IDC Covid-19 Inquiry _ Second Submission: Input from the UK Working Group on NCDs[1]

A global health crisis: responding to the International Development Committee’s inquiry on longer term issues, implications and lessons to be learned from Covid-19

Please note that we have responded to the points most relevant to our Working Group members’ experience and expertise.

1). The emergence, incidence and spread of coronavirus virus infections and the Covid-19 disease in developing countries:

The spread and impact of Covid-19 amongst older people and those with underlying chronic conditions in developing countries, especially in humanitarian contexts, are of particular concern. We know that people living with underlying chronic conditions/Non-Communicable Diseases – NCDs (such as cardiovascular disease -heart disease and stroke, diabetes, chronic lung disease and cancer), and older people are at higher risk of more severe illness or dying from Covid-19, and in some cases appear to be more susceptible to contracting Covid-19.  (NCD Alliance,27/4/2020, COVID-19 and Noncommunicable Diseases (NCDs): Questions and Answers https://ncdalliance.org/resources/covid-19-and-noncommunicable-diseases-ncds-questions-and-answers )

NCDs already account for 70% of deaths worldwide, with mental-health conditions such as dementia adding significantly to this burden of ill health. NCDs are a global epidemic. The burden of NCDs diseases is rising disproportionately among developing countries and the risk of dying prematurely from an NCD is almost double that in high-income countries. (WHO - https://www.who.int/nmh/publications/ncd-profiles-2018/en/  https://globalncdsuk.files.wordpress.com/2020/03/201805_uk-wg-ncd-briefing-paper_web.pdf

This burden runs across the whole life course, with children and young people in developing countries having a higher NCD burden (measured through Disability Adjusted Life Years) than those in higher-income countries (The Lancet Commission on Adolescent Health and Wellbeing, graph p92 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5832967/pdf/nihms848847.pdf )

The risk of spread and impact of Covid-19 in humanitarian settings such as refugee camps (with the huge challenges of social distancing or regular handwashing), particularly where there is a high NCD burden (a challenge being increasingly recognised and responded to in humanitarian settings), will likely mean even higher incidence than other low and resource poor settings.

Overall there is a strong need for disaggregated data (by gender, age, ethnicity, existing underlying conditions etc.) to understand who is being infected (and impacted) -to ensure an effective, targeted response. There is good evidence from a large number of countries that do disaggregate data by sex that, although men and women are infected in roughly equal numbers, men are much more likely to die. The reasons for this must be better understood but it is likely to be linked to the higher incidence of many of the major NCDs in men and also their higher levels of tobacco and alcohol use.

2). The direct and indirect impacts of the outbreak on developing countries, and specific risks and threats:

The spread of the Covid-19 pandemic will exacerbate existing inequalities and have huge direct and indirect impacts on developing countries. We must respond to ensure now, more than ever, no one is left behind.

Recent data shows that 16% of the population of Africa is at increased risk from Covid-19 due to being older or having underlying conditions. This figure highlights how huge the impacts of Covid-19 will be in developing countries. (https://cmmid.github.io/topics/covid19/Global_risk_factors.html)

The impacts can be broken down into different impacts (and some suggested actions) that relate particularly to NCDs:

• Impact on already overburdened health systems – especially in humanitarian settings. Unable to respond to the impact of Covid-19, and even less able to respond to other issues
• Access to chronic disease screening and treatments/medication is reduced or stopped. In some cases, even in the most equipped and strong (UHC) health systems, people living with NCDs like cancer, dementia and stroke, are finding it more difficult to access the regular screening, treatment and care, including palliative care, that they need due to isolation/lockdown, and strain on health systems. In developing countries- and especially in humanitarian settings, access to treatment and care for NCDs is already stretched ( CNBC news, 23/4/20, Non-covid patients struggle for health services; dialysis patients worst hit (India) https://www.cnbctv18.com/healthcare/non-covid-patients-struggle-for-health-services-dialysis-patients-worst-hit-5758891.htm )
• Look for new ways to ensure meds supply during lockdown - e.g. insulin to be taken home for e.g. 3 or 6 months, so that people living with NCDs do not have to leave their homes to access their medication. Also, look at how regulatory barriers to access to morphine can be addressed given the importance of morphine to address severe breathlessness.
• Impact on health workers both in terms of increased risk of catching Covid-19/no PPE and less workforce available because they are sick. Already overburdened with impact of chronic and other diseases - and under resourced and trained – especially in humanitarian settings

• Undermining any gains made increasing governments’ focus on public health and laws/polices that help prevent NCDs

• Impact on availability of healthier food: The Covid-19 pandemic is already disrupting global food supplies, especially in already vulnerable areas ( AP news, 15/4/20, Virus choking off supply of what Africa needs most: Food: https://apnews.com/28a52737e04e11271b62982a462232b5) (FAO, 29,3,20, COVID-19 and the risk to food supply chains: How to respond? http://www.fao.org/3/ca8388en/CA8388EN.pdf)   :There is a risk of increased food insecurity and of reduced access to healthy diets that are essential for maintaining immune functions. Malnutrition in all its forms can then cause additional vulnerabilities and poor health. This is true in many resource poor settings but especially so in humanitarian settings such as refugee camps. Plus commercial determinants of health - inappropriate marketing or even donation of very unhealthy foods at a time when good nutrition is as important as ever.  The Access to Nutrition Initiative (with support from DFID) is working on mapping how the private sector is influencing nutrition in developing countries - an example of how this is an international development issue.

