What’s Wrong with African Health Ministries? The Killers We ignore 22 asia’s struggle with chronic disease 06 12
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Issue 04
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issue 04
contents —
In this issue:
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15 Think HIV/AIDS is Africa’s Greatest tHreat? Think Again
19 North American Diseases Go South of the Border
COVER STORY: Chronic disease
6 What’s Wrong with African Health Ministries? 0 08 Kiev Photo Diary: Tb, HIV and Junkies 10 silent Burden of Cancer 12 Killers We Ignore
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22 Asia’s Struggle with chronic Disease
stories online: C Carter Pushes for Malaria Elimination
in hispaniola C Ghosts of War Haunt Middle East C Honduran doctor persecuted for Work C Why Should We Care About COPD?
screenshots —
04 How Safe are Aid Workers? 05 Hospital Beds Per 10,000 People 05 Human Trafficking – the $31.6 B Industry
www.globalhealthmagazine.com
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Issue 04
Global Health
letter
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from the editor
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Executive Editor
Annmarie Christensen Managing Editor
Tina Flores editorial assistant
Geoffrey Calver Web
Winnie Mutch Liza Nanni Graphic Design
Shawn Braley
chronic disease Heart disease, diabetes, depression – diseases of the rich, yes. But of the poor as well? It’s hard to phantom that in developing countries, which lack even the most basic health interventions, people struggle with the same chronic illnesses that plague their peers in wealthier nations. While HIV/AIDS, malaria and tuberculosis have taken center stage, chronic diseases such as mental illness, cardiovascular disease and cancers have been sidelined. Yet according to the World Health Organization, developing countries shoulder more than 60 percent of the global burden of coronary heart disease. As we see in this issue of GLOBAL HEALTH, chronic diseases, much like their communicable counterparts, are overarching conditions that have immense impact on the health of the population. Moreover, developing and transitional economies are less able to address these socalled “diseases of the rich.” In countries taxed by HIV, infectious diseases, malnutrition and diarrhea, screening for depression, cancer and heart disease might not be priorities. But as the articles in this issue show, it is just as important to address noncommunicable diseases if we are to improve the lives of people around the world. The good news is that we know what to do – eat a healthier diet, increase physical activity, stop smoking. But there are even harder fixes: systems need to be put in place so that there is a greater emphasis on prevention, early screening, and treatment. This cannot happen, of course, without greater investment in strengthening health systems within countries. We need to build capacity in-country to ensure the long-term sustainability of all health interventions. We hope you enter into the dialogue by continuing this conversation at www.globalhealthmagazine.com
The Editors
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E-mail:
magazine@globalhealth.org Global Health Council Board of Directors
Susan Dentzer, chair, William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Haile T. Debas, MD Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Joel Lamstein, SM Joy Phumaphi Reeta Roy Jeffrey L. Sturchio, PhD, President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at www.globalhealth.org
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issue 04
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C
online exclusives
go to www.globalhealthmagazine.com for further reading
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C Hot Escapes
C The Blog
Snap Happy Photoshare Manager David Alexander shares his secrets to taking great photos in the field every time.
Doctor to Honduras’ Ethnic Minorities Persecuted for Work MEDICC’s Diane Appelbaum on the plight of a fugitive doctor who provides health services to indigenous Hondurans. © Peter DiCampo/The Carter Center
Carter Pushes for Malaria Elimination, Bi-National Cooperation Former President and Mrs. Carter visit a bi-national program to eliminate malaria in the Dominican Republic and Haiti. Senior Editor Tina Flores blogs on their visit to Hispaniola and the pilot project supported by the Carter Center.
Photos courtesty of MEDICC
C Field Notes
Ghosts of War Haunt Middle East The International Medical Corps addresses mental health issues in the Middle East.
Why Should We Care About COPD? Dr. Suzanne S. Hurd blogs on the global impact of chronic obstructive lung disease.
© Felix Masi
C Dim Sum
A collection of book reviews, music picks, and other cultural forays.
C Going Viral
What’s the buzz on Twitter, YouTube, Facebook, LinkedIn and other places online.
International Medical Corps/Margaret Aguirre www.globalhealthmagazine.com
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Global health statistics
screenshots —
how safe are aid workers? Ambush/attack on the road
30%
Raid/armed incursion
9%
25%
Other methods
11%
6%
Kidnapping
IEDs and bombs
19%
Individual attack/assassination with small arms
60% of violent incidents were in Darfur, Afghanistan and Somalia
Killed Injured Kidnapped Total Aid Worker Victims
2003 87 49 7
2004 56 46 23
2005 54 95 23
2006 86 87 66
2007 79 84 43
2008 122 76 62
143
125
172
239
206
260
Source: Humanitarian Policy Group, 2009 ISSUE 04 fall 2009
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Click on the source at C www.globalhealthmagazine.com.
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The Number of Hospital Beds for Every 10,000 people 25
140
Global
61
Japan
13
13
132
97
39
Mongolia Cuba United Kingdom
22
10
China
Barbados
31
24
24
United States of America
Botswana
Brazil
8
Nicaragua
66
Russian Republic of Korea Federation
Democratic People’s Republic of Korea
49
87
Democratic Republic of Congo
7 India
2 Ethiopia
1 Senegal
Where does your country fall? Click on the source at C www.globalhealthmagazine.com. Source: WHO World Health Statistics 2009
human trafficking “Trafficking in persons” shall mean the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.
– Protocol to Prevent, Suppress and Punish Trafficking In Persons, Especially Women and Children, Supplementing the United Nations Convention Against Transnational Organized Crime
Regional Distribution of Victims and Profits from Trafficked Labor
Victims
Profits from
Asia and Pacific
1, 360,000
$9.7 billion
Industrialized Countries
270,000
$15.5 billion
Latin America and Caribbean
250,000
$1.3 billion
Middle East and North Africa
230,000
$1.5 billion
Transition countries
200,000
$3.4 billion
Sub-Saharan Africa
130,000
$159 million
Global
2,450,000
$31.6 billion
56 %
are women and girls
43 %
for forced commercial sexual exploitation
32 %
for forced economic exploitation
Source: International Labour Office (ILO)
Editors’ note: Because of the covert nature of human trafficking and forced labor, it is nearly impossible to quantify the gravity of these crimes. However, a number of sources, including the ILO, the UNDOC and the U.S. State Department provide information on human trafficking and forced labor around the world. Click on the source at C www.globalhealthmagazine.com.
www.globalhealthmagazine.com
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By john donnelly
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Probing the Cause of Weak Health Ministries
FREETOWN, Sierra Leone – Inside the fifth-floor conference room at the Ministry of Health and Sanitation, Minister Sheiku T. Koroma faced a team of visiting financial auditors, and laid open his troubles.
