Noncommunicable diseases (NCDs) are chronic, long-duration, slowly progressing, and non-transmittable diseases. The main types are cardiovascular, respiratory, cancer, and diabetes mellitus,*1 with mental health recently added by the World Health Organization.*2 NCDs are currently replacing infectious diseases to become a major threat to the health and well-being of people around the world.*3 Such an epidemiological transition urges health professionals and policy makers to take action and look further into the spread of NCDs in both developed and underdeveloped countries.
Globally, NCDs are considered to be the leading causes of mortality and disability, creating a serious burden on public health. In Palestine specifically, the epidemiological transition is rapidly growing, making NCDs the number one cause of death in Palestine.*4 Cancer cases increased by around 400 (15.3 percent) between 2016 and 2017, causing 14.7 percent of deaths in 2017; cardiovascular diseases, on the other hand, caused 30.3 percent of deaths in the same year.*5 Such health evidence indicates an increase not merely in the direct costs of providing additional health care but also in the indirect costs incurred to cover the loss in GDP and the increase in societal stress.*6
There are three main contributors to the rapid growth of NCDs: environmental factors (e.g., air pollution), demographic factors (e.g., age), and social factors (e.g., poverty and political instability).*7 The socio-political situation in Palestine creates fitting circumstances for the development of social and environmental factors, taking into account that prevalence of NCDs is not only associated with individual behavior.*8 Living through a persistent political conflict and economic instability contributes to developing high emotional stress and low quality of life, and stimulates risky behaviors such as smoking.*9 Moreover, the presence of checkpoints, the spread of new settlements in the West Bank, and the confiscation of lands in Area C prohibit freedom of movement, which demotivates Palestinians and dissuades them from considering healthy life options and engaging in outdoor activities such as camping, hiking, running, swimming, water sports, mountain climbing, and forest trekking. These activities have a positive impact on the physical well-being of citizens as well as on their general feelings and mental health.*10
On the other hand, Israeli control over water resources limits agricultural development, and hence, the ability to obtain low-cost healthy food options. This gives the increasing number of fast-food chains in Palestine the opportunity to sell more of their cheaper calorie-rich offerings. It is expensive to eat healthy food in Palestine, especially since organic crops and superfoods are limited and are only available at very few selling points for the high-income population. The Palestinian government can provide limited support to farmers whose lands are confiscated by the Israeli occupation, which compels these farmers to rely on emergency or project-based donor funding.*11
From a socioeconomic perspective, the Palestinian economy suffers high unemployment rates, poverty, and low wages, which all trigger the development of NCDs.*12 At the public health level, the shortage of specialized health professionals and essential medications contributes to the increased prevalence of NCDs; especially in marginalized areas which are most affected by NCDs.*13
NCDs can be looked at from two different angles: the surrounding environment and individual behavior.*14
In Palestine, data indicates that the prevalence of obesity among women was reported to be 46.5 percent in the Gaza Strip and 41.7 percent in the West Bank in 2013;*15 and 22.5 percent and 15.4 percent of adults (≥18 years old) and youth (15–29 years old), respectively, were current tobacco smokers in 2010.*16 However, the victim is not to be blamed solely; Palestinians may smoke to cope with stress or to socialize with others. They may also adhere to a sedentary lifestyle due to gendered norms, cultural habits, limited sport activities, and restrictions on movement.*17 The individual behavior of someone who smokes, does not exercise, eats junk food, and consumes much sugar and salt cannot be easily changed without an enabling environment that stimulates behavioral change or a law that enforces the restructuring of the surrounding environment (e.g., a ban on smoking in public places).
NCDs can be prevented and managed through promoting healthy lifestyles, including a healthy diet, physical activity, tobacco and alcohol cessation, and stress management.*18 However, health promotion should not be limited to mass-media awareness campaigns and should include advocacy, community engagement, policy change, and law enforcement. While we do have a law that bans smoking in public places, it is alas not active or enforced. There are no restrictions on the number of fast-food shops, no legal consequences for the destruction of farmlands, no attention given to physical education at schools and universities, and no active policy to build more public parks for family and sport activities in Palestine.
The medical model, on the contrary, which focuses on early detection and provision of medications and treatment, has drastically failed to control and prevent NCDs.*19 They say “an ounce of prevention is worth a pound of cure,” so without lifestyle intervention and easy access to health care services, the medical model will only have minimal impact.*20 Part of the responsibility here lies on health care providers, who should advise their patients on how to prevent and limit the escalation of their diseases through behavioral change, and not only prescribe a medicine to eliminate symptoms.
