The NCD-CD divide: to improve global health, they should not be considered a zero-sum game.

By Ashok Malik

It is tempting to see the non-communicable diseases/communicable diseases equation as a zero-sum game. The conventional wisdom is that as NCDs become the epidemic of the middle classes in the developing world – in the emerging economies of Asia for instance – attention and money devoted to CDs will decline. There are alarmists who believe NCDs, with a middle-class demographic profile, will crowd out CDs, which have an underprivileged demographic profile.

I recently participated in a conference on tuberculosis (TB) in Bangalore, India and realized how specious such reasoning is. NCDs and CDs don’t exist in watertight compartments, permanently sequestered from each other. The interaction and the osmosis are far greater than we imagine.

India is the world leader in TB, a communicable disease, with two million new cases diagnosed every year. Most of these cases are pulmonary (lung-related) TB and are prevalent in lower-income populations, In recent years TB has also emerged as the number one opportunistic infection for those living with HIV/AIDS.

Now, a new form of TB is emerging: urban, upper-middle class TB, related to lifestyle changes. Although most TB cases in India are pulmonary, non-pulmonary TB numbers are growing rapidly. Doctors and others at the conference were saying “most of the middle-class TB patients we encounter seem to have non-pulmonary TB.”

Non-pulmonary TB can infect one’s stomach or genitourinary tract. A few years ago, India’s leading female movie star was rumoured to have been suffering from stomach TB, a condition she apparently discovered – as have others – only when she went to a doctor and complained she was unable to conceive.

Non-pulmonary TB tends to strike those whose immunity has been weakened by one of a series of lifestyle or NCD issues – diabetes, alcohol and tobacco use, liver disorders, hypertension and so on. Detection is difficult as it could often be confused with, say, a bad and persistent viral infection.

Taking part in a media and civil society panel discussion towards the end of the conference, I was asked what it would take for TB to get more media coverage and acquire a higher profile among journalists. My conclusion: TB, at least non-pulmonary TB, is going to piggyback on the NCD epidemic and get enormous attention in the next 10 years or so.

Increasingly, TB meetings will need to include discussions on NCDs and associated preventable lifestyle issues. Similarly, any discussion on NCDs in India needs to address TB – at least non-pulmonary TB – as a possible complication arising out of the lifestyle risk factors that cause NCDs.

For better or worse, the NCD-CD divide is being obliterated. 


Ashok Malik is a journalist writing primarily on public policy.  Ashok is based in Delhi India and his columns and articles have appeared in several newspapers over the last 20 years.