INTRODUCTION

In its first Global Status Report on Non-Communicable Diseases 2010, World Health Organization (WHO, 2011) addressed non-communicable diseases (NCDs) as the leading global causes of death and the major health problem worldwide for the time being. Cardiovascular diseases, cancer, respiratory diseases and diabetes are the most frequent illnesses and causes of premature death. There is much progress in treatment of NCDs caused dysfunction and distress, but little in healing. Once an NCDs diagnosed most patients need medication for the rest of their lives. Some patients respond well to therapeutic measures, suffer less and enjoy almost normal life expectancy, many do not. By now NCDs treatment causes 70-80% of healthcare expenses in industrialised countries. High NCDs total costs threaten equal access to advanced healthcare. Cumulated economic losses caused by NCDs in 2011-2015 were projected at 7 trillion USD for middle and low income countries if health policies would not change. High impact interventions for reducing the NCDs burden would have required 11.2 billion (WHO, 2016). A huge prevention potential is poorly used. NCDs urge healthcare to reconsider its disease driven approach. Cuban family medicine is an efficient and well-tried model of health driven medicine. The current paper presents a tool for increasing the effectiveness of this model in reducing NCDs risk.

When the Global Status Report was issued in 2010, NCDs caused two-thirds of deaths worldwide, 80% of them in low- and middle-income countries. Two years later, in 2012, 68% of all deaths worldwide were due to NCDs, 40% of them prematurely.2 In 2015 NCDs caused 70% of all deaths, 48% prematurely (WHO, 2014). WHO’s Global Action Plan for the Prevention and Control of NCDs 2013- 2020 aims at lowering the overall the mortality from NCDs by 25% until 2025 (Riley & Cowan, 2015). To this end it calls for at least 10% relative reduction of harmful alcohol intake, 30% relative reduction of tobacco use, stop of rising obesity incidence, 10% relative reduction of insufficient physical activity, 30% relative reduction of salt/sodium intake, 25% relative reduction of elevated blood pressure, stop of rising diabetes incidence, at least 50% of eligible individuals under drug therapy and counselling including blood sugar control to prevent heart attacks and strokes, 80% availability of basic technologies and essential medicines for NCDs treatment. WHO member states were invited to come up with corresponding national action plans. In 2015 WHO published a first NCDs progress monitor (Fernández Oliva et al., 2014), actualized in 2017 and 1918. The latter informs about NCDs related activities of each WHO member state including health targets and statistics, regular health examinations, multi-sector health strategy, measures to reducing of tobacco and harmful alcohol use, healthy diet, physical activity, attention for NCDs in primary care, drug therapy.

At the present, NCDs prevention efforts focus on smoking, reduced physical activity, harmful use of alcohol and unhealthy diet. The four prominent risk factors definitely need to be controlled population-wide. However, they are not the primary causes of NCDs, but follow from underlying biological and mental traits, lifestyle, and social conditions such as education, food supply and preference, housing, employment, transport, social coherence of the population, natural environment etc. Sustainable prevention has to tackle ‘the causes of the causes’. Healthcare, social policy, economy, education, mass media, and the people themselves contribute to a multi-sector prevention approach to reducing NCDs risk. In industrialised countries NCDs health promotion is becoming popular and effective to some extent in the better-off strata. Most people in middle- and low-income countries and less well-off people in affluent societies go on facing a high and rising NCDs burden. There is need for more effective NCDs prevention. As NCDs risk depends on widely differing individual bio-psycho-behavioural patterns and social conditions, sustainable NCDs prevention requires a personalised approach in addition to algorithmic medical and inter-sector measures. The latter are indispensable but insufficient to exhaust the huge NCDs prevention potential. Medical sciences and healthcare are called upon to come up with a strategy that considers the personal and social diversity of NCDs risk in addition to algorithmic performance.

