The questions we should be asking in noncommunicable disease research
By Jame Hansen, Communications Manager
Dr. Christine Ngaruiya is committed to fostering research that supports better health outcomes for underserved and minority populations in the United States and in low-and-middle-income countries – particularly in relation to the global crisis of noncommunicable diseases (NCDs).
Over the past decade, she’s partnered with local institutions to raise awareness of the burden of NCDs in low-resource settings ranging from Nebraska in the United States to Kenya and Pakistan. She was a senior collaborator on the first-ever national study on NCDs in Kenya in a WHO-validated survey, coordinated by the Kenya Ministry of Health and a variety of local NCD stakeholders. She also researches community-based and technological interventions, including the use of mobile technology and artificial intelligence in low-resource settings. A graduate of WomenLift Health’s leadership program, she advocates for addressing gender gaps in global NCD outcomes by building a gendered NCD agenda.
Now, Ngaruiya has joined Stanford to fill a new role as Population and Global Health Research Director within the Department of Emergency Medicine. In this position, she will provide guidance, insight, resources, and leadership related to public and global health research for faculty, residents, and students within the department.
“I’m really excited to start the role and be able to contribute and help others grow in these areas,” Ngaruiya said.
Ngaruiya spoke with us about her work and insights related to addressing global disparities in NCD outcomes. She also discussed new frontiers she’s beginning to explore – including the impact of climate change on NCDs in Kenya, and the role of artificial intelligence in disease prevention and intervention.
How did you become interested in NCDs and the critical role they play in global health outcomes?
Dr. Sunny Kishore and many others have called NCDs the social justice issue of our time. Those words give homage to my origin story working in noncommunicable diseases.
As an undergraduate sociology major in the US, I was struck by the systematic differences in health and health outcomes across diseases – particularly with noncommunicable diseases that at first glance seem easily preventable with well established, fairly accessible measures such as education and regular screenings. Despite this, we continue to see systematic differences in outcomes for underserved populations in the US. These disparities are magnified at the global scale in low-resource settings and low-and-middle-income countries like Kenya, where much of my work has been based.
This work – to understand and address these disparities – is where my heart is. I’m extremely passionate about increasing equity and equitable outcomes around NCDs and their risk factors. So when I joined a global health fellowship at Yale about ten years ago, I did so with the express interest of studying, exploring, and becoming an expert contributor in global NCDs.
You’ve said that your greatest mantra in global health has been “What we think about, we measure.” What key measurements are being missed?
We’ve come a long way from where we were a decade ago, when many countries really didn’t recognize or measure NCDs as a problem – but we still have a long way to go.
For example, we still don’t have appropriate capacity assessments for NCD care in many contexts. Many of the existing tools or standardized assessments for global health capacity include few if any indicators targeting NCDs. We have a forthcoming systematic review that details this problem further, including the fact that context-sensitive tools for the NCD capacity assessment are still needed for low-resource settings . This is just one example of a missed opportunity to understand and respond to this burgeoning problem.
More generally, we know the burden of NCDs is increasing with time, but the level of response is not commensurate with that. We see a disproportionate amount of funding and research given to communicable diseases, which is laudable but a bit short-sighted given that NCDs now cause higher mortality globally. Many of us foresee that the lag in NCD research will shortchange the progress we’ve made with communicable diseases. If you have a patient who survives HIV thanks to access to antiretroviral therapy who later dies prematurely from Chronic Kidney Disease, then we’ve probably failed that patient.
You’ve advocated for greater research and interventions related to women and NCDs. Where are the greatest gaps and how can we fill them?
Gendered differences in global health as well as NCDs continue to be under-addressed. To raise awareness about this problem, last year, I wrote a position piece for FASEB BioAdvances, “When women win, we all win-Call for a gendered global NCD agenda.” This piece argued that a penultimate research focus on mortality in NCDs overshadows many important health outcomes that women uniquely experience, which, in turn, affects how resources, programs, and interventions are implemented.
As a prime example, the sustainable development goals target mortality outcomes for NCDs by 2030, but fail to note gender-specific targets for NCDs and particularly omit a focus on morbidity. In the paper, I give the example of chronic obstructive pulmonary disease. In many low and middle-income countries, women are disproportionately affected through their exposure to indoor household pollution and fossil fuels. While this disease may not always cause mortality (what we target with sustainable development goals), it is impacting morbidity in the population.
This underscores my belief in the importance of what we measure. Obtaining gender-based indicators in any project is ideal (and now mandated by several funders, which shows progress). We need to ensure equitable representation of women in studies as well.
Tell us about your new research at the intersection of climate change and NCDs.
I’ve been really keen on thinking about how to incorporate climate change into the scope of my work in order to be responsive to this growing challenge.
About a year and a half ago, I received a grant to conduct a capacity-building pilot around climate change and NCDs. In partnership with the National Cancer Institute of Kenya, we decided to assess Kenya’s readiness and capacity to address climate change’s effects on cancer.
Based on the literature, we identified cancers that could pose an increased threat because of climate change. These include skin cancer because of changes in UV exposure and liver cancer due to changes in aflatoxin in agricultural soil. We developed a theory of change to understand what devices, tools, and leadership need to be in place in order for Kenya to be ready to meet these changing needs. We’re looking forward to sensitizing key stakeholders in leadership in Kenya on this topic and plan to conduct surveys later this year to better understand readiness.
Tell us about your recent research investigating the role of artificial intelligence to target NCDs in low-resource settings.
It’s a natural progression in any research scientist’s work to be thinking about AI now in a responsive, proactive way. The technology is here, so we should be leveraging it, and thinking about readiness for its use – especially in low-resource settings.
I led a project funded by the Yale Institute for Global Health using natural language processing (NLP) – a tool within AI that can be leveraged to extract data from large datasets. We looked at 5,000 charts of patients with cardiovascular disease in Pakistan to assess gender differences in cardiovascular disease symptoms and management. Our group found differences in the symptoms that women presented with. We also found women were less likely to be prescribed the four most common discharge medications than men. It’s a fascinating study. We have a pre-print on our outcomes and are pending final review for publication at this time. We hope to disseminate this NLP model as well so that it can be adopted for use in different contexts to understand NCD symptoms and management.
A second, Gates Foundation funded pilot project which I am co-PI on is now underway to assess the feasibility of using large language models like Chat GPT to educate the youth about NCD risk factors such as smoking and drinking alcohol. We hope to understand the youth communities’ readiness to use this technology to receive health information – along with how the use might impact their knowledge, attitudes, and practices around risk factors such as alcohol, tobacco use, and exercise.