“We have a budget of nearly $11 million, and here we are in the seventh, eighth month of the year, and we’ve spent just $3 million,’’ he told them. “Something is wrong. There is money. But how do we spend it? We don’t know. The system is broken and we want you to help us.’’ If the auditors were startled, they didn’t show it. They simply nodded and scribbled notes. They were at the meeting as part of a project by the Ministerial Leadership Initiative for Global Health (MLI), a four-year initiative funded by the Bill & Melinda Gates Foundation and the David and Lucile Packard Foundation to help strengthen the capacities of five health ministries in the developing world. The auditors’ very presence was noteworthy. While some people in global health speak of neglected tropical diseases, a recent Rockefeller Foundation report found that health ministries themselves have been long neglected, calling them one of the most forgotten parts of government in poor countries. The report detailed a history of how donors place heavy demands and expectations on the people who run their country’s health system, but rarely help them succeed in meeting those tasks. But signs of change are beginning to emerge – inspired from a gradual understanding that the crush of new global health initiatives will not work to potential unless health officials strengthen their systems, allowing them to absorb new funding and new programs.
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Now, a few relatively small pioneering efforts have begun to start supporting leaders in the ministries. They include MLI’s $11.2 million initiative in five countries and Synergos Institute’s Gates-funded work in Namibia, along with new funding made available for health system strengthening by the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the GAVI Alliance; that system-strengthening money could potentially be put toward bolstering the capacity inside ministries. The dollars overall are not huge yet, but no longer are almost all the funds going toward programs, drug purchases, or vaccine campaigns or research. “One reason for the low funding has been that the big international donors and most countries see the health ministry as part of a consuming sector as opposed to a growth sector that could contribute to economic development,’’ said Jo Ivey Boufford, president of the New York Academy of Medicine who helped lead the Rockefeller study. “Another reason is that the structural adjustment patterns in the 1980s and 1990s focused on shrinking the public budget. The first thing that governments did was cut administrative expenses, and ministries of health absorbed many cuts in staff. The ministries have not been a strong political force in these countries.’’ Boufford and Dr. Francis Omaswa, who also helped direct the Rockefeller report, both said that ministries deserved much more direct assistance, ranging from helping them sort out their financial systems to day-today peer management training to building a work plan on reproductive health issues. “They all know what their problems are,’’ Boufford said of the leaders in health ministries. “But they generally do not have many people who can do needs assessments and policy analysis. In many of the poor countries,
John Donnelly is a freelance writer based in Washington, D.C. Part of his reporting for this story was done on a trip to Senegal and Sierra Leone supported by the Ministerial Leadership Initiative for Global Health. He can be reached at donnellyglobe@gmail.com
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supporting institutions such as universities and thinktanks ought to be available to the ministries, but they, too, lack capacity to help.’’ Omaswa, who was director general of Uganda’s Ministry of Health from 1999 to 2005, said that international donors could help the long-range performance of their programs if they helped build a better-functioning ministry. Instead, he said, most donors focused on the short-term results from their own programs. He cited one prominent example – the U.S. global AIDS program known as PEPFAR. “PEPFAR helped save many, many lives,’’ he said. “It also put U.S. ambassadors in charge of the program in their country. Now the U.S. government is saying the countries have to take it over, even though PEPFAR hasn’t allowed the countries to have ownership of the programs until now. In an environment like this, which has undermined the ministries in the past, outsiders should think about ways of supporting the countries and each of its institutions – ministries, think-tanks, universities – so that they will be able to use aid as well as possible.’’ MLI, a program of Realizing Rights that is housed in the Aspen Institute, is working with ministries in Sierra Leone, Senegal, Mali, Ethiopia and Nepal. Each of the five countries has helped design the type of assistance it most desperately needs. MLI hasn’t focused solely on ministers – three of the five countries had a turnover in the position in 2009 – but rather has sought to help the entire senior leadership in the ministries. MLI’s assistance has been in three policy areas: equitable health financing and resource allocation formulas to make sure money was going to reach the poorest; coordination of donor activities and projects; and working on reproduction health policy toward improving access to quality services, especially for the most vulnerable. Rosann Wisman, MLI director, said the feedback has been positive so far. “Health systems are important to strengthen, but you’ve got to have leaders to make the systems work,’’ she said. “The approach that is emerging for us is placing more importance on collaborative learning, peer learning, and developing trusted relationships with a range of partners, including donors, NGOs and people inside other ministries.’’ In Nepal, Dr. Baburam Marasini, chief of the Health Sector Reform Unit at the Ministry of Health and Population, said MLI helped the ministry start to build a better relationship with donors. He said one of the most difficult issues for the ministry is not knowing exactly what the various non-governmental organizations are working on. He estimated that 25 percent of the money spent on health programs in Nepal – more than $50 million – came from NGO-funded programs.
Minister Sheiku Koroma of Sierra Leone
Photo by Dominic Chavez
“So much of what is happening in Nepal’s health sector is done by donors but not coordinated by us,’’ Marasini said. “Our government has to build up their capacity so that we can understand and track these programs much better.’’ John Heller, senior director of partnerships at Synergos, said that his team’s approach in Namibia has been to listen to people in the ministry tell Synergos what they need – and then to act on it. “One of the underlying lessons for us is there’s leadership and capacity within the system, but that it is latent and hasn’t been pulled out yet,’’ he said. “We help bring people together in the right kind of way to help unblock things. We assume they know what they are doing. But we also know they need coaching, guiding, helping and supporting ways to help remove the blockages.’’ Despite these new initiatives, Boufford remains concerned that donors and governments will not continue to support the ministries of health. “The management capacities of these groups have not been valued,’’ she said. “There has been so much more priority put on drugs, vaccines and now workforce. But the systems and infrastructure has to be managed properly.’’ In Sierra Leone, Minister Koroma is grateful for the help – as are people in charge of his numerous departments, from environmental health to reproductive health. “We need to bring many things under control – financially and with our programs,’’ Minister Koroma said in an interview after the auditors left to begin their investigation. “We have the people in the ministry who can make things work. We need outside help to guide us, to help us do our jobs better. We have a big problem in Sierra Leone – rebuilding a health system from 11 years of civil war. But we can do it.’’ GH —
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photos and story by michael wang —
Kiev Diary: TB, HIV and Junkies
Counter clockwise from top: TB hospital. Health worker training. Intravenous drug user, living in a housing project in Kiev. Opposite page, clockwise from top: IDUs at a Kiev housing project. Woman at a health clinic. TB hospital.
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“I have been graced. In my 20-year career as a photographer, the most satisfying work has come now with PATH. I believe in their mission to improve the health of people around the world. And when I document their projects, I am a step toward a solution I could never accomplish alone.”
As I travel the world, it is my hope to do justice to the men, women and children I photograph. No matter how far from home I am, even in the harshest conditions in Latin America or Africa, I always feel a bond with the people I photograph – as if they were my own family. I’ve been able to see strangers with the eyes I use for relatives. But that wasn’t the case in Ukraine, at least not at first.
clean needles to injection drug users in Kiev. He's one of three men living in the projects. These men are rough, urban and anything but inspiring at first glance. But as I speak to them (or communicate as best I can with the little Ukrainian I know) my guard begins to drop.
These facts can be easily understood by a layman like me, but what do they mean? I was out of my depth. Here’s a story unlike any other I’ve photographed … A story not about the struggle of a family to find health care, or of a woman finding the strength in herself to fight against adversity, or of a poor baby struggling to stay alive for lack of a simple vaccine or clean water. I was to take photographs of injection-drug users.
