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An Introduction to Population-Level Prevention of Non-Communicable Diseases
An Introduction to Population-Level Prevention of Non-Communicable Diseases
Edited by Mike Rayner
British Heart Foundation Centre on Population Approaches for Non-Communicable Diseases Prevention, Nuffield Department of Population Health, University of Oxford, UK
Kremlin Wickramasinghe
British Heart Foundation Centre on Population Approaches for Non-Communicable Diseases Prevention, Nuffield Department of Population Health, University of Oxford, UK
Julianne Williams
British Heart Foundation Centre on Population Approaches for Non-Communicable Diseases Prevention, Nuffield Department of Population Health, University of Oxford, UK
Karen McColl
Freelance consultant/writer
Shanthi Mendis
Geneva Learning Foundation, Geneva, Switzerland
1
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Foreword
Non-communicable diseases (NCDs), including heart disease, stroke, cancer, diabetes, and chronic lung disease, are collectively responsible for more than two-thirds of all deaths worldwide. Primarily four risk factors are responsible for the burden of NCDs: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets.
Almost three-quarters of all deaths from NCDs before the age of 70 occur in low- and middle-income countries. For a long time there was a strong belief that NCDs are associated with affluent lifestyles. But current statistics clearly show that not just developed countries, but low- and middle-income countries face a growing burden of NCDs and that it is in some of the poorest populations around the world where NCDs have the greatest impact.
In 2011 a high-level meeting of the United Nations recognized the growing burden of NCDs as a threat to global development and called for actions from heads of state to tackle the issue. The inclusion of a goal to reduce premature mortality from NCDs by one-third in the Sustainable Development Goals agreed in 2015 was a turning point in scaling up the global response. The World Health Organization (WHO) recommends a series of actions to tackle NCDs and they can be categorized as the following: improved governance, tackling risk factors more effectively, strengthening health systems, and better monitoring and evaluation. Health systems in all but a few countries are more focused on treatment of individuals with disease than prevention. Population-level prevention approaches such as national-level policies to raise taxes on tobacco or restrict the marketing of unhealthy food and drinks to children are likely to be extremely cost-effective, but many countries lack the capacity to implement such actions.
Since 2012 the WHO Collaborating Centre on Population Approaches for NonCommunicable Disease Prevention at the Nuffield Department for Population Health, University of Oxford has organized a regular short course on population approaches to NCD prevention. With the participation of other experts, including representatives of WHO, the course aims to build capacity for population-level action to tackle NCDs. However, given the large number of trained professionals needed to tackle this global issue, a face-to-face training programme is not able to reach everyone who requires the knowledge and skills necessary for effective action.
An Introduction to Population-Level Prevention of Non-Communicable Diseases is mainly based on material presented at the course, and it provides an exciting opportunity for this to be shared with a greater global audience. This book brings together evidence about different aspects of the problem of NCDs and their solution for academics, policy-makers, and other practitioners. It is structured around the key steps of the policy cycle and encourages evidence-based policy-making and evaluation at a population level.
While providing the general principles and scientific basis to population-level prevention for NCDs, it also provides case studies from countries around the world seeking to implement such prevention in practice.
I hope this book will play a significant role in our global response to the prevention of NCDs in coming years and decades. I congratulate the authors on this publication and wish every success for the dissemination and future updates.
Dr Oleg Chestnov
Assistant Director-General—Noncommunicable Diseases and Mental Health World Health Organization
Acknowledgements
We would like to thank all the participants and resource persons who have presented at the short course on Prevention Strategies for Non-Communicable Diseases run by the University of Oxford. This book is based on presentations made during short courses held between 2012 and 2015. Presenters during these courses included the following: Steve Allender, Virginia Arnold, Prachi Bhatnagar, Francesco Branca, Adam Briggs, Simon Capewell, Sudeep Chand, Michel Coleman, Gill Cowburn, Aiden Doherty, Kaia Engesveen, Charlie Foster, Gauden Galea, Simon Gillespie, Celina Gorre, Corinna Hawkes, Shabbar
Jaffar, Prasad Katulanda, Mike Kelly, Paul Kelly, Mike Knapton, Alexandra Krettek, David Matthews, Karina McHardy, Klim McPherson, Shanthi Mendis, Bente Mikkelsen, Colin Mitchell, Modi Mwatsama, Oliver Mytton, Melanie Nichols, Brian Oldenburg, Richard Peto, Emma Plugge, Johanna Ralston, Mike Rayner, Srinath Reddy, Aaron Reeves, Justin Richards, Harry Rutter, Peter Scarborough, David Stuckler, William Summerskill, Nick Townsend, Temo Waqanivalu, Kremlin Wickramasinghe, Denis Xavier, and Xuefeng Zhong.
