Noncommunicable Diseases

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Why addressing chronic diseases is crucial for future pandemic preparedness

Democracy does not die in the darkness so often anymore. It dies in the light, one election at a time, with voters embracing the populists and autocrats who promise to cut the red tape and deliver the better life that democracy has failed to provide. It was not midnight military coups or dark backroom deals that brought strongmen to power in Nicaragua, Turkey, and Venezuela, former democracies that have joined the ranks of the world’s autocracies. Everyday frustrations over high health-care costs, poorly performing schools, and corrupt politicians drove voters in those countries to elect populists. Once in power, those populist leaders openly and steadily undermined the fair elections, free media, and institutional restraints that are the hallmarks of democracy, cheered on by supporters hungry for results. The result of this trend has been the global rise in the number of countries undergoing autocratization, or significant declines in the quality of their democracy. At the same time, the number of nations that are democratizing—or experiencing significant improvements in the quality of their democracy—peaked in 1994 soon after the end of the Cold War and has been falling ever since (see figure below).  In some nations, like Nicaragua and Turkey, the extent of that autocratization has advanced so far that those nations are now considered electoral autocracies, countries in which elections are still held but under conditions that prevent opposition parties from fairly campaigning or that keep votes from being freely cast or accurately counted. According to recent research from Anna Luhrmann and Staffan I. Lindberg from the University of Gothenburg’s Varieties of Democracy (V-Dem) Project, more than two-thirds of this rise in electoral autocracies is due to the gradual deterioration of former democracies. This year, the V-Dem Project designated twenty-four democracies as autocratizing. The United States is on that list. Voters may turn to autocracy for promises of a better life, but, at least with regard to health, those expectations are not fulfilled. Life expectancy has declined 2 percent on average in former democracies that have recently transitioned to autocracy (Honduras, Nicaragua, Turkey, and Venezuela) relative to democracies that have not made that transition (see figure below). The unhealthful effects of autocracy remain robust even when accounting for economic differences and excluding Venezuela, with its collapsing health system. Without the pressure of fair electoral competition or accountability to a free media, autocratic leaders have less incentive than their democratic counterparts to do the hard work of sustaining health-care infrastructure and improving care for chronic diseases. Instead of adopting measures that improve the health of the population, autocrats in nations such as Turkey have exploited ethnic and class divisions and resorted to patronage to keep power. Autocratization is hazardous to health. Part of its toll on longevity might be the result of missing out on the benefits democracy can make to reduce deaths from noncommunicable diseases, which are rapidly increasing in many low- and middle-income nations. A nation’s democratic experience—a measure of how democratic a country has been and for how long—matters more than its gross domestic product (GDP) in the reductions in deaths from cardiovascular diseases, transportation injuries, cancers, and other noncommunicable diseases. Cardiovascular disease is the leading cause of death worldwide, killing more than seventeen million people in 2015. Stroke, cancers, and other noncommunicable diseases are responsible for more than two-thirds of deaths globally, including those of eight million people under the age of sixty in poorer countries. By 2040, noncommunicable diseases will affect roughly the same share of the populations in many low- and middle-income countries as they do in the United States.  Previous research estimated that increases in democratic experience averted sixteen million deaths globally between 1995 and 2015 from cardiovascular diseases alone. The figure below indicates which countries benefited from the health improvements associated with democracy. The Baltic states, Brazil, Mongolia, Poland, and South Africa experienced some of the greatest improvements in health as democratizing states. Tragically, some of those nations, including Brazil and Poland, may now be drifting toward autocracy. Free and fair elections appear to be particularly important for these improved adult health outcomes, most likely because they increase government accountability and responsiveness. The health benefits of democracy are greater in nations that maintain genuine electoral competition and have experienced at least one transfer of power. Nations such as Botswana and South Africa that held multiparty-elections between 1995 and 2015 but did not experience a turnover in their ruling party did not fare as well in reducing deaths from cardiovascular disease as those nations such as Uruguay and Zambia that had at least one turnover (see figure below). However, having multiple turnovers of the ruling party did not increase the positive or negative effects of having experienced at least one transfer of power.  Elections and the health of a nation’s people are increasingly inseparable. Democratic institutions and processes, particularly free and fair elections, can improve population health, especially with regard to cardiovascular and other noncommunicable diseases. Voters should remain wary of populists who promise to deliver better health by undermining the accountability, messy compromise, and slow consensus-building that democracy requires.   To understand the methodology used, see this annex [PDF]. This interactive was made possible by a generous grant from Bloomberg Philanthropies. The statements made and views expressed are solely the responsibility of the authors. We thank Maria Teresa Alzuru and Kevin Lizarazo for their assistance with this interactive. The Council on Foreign Relations takes no institutional positions on policy issues and has no affiliation with the U.S. government.

