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Chronic Diseases in Palestine: The Rising Tide. By Hani Abdeen Israeli-Palestinian Public Health Magazine (Bridges) Volume 2, Issue 3, April - May 2006
http://www.bridgesmagazine.org/index.php?page=issues.9.2
Overview
At the current stage of Palestine’s health transition, chronic diseases contribute to a substantial proportion of total deaths in the population. Cardiovascular diseases and diabetes are highly prevalent in the Palestinian society. Tobacco-related cancer account for a large proportion of all cancers. Tobacco consumption is common, especially among the poor. Hypertension and dyslipidaemia, although common, are inadequately detected and treated. Demographic and socioeconomic factors are hastening the health transition, with sharp escalation of chronic disease burdens expected over the next 20 years. Epidemiological surveys to delineate the incidence, prevalence and severity of these diseases are key to estimate the costs and resources required and to design appropriate health prevention and treatment policy strategies. A national cancer control program is urgently needed as well as comprehensive tobacco control laws. There is a need to increase resource allocation, coordinate multi-sectoral policy interventions, and enhance the engagement of the health system in activities related to chronic disease prevention and control.
Burden of Chronic Diseases
Palestine is experiencing a rapid health transition, with a large and rising burden of chronic diseases, which are estimated to account for a large proportion of all deaths. There are no available data to suggest the overall prevalence or incidence of diseases like cardiovascular disease, hypertension or diabetes mellitus. In general, we depend on mortality data from the different health centers to estimate the impact of theses diseases on society. The current system counts mainly the visits of the patients to the Palestinian health centers which do not reflect the real prevalence or incidence. In addition, there is no classification by age or gender mainly because of a lack of a computerized system. Neither is there any information on disabilities resulting from any of the chronic diseases. This lack of information leads to an inability to estimate the direct or indirect costs, resources required, policy and decision making regarding management and prevention.
In this article, the following common chronic diseases will be discussed:
Cardiovascular Diseases
The burden of cardiovascular disease is rising in the Palestinian territories. Heart disease was the first leading cause of death among population in the year 2004 (Table 1).
Mortality among males was more predominant than females (95.4% in males vs. 43.6% in females), with a rate of 60.5 per 100,000 in males and in 48 per 100,000 in females.
Hypertensive disease is the seventh leading cause of death in total population and in males (5.9% of total deaths and 4.1% of male deaths), while it was the fourth leading cause of death in females (8.3% of females deaths). Cerebrovascular disease was the fourth leading cause of death in the general population (8.3%), the sixth in males (6.7%) and the third in females (10.5%).The annual average specific mortality rate of cerebrovascular disease per 100,000 population was 26.1 in the last five years and 30.2 in year 2000. (Graph 1)
Diabetes Mellitus
According to the WHO global estimate, and on account of the epidemic nature of diabetes, prevalence of diabetes is expected to increase in Palestine. This was examined in a study conducted in 2000 in cooperation with Al-Quds University and the Ministry of Health. The preliminary results indicated that the prevalence of diabetes in Palestine was about 9% in 2000. In 2001, the Union of Palestinian Medical Relief Committee screened 2,482 people through their mobile clinics for obesity, hypertension, diabetes and dyslipidaemia. The preliminary results showed that 77% of the population was overweight (BMI > 25); 47% was obese (BMI > 30); 31% had hypertension; 18% had diabetes; and 49% dyslipidaemia. These figures should be cautiously considered as the targeted population included men and women between 35 and 65. In another urban population study of people between 35 and 65, Abdul-Rahim, et al found diabetes mellitus in 12% of the surveyed population. (1) Diabetes mellitus constituted 3.6% of total population deaths. The average annual mortality rate of diabetes was 12.4 per 100,000 population in the last 5 years. (Graph 2).
Cancer
According to the cancer registry center (CRS) in Gaza, the incidence rate of breast cancer is 60 per 100,000 population making it the most prevalent type of cancer (16.4%) in the total population. Lung cancer was the most prevalent type of male cancer (12.7%), whilst breast cancer occupied the most prevalent type in females (31%).
Data on cancer mortality in Palestine indicated an annual average mortality rate of 26.8 per 100,000 population in the last five years (see Graphs 3 & 4).
Risk Factor Levels: Grim Outlook
These advancing chronic diseases epidemics are propelled by demographic, economic, and social factors, of which urbanization, industrialization, and globalization, are the main determinants. With increasing life expectancy, the proportion of the population older than 35 years is expected to rise in the coming decades. Urbanization and industrialization are changing the patterns of living in ways that increase behavioral and biological risk factor levels in the population.
Substantial variations exist between different regions, but risk levels are rising across the country, most notably in urban areas. An excess risk of death from coronary disease has been observed in men and women. The increased risk of cardiovascular problems noted in Palestinians is a portent of the further rise in risk that is likely to be experienced alongside the developmental transition of the country. A high frequency of diabetes, central obesity, and other features of the metabolic syndrome (especially the characteristic dyslipidaemia of reduced HDL cholesterol and raised triglycerides), together with the conventional risk factors like smoking, blood pressure, plasma cholesterol, and body-mass index (BMI) are proving the major determinants of the rise in chronic disease in Palestine.
The INTERHEART study found that the cluster of nine coronary risk factors identified in the global population was also applicable to Asians as a group.(2) Unfortunately there are no rigorous scientific data to highlight the importance of these risk factors to the epidemic of non-communicable diseases in Palestine.
With advancing health transition, the poor are increasingly affected by chronic diseases and their risk factors. Low levels of education and income now predict not only higher levels of tobacco consumption, but also increased risk of coronary heart disease. Poor people may also have deficiencies of protective phytonutrients. Lack of awareness of risk factors and diseases, and inadequate access to health care, increase the risk of early death or severe disability in such disadvantaged groups.
The Policy Response
The advancing epidemics of chronic diseases require a comprehensive policy response that caters to the varied needs of population-based prevention and essential clinical care. The health system is presently geared to provide prioritized care for communicable diseases and services related to maternal and child health. The agenda of health promotion and chronic disease prevention has not yet been adequately incorporated. Clinical services are not currently designed to provide the required level of care for these diseases in primary and secondary health-care settings.
As in other developing countries, public health advocacy has been mostly devoted to communicable diseases, nutritional deficiencies, population stabilization, and recently injuries to the ongoing conflict. Clinical health-care providers, on the other hand, were more focused on developing advanced health-care facilities for treatment of established chronic diseases.
Policymakers have been impeded, until recently, by inadequacy of data on the burden of chronic diseases. Perceptions that these diseases mainly affect the rich, who can purchase private health care, also prevented public sector resources from flowing into chronic disease prevention and control. The limited health budgets were not ready to take on the additional costs of treating chronic diseases at the authority expense. The huge expenditure that the Authority and society are incurring on the tertiary care of advanced chronic diseases has only been recently recognized.
Conclusions
As chronic disease epidemics gather pace in Palestine and threaten harm to individuals, families, and the society at large, a comprehensive strategy for their prevention and control is needed such as control programs for tobacco use and cancer. In other areas, such as diet and physical activity, the process must move from contemplation to action. Health systems need to be reoriented to accommodate the needs of chronic disease prevention and control, by enhancing the skills of health-care providers and equipping health-care facilities to provide services related to health promotion, risk detection, and risk reduction.
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Hani Abdeen, MD, is from the Al-Quds Medical School , Al-Quds University, Palestine
References
Bibliography
Ministry of Health Annual Report 2004: Health Status in Palestine. Chapter 5 Non-Communicable diseases.
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