Is it time to discard the communicable vs. non-communicable dichotomy?

Adamson S. Muula

Editor-in-Chief, Malawi Medical Journal, Blantyre, Malawi

Professor and Head, Department of Community and Environmental Health, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi

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Globally, non-communicable diseases (NCDs) kill more than 41 million people annually with Low- and Middle-Income Countries (LMICs) sharing much of the brunt. Communicable diseases, often led by malaria, tuberculosis and HIV, when Africa is the region under discussion, are put in the diametrically opposing group. High-income countries also deal with recalcitrant communicable diseases as well as vermin and pests. The recent (2023) bed bug outbreak in Paris is a case in point. With non-communicable diseases, the knee-jerk medical conditions include hypertension and heart diseases, diabetes mellitus, suicides and cancers. Yet, as we should appreciate, if we went to reputable medical schools, there are infectious determinants of hypertension, heart diseases and cancers. Some heart diseases are caused by infectious agents, even when the heart manifestations of the disease (e.g. cardiac tamponade and failure), may not be infectious per se. In addition, an individual afflicted by an infectious disease is not immune to what we traditionally refer to as NCDs, such as hypertension and cardiovascular accident. We sometimes behave as if an individual with diabetes will be exempted from Streptococcal pneumonia, just because that individual attends an NCD Clinic and therefore has already been taken. In fact, the person with diabetes is at great risk of another disease from an infectious cause, especially when the diabetes is not well controlled. How we end up managing an individual with both diabetes and an abscess can sometimes be described as a circus.

Some cancers, such as (uterine) cervical cancer and Kaposi’s sarcoma are tightly linked to HIV, especially in Africa. The majority of cervical cancers are associated with Human papilloma viruses anyway. The question as to how such a disease ends up being classified as non-communicable is the reason I have written this editorial. Again, for some weird reasons, mental health conditions have been lumped together with, and as, non-communicable diseases. If we consider the “infection” with the unenviable accolade as “The Great Imitator”, i.e.  syphilis, we can gain insights also as to why the communicable versus non-communicable dichotomy is problematic. Syphilis is caused by an infectious agent that is largely spread through sex, from mother to child and sometimes via unsafe blood transfusions. And in my days as a medical student, one would not be forgiven if they did not recite that “syphilis is an infectious multisystem chronic infection caused by Treponema pallidum. It can cause psychiatric disorders including depression, mania, psychosis, personality changes, delirium and dementia.” It is therefore nonsensical when we always categorise depression, mania, psychosis, personality changes, delirium and dementia, which could have arisen from syphilis, as non-communicable. That suicide may just have been a late manifestation of syphilis! In any case, we may not even know whether the social environment that contribute to these so called NCDs.  Perhaps that is the reason we see that people afflicted by any of these conditions (depression, mania, psychosis, dementia and delirium) are not routinely offered the VDRL or TPHA tests (laboratory tests for the diagnosis of syphilis). Rheumatic heart disease also has infectious origins. Tuberculosis of the heart or its lining clearly shows that this is just tuberculosis but of course affecting the heart. Diseases seem not to have bought into our communicable versus non-communicable dichotomy.

Is it time therefore for us to be ashamed with and of ourselves and let sanity prevail? Or, do we fear that we have invested so much in what we have always been doing that it is impossible to change? Should we, as a compromise still categorise diseases as communicable and NCD at the theoretical level but in practice deal with the patient a little more, if not a whole lot, holistically especially at primary and secondary health facilities? This is where the Family Medicine physicians seem the most reasonable among our lot. I am not against specialisations and super-specialisations. But perhaps these communicable and non-communicable diseases clinics can be reserved for the tertiary and quaternary health facilities and not the majority health centers and district hospitals. And, please remember the Great Imitator in the Non-Communicable Diseases Mental Health Clinic.

Conflict of Interest: Public Health Physician

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