A Fellow’s Role in Non-Communicable Disease Management in the Americas
February 24, 2017 | Daniel Sierra, MD
There is an important epidemiological shift in Latin America attributable to a rapid population overgrowth, a decrease in infant mortality and an increase in life expectancy. The result is an overwhelming demographic explosion in the Americas. In Latin America, this population overgrowth has shown that the population´s needs and demands greatly surpass their supplies.
From an epidemiological point of view, the health transition occurring in Mexico is quite unique. From 1980 through 2000, due to health policies implemented in primary health care, there has been a decrease in maternal mortality ratio and years of life lost (YLL) in childhood. However, since 2000, there has been an increase in non-communicable diseases (NCDs) such as diabetes mellitus, hypertension, chronic kidney disease and ischemic heart disease and cancer, leading to a change in public health concerns.
In 2011, the PURE Study analyzed the factors associated with poor control of NCDs. The study revealed lower use of secondary prevention drugs in low-income countries. In an effort to explain these findings, an analysis authored by Salim Yusuf, DPhil, et al, showed that low availability and affordability of cardiovascular drugs was associated with a lower rate of usage. However, even when these factors were ameliorated, a total usage from the affected population was not achieved. This quandary may be explained by some inherent patient’s attributes, such as behavior, education, self-consciousness and knowledge of their diseases, emphasizing the need for improvement in patients´ health-care and education access.
Mexico, an upper middle income country, has experienced a non-typical epidemiological transition with an increase in life expectancy, but not associated with a full-health life. Although mortality from communicable diseases has been reduced, there is an increase in mortality from NCDs such as diabetes mellitus, chronic kidney disease and violence. The increased rate of homicide due to interpersonal violence, alcohol consumption and depressive disorders, reflects Mexico´s high disparity in income, education and health access, factors which are not always addressed.
In June 2016, during the World Congress of Cardiology & Cardiovascular Health, the Mexico Declaration, was promulgated, to reinforce the World Health Organization´s (WHO’s) goal to reduce NCDs by 25 percent by 2025. However, there are still questions about Latin American´s commitment to achieve this universal goal. As FITs in Mexico, we need to identify our role in this world wide mission. We need to identify which interventions will actually make a difference in reducing cardiovascular disease in the population and what are the far-reaching effects of these interventions on the population. FITs must identify how much time to devote to patient education.
Adequate control of NCDs goes far beyond health policies. There are some population issues that are out of our reach, such as a household's financial status, personal priorities and attitudes. Another factor that hinder NCD control is a patient´s lack of self-awareness, arising perhaps from inefficient care and attention on our part. Likewise, violence, drug abuse and mood disorders could be ameliorated with psychological assistance as cognitive-behavioral, interpersonal and somatosensory therapies or psychiatric care.
Mexico´s health system is not infallible and requires many reforms. As FITs, we should not be passive, but demonstrate our commitment to global health. We should provide constructive criticism for health policy, in addition, continue working with our healthcare tools as there are many transcendent interventions that we can do from our bench side. Some of these interventions are easy and sometimes no financial budget is required such as providing patient education for lifestyle modifications. FITs can improve patient-physician communication and help improve knowledge, attitude and patient´s behavior. Medication regimens can be simplified to single daily doses or fixed combinations to improve medication compliance.
In countries with social inequalities such as in Mexico, our attitudes as FITs could have an important effect on population health.
This article was authored by Daniel Sierra, MD, a Fellow in Training (FIT) at Instituto Nacional De Cardiología Ignacio Chávez in Mexico.