Thursday, 7 April 2011

Non-communicable diseases and harm reduction threaten the world?

Well, do they?

Guardian health blogger Sarah Bosely thinks the name non-communicable diseases isn't quite sexy enough to get people concerned and motivated as they were about HIV and AIDS. Quoting a Professor Beaglehole in The Lancet:
The spread of non-communicable diseases (NCDs) presents a global crisis; in almost all countries and in all income groups, men, women and children are at risk of these diseases. Worldwide, substantial gains have been achieved in economic growth, health, and living standards in the past century. This progress is now threatened by crises of our own creation–climate change, finance and food insecurities, and the crisis in NCDs, principally heart disease, stroke, diabetes, cancers, and chronic respiratory disease.
Do I think this is alarmist? Yes, to the extent that non-communicable diseases can't be considered by anyone's standards as threatening to human life as diseases that spread through populations by contagion or infection.

We are told that 'two-thirds of all deaths globally are from NCDs every year - and four out of five of those deaths are in low and middle-income countries. One third are in people aged less than 60.' I have a table in front of me with UK mortality from 2003, a year when the total mortality was 610,871, of which 397,609 were over 75. Before I saw the table I never imagined that living to 75 was normal! In early 2000s UK, two-thirds were living more than 75 years, compared with two-thirds globally surviving 60, as in the Lancet report. I am not sure why it should come as a shock that one-third should die before the age of 60, and I don't see why it should be surprising that heart failure or failures in the respiratory system should cause fatal collapses in people of all ages, since these are the vital systems that keep our bodies going.

I'n not quite sure what's driving the non-communicable diseases campaign. They want to advance tobacco control (are people in low and middle income countries aware what vicious proportions anti-smoking campaigns can assume?), and tackle salt consumption as well as going for more specific campaigns, such as improving HPV protection in young women.

The cynic in me says they want to distribute more drugs and push for more restrictive tobacco and alcohol laws. It says that the figures tell us nothing about quality of life but treat longevity as a goal for good or ill, and that anti-smoking campaigns of the kind seen in this country are not likely to increase the sum of human happiness. How do they propose to cut down people's consumption of salt?
We know how to tackle the tobacco companies and fast-food chains. We have the pills to protect people from cardiovascular disease. Our teenage daughters are being protected from cervical cancer - and the same jab ought to be available in countries where the death toll is far higher than it is here.
Nothing to be cynical about at all really, is there?

Note the confidence in being able to 'tackle the tobacco companies'. Has it occurred to these worthies from the global health community that a less doctrinaire approach to their pet projects might save more lives? A European Commission public consultation on revising the 2001 tobacco directive included the suggestion of banning snus throughout Europe. Snus, chewable tobacco, is considered to be far less injurious to health than smoked tobacco, but the logic of anti-smokers dictates banning because it carries unknown risks.

Hat tip to Dick Puddlecote for this part of the story: a link to former director of Action on Smoking and Health Clive Bates, discussing a position paper on snus from 2007 in a blog post entitled Saying stupid things with fake sophistication:
So the main ASH Scotland policy idea is that other countries should be prevented by law from reaching a position where more of the tobacco use is through far less harmful forms of tobacco consumption and that addicted individuals should be prevented by law from having access to lower risk products. What next? A ban on anti-lock brakes? Cycle helmets? Ropes while rock climbing? Any risk reduction measures at all while engaging in inherently risky behaviour? There's the warped logic of the overweening health planner behind all this ... if you make a risky activity much safer, then people might not stop doing it altogether.
Can you imagine Clive Bates getting a job with ASH or ASH Scotland today? He opines, 'No less than 266 references are used to support the truly stupid idea that smokeless tobacco, which can substitute for cigarettes and is far less hazardous, should be banned. He says, 'Even tobacco companies provide better and more balanced analysis than this effort by ASH Scotland' [emphasis added]: stop right there!

Clive Bates defends the idea of harm reduction: people can choose vastly less harmful products than smoked tobacco, and it is perverse to obstruct the public from choosing safer alternatives.

Tobacco control, the whole community, will favour outlawing snus. This makes them the worst possible candidates for advocating global tobacco control because they will 'encourage' countries to ban these products, which are safer than tobacco, in their attempts to reduce cancer rates, heart attacks and respiratory problems. Does this increase our confidence that they can effectively tackle non-communicable diseases? Not really.

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