Reframing a "vicious debate"

“For chronic disease, we need a community-based model," said PIH co-founder Paul Farmer during his keynote address at The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion conference. "We know that is the highest standard of care for a chronic disease.”

In early March, Dr. Farmer joined health workers and public health experts from around the world to discuss ways of increasing attention and resources for treating chronic, non-communicable diseases (NCDs)--such as cancer, heart disease, and asthma--among the world's poor. 

The new Butaro Hospital in northern Rwanda is an example of how to treat NCDs, explained Dr. Farmer. The district-level hospital is connected to a system of community health centers, which employ a cadre of community health workers (CHWs), who serve as a link between their villages and the medical services. If someone in a village is sick--whether from asthma or from an infectious disease, such as tuberculosis or HIV--the CHW can be there to deliver the needed medicine and social support on a daily basis; and if needed, refer and accompany the patient to the health center or hospital for more specialized care. 

Changing policies and reframing priorities 

Many public health leaders have chosen to focus policy and funding on addressing infectious diseases, like HIV and tuberculosis, which often sicken more people and incur a lower per-patient cost for treatment than NCDs. However, NCDs still afflict many people in poor countries. According to the Global Burden of Disease Study, these conditions--often linked directly to poverty and infection--account for more than a quarter of the disease burden in the very poorest populations.

"If you have a country that is deemed very poor... and you have an intervention like cervical cancer vaccinations, that could take up to half of all [that country's] health expenditures," said Dr. Farmer in an interview prior to the conference. "So then these vicious debates ensue--should we prioritize this, prioritize that. It's a very painful process for the public health leaders." 

There doesn't necessarily have to be a choice between treating either infectious diseases or NCDs, said Dr. Farmer. “You can use vertical programs like an AIDS program or even a cardiac surgery program to strengthen health systems in general. For example: A good cardiac surgery program would improve the quality of surgical care in general. Not just for one disease," he said. "If you have a good vaccination program that you use to vaccinate for polio, measles, or tetanus, it is a delivery system for the cervical cancer vaccine, Gardasil."

In order to change current policies, concrete data from research is needed to prove the effectiveness of such programs, added Dr. Farmer during his conference address. This research would then need to be shared with "a whole generation of people anxious to not be told they can't intervene effectively against NCDs among the bottom billion."

Driving policy on a world scale

The March conference, held in Boston at the Harvard School of Public Health, was the first in a lineup of discussions leading up to the UN General Assembly on September 19-20. UN discussions about global health, and the allocation of global health funding, will offer “a huge opportunity for the world to unite about non-communicable diseases, we are focusing on non-communicable diseases affecting people around the world living on less than a dollar a day—the world’s bottom billion,” said PIH physician Gene Bukhman, who organized the conference. 

The UN’s high-level meeting on NCDs will be only the 29th such meeting that the UN has ever held, and just the second pertaining specifically to a health issue. 

Watch Paul's keynote speech in its entirety.

Learn more about treating NCDs in poor communities in the video below.

Learn more about treating non-communicable diseases in poor communities.