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Test your knowledge of noncommunicable diseases and health in the developing world, from conditions such as Alzheimer’s and diabetes to global efforts to end HIV/AIDS.

Nearly twenty years ago, research from a group of political scientists suggested that people live longer under democracy. While this finding is not entirely unexpected, one can wonder how it fits into the case of China, where nearly 20 percent of the world’s population lives. After all, the post-1949 regime was able to significantly improve people’s health status despite relatively low income levels in the country. Tom Bollyky and his collaborators recently unraveled the puzzle, and the Lancet published their findings in the first comprehensive assessment of the relationship between democracy and disease-specific mortality. In the study, they noted that authoritarian countries like China have not been successful in addressing the epidemiological transition to noncommunicable diseases (NCDs) even though they may have managed to bring down incidences of infectious diseases and infant or child mortality. Their findings are consistent with my own research and a 2017 study, which found that China’s observed life expectancy in the post-Mao era was not as impressive as its robust economic growth would suggest. Indeed, NCDs now claim more than 85 percent of mortality in the country. Cancer alone accounts for 23 percent of the deaths in China. In 2015, China had an estimated 4.3 million new cancer cases and 2.8 million deaths from cancer, compared to nine hundred thousand cancer patients and seven hundred thousand cancer-caused deaths in the early 1970s. The rapid increase in the incidences of and deaths from cancer in China transpired at the same time that cancer incidences and deaths dropped in many Western democracies. Because the most effective anticancer drugs were typically expensive and not covered by major health insurance schemes, terminally ill patients who could not afford those medicines had to give up treatment or hunt around for the life-saving drugs. They smuggled genetic drugs from India, volunteered in clinical trial of new drugs, or made the drugs on their own. That said, authoritarian rulers do have to take citizens’ possible reactions to health-care systems into account. Otherwise, they risk loss of political legitimacy. That is particularly the case for China, where performance-based legitimacy requires the government to keep on delivering tangible social-economic progress. In February 2017, the government released their Plan on NCD Prevention and Control (2017-2025), which identifies improving health-care quality and reducing premature deaths of major NCDs as primary objectives. Among others, the government plan aims to increase the overall cancer five-year survival rate from 31 percent to 36 percent by 2020 and to 41 percent by 2025. Since then, the government has shaved years off the approval process for new cancer drugs. According to a policy document issued by the Office of the Communist Party of China (CPC) Central Committee and the Office of the State Council in October 2017, China accepts overseas clinical trial data in evaluating and approving the marketing of imported innovative drugs and medical devices. In order to further improve drug access and make imported drugs more affordable, beginning on May 1, 2018, China has implemented a zero tariff policy on a range of anticancer drugs and other pharmaceuticals made overseas. It has also cut a value-added tax on the production and import of drugs from 17 percent to around 3 percent. Beginning in 2017, the government health bureaucracy has also become more aggressive in negotiating with pharmaceutical firms to reduce high drug prices. The two rounds of negotiations organized by the Chinese National Health and Family Planning Commission (the predecessor of National Health Commission) led to a 50 percent reduction in price for the thirty-six drugs included in the negotiations. In April 2018, the Chinese government unveiled measures that include authorizing compulsory licensing to enhance the availability of innovative drugs. The newly created Chinese National Health Security Bureau, which pools health insurance funding from the National Health Commission, the Ministry of Human Resources and Social Security, and the Ministry of Civil Affairs, is now in a strong position to start a new round of national drug price negotiation with a focus on seventeen anticancer drugs. The government campaign to tame cancer drug prices sold by foreign pharmaceutical firms was abetted by a Chinese movie Dying to Survive. Based on the real-life exploits of a leukemia patient who smuggled cheaper generic drugs from India to save himself and others, the movie quickly became a box-office hit in the summer of 2018. By the end of the year, the government procurement of the seventeen anticancer drugs had amounted to 562 million yuan, representing a 62 percent overall drop in price. By including the drugs in the national reimbursement list under the basic medical insurance scheme, patients who are covered have reportedly seen their out-of-pocket payment lowered by more than 75 percent. Still, these measures are far from sufficient in significantly improving access and affordability in the country. By the end of 2018, only 44,600 people had benefited from the new reimbursement policy. Indeed, even if the government manages to hit its target of achieving a 41 percent five-year cancer survival rate by 2025, it would still lag far behind the United States (which has an overall cancer survival rate of 69 percent). The health gap between authoritarianism and democracy likely will remain in place.

Democracy has played little role in the recent history of global health, but new research published in the Lancet shows democracy is becoming more important as the health needs of low- and middle-income nations shift from infectious diseases to noncommunicable diseases. 

Health and infectious diseases have shaped the history of urbanization, but it is cities that will define the future of global health.

Population growth and aging are fueling a spectacular rise in noncommunicable diseases, such as cancers and cardiovascular diseases, in poor countries that are ill-prepared to handle them.