To assess the feasibility and effectiveness of a personalised NCDs prevention approach ten family doctors of the policlinic Dr. Tomás Romay in the historical centre of Havana had launched the project DISSFA (in Spanish, Determinantes individuales y sociales de salud en la medicina familiar), in 2012. For one year 1,500 widely healthy volunteers participated in the project, 900 continued for a second year, one half each in a study, the other half in a control group. The study group members had four individual NCD risk focussing health consultations per year, the control group none. The consultations followed a communication guide developed at CNIC (National Centre for Scientific Research) and refined during the study jointly with the physicians involved. The guide focuses on major individual health determinants such as constitution, lifestyle and living conditions. It serves as an orientation for face-to-face consultations that explore the specific health conditions of the individual with a particular view on NCDs resistance and risk related constitution and conditions of life. The family doctors had been advised to dive into the particular NCDs related conditions of the individual and come up with a tailored advice for health promotion and risk reduction. The results after one-year study were previously published (Welsh, Davis & Shaw, 1993). The frequency of overweight, smoking, and alcohol misusing individuals had decreased slightly in the study group compared with the control group. Fewer individuals with faintly increased blood pressure were seen in the study group, a few more new cases of diabetes appeared in the control group. All changes were discrete. In the second year group the changes excelled those of the first year. The numbers of overweight, smoking and alcohol misusing individuals significantly decreased in both studies, by 43% and 15% respectively, for smoking by 55% and 13%, for alcohol misuse by 69% and 25%.

Positive, non-significant changes also occur in control group, probably due to intensified population-wide prevention measures. The differences between the study and the control groups show the impact of the additional personalised approach. Average body weight, Body Mass Index (BMI), blood pressure, nutritional preferences and physical activity improved discretely in the study group. The incidence of hypertension, diabetes, muscular-skeletal disorders and dyslipoproteinaemias was slightly lower than in the control group.

As quoted above, the Global Action Plan for the prevention and control of NCDs 2013- 2020 of WHO (Riley & Cowan, 2015) suggests reducing of alcohol misuse by 10%, smoking by 30% and stop rising obesity in twelve years, i.e. until 2025, aiming to reduce the overall mortality of NCDs by 25%. The outcome of the project DISSFA excelled these targets in two years. As the communication guide is considered crucial for the outcome and recommended for wider application, the current paper presents it in more detail than so far published.

Communication Guide for Health Counselling

A digitized database was installed in note-books (others electronic devises or hard support might also be used) which were distributed to each family doctor, and the collected data by each one was then stored in a central computer for statistical evaluation.

Discussion

As the NCDs burden is brought about by only four groups of afflictions - cardiovascular diseases, cancers, respiratory diseases and diabetes, and only four main risks factors are blamed to trigger them - smoking, physical inactivity, harmful drinking and unhealthy diet -, it is consistent to take an algorithmic approach to NCDs prevention and claim: No smoking, more physical activity, less alcohol, healthy diet. That is what healthcare rightly does support by other sectors such as education, media, sports, food industry etc. The algorithmic inter-sector proceeding is definitely essential and does have an effect, but is falls short. NCDs are on the rise despite massive efforts. The NCDs burden is paradoxically even aggravated by strongly curative biased medical progress but low healing rates. Continuously growing curative costs threaten equal access to contemporary care. Equality though is a fundamental commitment of the medical profession and healthcare. Reducing of NCDs morbidity by more effective prevention is the only way out of the dilemma. Healthy lifestyle is becoming popular in some countries, health oriented efforts gain momentum in societal, economic and commercial sectors. Nevertheless, the outcome is still poor due to variegated underlying conditions.

Harmful habits use to follow from multiple complex social, socio-economic and natural environmental conditions the health implications of which depend on the biological and psychological constitution of the individual. The algorithmic approach to changing the four harmful behavioural patterns blamed to cause the four main NCD groups cannot cope with the complexity of the wide variety of underlying causes and their multiple interactions. A more promising prevention strategy has to address the individual traits and conditions in addition to algorithmic measures. Medicine and healthcare are called upon to come up with a strategy that complements the algorithmic approach to NCDs prevention with a personalised one.