These junkies came to me with open eyes and open faces. In one of the moments of documenting them, I shot a picture that reversed my stereotype of them. This photo (man, bottom right, opposite page) is here for you to see, for you to decide what constitutes a sympathetic person. Totally vulnerable to my lens, cascading a light that’s Rembrandt in its mirroring… at the decisive moment of the shutter’s click I know that as much as a baby in need of vaccine, this man is in need. This man, with his faults and his self-inflicted harm, is in need of help and he deserves aid as much as the strong woman who walked 5 miles across the Andes in Bolivia to get to a health clinic. He has as much right to health care as the mother of five in Kenya. That’s the realization I have when I click the shutter. I had to see him clearly as a human in need before I could show him to you that way.
Their story is hard to tell through images. There are no sympathetic faces of strong mothers and vulnerable, beautiful children. Instead there’s a junkie. A man, maybe in his late 20s – but I can’t tell because of the ravages of his drug use. I find him with the help of a Ukrainian NGO called Club N.A., who gives support, counseling and
The marginalized sufferers are easy to ignore and dismiss, whether it’s because we are casting moral judgments on their actions or because it’s just too hard for us to summon empathy. But they are the ground zero, they are the nexus of many epidemics and they need and deserve the kindest eye. GH
I was there to turn my camera to PATH's work on HIV and tuberculosis prevention and education. Ukraine has one of the fastest-growing AIDS epidemics in the world. More than half the HIV infections are caused by IV drug use. When HIV infection weakens the immune system, TB infection can activate and become TB disease. Without treatment these two infections are fatal.
Michael Wang is a photographer for PATH.
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by john r. seffrin, phD, et al
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Silent but Intense, Cancer Threatens This article is an abbreviated version of an editorial entitled “It Is Time to Include Cancer and Other Noncommunicable Diseases in the Millennium Development Goals” that appeared in the September/ October 2009 issue of CA: A Cancer Journal for Clinicians. The material has been excerpted and reprinted with permission from John Wiley & Sons and the American Cancer Society. For free access to the original and complete text of the editorial please go to cajournal.org.
The worthy efforts in recent years to increase attention on HIV/AIDS, tuberculosis, malaria and other communicable diseases have helped the world respond more effectively to the threat these diseases pose in low- and middle-income countries. But at the same time in these countries, a silent pandemic of cancer and other noncommunicable diseases (NCDs) has been spreading and now threatens to overwhelm health systems and undermine social structures. NCDs, which include cancer, cardiovascular disease, diabetes and chronic obstructive lung disease, claim more than 35 million lives each year, accounting for 60 percent of all deaths worldwide. According to the World Health Organization, mortality rates are higher for noncommunicable diseases than for communicable disease among men and women age 15 to 59 in all regions of the world save Africa. Now, more than ever, the world must take steps to balance the global response to both communicable and noncommunicable diseases, especially in low- and middle-income countries where the burden of NCDs is already great and the level of unnecessary suffering profound.
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Frightening Threshold In 2008, cancer accounted for 7.6 million deaths globally, more than AIDS, malaria and tuberculosis combined. We have reached the point where cancer is set to become the leading cause of death in the world, followed by heart disease and then stroke. This threshold has been approaching for years, yet has largely gone unnoticed. Cancer and other NCDs are rarely addressed in major policy forums, such as meetings of the G8 and G7, and have only recently been incorporated into discussions at the World Economic Forum. Perhaps most strikingly, NCDs are not specifically referenced in the United Nation’s landmark Millennium Development Goals (MDGs), which are designed to reduce “income poverty, hunger, disease, lack of adequate shelter and exclusion.” Expanding the Millennium Development Goals to specifically address cancer and other noncommunicable diseases and setting firm targets (or indicators) for controlling these diseases are important steps toward more fully addressing the world’s leading causes of death and disability. All Income Groups, Ages Touched The impact of NCDs can be felt throughout the world and cuts across all income groups and ages. In absolute numbers, the vast majority of NCD deaths – more than 80 percent – occur in low- and middle-income countries, where population sizes are high, access to high quality health care is often limited, and health promotion programs are rare. Cancer alone claims more than 5.3 million deaths annually in low- and middleincome counties – more than 70 percent of all cancer
In 2008, cancer accounted for 7.6 million deaths globally, more than AIDS, malaria and tuberculosis combined.
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Projected Global Deaths, 2002-2030 (in millions) 12
Cancer
10
ischaemic heart disease stroke
8
hiv/aids
6 4
tuberculosis
other infectious diseases
malaria
2
road traffic accidents
0 2000
2010
2020
2030 Source: WHO, World Health Statistics 2007
most common cancer among women worldwide, is caused by human papillomavirus. Despite the fact that most cases of cervical cancer could be prevented or effectively treated, approximately 273,000 women die from the disease each year. The vast majority of these deaths – more than 80 percent – are among women in low- and middle-income countries. Most women in these nations do not have access to care that can prevent the onset of this disease or detect it early. Overall, infection-related cancers account for approximately 26 percent of all cancer cases in lowand middle-income countries compared to 8 percent in economically developed countries. These and other disparities must be addressed.
