Reforming our Reforms : Encouraging Trespassing, Transgressing the lines that Divide

 

Bounded.

               Divided.

                               Hemmed in.

We’re doing away with these words. We’re being encouraged to disrespect them.

It was once commonplace in public health discourse to talk of NCD’s and ID’s as belonging to separate categories. On one side of the fence lay diabetes, CVD’s and cancers, for instance; on the other side were infectious diseases (ID’s). The difference was clear, and, health systems formulated reforms that addressed both sides of the fence, but separately. 

                                             
Barbed_Wire_Fence_by_Brime

 

So where are our reforms headed to, now? Is epidemiological transition too simplistic a model to base our reforms on? Something has changed over the last few years: LMIC’s are faced with the task of developing health reforms that no longer look at NCD’s and ID’s as two opposing ends of a spectrum. Instead NCD’s and ID’s are increasingly being seen as existing along the same continuum. With this convergence, LMIC’s who are already in the process of re-shaping their health systems are faced with the challenge of developing health reforms to address this change. Take for instance certain types of cancer: In 2008, an estimated 55% in of new cancer cases arise from ‘developing countries’. If something is not done quickly, that figure is estimated to rise to upto 70% by 2030 http://www.worldcancerday.org/myth-2-cancer-disease-wealthy-elderly-and-developed-countries.

Here’s the problem: On the one hand, health system reforms have successfully addressed and tackled rates of ID’s, thus increasing life expectancy. The paradox is, increased life expectancy has brought with it an increase in susceptibility to NCD’s, cancer being one of them. However, in LMIC’s, most malignant tumors are linked to infections such Helicobacter pylori, hepatitis B and C, and human papilloma virus http://www.worldcancerday.org/cancer-causing-infections-0.

Is it possible then that LMIC’s may provide a model for health system reforms that can integrate NCD’s with ID’s? Reforms that address this convergence are already underway. In Botswana for example, an organization called PRRR supported by the World Bank and through NACA, an organization that typically funds communicable diseases, was used to tackle cervical cancer http://www.bushcenter.org/blog/2013/02/01/together-stronger. Are distinctions between ID’s and NCD’s once upheld by public health scholars to design reforms increasingly becoming redundant? GAVI, traditionally associated with control of infectious diseases , helped bring down rates for hepatitis B vaccine from US$100 in 1982 to $O.20 thus bringing down rates of hepatocellular cancer significantly. In light of this NCD’s were given a new identity, referred to as ‘New Challenge Diseases’ http://www.hsph.harvard.edu/news/magazine/new-challenge-diseases

Maybe a changed rubric can help re-invent our reforms Reforming language within public health discourse then becomes of urgent need. If the argument within health system reforms has always been directed at how LMIC’s cannot find cost effective ways to combat NCD’s, this may undergo a change if we break down the divide between NCD’s and ID’s. Herein lays the dilemma: what should our health reforms address? On the one hand, control of infectious diseases can lead to longer life expectancies and higher rates of non communicable diseases. Yet the control of infectious diseases can also prove to be a cost effective way  of lowering rates of certain types of non communicable diseases, like certain types of cancer.

                                                    Where are the stakes higher? Only future reforms will tell.

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