A wave of non-communicable disease complications is looming post-Covid

NCDs are caused by a complex interplay of multiple factors, which can make them hard to tackle. — AFP

Which action do you find easier to do: wearing a face mask whenever you leave your home or permanently changing your diet to consist of at least half vegetables and fruits?

Considering that the vast majority of Malaysians have been doing the former for the past year or more (mandatory wearing of face masks in crowded public places was implemented beginning Aug 1, 2020), while the 2019 National Health and Morbidity Survey (NHMS) reported that only 5.1% of Malaysian adults consume the adequate amount of vegetables and fruits daily, it would hardly be surprising if your answer is wearing a face mask.

And herein lies the fundamental difference between tackling infectious diseases like Covid-19 and non-communicable diseases (NCDs) like heart disease and diabetes.

There is usually a straight line between cause and effect in infectious diseases.

Therefore, stopping the spread of a harmful virus, bacteria, fungus or parasite that causes illness usually requires simple actions based on how such microorganisms infect humans.

If it is through droplets in the air, you wear a face mask and wash or sanitise your hands regularly; if it is through ingestion, you boil your drinking water and cook your food thoroughly; if it’s through bodily fluids like semen and vaginal fluids, you use condoms during sex; and so on.

And of course, if it is vaccine-preventable, you get the vaccine.

NCDs, however, are often caused by a complex interplay of multiple factors, which can include genes, environment, income, time and willpower, among others – not all of which are within the control of the individual.

Because of this, effective prevention of NCDs requires a two-pronged approach: on the individual level to lead as healthy a lifestyle as possible, and on the institutional level to ensure that the environment is conducive to enabling individuals to lead a healthy lifestyle.

Problems and plusses

Health Deputy Minister Datuk Dr Noor Azmi Ghazali noted that: “People living with NCDs are faced with numerous challenges and stigma.

Dr Noor Azmi stressed that we must deal with NCDs with the same urgency as we are dealing with Covid-19. — Photos: Filepic

“Oftentimes, we only see the disease and not the person living with the disease.

“Oftentimes, we consider them as making poor lifestyle choices, and it is easy to forget, it is the wider determinants of health that influence behaviours of populations.”

He added: “NCDs affect vulnerable groups of the population disproportionately, and oftentimes, policies and interventions overlook these vulnerable groups.”

He was speaking at the virtual South-East Asia and Western Pacific Joint Regional Multistakeholder Dialogue on Shaping Responsive Health Systems for People Living with NCDs in the Covid-19 Era organised by the Geneva-based non-governmental organisation NCD Alliance.

The key theme of the discussion, which was part of a worldwide consultative process aimed at helping to formulate a Global Charter on Meaningful Involvement of People Living with NCDs, was the adoption of people-centred approaches in tackling NCDs.

Said Dr Noor Azmi: “There are many challenges in adopting a people-centred approach when it comes to tackling NCDs in our region.

“Firstly, a people-centred approach requires a whole-of-government and whole-of-society approach.

“Everyone must be involved, not only the Health Ministry and not only the health sector.

“Even in my country Malaysia, this is an ongoing challenge, to put health in all policies.

“Secondly, many countries in this region are developing countries.

“Malaysia is an upper middle-income country, and we spend about 4% of our GDP (gross domestic product) on health.

“Although we are proud of our healthcare system and successes, we know that we need to spend more on health and we know that our current healthcare system will not be able to cope with the increasing burden of NCDs and an ageing population.”

He noted that Malaysia was not unique in this situation as many countries also face the same issues.

“Thirdly, our population has low health literacy.

“It is challenging to empower people living with NCDs to take on more responsibility in managing their health when their health literacy is poor.

“In Malaysia, an estimated third of the population has low health literacy.

“Many countries in this region are also facing similar problems.”

He admitted that when the Covid-19 pandemic hit, NCDs had to unfortunately take a backseat when it came to the Health Ministry’s priorities.

However, he noted that the pandemic also enhanced several developments.

“Firstly, as a region, we have long focused on economic growth, and only now is there more understanding and acceptance that health is a necessary investment.

“Now many different government ministries and agencies are working together towards a common goal in health.

“Secondly, we finally welcomed greater use of digital technology in healthcare.

“In Malaysia, adoption of digital health interventions only accelerated during this pandemic, despite having spent many years before this discussing it.

“We developed more effective ways to deliver healthcare services throughout this pandemic using digital health interventions, even with the limitations of our current healthcare system.