Photo by Fundación CIM*AB
deaths worldwide. According to the World Health Organization, adults are especially vulnerable to NCDs. “People in these countries tend to develop disease at younger ages, suffer longer – often with preventable complications – and die sooner than those in highincome countries.” Link to Infectious Diseases Although NCDs are often associated with unhealthy lifestyle behaviors, such as tobacco use and poor diet, a significant number of NCDs are closely connected to infectious agents. Cervical cancer, which is the second
Balancing Priorities Efforts to control noncommunicable diseases should not come at the expense of other global health initiatives. Too often calls for disease-specific interventions force decision makers into a zero-sum approach to resource allocation. In reality, a higher overall level of funding – even in hard economic times – is needed to effectively address major disease issues globally. We must identify new resources for combating NCDs and, over time, build a more balanced public health portfolio that includes health promotion and policy reform along with prevention and treatment. The cost to address noncommunicable diseases will not be insignificant, but it pales in comparison to the very real costs – economic and human – of doing nothing. GH —
Authors: John R. Seffrin, PhD, Chief Executive Officer, American Cancer Society, Atlanta, GA; David Hill, PhD, President, International Union Against Cancer (UICC), Geneva, Switzerland; Werner Burkart, PhD, Deputy Director General, International Atomic Energy Authority, Vienna, Austria; Ian Magrath, MB, BS, FRCP, FRCPath, President, International Network for Cancer Treatment and Research (INCTR), Brussels, Belgium; Rajendra A Badwe, MD, MBBS, Director, Tata Memorial Centre, Mumbai, India; Twalib Ngoma, MD, President, African Organisation for Research and Training in Cancer (AORTIC), Ocean Road Cancer Institute, Dar-Es-Salaam, Tanzania; Alejandro Mohar, MD, Director General, Mexican National Cancer Institute, Mexico City, Mexico; Nathan Grey, MPH, National Vice President, International Affairs, American Cancer Society, Atlanta, GA. www.globalhealthmagazine.com
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By Nellie bristol
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The Killers We Ignore Americans and other rich country denizens have been hearing the message for years: snub out the smokes, cut out the chips, crawl off the couch, and move your body. But in many low- and middle-income countries, daily lives were consumed with ensuring children lived past the age of five and getting through the days’ back breaking labor to feed the family. Now globalization, urbanization and successes in combating infectious disease are bringing the burden of “lifestyle” diseases to health systems that are still struggling to catch up with rich-country levels of vaccine coverage and sanitary standards. Experts say the trend adds another formidable argument for focusing scant resources less on specific diseases and more toward health system strengthening and public health activities. Chronic diseases, including cardiovascular disease, chronic respiratory disease, diabetes and cancer, now account for about half of all deaths and disability in lowand middle-income countries, a figure that is expected to increase dramatically in the coming decades. The rise is occurring in compressed form, catching health systems and donors unprepared. “It’s quite astonishing how quickly chronic diseases have overtaken infectious diseases in developing countries,” said Rachel Nugent, the Center for Global Development’s deputy director for global health. She cites figures from Bangladesh that show an 86 percent reduction in age-standardized mortality for diarrhea and dysentery, and 79 percent for respiratory infections (excluding TB). The same time period (1986-2006) shows a 3,500 percent increase in deaths from cardiovascular and cerebrovascular disease, and a 495 percent increase from cancer. Several factors contribute to the rapid rise: successful efforts against infectious diseases, which both decreased the total disease burden and allowed more people to age to the point where chronic disease could become an issue. Also fueling the surge is the ISSUE 04 fall 2009
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spread of smoking, which the UN Food and Agriculture Organization says is growing at a rate of 1.5 percent a year, almost exclusively in developing countries. Add to that urbanization, resulting in changes in exercise habits, providing greater access to a less healthy diet, and increasing exposure to toxic agents like air pollution and industrial waste. The change in conditions can affect a family in as little as a generation and has been shown to have even more harmful biological effects as a result. Research indicates that fetuses and infants whose mothers are malnourished develop bodies that have adjusted to the nutritional shortfall. The adaptation has been shown to make those children of shorter stature even more susceptible to obesity and its associated metabolic effects if overnutrition becomes an issue later in life.1 “Their lifestyles have changed dramatically in a pretty short time,” Nugent points out. Further, chronic diseases are disabling and killing those in the developing world at a younger age since cholesterol reducing pills and screening for pre-diabetes are rarely available. The World Bank reports that more than three-quarters of chronic disease disability in lowand middle-income countries affects those between the ages of 15 and 69, prime age for economic productivity. Keith Norris, interim president of Charles Drew University of Medicine and Science and an ambassador in Research!America’s Paul G. Rogers Society for Global Health Research, points out another factor that exacerbates conditions in the developing world. Globalization not only introduces Western World sedentary, fast food lifestyles to developing countries, but also results in the dumping of toxic technology trash in some areas. The lack of environmental pollution controls and some countries’ acceptance of contaminated waste contribute to “an exposure to environmental toxins that is going to be many fold greater than what people in developed nations may experience,” he said. 1. Gluckman, PD and Hanson, MA, 2008, “Developmental and Epigenetic Pathways to Obesity: an Evolutionary-Development Perspective,” International Journal of Obesity, vol. 32, pgs S62-S71
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Projected Main Causes of Death Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies
30%
injuries
cardiovascular diseases
Total deaths 2005
58
30%
million cancer
9%
13% other chronic diseases
diabetes
chronic respiratory diseases
9% 2% 7%
The combination could prove to be particularly lethal, Norris added. ”We’ll have numerous children who not only will be developing obesity and diabetes at higher rates than previously – they’re also going to be exposed to an additional burden of toxins and substances that are going to further accelerate the vascular complications for them,” he said. WHO, the World Bank and others have expressed concern over this development for several years, but voices calling for greater attention are getting louder. The Institute of Medicine is working on a report with recommendations for combating cardiovascular disease in developing countries. It follows a 2007 report on
Source: Center for Strategic and International Studies, Commission on Smart Global Health Policy.
cancer control in low- and middle-income countries and is expected to be released next year. Chronic disease is likely to be addressed in recommendations released in January 2010 by the Center for Strategic and International Studies’ Commission on Smart Global Health Policy. “We wanted to signal that in many of the countries we’re working in … we often focus on the traditional infectious diseases and maternal and child health and increasingly, chronic diseases are going to be the more important on the landscape for low- and middle-income countries,” said commission co-chair Helene Gayle, president and CEO of CARE. www.globalhealthmagazine.com
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it will be difficult to convince major tobacco producer China to cut back when it counts on the industry for a substantial percentage of its net government income. “We’re going to have to think about ways of making those services available at a reasonable cost because otherwise the cost of these secondary measures is going to overwhelm the health system,” Meiro-Lorenzo said. Retraining of health-care providers, and patients themselves, is also required. In places where many people encounter the health-care system rarely and sometimes never, providers need to ensure patients remain connected for a number of years, and probably for the rest of their lives. “Treatment [for chronic disease] requires a completely different mindset for the person that provides the health care,” Meiro-Lorenzo said.
Greater attention both within countries and from donors is desperately needed. In numbers she is developing for a new paper, CGD’s Nugent estimates chronic disease attracts a mere 0.23 percent of donor funding compared to an Institute for Health Metrics and Evaluation estimate of 23 percent of disease-specific funding for HIV/AIDS. Meanwhile, cardiovascular disease alone kills five times as many people as HIV/AIDS in low- and middle-income countries, according to WHO. Experts agree that the trend calls for concerted public health education efforts in developing countries. Not only is awareness of the negative health effects of their new lives limited, but resources to deal with them are scant. “I think particularly in low-income countries, when resources are low, prevention is absolutely paramount,” said Montserrat Meiro-Lorenzo, senior public health specialist for the World Bank. Relatively inexpensive measures for primary prevention include smoking cessation, increasing taxes on tobacco and alcohol, ensuring vaccination coverage, and improving water and sanitation. Overall health improvements and vaccinations, she said, will reduce exposure to agents linked with cancer, including hepatitis and the human papillomavirus. The increase in chronic diseases also will force new thinking on the provision of screening and prevention methods. Since some of the technology required, such as mammograms, is very expensive, centralization may be required. Dissemination of new, less expensive tests, such as use of Lugol’s iodine to identify women at risk of cervical cancer, also is necessary.
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The diseases also require a different economic approach for the family. Whereas an acute disease can require a bankruptcy-inducing cash outflow for many families, chronic diseases can have similar but more subtle consequences, requiring the family to devote substantial resources to it on a regular basis. “The burden on the family, while it may not be as catastrophic as an acute disease, it may be more progressive and it may be much more insidious,” Meiro-Lorenzo said. This makes properly regulated risk-sharing insurance arrangements even more necessary, a solution that will need to be developed by a country’s legislators. But getting policy-makers to give chronic disease proper attention will be difficult in countries already overwhelmed by acute diseases and a global recession. Gayle, the co-co-chair of the Commission on Smart Global Health Policy, notes, for example, that it will be difficult to convince major tobacco producer China to cut back when it counts on the industry for a substantial percentage of its net government income. But some of the tools needed to improve detection and treatment in the developing world are simple and available. Blood pressure and diabetes screening can be incorporated into vaccination days; pharmacists can be trained to track patients; and developing world public health officials can implement the same messages in their countries that have become the mantra here. “If pushed now [public health interventions] could have a huge impact on the health of nations in the future,” Gayle said. GH —
Nellie Bristol is a freelance journalist specializing in health policy.
