Some children overcome malaria only to confront chronic disease

A patient at a rural health camp in Mwae County, Kenya has his blood pressure checked as part of a full physical exam. If needed, non-communicable disease drugs will be made available through Novartis Access, a new program to make NCD drugs available in developing countries.

This was originally published on Global Health TV on January 13, 2017.

We have much to celebrate with the news contained in the World Malaria Report 2016, released by the World Health Organization (WHO) last month. WHO estimated that a cumulative 1.3 billion fewer malaria cases and 6.8 million fewer malaria deaths occurred between 2001 and 2015 than would have occurred had incidence and mortality remained the same. About 97% of those deaths averted were for children under five years.

Buried, and little-noticed in the report (Page 50), is the gist of what makes this news so exciting: In WHO’s Africa Region, these reduced malaria mortality rates have translated to a rise in life expectancy at birth of 1.2 years, accounting for 12% of the total increase in life expectancy of 9.4 years.

This means many more children will survive the perils of childhood in Africa and go on to lead productive lives as adults. This is one of the most exciting global health developments of several encouraging trends in recent years.

However, these children surviving communicable diseases like malaria, AIDS and tuberculosis may now live long enough to confront growing non-communicable disease (NCD) epidemics now surging in many developing countries. Almost three-quarters of the 38 million NCD deaths that occur each year occur in low- and middle-income countries. The four main NCDs are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma) and diabetes

Charles Nelson, chief executive of the Malaria Consortium, talked about the great progress that has been made in fighting malaria at the recent conference of the American Society for Tropical Medicine and Hygiene in Atlanta. Between 2000 and 2015, malaria death rates among populations at risk fell by 62% among all age groups and by 69% among children under 5

Malaria is down just about everywhere and has been eliminated in some places. In 2015, the 53 countries of the European Region were declared malaria-free by the WHO. In recent months, the WHO certified that Kyrgyzstan and Sri Lanka had eliminated malaria. The island nation of São Tomé and Príncipe is close to elimination.

Nelson explained how the disease burden in many countries is now shifting from communicable to non-communicable disease. Disability-adjusted life years (DALYs), which is a measure of overall disease burden, coming from communicable maternal, perinatal and nutritional diseases is decreasing while DALYs from NCDs is increasing, said Nelson. This is true globally, as well as in Africa and Southeast Asia.

But while the global disease burden is shifting dramatically, global health funding has not followed suit.

“The productivity loss for NCDs is estimated to be $500 billion annually yet almost no donor funding is being deployed against them,” said Dr. Harald Nusser, global head of Novartis Access and Novartis Malaria Initiative. “We need robust funding for both communicable and non-communicable disease, and more robust health systems in general to start turning our efforts towards NCDs while not relenting in the fight against AIDS, malaria and tuberculosis.”

Nusser is now trying to address that imbalance through an innovative strategy to provide NCD treatment in low- and middle-income countries. In 2015, he helped launch Novartis Access in Kenya, where NCDs now account for 27 percent of deaths, according to WHO. Novartis Access is making 15 on- and off-patent medicines available to treat NCDs in Kenya, at $1.00 per treatment per month.

Novartis has different strategies for reaching patients at different socio-economic levels: For high and upper-middle income, they use a standard business approach. For middle and low-income, they use differential pricing, social business and the Novartis Access and Novartis Malaria Initiative. For the poor, they use philanthropy.

In these early days, Novartis Access is losing money but long term, the objective is to become commercially sustainable. “If we want to tackle NCDs, the solution has to be sustainable, long-lasting and scalable, and this can only happen if it makes commercial sense for Novartis,” said Nusser.

The result of Novartis’ work in malaria, NCDs, leprosy and other diseases has resulted in Novartis being ranked quite high in the 2016 Access to Medicine Index announced in November.

What has been learned in managing communicable disease that we can now apply to non-communicable disease? Nelson pointed to several lessons:

• Differential diagnosis (the distinguishing of a particular disease from others that present similar symptoms) is critical to the rational use of resources.
• The role of community health workers will necessarily transition towards NCDs but we need to be careful about overloading them.
• Though common principles can be applied, tailoring is critical. “One size fits all” will create inequality.

Nusser said that building a sustainable system to address NCDs is no quick fix. “It is real hard work,” he said. “It starts at the primary level, the community level. Nobody has the answers. Actually, I have far more questions than a year ago when I started to implement this program. But it’s something worth dealing with because of the many premature deaths and the productivity that is being lost to NCDs.”