“Thirdly, we came out with creative ways to cooperate with the private sector and the non-profit sector.

“The private hospitals helped provide additional capacity for non-Covid-related operations when the public hospitals were at maximum capacity.

“The non-profit sector has helped play a huge role in tackling domestic violence and mental health issues, both of which have increased during the pandemic.

“It taught us that public, private and non-profit partnership is a relationship that we can leverage on to solve greater problems together in the future.

“Lastly, we have come to realise the importance of good strategic communication.

“Many countries have tackled the Covid-19 infodemic aggressively by increasing accurate health messaging, exposing fake news and imposing punitive measures on those acting against the greater good.

“Through these intense health education interventions, the public has adapted to better hygiene practices, indirectly increasing the level of overall health literacy of the population.”

Dr Noor Azmi noted that countries need to brace for an immediate and prolonged wave of NCD-related problems once the pandemic eases.

This wave would include those coming in late with NCD complications because they were either not diagnosed or lost to follow-up during the pandemic, and those with mental health problems caused by socioeconomic factors like job loss or social isolation due to the pandemic.

A wide gap

Indeed, National Cancer Society of Malaysia (NCSM) president Datuk Dr Saunthari Somasundram pointed out that many people have been reluctant to see the doctor over the last year and a half.

Dr Saunthari noted that while Malaysia has a solid plan for tackling NCDs, the implementation has been weak.

“Basically, people who had signs or symptoms of an NCD, e.g. cancer, were hesitant to make medical appointments – they felt they were being selfish by taking resources from vital Covid-19 services.

“Same for those who had routine follow-ups.

“Unfortunately, this meant delays in diagnosis and treatment,” she said during her session at the Dialogue, adding that this pushed some initially curable patients into later stages of their disease.

The NCD Malaysia chairperson noted that: “Malaysia has had a strong, consolidated plan for NCDs since 2019, providing an overall framework of strategies to prevent NCDs.

“The challenge however, was perhaps that the implementation of strategies within government and the larger societal framework was a little bit weaker.

“This was reflected by WHO (the World Health Organization) in 2019, which pointed out that Malaysia lacked an operational multisectoral action plan.”

She added that local civil societies were usually barely included in such plans, with the exception of tobacco control, where non-governmental organisations (NGOs) and the Health Ministry have a close working relationship.

However, the Covid-19 pandemic has resulted in a healthcare gap that NGOs have endeavoured to fill.

With the diagnosis and management of NCDs primarily taking place in hospitals (rather than primary care clinics), such procedures took a big hit with hospitals being overwhelmed by Covid-19 cases.

This was further exacerbated by the fact that there is no pathway to transfer the care of NCD patients to their local clinics.

“With that landscape, the Covid-19 pandemic was literally the straw that broke the camel’s back.

“It really highlighted and amplified the gaps and constraints in the health system to the detriment of people living with NCDs,” said Dr Saunthari.

To make things worse, a study showed that one in four patients hospitalised for Covid-19 had at least one NCD, while 87% of those who died from Covid-19 were also NCD patients.

“So people living with NCDs were suffering from a double burden,” she said.

She shared that NGOs like NCSM tried to fill the gap by providing diagnostic services; hotlines for advice and counselling on Covid-19, vaccination and NCDs; logistic help like rearranging medical appointments and providing letters for travel; and health promotion via social media, as well as initiating patient access programmes to provide free or subsidised medications for those who cannot afford them.

“And lastly, where we had to focus – even though most of the focus was on Covid-19 – was to play the role of a watchdog, to ensure that policies such as tobacco control are enforced,” she said.

She added: “Industry has taken advantage by increasing direct and indirect promotion through Covid-19 relief CSR (corporate social responsibility) programmes and financial support, and we need to shine a light on actions such as that.”

At the end of the day, Dr Saunthari pointed out that: “Pandemics will be here to stay in different reiterations, but the NCD fight is a marathon – it’s not a sprint.

“We need to reevaluate healthcare processes, and we need to build stronger primary healthcare to be front and centre in order to maintain the continuity for care of patients with NCDs.”

As Dr Noor Azmi said: “We need to control and prevent NCDs using some of the strategies that were used for Covid-19.

“We must urge our people to deal with NCDs with the same urgency as they had with Covid-19.”

Tan Shiow Chin is a 2021 APCAT Media Fellow.