Introduction
During pandemics and other health system shocks, such as natural disasters, climate change, or humanitarian emergencies, non-communicable diseases have been neglected, despite them causing the highest burden of morbidity and mortality globally. The COVID-19 pandemic has highlighted the need to prioritize research on the long-term impact of non-communicable diseases in planning the response to and management of future health shocks.
The Need to Prioritize Non-Communicable Diseases in Health Shocks
While policy, public health, and the media have primarily focused on critical care admission, hospital admission, and mortality related to COVID-19, the pandemic’s indirect effects on non-communicable diseases have been significant. Excess all-cause mortality, mostly due to non-communicable diseases, greatly exceeded mortality due to COVID-19 in the first two years of the pandemic, with an estimated 18.2 million overall excess deaths worldwide and 5.94 million COVID-19-related deaths.
Non-communicable diseases are implicated in the direct, indirect, and long-term effects of COVID-19, whether as risk factors for COVID-19-related mortality, as concomitant diseases affected by disruptions, or as chronic outcomes. However, these impacts have been overlooked for several reasons:
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Siloed Thinking: A culture of separating non-communicable diseases from infectious diseases spans funding, research, policy, guidelines, and care.
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Pandemic Preparedness Focus: Pandemic preparedness is concerned with acute insults to individuals and populations rather than the more chronic timescales of non-communicable diseases.
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Resource Allocation: Resources, whether financial, human, research, policy, or care, have been substantially less for non-communicable diseases compared to infectious diseases.
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Data Limitations: Research and policy data have emphasized mortality rather than morbidity, neglecting important effects and populations affected by health shocks.
To address these issues, this article provides recommendations for including non-communicable diseases in research and policy for future shock preparedness, drawing on examples from the COVID-19 pandemic in the UK.
Involving Patients and the Public
Better representation of non-communicable diseases in preparedness for shocks requires fundamental shifts in the involvement of patients and the public in all areas of research, from design to dissemination. The COVID-19 pandemic has led to greater use and dissemination of, and public interest in, routine health data. However, without integrated patient and public involvement, research may not be inclusive in terms of study populations, baseline characteristics and risk factors, outcomes, and health system characteristics.
Encouraging trends include patients leading research agendas and publishing research independently, which should inform future research in non-communicable diseases during shocks. Shocks are likely to have differential effects on various social determinants of health, such as sex, gender, ethnicity, disability, homelessness, and educational attainment. Therefore, research must collect, analyze, interpret, and disseminate data that include these determinants to recognize, prevent, and tackle potential inequalities.
Integrated Research and Care
Most data-driven research in non-communicable diseases has been disease-specific and from high or high-middle-income countries. Availability of national data for research across multiple datasets offers huge dividends, but the UK government’s emergency pandemic response restricts legislation and approvals to research related to COVID-19. To guarantee the availability and benefits of data in future shocks, the government must revise legislation with wide stakeholder engagement, including patients and the public.
Healthcare and healthcare research include many paradigms aiming to improve the effectiveness of research pipelines and care, such as translational medicine, precision medicine, and data-driven healthcare. However, these paradigms assume linear processes instead of “improvement cycles” or more complex systems characterizing quality improvement, implementation science, and learning health systems. These cross-cutting concepts could accelerate and maximize benefits for patients during shocks, when gaps simultaneously emerge in care and research.
For example, conferences and specialty training could incorporate more “generalist” content, and journals could have specific calls for papers relating to cross-specialty themes. This would help traverse boundaries of diseases, drugs, and disciplines during shocks, including new research funding calls and new ways of thinking.
Documenting Long-Term Consequences
Risk of cardiovascular disease is over the lifetime, related to multiple comorbidities, and associated with chronic disability. Therefore, associations of non-communicable diseases with shocks such as pandemics may occur over much longer timescales. During the COVID-19 pandemic, electronic health record data from primary and secondary care at the national level have been linked with disease-specific registries and other datasets, enabling the study of longitudinal associations with different non-communicable diseases.
The movement towards continuously updated evidence, such as living reviews and guidelines, should be extended to longer-term consequences of shocks. To understand the true impact of shocks among all non-communicable diseases, timely evidence and guideline development that traverse disease, specialty, and disciplinary silos and over the longer term are needed. This responsibility is beyond individual researchers and funders and requires central governmental coordination with public support.
Long COVID is a condition that started to be defined by patient communities globally from April 2020. Post-infectious chronic conditions have been described with several viruses, but health systems were unprepared for the scale and severity of the burden of long COVID. Evidence from multiple countries shows symptoms affecting multiple organ systems, creating major strains on individuals, populations, health systems, and economies. Consensus definitions and coding in research and practice should be used as early as possible, and research should include modeling of the potential burden of longer-term consequences of shocks.