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By dr. peter lamptey
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Think HIV/AIDS is Africa’s Greatest Threat? Think Again Women with depression, men with heart disease: Africa has acquired the so-called diseases of the wealthy, but without the wealth. Chronic, non-communicable diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the world’s leading cause of mortality, representing 60 percent of all deaths, according to the World Health Organization (WHO). Of the 35 million people who died from chronic diseases in 2005, half were younger than 70. WHO projects that, globally, non-communicable disease-related deaths will increase by 17 percent over the next 10 years and even more severely in Africa, where up to a 27 percent increase is projected. However, international health aid to Africa has largely been limited to communicable diseases, reproductive health and disaster relief. While we must continue to address these issues, African health systems also deserve attention, as they are systematically failing to address chronic disease epidemics. The reasons are many: overburdened health-care systems that are unable to meet the needs of chronic diseases and acute communicable diseases; a lack of donor attention (there is no Millennium Development Goal related to chronic disease epidemics); poor infrastructure; and poor governance. As a result, deaths from cardiovascular disease, depression and cancers may soon overwhelm the fragile health infrastructure of developing countries. Africa’s “double disease burden” of acute communicable disease and chronic disease demands an enhanced response. Africa Here and Now The most common form of cardiovascular disease, hypertension, is strongly associated with urbanization, and as African nations race to develop, people are moving to cities in droves. The lifestyle changes – including Westernized diets, lower physical activity, and increased consumption of alcohol and cigarettes – Photo by Jim Daniels
Dr. Peter Lamptey is president of public health programs of Family Health International, a global public health and development organization that builds capacities of health systems to address infectious and chronic diseases and other health needs in more than 100 countries in the developing world.
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disease burden in men Percentage of DALYs Lost
HIV/ coronary AIDS heart disease stroke
7.4% 6.9%
5%
depression
4.8%
road traffic injuries tuberculosis
4.3%
4.2%
alcohol use disorders
3.4%
violence
COpd hearing loss
3.3% 3.1% 2.7%
Source: WHO Atlas of Heart Disease and Stroke.
associated with urban migration are so extreme that one study in Ghana found that urban dwellers have nearly a twofold increase in hypertension compared to their rural counterparts. Because cardiovascular disease in developing countries strikes younger working age populations at higher rates than in high-income countries, the economic impact is more severe in terms of lost productivity from illness and premature death. A study of patients attending a cardiac service in Nigeria found that 57 percent suffered from hypertension and 12 percent suffered from some other form of cardiovascular disease. These and other studies make it clear we are missing vital opportunities to slow this epidemic. However, a lack of epidemiological data on cardiovascular disease in Africa is creating a deadly Catch-22: without reliable data on the disease burden, resources will not be devoted to the problem; without resources, African countries will not be able to make cardiovascular or other chronic diseases a priority. Mental illness, including depression, is among the most stigmatized of chronic diseases, and also has a shockingly high prevalence, according to some studies. For example, South Africa’s 2003-2004 Stress and Health Survey indicated that 16.6 percent of participants experienced some form of mental disorder in the past 12-month period, and less than a third of those with a diagnosed mental disorder are in treatment. The relationship between mental health and other disease is cyclical: poor mental health increases likelihood of other diseases, and other diseases can fuel mental health disorders. This interrelationship suggests we need to increase attention to mental illness and to treatment integration.
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Incidence of cancer worldwide is projected to double over the next two decades, with roughly 26.4 million new cases and 17 million deaths annually by 2030. WHO data shows that in most developed countries, cancer is the second largest cause of death after cardiovascular disease, and epidemiological evidence suggests this trend is emerging in the developing world. Women in developing countries are disproportionately affected: according to the WHO, more than 270,000 women died of cervical cancer in 2007. Human papillomavirus (HPV) is considered the primary cause of this chronic disease. Worldwide it is estimated that one in 10 women are infected with HPV, with rates of almost one in four in Africa. Cases of breast cancer in these countries are growing at up to 10 times the global average. The Pitfalls of Modernization A small set of common risk factors are responsible for the majority of chronic disease worldwide: smoking, poor diet, and lack of exercise. Tobacco use is growing fastest in low-income countries as a result of steady population growth and aggressive marketing by the tobacco industry. Poor diet and lack of exercise contribute to the alarming escalation of obesity, hypertension and diabetes. Most of the rise in cancers can also be explained by these common risk factors and infectious diseases, such as sexually transmitted human papillomavirus infection, Helicobacter pylori bacterium infection, and occupational carcinogens. Lessons learned from high-income countries prove that most of the risks associated with chronic diseases are preventable. According to WHO, “if major risk factors were eliminated, it is estimated that 80 percent of heart disease, stroke and type 2 diabetes, and 40 percent of cancer [in Europe] could be avoided.”
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depression
HIV/ AIDS
disease burden in women Percentage of DALYs Lost coronary heart disease stroke cataracts
8.4% 7.2%
5.3%
5.2%
hearing loss
3.1%
2.8%
COpd
2.7%
tuberculosis
osteoarthritis
violence
2.6%
2%
1.9%
The nutrition transition in developing countries from home-grown to packaged and processed foods has resulted in increasing rates of adult obesity, a major risk factor for chronic diseases. Recent trends show a shift in obesity prevalence from the rich to the poor. There is increasing evidence that early nutrition can biologically program later cardiovascular health. For example, studies have established that low birth weight followed by fast weight gain increases cardiovascular risk and disease in adulthood. This association of early undernutrition with cardiovascular disease risk factors such as obesity has critical implications for developing countries. The increase in cardiovascular disease in Africa reflects a major epidemiological transition as a result of industrialization, urbanization, economic development, globalization and aging populations. With increased access to antiretroviral medicines, people are living longer, and HIV is now a chronic disease. The disease and the treatment are, however, causing other risks. According to a joint report by the American Heart Association and the American Academy of HIV Medicine, people living with HIV have an increased risk of cardiovascular disease. The risk of heart attack is 70 to 80 percent higher among this population as compared to their HIV-negative counter-parts. Weak Policy Formation and Implementation There are several examples of policies in Africa aimed at addressing the causes of chronic disease. However, in most instances, implementation is lacking. Lack of stakeholder engagement contributes to this failed implementation and is a major barrier to the advancement of chronic disease-prevention legislation. An example of an effective policy may be South Africa’s Tobacco Products Control Act of 1993, which some consider responsible, in part, for the observed decrease Photo by Jim Daniels
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Photo by Jim Daniels
in the number of deaths due to smoking-related diseases (including heart disease, cancer and respiratory illnesses). South Africa also has less well-known policies that address mental health and chronic disease generally; however, their implementation is weak. At the policy formation stage, factors beyond public health must be considered, or policies may not be implementable. For example, anti-tobacco advocacy groups in Nigeria are trying to pass legislation to restrict tobacco sales and keep cigarettes from minors. The bill is being contested by the tobacco lobby, and by farmers and workers who fear they will lose their jobs. Without effectively addressing these competing priorities – in this case, public health, the business sector, and the need for jobs – bills like Nigeria’s will be in jeopardy. We Must Respond with Urgency We must act now to address chronic disease in Africa. HIV – an emerging chronic disease and an international priority – provides an opportunity to engage international agencies and donors in strengthening health systems and workforce development, initiatives that benefit a broader array of health needs. It would not be enough, however, to simply piggyback chronic disease efforts on HIV-focused care. Chronic diseases demand their own international movement. A strong first step would be to develop a Millennium Development Goal that speaks to this issue, one that also supports the integration of global health initiatives to improve efficiency and increase likelihood of sustainability.
