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  • Reframing non communicable diseases NCDs to spur


    Reframing non-communicable diseases (NCDs) to “spur a sense of urgency” and “focus attention on effective system-wide interventions” makes sense. With almost three-quarters of NCD deaths now occurring in low-income and middle-income countries (LMICs), the increasing burden of NCDs already has severe economic consequences that impoverish families, jeopardise health systems, and hinder social and economic development. However, development assistance still does not prioritise NCD prevention and control for a number of reasons. Foreign policy is commonly based on national interest and NCDs are not popularly understood to pose tangible threats to donor countries. Donor agencies appear to find investing in infectious disease control easier to justify to tax payers. In times of increasing nationalism, isolationism, and protectionism, focusing a substantial part of development cooperation on NCDs will be even more challenging. NCDs should gain more traction in the development agenda as a fundamental socioeconomic development and justice issue. The rise of NCDs is driven by globalisation, through unfair trade and irresponsible marketing (eg, those targeted at children), and unplanned urbanisation. These increase people\'s exposure to shared risk factors (eg, junk food, tobacco smoke). Other social determinants—poverty in particular—increase people\'s exposure to risk factors, while NCDs may keep people trapped in chronic poverty. NCDs and injuries collectively constitute over a third of the disease burden among the poorest populations. The highly inequitable distribution and impact of NCDs and their risk factors also warrant the attention of development policy.
    In their Comment in , Eugene Richardson and colleagues criticised the tendency of many analyses of the Ebola epidemic (eg, a WHO report) to ignore that it faah inhibitor may be rational for a patient with a fever to avoid an Ebola treatment unit. They use the prisoner\'s dilemma to explain such non-cooperative behaviour. The prisoner\'s dilemma, however, is not the most appropriate faah inhibitor analytical framework for this situation. It involves two parties, each with their own interests, while the patient\'s dilemma might better be understood as a game against nature, ie, without a rational and self-interested opponent. We suggest that the threshold approach introduced by Pauker and Kassirer better explains the described phenomenon. The threshold model prescribes a probability of disease at which treatment becomes a better option than no treatment. The threshold is a function of the relative effects of the possible actions and compares the benefit of treating a true Ebola patient against the harm of treating a non-Ebola patient. In this example, exposure to the virus from contact with other (true) Ebola patients represents the harm condition. Using the mortality numbers provided, the benefit is the mortality reduction for true Ebola patients (70·8%–64·3%=6·5%), while the harm is the mortality increase for patients without Ebola (16·1%–0·2%=15·9%). The treatment threshold is calculated as harm/(harm+benefit). Given these data, the treatment threshold is 71·0% (). If individuals with suspected Ebola assume that their probability of having Ebola is below this threshold—eg, Richardson and colleagues assume a probability of 50%—the rational behaviour from the individual\'s point of view is to not seek treatment. In conclusion, the threshold model might explain patients\' avoidance of Ebola treatment better and more elegantly than the prisoner\'s dilemma does.
    We appreciate Eugene Richardson and colleagues\' framing of the Ebola suspect using the “Ebola suspect\'s dilemma” heuristic. Nevertheless, we disagree with some data used to inform their argument. For instance, the authors (presumably facetiously) mention that “a rational decision might be to deliberately infect yourself with malaria” on the basis of data showing that patients with plasmodium parasitaemia and Ebola virus disease who received anti-malarial treatment had 20% increased survival compared with a group infected with Ebola virus disease only. In an independent cohort of patients with Ebola virus disease, the inverse was found to be true—mortality was significantly higher in patients with malaria and Ebola virus disease co-infection (66%) compared with patients with Ebola virus disease alone (52%). Thus, the apparent survival benefit has not been reproduced and caution should be exercised when suggesting a potential benefit of malaria in patients with Ebola virus disease. Additionally, the 25% chance of nosocomial transmission of Ebola virus disease cited by the authors is a probable overestimate given that only 3·3% of discharged negative patients returned to Ebola Holding Units in Sierra Leone with Ebola virus disease. Finally, we fully agree with the emphasis of this Comment on the importance of administering intravenous fluid as part of the clinical management of Ebola virus disease. To clarify, fluid loss associated with diarrhoea or shock might occasionally need “injection of saline solutions in extraordinary quantities”, as required for some cholera patients. However, as has now been seen in some patients with Ebola virus disease to whom such aggressive fluid resuscitation has been administered, the risk of fluid overload is high, so such risks should be weighed against the potential benefits to appropriately tailor the therapy of a patient with Ebola virus disease.