Metrics matter: the case of assessing the importance of non-communicable diseases for the poor

As the saying goes, ‘bad publicity is better than no publicity.’ So I was gratified to see in IJE such a prominent, even if highly critical, reference to a piece that two colleagues and I did nearly 15 years ago and that I’d thought long forgotten. In our piece my colleagues and I had questioned, on equity grounds, the then-incipient shift in emphasis from communicable to non-communicable diseases (NCDs) in global health policy. Using 1990 data from the 1996 World Health Organization (WHO) global burden of disease (GBD) study, we had estimated that communicable illnesses were still responsible for a majority of the disease burden in the poorest quintile of the world’s population. But in the richest quintile, the situation was the reverse: NCDs were overwhelmingly dominant. This finding had led us to advocate a continuing focus on communicable diseases because of their central importance to the health of the global poor, a group of especially high priority in the 2015 Millennium Development Goals that were then being formulated. To move toward NCDs, we argued, would result in increased attention for a set of conditions far more relevant to the world’s better-off. Not surprisingly, perhaps, NCD advocates did not find this argument very compelling. Nor did any of the four commentatorson a similar argument for India advanced by S.V. Subramanian and colleagues in the article featured in this current IJE collection of papers on equity and the pattern of disease. In that article, Subramanian et al. challenge the argument that the distribution of cardiovascular diseases and risk factors has shifted so that they have become more prevalent in lowthan in high-income groups. The many problems they find with this argument lead them to consider a shift away from communicable diseases toward cardiovascular issues to be premature, or ‘jumping the gun’ as they put it. Among the several arguments advanced by the commentators disagreeing with this conclusion, two stand out. The first is that Subramanian et al. have simply misread the available literature, and that the burden of disease from NCDs is in fact higher among the poor. The second is that, even if they did not misread, NCDs now constitute an adequately important (and growing) minority of the disease burden in even the poorest population groups to justify significant attention.