Understanding risk factors such as smoking and obesity is also not enough as long as the population lacks behavioral change opportunities. Public health interventions must be implemented collaboratively at a multi-sectoral level to address the social determinants of health and inequalities within the framework of human rights and social justice.*21 We will look at the bigger picture in order to be able to build better daily living conditions and an equal distribution of resources in Palestine. Only when we create the right environment can we focus on awareness and social marketing.
The Palestinian National Institute of Public Health, a WHO-led project founded to become an independent governmental organization, is following a STEPwise approach in conducting a noncommunicable disease risk-factor surveillance survey. This survey aims to fulfill the need for comprehensive, updated, and representative baseline data on the prevalence of NCD risk factors. Results of the survey will inform health promotion and disease-prevention policies in order to aid in the development of appropriate interventions and proper resource allocation.
The alarming rise in noncommunicable diseases, also labeled lifestyle diseases, can be observed worldwide and is the number one cause of death in Palestine. The good news is that these diseases can be avoided, and in many cases even reversed, through proper education programs and the creation of an environment that is conducive to a healthy lifestyle that incorporates exercise, the avoidance of smoking, and the consumption of healthy foods.
By modifying the national risk-factor profile, Finland has succeeded in reducing cardiovascular disease mortality through a salt-reduction program. Policy makers introduced the high-salt product labeling in 1975, as well as the “healthy choice” label for products with lower salt content and improved fat composition. In Colombia, TV commercials, video games, and songs were successfully used to influence the dietary patterns of preschool children. In South Korea, obesity decreased by 40 percent after schools were targeted to promote nutritional guidelines based on the traditional Korean diet, which is found to be balanced and healthy, over a Western fast-food diet.*22 Similar efforts need to be made in Palestine, especially since our Middle Eastern cuisine offers a variety of healthy options.
*1 Marwan Mosleh, Yousef Aljeesh, and Koutov Dalal, “Burden of chronic diseases in the Palestinian healthcare sector using disability-adjusted life years (DALY), Palestine,” Diversity and Equality in Health and Care, 13(3), 2016.
*2 Dan J. Stein et al., “Integrating mental health with other non-communicable diseases,” British Medical Journal, 2019, available at https://www.bmj.com/content/364/bmj.l29.
*3 Mosleh, Aljeesh, and Koutov.
*4 Palestinian Health Information Center, Health: Annual Report 2017, available at https://www.site.moh.ps/Content/Books/ZxRcynmiUofNqt66u4CrHRgmJR6Uv7z77srjjIEAho6xnz5V3rgLTu_RhO7xf2j2VusNiIvWkjwp84yXHLdGleB97gKrHHI5iZ9oPJ25owGEN.pdf.
*6 Jane Collier and Hanna Kienzler, “Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine – a health professional perspective,” Conflict and Health, 12(1), 2018.
*7 Katharine Pulvermacher, “The next pandemic? Non-communicable diseases in developing countries 2017,” The Economist, available at http://accessaccelerated.economist.com/reports/thenextpandemic/.
*8 Collier and Kienzler.
*11 The Offie of the European Union Representative, “The European Union provides €2.37 million to support Palestinian farmers,” January 31, 2019.
*12 Collier and Kienzler.
*15 World Health Organization, World Health Day 2016: Beat diabetes in Palestine, 2016.
*16 Palestinian Central Bureau of Statistics, Final Report of the Palestinian Family Survey 2010, 2013.
*17 Collier and Kienzler.
*18 Sunil Kumar Raina, From NHM to NPCDCS: Epidemiological Transition and Need for a National Program for Diabetes in India. J Metabolic Synd, 2016. 5(204): p. 2167-0943.1000204.
*19 Dyson, P.A., et al., Successful up-scaled population interventions to reduce risk factors for non-communicable disease in adults: results from the International Community Interventions for Health (CIH) Project in China, India and Mexico. PloS one, 2015. 10(4): p. e0120941.
*20 Bozeman Wellness Center, An ounce of prevention is worth a pound of cure, 2013.
*21 Collier and Kienzler.
*22 Klaus Kraemer et al., “Diet and Non-Communicable Diseases: An urgent need for new paradigms,” in Good Nutrition: Perspectives for the 21st Century, Karger Publishers, 2016.