This book contains a number of case studies. The following individuals contributed to these cases studies or provided other additional material for the book: Luke Allen, Simone Bösch, Hannah Brinsden, Linda Cobiac, Dylan Collins, Alessandro de Maio, Randa Hamadeh, Erin Hoare, Nousin Hussain, Kiran Jobanputra, Sandeep Kishore, Alexandra Krettek, Tim Lang, Nijole Gostautaite Midttun, Modi Mwatsama, Jessica Pullar, Nabil Sulaiman, Anne-Marie Thow, Daniel Vujcich, Temo Waqanivalu, and Rouham Yamout.
We also appreciate the help of Sahar Bhatti, Oluwatosin Ogunmoyero, Anja Mizdrak, and Lizzie Wilkins, who documented presentations and discussions from the short course. We would also like to thank all our colleagues at the British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford and the Department for Continuing Education, University of Oxford for their support throughout this publication. Finally, we are so grateful for the team at the Oxford University Press, who worked very hard to publish this book on a tight timeline. Thank you to James Cox, Geraldine Jeffers, Catherine Barnes, and Nicola Wilson for their tireless help as we prepared the manuscript for publication.
Foreword v Acknowledgements vii
Abbreviations xi
Part I Introduction
1 Introduction 3
Part II Problem definition
2 Understanding NCDs 13
3 NCDs: Risk factors and determinants 31
4 The sociopolitical landscape of NCDs, Part I 47
5 The sociopolitical landscape of NCDs, Part II 63
6 Public health advocacy for the prevention of NCDs 81
7 Screening and surveillance 107
Part III Solution generation
8 Evidence for population-level approaches to the prevention of NCDs: Evaluating effectiveness and modelling 129
9 Evidence for population-level approaches to the prevention of NCDs: Economic evaluation 147
10 Developing a prevention strategy 167
Part IV Resource mobilization and implementation
11 Capacity building 181
12 Implementation of an NCD prevention strategy 191
13 Implementation: Beyond the health sector 207
Part V Monitoring progress
14 Evaluation and monitoring 227
15 Revisiting the stages of the policy cycle 249
Index 257
Abbreviations
ANGELO analysis grid for elements linked to obesity
ATLAS Active Teen Leaders Avoiding Screen Time
BMI body mass index
BMJ British Medical Journal
BRFSS Behavioural Risk Factor Surveillance Study
BSE bovine spongiform encephalopathy
CASH Consensus Action on Salt and Health
CDC Centers for Disease Control and Prevention
CER cost-effectiveness ratio
CFIR Consolidated Framework for Implementation Research
CHD coronary heart disease
CHP community health programme
COPD chronic obstructive pulmonary disease
CPG Coronary Prevention Group
CVD cardiovascular disease
DALY disability-adjusted life years
DfID Department for International Development
DHS Demograghic and Health Survey
DNAP District Nutrition Action Plan
FCTC Framework Convention on Tobacco Control
FFQ Food Frequency Questionnaire
FSA Food Standards Agency
GBD Global Burden of Disease
GDA guideline daily amount
GSHS Global School-Based Health Survey
HARDIC Heart-Health Associated Research and Dissemination in the Community
HDSS Health Demographic Surveillance System
INFORMAS International Network for Obesity Research, Monitoring and Action Support
INPARD Integrating Nutrition Promotion and Rural Development
ISH Internal Society of Hypertension
IMF International Monetary Fund
LMIC low- and middle-income countries
LY life year
MAFF Ministry of Agriculture, Fisheries and Food
MOPH Ministry of Public Health
MSAP multisectoral action plan
MSF Médecins sans Frontières
NCD non-communicable disease
NGO Non-governmental organization
NICE National Institute for Health and Care Excellence
NNCDC National NCD Committee
NSDF National Strategic Development Framework
OECD Organisation for Economic Cooperation and Development
PAR population attributable risk
PBAC Pharmaceutical Benefits Advisory Committee
PHARMAC Pharmaceutical Management Agency
QALY quality-adjusted life year
RCT randomized controlled trial
SDG sustainable development goal
SES socioeconomic status
SPAGHL Samoan Parliamentary Advocacy Group on Healthy Lifestyles
SSB sugar-sweetened beverages
UN United Nations
UNDP United Nations Development Programme
WHA World Health Assembly
WHO World Health Organization
WHO PEN WHO Package of Essential NCD Interventions for Primary Health Care in Low-Resource Settings
WTO World Trade Organization
YLD years lived with disability
YLL years of life lost
YP-CDN Young Professionals-Chronic Disease Network
Part I Introduction
Chapter 1 Introduction
1.1 Aims of the book
This book is intended to capture the material covered in an accredited six-day short course on Prevention Strategies for Non-communicable Diseases which takes place in Oxford. This course is organized by the British Heart Foundation Centre on Population Approaches for Non-communicable Disease Prevention of the Nuffield Department of Population Health at the University of Oxford and the Department of Continuing Education at the University Oxford. This document also encompasses material discussed during a workshop on Non-communicable Disease Prevention: Policy Development and Implementation Issues in Low- and Middle-Income Countries, organized jointly by the World Health Organization and the University of Oxford, which has drawn the first two courses to an end. Speakers for both the course and the workshop are selected to share their expertise and engage in debates on some of the most contentious and challenging issues facing non-communicable disease (NCD) prevention today. To complement the content of the short courses and workshops, some additional contributors have provided material on issues not previously covered. In addition, many case studies are included to illustrate NCD prevention in practice.