The NCDs dilemma urges modern medicine to reconsider the relation of each two aspects of three of its essential competences. (i) Treating patients vs. avoiding disease. More effective health promotion and prevention of disease is needed to slow down curative needs, avoid human suffering and allow for equal access to up-to-date care. (ii) Natural scientific vs. social scientific concepts and methods. More personalised social-medical performance is required on both the individual and communal levels. (iii) Algorithmic vs. casuistic proceeding. The algorithmic approach is indispensable for general measures as well as for orientation in the particular case. More effective prevention though needs casuistic proceeding in addition, i.e. consideration of individual traits, conditions and behaviour, and face-to-face motivation.

The project DISSFA aimed to contribute to strengthening the casuistic approach by testing the feasibility and effectiveness of personalised NCDs risk focussed health counselling. The counselling guide developed for this purpose at CNIC and enhanced jointly with the family physicians involved in the project and presented in some detail in this paper was easy to handle and well accepted by population and physicians. Its use proved effective. The targets of the WHO Global NCDs Action Plan 2013-2020 (Riley & Cowan, 2015) for reducing alcohol misuse and smoking until 2025 were reached in two years. Labour investment though was high. 20-30 min per consultation is much time for a busy policlinic, but definitely needed for effective counselling and welcomed by the people who appreciate thorough health oriented communication with their doctor and respond appropriately depending on the motivation skills of the physician. Once the procedure perfected one consultation per year and citizen is expected to meet the targets for NCDs risk reduction set by the WHO Global Action Plan (Riley & Cowan, 2015). It might be considered to convert the common yearly health check of every Cuban into a communication guide steered health consultation.

Perfection of the procedure refers to the following issues: - Continuous optimisation of the guide should become a common concern of family physicians worldwide. - As health counselling along the guide must not require more than 20-30 min once a year the outcome highly depends on the communication and motivation skills of family physicians. Proper training should be offered. - Media should be invited to popularise health counselling, elucidate the significance and stimulate the receptiveness and cooperativeness of the population. - The guide should be made available as app. - Family physicians involved in an NCDs risk reduction programme might become interconnected via intra-net for exchange of information and suggestions including optimisation of the counselling guide. - Central data collection and accessibility of data should be arranged, possibly by cloud computing, in any case under safeguarding confidentiality of sensitive personal data.

Cuban healthcare is well prepared for coming up with a model for slowing down the NCD pandemic. Prevention of disease is fundamental to its concept. The results are noteworthy: life expectancy 78.45 yrs. (f 80.45, m 76.50), infant mortality 4.1 yrs. per 1000 live births in 2017. Primary care by family physicians and primary care teams has a crucial share in these results. Family physicians work in the midst of the society. They are well familiar with the particular social and natural environment and enjoy the respect and confidence of the people, which is essential for effective comprehensive health counselling for NCD risk reduction (Stephani, opoku & Quentin, 2016). An extensive research project of Cuban family physicians could elaborate a model for the reduction of NCDs risk, NCDs incidence and premature death due to NCDs and monitor the outcome under real life conditions

Acknowledgments

The autors highly acknowledge:

• The excellent work carried out by the FDs of the Policlinic Dr. Tomás Romay involved: Bermúdez-Conrrado S, Bormey- Quiñones MB, Calderón -Izquierdo I, Cordova -Rojas L, González -Caraballo M, Hernández -Pérez E, Padrón- Duquesne J, Pereira- Delisle R, Reyes -Naranjo P, Rizo- Escalona E, Rosas- Perdomo YM, Toirac - Rodríguez M.;

• The statistical evaluation of the data by Fernandez-Travieso JC, Reyes-Naranjo P, Alvarez E., Cruz Y, from the National Centre of Scientific Research (CNIC), Havana;

• The generous sponsoring of equipment by Dr. Gunter Frenzel, Tagesklinik Esplanade, Berlin-Pankow; Prof. Dr. June Crown, London; Dr. Helmut Recknagel, Berlin; Prof. Dr. Ina Veronika Wagner-Ellinghaus and Jürgen Ellinghaus, Potsdam; Gerda Daenecke, KarEn e.V., Berlin; Dr. Günther Jonitz, President of the Physicians' Chamber of Berlin;

• The logistic support by the Office of the City Historian and most valuable conceptual participation of the City Historian of Havana himself, Dr. Drs. h. c. mult. Eusebio Leal Spengler.

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Author notes