As with HIV, prevention is always the best medicine. We call on national governments to step up efforts to reduce smoking, improve nutrition, promote exercise, and start chipping away at the root causes of chronic diseases. African governments must play the primary role in reducing rates of chronic disease in their countries. As we are seeing in Nigeria, however, this cannot be achieved without the engagement of communities and other stakeholders. There is a large knowledge gap on the prevalence and impact of chronic diseases in African countries. Research is needed to assess the extent of these epidemics, including behavioral, vocational and other factors that fuel them. With this information, efforts to fight chronic disease can be accurately targeted for greater impact. There may be some lessons from highincome countries that have succeeded in reducing the burden of many of these diseases. In many African nations, the public is unaware of the long-term risks of poor diet, smoking, pollutants or infectious agents. They are not educated about warning signs and symptoms. Mass education will require mobilization of local and international government and advocacy groups to highlight the importance of chronic disease and promote healthy diet and lifestyles. Ultimately, the people affected must be empowered to make decisions and take responsibility for their own health and well-being. GH —
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By dr. james hospedales
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Photo by PAHO
North American Diseases Go South of the Border
Rates of chronic disease have risen sharply in Latin America and the Caribbean over the past 15 years, as the population has aged and the effects of lifestyle changes have taken hold.
Patricia Pizarro thought she was a good mother, so she was upset when the pediatrician told her she needed to change how she was raising her son Fernando. She had taken the 12-year-old in for a rash, but the doctor gave her an unexpected diagnosis: the boy was obese and had high blood pressure, and if things didn’t change, he could become diabetic or even worse.
Fernando’s lifestyle, it seems, was the problem. After eating a sandwich each morning for breakfast, he’d snack on sweets at recess and eat just about anything but vegetables at lunch. At home, he spent most of his time watching TV and playing or chatting on the computer, all the while snacking on cookies, potato chips, candy, more sandwiches and sodas. When his parents got home, he’d eat one more time before going to bed. A daily routine like this is not unusual for a child in Santiago, Chile, or in any other Latin American city
Dr. James Hospedales is senior advisor for prevention and control of chronic diseases at the Pan American Health Organization (PAHO).
today. “Modern” lifestyles are on the rise throughout the hemisphere, and with them chronic non-communicable diseases (CNCDs). Heart attacks, strokes, diabetes and cancer now cause two out of every three deaths in the Americas and consume by far the largest share of health-care spending. And as is true in other regions of the world, chronic diseases take their greatest toll on the poor, who have less access to health care and fewer resources to cope with loss of income or disability. The good news is that most of it is preventable. It is tempting to blame the rise of chronic diseases on only junk food and TV, but the root causes are more complex. Most CNCDs are strongly related to a handful of risk factors, chief among them, unhealthy diet, physical inactivity, and tobacco use. All of these have increased as a result of urbanization, changes in work, transportation and leisure, as well as modernization and globalization of agriculture and new marketing and retail trends.
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Cervical cancer is a major cause of death for women in Central America, while breast cancer claims more lives in South America.
For example, trade liberalization in Central America has been shown to be a factor in the “nutrition transition” and rising rates of obesity and CNCDs. Data from the World Health Organization/Pan American Health Organization (WHO/PAHO) show that fewer than half the region’s residents get the recommended 30 minutes of physical activity per day. Now an alarming 50-70 percent of adults in Latin America and the Caribbean are overweight or obese, along with 7-12 percent of children under 5 years. The growing epidemic of CNCDs is forcing public health advocates in the region to broaden their focus beyond infectious diseases, maternal and child mortality, and malnutrition. It also demands a different approach. Unlike infectious diseases, which are linked to germs and can be targeted with vaccines or other drugs, chronic diseases result from a combination of causes that are difficult – but necessary – to address at the same time. Fighting back In the past five years, countries in Latin America and the Caribbean have begun to respond in earnest to
Chronic Disease in the Americas Cardiovascular disease. Heart disease and stroke account for one in three deaths in Latin America and the Caribbean (LAC). Though CVD death rates have been declining in North America, in LAC they are expected to nearly triple over the next 20 years. Cancer. Deaths from cancer increased 33 percent between 1990 and 2002 in LAC. Lung cancer is the leading cancer killer, thanks to smoking rates as high as 30–40 percent in some countries. Cervical cancer is a major cause of death for women in Central America, while breast cancer claims more lives in South America.
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The annual Caribbean Wellness Day, celebrated for the second time this past September, encourages healthy eating and physical activity to combat rising rates of chronic disease.
the CNCD epidemic. In 2006, ministers of health of the Americas approved a regional strategy for the prevention and control of chronic diseases, including diet and physical activity. In 2007, at a special summit on CNCDs in Trinidad and Tobago, Caribbean heads of state put chronic diseases at the top of their health agenda in a 14-point declaration, “Uniting to Stop the Epidemic of Chronic Diseases.” In 2009, Central American health ministers also issued a resolution calling for action on CNCDs. These and related initiatives have spurred actions such as the “five-a-day” campaigns, encouraging people to eat fruits and vegetables to wider interventions to make “the healthy choice the easier choice.” WHO’s recent publication Interventions on Diet and Physical Activity: What Works cites several of the region’s recent efforts as models of effective action. These include Brazil’s national school meals program, which promotes healthy eating based on locally produced foods, and the Ciclovias movement, which closes off city streets to create safe spaces to promote physical activity (see box on next page).
Hypertension. PAHO data show that some 140 million people in the Americas suffer from hypertension. The chief risk factors are smoking and especially dietary salt. People in Latin American countries eat two to three times the maximum recommended levels of salt. Diabetes. Some 35 million people in the Americas have diabetes (whose main risk factor is obesity) and the number is expected to double by 2025. Diabetes is now the leading cause of death in Mexico and claims some 340,000 lives annually throughout the region. PAHO estimates the cost of diabetes in the Americas at over US$65 million annually, as a result of premature death, worker absenteeism, disability, drugs, hospitalization and doctor visits.
Diabetes is now the leading cause of death in Mexico and claims some 340,000 lives annually throughout the region.
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Other promising initiatives in the region include: Agricultural policies that encourage increased production of, and lower prices on, healthy foods (Brazil and Chile); ■ Urban development policies that promote public transportation as well as green and recreational spaces (Brasilia, Curitiba and Porto Alegre, Brazil; Santiago, Chile; Bogotá, Medellín and Pereira, Colombia; Quito, Ecuador; México City and Leon, Mexico); ■ Voluntary or mandatory labeling of fat and salt content in processed foods (Argentina, Bolivia, Brazil, Chile, Paraguay and Uruguay); ■ Restrictions on advertising of junk foods to children (Brazil and Mexico); ■ Prohibiting the sale of soft drinks and junk food in schools (Chile and Argentina); ■ Increased taxes and restrictions on advertising and sales of tobacco products (Trinidad and Tobago, Uruguay).