This document reflects the breadth of the material covered and also highlights some key discussion points. It is expected that this document will provide useful information for individuals and organizations interested in NCDs and their prevention, in particular public health practitioners, policy-makers, post- graduate students, and early career level professionals working in the field of NCDs. There is a need for training courses and materials to help equip such interested parties to design, implement, and evaluate strategies for NCD control; this document has been designed with this need in mind, particularly in the context of low- and middle-income countries (LMICs).
1.2 How the book is structured
This document is structured to reflect the strategy- or policy-making cycle shown in Figure 1.1.
Part II covers problem definition, the first stage of the policy cycle. Problem definition involves establishing the nature and the extent of the problem of NCDs in a particular
situation. It also involves consideration of the causes of the problem (such as NCD risk factors) and the wider determinants of health. Chapter 2 sets out an initial understanding of what NCDs are and the burden they present to low-, middle-, and high-income countries. It goes on to explore the risk factors and determinants of NCDs throughout the life course (Chapter 3) and the sociopolitical landscape, including the competing interests that can render NCD prevention more challenging (Chapter 4). The section then sets out how the global response to NCDs is shifting from apathy to action (Chapter 5) and the important role of public health advocacy in tackling NCDs (Chapter 6). Finally, the section takes a more operational look at how to define the problem in a particular context, through use of screening and/or surveillance (Chapter 7).
The second stage of the policy-making cycle is solution generation, which involves assessing the evidence for the potential costs and benefits of a particular intervention, considering potential barriers to, and facilitators of, different solutions and prioritizing possible actions, and finally, developing a plan. Solution generation is explored in Part III (Chapters 8–10).
Chapters 8 and 9 examine the types of evidence required for population-level approaches to NCD prevention. More specifically, addressing approaches to evaluating effectiveness and cost effectiveness and modelling different interventions. Chapter 10 outlines the steps involved in building a prevention strategy and introduces some tools for priority setting.
Part IV addresses the important issue of resource mobilization and implementation (sometimes referred to as ‘capacity building’). Chapter 11 provides some pointers for implementation, including the critical importance of strengthening health systems (Chapter 12), how to consider tackling inequalities, the key role of disadvantaged groups as stakeholders in the process, and the fundamental need to reach beyond the health sector and develop multisectoral solutions to the challenges of NCDs (Chapter 13).
Figure 1.1 the strategy/policy-making cycle.
It is vital that progress towards goals and targets is monitored and that programmes and interventions are evaluated. Part V addresses evaluation and monitoring, which is the fourth stage of the policy cycle. Evaluations may assess whether the interventions for preventing NCDs, once implemented, met their aims and objectives or to generate evidence which may be generalized to other situations. Chapter 14 outlines different types of evaluation and identifies some of the core issues to consider when evaluating a programme. It also sets out the issues in formulating an evaluation plan, and the choice of reliable and valid measures, as well as highlighting some of the challenges in relation to reporting and monitoring progress towards goals. Finally, Chapter 15 emphasizes policy-making as a cyclical process in which the various steps must be revisited in order to ask new questions about the problem and the solutions before proceeding to a new round of implementation.
1.3 Key concepts
The three concepts of prevention, treatment (or control), and care are not competing and should instead be seen as complementary in the fight against NCDs. Prevention, treatment, and care are all important responses to the global NCD problem. It is notable, for example, that two of the nine voluntary targets in Global NCD Action Plan relate to treatment. The main focus of this book, however, is on population approaches to prevention.
