The Bottom Billion and NCDs: Claudine Manizabayo's story

28th February 2011

Claudine Manizabayo was suffering from shortness of breath and a cough. At first, doctors mistook her symptoms for asthma. Then a clinical team specializing in non-communicable diseases examined her and came back with a different diagnosis--heart failure. In affluent countries like the United States, the symptoms and the diagnosis are feared and familiar among the elderly and people with coronary artery disease.

Claudine is only 18. In poor countries like Rwanda, where she grew up in a family of farm laborers, heart failure often afflicts the young and the destitute. Non-communicable diseases (NCDs) like coronary disease, adult-onset diabetes, and some cancers have attracted a great deal of attention and resources in wealthy and middle-income countries, where they have emerged as leading causes of death and disability among populations who eat too much, exercise too little, and are heavy consumers of tobacco and alcohol.

“The NCDs that afflict people living on less than a dollar a day in countries like Rwanda or Haiti, have received far less attention and have very different causes,” says PIH physician Gene Bukhman. “For this ‘bottom billion,’ NCDs--like rheumatic heart disease, type 1 diabetes, mental illnesses, epilepsy, and cervical cancer--are often the result of lack of access to food, shelter, education, and health care interventions readily available in developed countries.”

For example, Claudine’s condition--rheumatic heart disease most likely caused by a bacterial infection--required an operation to replace a damaged valve in her heart, said Dr. Bukhman, who is also Director of the Program in Global Non-communicable Disease and Social Change at Harvard Medical School. While such procedures are available to people living in places like the United States, they are rarely accessible to poor populations like Claudine’s community.

Fortunately for Claudine, the Rwandan Government has begun a focus on treating NCDs; and in partnership with a visiting surgical team from the US (Team Heart), Claudine was able to receive the treatment she needed. “PIH has faced this issue of inequity before—for treating HIV and MDR-TB patients in poor populations,” says Dr. Bukhman. “Likewise, I see treating NCDs in poor populations as a social justice issue.” To call attention to the plight of these underserved populations, Partners In Health, The NCD Alliance, Harvard Medical School and Brigham and Women’s Hospital have joined with numerous likeminded organizations to host a landmark conference, “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion,” on March 2- 3, 2011.

This “long tail” refers to the curve of a graph plotting out the diseases that most affect a population. Communicable diseases like HIV and malaria at the top of the curve may cause more deaths and infect more people than NCDs like epilepsy or heart disease on the long end of the curve.

However, NCDs still add up to a substantial burden of disease, says Dr. Bukhman. “In communities where PIH has been providing comprehensive, community-based care for many years, we no longer see large numbers of patients coming to the hospital suffering from HIV, tuberculosis, and other infectious diseases,” he adds. “Instead, our wards are increasingly filled with patients requiring treatment for NCDs.”

Partners in Health, the NCD Alliance and other conference organizers intend to use the event to focus attention on NCDs among the world’s bottom billion in advance of a United Nations high-level assembly meeting on NCDs in September 2011.

“The single previous occasion on which the United Nations held a high level, disease-focused assembly meeting was in 2001. The assembly focused on HIV and played a crucial role in launching the incredibly effective Global Fund to Fight AIDS, Tuberculosis & Malaria,” said Dr. Bukhman. “The UN assembly this September is a historic moment for the poor afflicted by non-communicable diseases,” Dr. Bukhman concluded. "We who advocate for their treatment must ensure their voice is heard."

The March 2-3 Long Tail conference features 50 respected speakers and panelists, both experts treating these illnesses and those living with non-communicable diseases in developing nations, including Claudine from Rwanda, who is now healthy enough to attend school.

In addition, several other speakers from Rwanda will also be featured, as the Government of Rwanda has been a leader in non-communicable disease control. In addition, the conference will include presentations from Julio Frenk (Dean, Harvard School of Public Health), Felicia Knaul (Director of the Harvard Global Equity Initiative), PIH co-founder and Harvard University Professor Paul Farmer, Ann Keeling (CEO, International Diabetes Federation and Chair, NCD Alliance Steering Group), Elizabeth G. Nabel (President, Brigham and Women's Hospital), Dean Jamison (Professor of Global Health, University of Washington), Peter Hotez (Professor and Chair, Department of Microbiology, Immunology, and Tropical Medicine, George Washington University) and K. Srinath Reddy (President, Public Health Foundation of India). Registration is free for public health professionals and advocates.

The conference will be webcast live.

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