Countries in the region are also working, with PAHO support, to improve prevention and treatment of CNCDs by strengthening health systems with an emphasis on health promotion and primary health care. The efforts include changes in medical school curricula and healthworker training to confront the new challenges of CNCDs. Meanwhile, advocates for chronic disease control will need to engage opinion leaders, lawmakers, the public and private companies to take joint and sustained action against chronic diseases at all levels and on all fronts. The lives and the health of millions of residents of the Americas are at stake. GH
dustry to work toward eliminating trans fatty acids from industrially processed foods.
What’s Being Done The countries of Latin America and the Caribbean have individually and collectively undertaken a number of innovative initiatives to counter the growing epidemic of CNCDs. Among them are: Brazil’s national school meals program is a comprehensive effort to improve and sustain the quality of food consumed by children in primary school. By law, 70 percent of the program’s budget for school meals – roughly $1 billion per year for 35 million children –must be spent on fresh vegetables and fruits and other minimally processed foods. Ciclovias, also known as “Car-Free Sundays,” in which city streets are temporarily closed to motor vehicles, allows exclusive access to pedestrians, runners, skaters and cyclists. Ciclovias have spread to at least 38 cities in the hemisphere, including Bogotá, Guatemala City, Lima, Mexico City and Quito; and in North America,
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A health care worker counsels a diabetes patient in Veracruz, Mexico. Diabetes is the leading cause of death in Mexico, ahead of heart attacks, and a major cause of illness throughout the Americas.
Chicago, El Paso, Portland, New York City and Ottawa. Smoke-Free Americas was launched in 2001 by PAHO to support efforts to reduce exposure to second-hand tobacco smoke in the Americas. The initiative provides help and advice to governments and a wide range of resources to help advocates, parents, communities and the public create smoke-free environments. Trans Fat Free Americas, another PAHO-led initiative, has brought nutrition experts together with representatives of the food in-
By law, 70 percent of the budget of Brazil’s national school meals program must be spent on fresh vegetables and fruits and other minimally processed foods.
The CARMEN network, which links health professionals and health institutions in 30 member countries, shares knowledge and best practices in chronic disease policy development, implementation and evaluation. The network’s CARMEN School provides training in these areas through partnerships between schools of public health, public health agencies and ministries of health. The Partners’ Forum for Action on Chronic Disease, which brings together members of the private sector, civil society and the public health community, exchanges ideas, mobilizes resources, and spurs action across sectors to prevent CNCDs. Launched in September 2009, the forum is being spearheaded by PAHO, the Pan American Health and Education Foundation (PAHEF), the World Economic Forum, and the International Business Leaders Forum. GH —
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By K. Srinath Reddy
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Photo by Public Health Foundation of India
Rapid Changes in Asia Alter Health Landscape
During 2000-2004, a quarter of the Indian children aged 13-15 years are reported using a tobacco product. Children from poor families are especially vulnerable. (Global Youth Tobacco Survey)
Many of the highly populous nations of the world are located in Asia. China, India, Indonesia, Bangladesh and Pakistan together add up to 45 percent of the world’s population. The health status of these countries, therefore, has a major bearing on global health indicators. Most of the countries of this large continent fall into the low- and middle-income categories. Their health profile is similar to that of developing countries across the world, with some regional variations. The rapid changes in the developmental and demographic profiles of these countries over the past two decades are reflected in an altered mix of the major public health challenges that they now face. Until about 30 years ago, the developing countries of Asia were mainly threatened by infectious diseases, nutritional deficiencies and unsafe pregnancies, K. Srinath Reddy is president of the Public Health Foundation of India.
resulting in a huge burden of death and disability in childhood and early adulthood. This pattern has now changed, swiftly and substantively. While some of these health problems do remain a concern and call for continued action, new threats to health have emerged, not only in the form of HIV/AIDS but also in terms of chronic illnesses, such as cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. We can examine how chronic diseases have evolved in Asia, using China and India as the main case studies and cardiovascular disease (CVD) as the primary chronic disease of interest. Delayed, but determined, industrialization and recent, but relentless, urbanization have initiated the socioeconomic and demographic transitions that propel the health and nutrition transitions in Asia. Globalization,
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which constituted the tail wind of the 20th century, greatly accelerated the progression of the chronic diseases by altering tradition as well as trade. Marked alteration of living habits, within a single generation, has seen risk behaviors lead to biological risk factors and then on to chronic disease-related clinical events at steeply spiraling rates. The age standardized death rates for cardiovascular disease were 365 per million for the Southeast Asia region of the World Health Organization, as compared to 202 per million for the Americas, in 2005. In China, the proportion of deaths attributable to CVD, chronic obstructive pulmonary disease and cancers rose from 41.7 percent in 1973 to 74.1 percent in 2005. Even in the rural areas of Andhra Pradesh, India, CVD accounted for 32 percent of all deaths in 2004. Many of the chronic disease-related deaths, in the low- and middle-income countries of Asia, occur at a much younger age than in the high-income countries of the world. In 1990, India was estimated to have lost 9.2 million potentially productive years of life, due to CVD-related deaths occurring in people 35-64 years old (570 percent more than the USA). The projected loss of productive life years from premature deaths caused by CVD will reach 17.9 million in 2030 (940 percent more than in USA). The corresponding losses for China were estimated to be 6.7 million years in 2000 and 10.9 million years in 2030. According to estimates by WHO, economic losses that result from CVD, diabetes and cancer are expected to be US $558 billion for China and US $237 billion for India, during the period 2005-2014. For families, the economic consequences can be disastrous. Among the survivors of a stroke in China, for example, 71 percent experienced catastrophic health expenditures. In the south Indian state of Kerala, families of people who had cardiovascular disease, 73 percent suffered catastrophic expenditures, 50 percent resorted to distress financing, and 40 percent lost sources of income. As the CVD epidemics advance globally, the poor are becoming increasingly vulnerable, among countries and within countries. Policy Implications Though policy responses to these epidemics were initially slow and hesitant, they have begun to take shape and gain traction over the past few years. These responses have to be examined in terms of their approach to the control of risk factors, as well as the development of national programs for providing preventive and clinical services.