1.4 Prevention
While the primary focus of this document is on prevention, it is important to recognize that it is neither feasible nor desirable to devote all resources to prevention. In effect, this would mean ignoring the millions of people already affected by NCDs who would then go on to develop complications or have their conditions deteriorate. There are considerable areas of overlap and prevention, cure, and care can be seen to exist on a continuum of activities that are needed to successfully tackle any disease (see Figure 1.2).
Figure 1.2 Continuum of
As shown in the figure, there are different levels of prevention:
◆ Primary prevention applies before the onset of a disease and aims to prevent it from occurring;
◆ Secondary prevention is used before the onset of a disease with individuals at high risk of developing that disease with the aim of detecting those individuals as early as possible;
◆ Tertiary prevention applies when the person already has established disease and aims to prevent or limit the condition from worsening, to slow down its progression, or to prevent complications.
Some authors would add ‘primordial prevention’ to this list, referring to a form of prevention—prior to primary prevention—that aims to establish and maintain the conditions for promoting health.
All forms of prevention, whether primary, secondary, or tertiary, can involve pharmacological interventions—aimed at reducing intermediate risk factors such as raised blood pressure or raised blood cholesterol levels—as well as interventions aimed at behavioural risk factors. This document focuses on prevention via behaviour change but this is not to say that pharmacological interventions do not also have an important role to play in the prevention of NCDs.
1.5 Population-level approaches to prevention
Public health can be defined as ‘the science and art of preventing disease and promoting health through the organized efforts of society, organizations, communities, families and individuals’.1 Crucially, public health programmes aim to improve the health, not only of individuals but also of groups (families, communities, the whole population of a country). WHO’s global action plan recognizes that it is not possible to tackle NCDs by only aiming interventions at individuals, and embraces both the population and individual approaches.
A population-based approach to NCD prevention, which is the predominant focus of this document, aims to shift the distribution of risk factors in the population as a whole, rather than those at greatest risk (Figure 1.3).
Another important aspect of the population-based approach to prevention is that it puts more of a focus on distal (rather than proximal) causes of disease—in other words, it places more importance on factors that are societal or environmental rather than individual. The individual (also called the high-risk) approach, in contrast, generally starts with intermediate risk factors, focusing on groups such as people with high blood pressure or high blood cholesterol levels.
1.6 Population-level approaches to the prevention of NCDs
There is an abundance of evidence that very many premature deaths caused by NCDs are avoidable and that prevention can work.
Figure 1.3 Relative gains of a population approach versus a high-risk approach. these figures, adapted from Geoffrey rose’s seminal work The Strategy of Preventive Medicine, illustrate the benefits of a population-based approach. the curve on the left illustrates how risk is distributed in a normal population—with much larger numbers with an intermediate level of risk and smaller numbers at high or low risk. a prevention approach which targets high-risk individuals (a) would have the effect of cutting off the tail of the curve with reduced risk shown as the shaded area. a population-based approach, which aims to bring about small changes in the population as a whole, would shift the whole disease curve to the left (b). the health gains, again shown by the shaded area, are therefore much larger, reducing the risk in many more people.
Factors that point to the substantial avoidability of premature deaths from NCDs include the following:
◆ Geographic variation—every disease common in one place is much less common elsewhere;
◆ Differences between population disease rates are not chiefly genetic;
◆ Trends—the big changes in disease over time reflect changes in particular causes; and
◆ Several major causes have been identified, so it is likely that there will be others identified in the future.
There is strong evidence that prevention works in reducing death and disease. Figure 1.4 illustrates the tremendous gains made in reducing death rates from coronary heart disease in several high-income countries in the latter half of the twentieth century. These health gains show that NCD deaths are preventable. Modelling work to analyse the factors contributing to these falling death rates estimates that about 50% of the drop in mortality can be attributed to prevention though reduced exposure to behavioural risk factors2,3 (see the section in Chapter 8 on impact modelling), and about 50% to improvements in treatment and prevention through pharmacological interventions and surgery.
Examination of the specific example of smoking, this time in the UK alone, also shows that prevention is effective. Figure 1.5 shows how the population risk of dying from smoking in the United Kingdom has changed between 1960 and 2010.
This chapter is based on presentations by Professor Mike Rayner, Professor Simon Capewell, Professor Brian Oldenburg, and Professor Richard Peto.
References
1. Winslow CA. (1920). The untilled fields of public health. Science 51(1306):23–33.
2. Bajekal M, Scholes S, Love H, Hawkins N, O’Flaherty M, Raine R, et al. (2012). Analysing recent socioeconomic trends in coronary heart disease mortality in England, 2000-2007: A population modeling study. PLoS Med 9(6): e1001237.