Minimizing Indirect Effects
Across diseases, specialties, and countries, non-COVID care was generally reduced during the pandemic, whether prevention or treatment in hospitals and communities. These evidence-based strategies for treatment and prevention are known to improve health and longevity; without them, population health will suffer. For example, activity in cardiovascular disease management decreased in the UK and has not yet returned to pre-pandemic levels.
Although each specialty faces similar challenges and backlogs, from orthopedic surgery to neurology, each has had to develop its own way of collecting, analyzing, and acting on data. For both procedural and non-interventional clinical disciplines, future research, including predictive models, would benefit from common frameworks for planning, monitoring, and minimizing indirect effects during shocks.
In medical education, postgraduate training, and continuing medical education, this will require “cross-pollination” (for example, non-communicable diseases in infectious disease training). People involved in policy, research, and dissemination need to rethink the extent to which superspecialization has come at the expense of the value of generalization in clinical and research spheres.
Prioritizing Resources
Globally, the focus on funding and policy is limited for research into the chronic effects compared to the acute effects of shocks. That non-communicable diseases are the major cause of disability in low- to middle-income countries, surpassing infectious diseases, is often still not appreciated. Similarly, most funders, health service providers, and policymakers have focused on the acute impact of shocks, even though their chronic impact, if properly documented and measured, is probably more significant, warranting far greater resource.
Future strategies to provide resources for research on non-communicable diseases during pandemics and future shocks should aim to capitalize on commonalities across specialties and disciplines to avoid duplication of effort and unnecessary competition for limited resources, as well as challenging beliefs that the chronic effects of shocks are less important. Governments, particularly in low-to-middle-income settings but also in the UK, need to be able to negotiate for and prioritize cross-disciplinary and cross-specialty research.
Measuring the Impact
Typically, trials and observational studies in shocks have focused on infectious disease metrics and outcomes, as well as those specific to a particular shock, such as hospital admissions related to COVID-19. The relevance of measuring non-communicable disease metrics and outcomes is shown by cardiovascular disease during the COVID-19 pandemic.
Large-scale epidemiological studies of national-level electronic health records in high-income countries have shown increased risk of cardiovascular disease, from myocardial infarction to stroke, for at least a year following COVID-19. Multiple potential mechanisms are implicated, including endothelial dysfunction, atherosclerosis, and thrombosis, but the epidemiology and mechanisms of new cardiovascular disease and other non-communicable diseases associated with COVID-19 have been studied in separate specialties with little joining up of research disciplines from physiology to population health, which slows the pace of progress in terms of translation to prevention and disease management.
Different disciplines and specialties need to work and learn together across silos, both for non-communicable diseases individually and when considered along with infectious diseases, to create “learning health system” models of research. To monitor and try to prevent non-communicable disease consequences of shocks, these need to be measured. Most early COVID-19 policy and pandemic preparedness focused on mortality and critical care admissions with relatively little attention paid to other forms of healthcare use, such as general practitioner or outpatient visits and emergency department attendances, pharmacy visits, patient-reported outcomes, or costs of care.
Conclusion
Preventing and managing future shocks in the most effective manner has to involve closer working between non-communicable diseases and infectious diseases. Data, funding, and staffing are needed to understand and tackle non-communicable diseases during shocks. An inclusive agenda to reduce inequalities starts with inclusive collection, analysis, interpretation, and dissemination of data from study populations through to health systems, and this has to include non-communicable disease research.
The classification of diseases as non-communicable or communicable has been a barrier in many ways to policy to mitigate against shocks. We should prioritize new avenues of research to tackle the healthcare needs of populations and systems more holistically during shocks. This includes:
- Involving patients and the public at all stages and in all areas of research
- Prioritizing timely inequalities research
- Promoting integrated research and care by providing human and financial resources
- Facilitating timely data linkage and guideline development for long-term non-communicable disease consequences of shocks
- Prioritizing long-term consequences in shocks with involvement of patients and public
- Developing frameworks across disciplines and specialties in research, including indirect effects
- Prioritizing cross-disciplinary resources, including funding to conduct research
- Including non-communicable disease metrics in learning health system models of research before, during, and after shocks
- Planning data and research to include morbidity and healthcare use during shocks
By prioritizing non-communicable diseases in research and policy for future health shocks, we can develop a more holistic and effective approach to preparedness and response.
