, as with all diseases, the poor and marginalized fare the worst off. NCDs are unique in that they are caused primarily by unhealthy lifestyle decisions and the epidemic scale of NCDs requires a macro-level response from governments and communities. This response should be multi-sectoral and attention towards NCD prevention is required in health policies and practices. The modern need to remain healthy within an urban environment requires creative and informed solutions. As a final thought, the fight against NCDs may leave one to wonder what type of death is ‘desired’, or what type of death will be common once we have ‘won the battle’ against NCDs. Death by ‘old age’, a common response, is not a type of death in itself but represents a death due to frailty as opposed to significant exogenous factors.
[1 464 words]
September 2014
References
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