• Negative impact on mental health of the pandemic itself and the measures being taken to address it – especially so for those more vulnerable or who have lived through situations that are already very challenging to mental health (eg conflict or being displaced). And around impact on mental health relating to people not being able to see/say goodbye to their relatives, traumatic end of life experiences due to Covid-19 without good palliative care and access to crucial medications (e.g. morphine). In addition, a focus on hygiene and social distancing in communities where there simply isn’t the means to follow general guidance can greatly increase stress and anxiety – messaging must be tailored for the most disadvantaged settings. (Consider supporting policies supporting ‘shielding’ of particularly vulnerable populations within densely populated communities – e.g. older people or those living with NCDs -e.g. guidance at https://www.lshtm.ac.uk/sites/default/files/2020-04/Guidance%20for%20the%20prevention%20of%20COVID-19%20infections%20among%20high-risk%20individuals%20in%20camps%20and%20camp-like%20settings.pdf )

• Impact on already existing challenges and tensions between host communities and IDPs in humanitarian settings (seeing refugee communities as a burden on already over-burdened health systems and other resources)

• Impact across the whole life course. The secondary impacts of Covid-19 on children's long-term health will be serious. Including impact of school closure in developing countries (nutrition, access to health messages, gendered angle, mental health

• Restrictions and coping mechanisms due to COVID-19, including physical distancing and self-isolation, may increase some NCD risk factors, including amongst young people, such as increased alcohol and tobacco use, reduced physical activity and ability to follow a healthy diet.

• Overall, there is a strong need for disaggregated data (by gender, age, ethnicity, underlying conditions etc.) to understand who is being impacted (and infected) - to ensure an effective, targeted response. There is emerging evidence of the increased indirect impact on women and girls -particularly in fragile and conflict affected settings, For example increase of incidences of domestic violence, disruption to education, the already disproportionate burden of unpaid care work on women, and the gendered nature of the health workforce and the risk that predominantly female health workers incur.(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30526-2/fulltext , Implications of the COVID-19 crisis on girls and young women, https://plan-uk.org/file/plan-uk-coronavirus-policy-briefingpdf/download?token=THR6Efm9 )

3). The UK’s response, bilaterally and with the international community, to the spread of coronavirus to developing countries:

Funding must include a focus on those most at risk from the impacts of Covid-19 (ie older people and those with underlying chronic conditions) and MUST take a rights-based approach (non-discrimination).

There is a severe mismatch between the scale of the NCD challenge and the allocation of official development assistance: in 2018 only 2% of development assistance for health was spent on NCDs. (https://globalncdsuk.files.wordpress.com/2020/03/201805_uk-wg-ncd-briefing-paper_web.pdf)

The UK government must ensure that palliative care is mainstreamed into Covid-19 responses including the training of health care workers at all levels and access to palliative medications including morphine. Palliative care is not a luxury add-on, it is a necessity both for many people with covid-19 and for those with NCDs that require palliative care. In many low-resource settings, there are going to be terrible ethical decisions around who can benefit from treatment (even where available) and who is sent home when there is no hope or where systems are overwhelmed. The decision should not be 'all or nothing' but must include the option of palliative care - whether for Covid-19 itself or any other condition including NCDs. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30964-8/fulltext)

5). The implications for DFID’s policy on a global health strategy:

Long term focus on NCDs needed to mitigate impacts of future outbreaks of Covid-19 or other viruses. i.e increase resilience. A reduction in NCDs globally may help when future viruses emerge.

Focus on prevention of other conditions that can lead to a higher risk of serious outcomes of COVID-19 eg obesity - including physical activity, good nutrition and support to quit smoking, and secondary prevention through medication. Obesity is increasing in LMICs, because all too often it's seen as only relevant in high income countries - and it is increasing rapidly. (for example, Lao PDR has had one of the highest rates of increase of obesity in the world - an average annual increase of 9.5% for men and 6.6% for women from 1995 to 2015 - and that obesity prevalence is predicted to be 8.9% (men) and 12.3% (women) by 2025. World Obesity Federation. 'Obesity: missing the 2025 global targets'. 2nd edition. WOF, London, UK, 2020. https://www.worldobesity.org/resources/resource-library/world-obesity-day-missing-the-targets-report)

The links between underlying conditions and COVID-19 demonstrate the need for a cross-cutting, holistic approach for any future broader approach/strategy.

8). The impact of the outbreak on UK aid funding in the longer term:

UK aid funding needs to support the concept of ‘Build back better’, with a real focus on equitable Universal Health Coverage. This must include a trained and supported health workforce with a particular focus on: primary healthcare and community health workers; systems to manage multiple chronic diseases and acute infection in parallel; and investment in digital solutions where appropriate

Building Back Better must also include much broader issues that impact on global health eg air pollution (The Guardian, 5/5/20, Is air pollution making the coronavirus pandemic even more deadly? https://www.theguardian.com/world/2020/may/04/is-air-pollution-making-the-coronavirus-pandemic-even-more-deadly) , focus on reduction in climate change, combating malnutrition in all its forms (including obesity), physical activity and the commercial determinants of health.

There is a huge potential for improved long-term health and prevention of NCDs, which are the leading cause of death in almost all regions of the world, much of that death being premature (This would also ensure we meet the target set out in SDG 3: to reduce premature mortality from non-communicable diseases, through prevention and treatment, by one-third by 2030).

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