India and China are major producers of tobacco, both in terms of agriculture and manufacture. India overcame its reluctance to curb the tobacco epidemic about a decade ago. Strident advocacy by civil society groups, judicial activism to uphold the rights of nonsmokers, the persuasive impact of growing global scientific evidence on the health effects of tobacco, the catalytic effect of the global inter-governmental negotiations on the Framework Convention on Tobacco Control (FCTC), the changing attitude of the media, and growing political support for tobacco control measures combined to decisively swing the balance in favor of a comprehensive tobacco control legislation that was initiated in 2001 and secured parliamentary approval in April 2003. India’s tobacco control law calls for a ban on most forms of advertising (other than at point of sale), prohibition of smoking in public places, prominent (pictorial) health warnings on tobacco products, a ban on the sale of tobacco to people under 18 years of age, and testing of tobacco products for their emissions and ingredients. The enforcement of these provisions, however, needs to gather strength across the country. The wayward tax policy needs to be rectified. While cigarettes could certainly do with higher taxes, other smoked tobacco products (“Beedis”) and smokeless tobacco continue to be very minimally taxed. However, a National Program for Tobacco Control has been launched in 2008 and is being scaled up. China has been more hesitant in enacting similar tobacco control measures, since tobacco manufacturing industries in China are owned by the government. However, China has begun to implement smoke-free policies for public places, spurred on by the smoke-free Olympics of 2008. But the absence of an organized civil society movement for tobacco control is a contributor to China’s slow progress in this arena. Recently reported declines in male smoking rates, though small, are a welcome sign. Lifestyle Changes Nutrition and physical activity, too, demand attention at the policy level in both countries. Edible oil consumption has risen sharply in both countries, as has the consumption of salt, fat and sugar-rich processed foods and beverages. In India, the per capita consumption of edible oil has nearly doubled in recent years, up from 128 Kcal/per capita/day in 1983 to 240 Kcal/per capita/ day in 2003. Even within the very short time window between 1989-1993, the proportion of Chinese people consuming more than 30 percent of their daily calories
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in the form of fat rose twofold in the low-income group (from 19.1 percent to 36.4 percent) and threefold in the high-income group (from 22.8 percent to 66.6 percent). Salt is an important risk factor for hypertension in both countries, especially in China which has a high incidence of strokes. Reduction of salt in processed foods requires a high priority, along with public education to reduce salt during cooking and at the table. Increase in the production and domestic consumption of vegetables and fruits will not only provide many protective phytonutrients but also act as a channel for supply of dietary potassium which counters the effect of dietary salt on blood pressure. Policies are also needed to counter the growing consumption of meat and to encourage the consumption of fish. As obesity levels rise sharply in adults and children in both countries, policies must address the aggressive marketing of high-calorie but low-nutrient beverages and fast foods. Availability of healthy edible oils at affordable prices is needed, while the removal of trans-fats from processed foods has become a public health priority. Urban design polices for enabling safe and pleasurable physical activity, as part of the daily routine of all citizens, are imperative to counter the ill effects of unplanned growth wherein pedestrian pathways are shrinking, protected cycle lanes are disappearing, and open spaces are becoming a rarity. Integrations into Health Systems Health services, too, need to be reconfigured to integrate health promotion, risk factor detection and management, cost-effective acute care and chronic care services for periodic re-evaluation. The needs of the health workforce also must be addressed, with nonphysician health-care providers recruited to strengthen prevention and early risk detection in primary care settings. India introduced a pilot component of the National Program for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke, in 2008. Based on the evaluation of this program, conducted in 10 districts, it is proposed to be scaled up to a national program in mid-2010. But this vertical program needs to be
In China, the proportion of deaths attributable to CVD, chronic obstructive pulmonary disease and cancers rose from 41.7 percent in 1973 to 74.1 percent in 2005. integrated into the national flagship health programs like the National Rural Health Mission (launched in 2005) and the soon to be initiated National Urban Health Mission. China has been working on a framework for a national program for prevention and control of noncommunicable diseases for more than six years. It should be ready to launch sometime soon. There have been several large-scale pilot programs for cardiovascular disease prevention in major cities (Beijing, Shanghai and Changsha) and at individual worksites. A community-based diabetes prevention trial has also validated the effectiveness of diet and physical activity in reducing the incidence of diabetes in highrisk individuals. China has strong surveillance systems for diseases and risk factors. Its Centers for Disease Control are well developed and capable of providing strong leadership to the national program when it is launched. Other Asian countries are gearing up to respond to the expanding threat of cardiovascular disease also. Pakistan has developed a national action plan for noncommunicable diseases (NCDs). Thailand, with its strong public health system, is developing a primary health-care approach to NCD prevention and control. All of these developments in Asia would need to be closely monitored over the next decade to evaluate the impact of multi-sectoral policies and programs on CVD. It would be equally important to ensure that these programs are well integrated into the overall health system rather than function as isolated vertical programs, which lack resources, penetration and impact. This space clearly needs to be watched closely. GH —
C Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. The Lancet, 2005;366: 1744-1749 : http:// download.thelancet.com/pdfs/journals/lancet/PIIS0140673605673436.pdf? id=5bbe37e152166496:123b1235:12452481a55:-50971255511929905
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Health Systems Reform in China, Lancet Series, October 20, 2008: http://www.thelancet.com/series/health-system-reform-in-china ISSUE 04 fall 2009
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Heartfile: http://heartfile.org/
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Preventing Chronic Diseases: a vital investment, WHO Global Report: http://www.who.int/chp/chronic_disease_report/contents/en/index.html Oxford Health Alliance: http://www.oxha.org/
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By john donnelley Global Health magazine interviews Dr. Eric Goosby, U.S. global AIDS coordinator at the State Department, in an upcoming blog post. Goosby talks about his vision for the job and what the new Obama administration’s Global Health Initiative will look like.
Strength In What Remains Strength In What Remains (Random House), by PulitzerPrize winning author Tracy Kidder, is a stunning true story of human endurance, and the will to do good and to forgive. It is a must read, and should be picked up by everyone interested in human welfare, global health, and anyone interested in reading a fascinating, touching story.
By ricky lu and sharon kibwana More than 95 percent of women globally have never had a PAP smear. But Jhpiego is addressing this inequity with a low-tech, cost-effective method of screening for cervical cancer. By orin levine Pneumonia kills 2 million children under five every year, more than HIV/AIDS and malaria combined, yet it receives only one-fiftieth of their combined R&D funding. How is it possible that such a large cause of childhood mortality persists despite affordable, effective interventions? Read the full blogs at www.globalhealthmagazine.com.
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Baking Cakes in Kigali So many in the global health community say they have a book in them. Baking Cakes in Kigali (Random House) is such a book. It is the charming and uplifting debut novel that brings to life the stories heard by author Gaile Perkin while she worked in Rwanda as an HIV/AIDS volunteer. This undeniably spirited novel shows the resilience – and joy – of modern day Rwandans without shying away from the painful past of the genocide.
Mosquito Splat! Mosquito Splat is a Facebook-based game that provides malaria education while raising money. In it, your goal is to swat as many mosquitoes as possible before they infect the baby on the screen with malaria. For every one hundred points scored, the game’s advertisers will give money to Malaria research at the National Institute for Medical Research in Tanzania.
The Weight of Heaven – Beautiful Prose and Characters That Thrive With Life GH The Weight Of Heaven — (HarperCollins) by Thrity Umrigar is the story of an American couple who moves to India after losing their young son to a sudden bout of illness. The story in The Weight of Heaven is a slow-burner. It is a detailed and often beautiful vision of loss, anger and culture shock that builds to a wonderful crescendo.
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Waves of Change: Married Adolescents in Nepal A short film on YouTube, documenting ACQUIRE’s and CARE’s initiatives in Nepal to increase health education and openness regarding reproductive health discussion in this Himalayan nation.
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