3. Smolina K, Wright FL, Rayner M, Goldacre MJ. (2012). Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study. BMJ 344:d8509. Available from: http://www.bmj.com/content/344/bmj.d8059
Further reading
Rose G. Rose’s strategy of preventive medicine. Revised edition with commentary from Kay-Tee Khaw and Michael Marmot. Oxford: Oxford University Press, 2008.
Part II
Problem definition
Chapter 2 Understanding NCDs
2.1 What are NCDs?
This chapter explains what is meant by the term non-communicable diseases (NCDs) in the context of this document and outlines the burden presented by NCDs in low-, middle-, and high-income countries.
The term non-communicable disease can refer to any condition which is not transmissible between people. In this book the term focuses on the four most prominent NCDs: cardiovascular disease (heart disease and stroke), diabetes, cancers, and chronic respiratory diseases.
It is important to note that the full NCD burden also includes death and illness caused by accidents and a range of other diseases. The approach taken here of focusing on cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes mirrors that of WHO and the wider United Nations (UN) system (see Box 2.1).
Cardiovascular diseases—principally, heart disease and stroke—are the most common cause of death worldwide, responsible for over 17 million deaths in 2012. Of these, 4.73 million deaths were in the western Pacific region, 4.58 million in Europe, 3.62 million in South East Asia, 1.94 million in the Americas, 1.25 million in Africa, and 1.19 million in the eastern Mediterranean. Cardiovascular diseases account for nearly half of all NCD deaths.
Cancer is another leading cause of death and ill health, and the growing cancer burden is a major cause for concern. On a worldwide basis, there were an estimated 14.1 million cancer cases in 2012 and this is expected to reach 24 million by 2025. In the same year 8.2 million deaths were attributable to cancer. 1 Globally, lung cancer was the most common, responsible for 13% of new cases diagnosed in 2012, followed by breast cancer (1.7 million new cases in women) and colorectal cancer (nearly 1.4 million new cases). 2 Specifically in men, the most common cancers were lung, prostate, and colorectal cancers, accounting together for nearly 4% of all cancers (excluding non-melanoma skin cancer).2 For women, breast cancer was most
Box 2.1 Scope of the 2011 political declaration of the high-level meeting of the General Assembly on the Prevention and
Control of Non-communicable Diseases
The UN political declaration on NCDs which emerged from the high-level meeting in September 2011 sets out the scope of UN action on NCDs and the subsequent global action plan as highlighted by this selection of quotes (emphasis added):
Note with profound concern that, according to the World Health Organization, in 2008, an estimated 36 million of the 57 million global deaths were due to noncommunicable diseases, principally cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, including about 9 million deaths before the age of 60, and that nearly 80 per cent of those deaths occurred in developing countries.
Note further that there is a range of other non-communicable diseases and conditions, for which the risk factors and the need for preventive measures, screening, treatment, and care are linked with the four most prominent non-communicable diseases.
Recognize that mental and neurological disorders, including Alzheimer’s disease, are an important cause of morbidity and contribute to the global non-communicable disease burden, for which there is a need to provide equitable access to effective programmes and health-care interventions.
Recognize that renal, oral, and eye diseases pose a major health burden for many countries and that these diseases share common risk factors and can benefit from common responses to non-communicable diseases.
Recognize that the most prominent non-communicable diseases are linked to common risk factors, namely tobacco use, harmful use of alcohol, an unhealthy diet, and lack of physical activity
Recognize that the conditions in which people live and their lifestyles influence their health and quality of life and that poverty, uneven distribution of wealth, lack of education, rapid urbanization, population ageing, and the economic social, gender, political, behavioural, and environmental determinants of health are among the contributing factors to the rising incidence and prevalence of non-communicable diseases.
Note with grave concern the vicious cycle whereby non-communicable diseases and their risk factors worsen poverty, while poverty contributes to rising rates of noncommunicable diseases, posing a threat to public health and economic and social development.
common (more than 25% of new cases) and this was followed by colorectal and lung cancers, on a worldwide basis. 2
In 2015, 415 million people worldwide were living with diabetes—equivalent to one in 11 adults—and this total is projected to reach 642 million by 2040. It is also estimated that one in two adults with diabetes is undiagnosed. Nearly 1.5 million deaths were attributed to diabetes in 2015. On the basis of 2010 data, an estimated 46.8 million disabilityadjusted life years (DALYs) were lost to diabetes. People with diabetes are at higher risk of developing other serious diseases—persistently high blood sugar levels can affect the heart, circulatory system, eyes, kidneys, nerves, and teeth. In many countries diabetes is a leading cause of cardiovascular disease, blindness, kidney failure, and lower limb amputation. Damage to the nerves can lead to problems with digestion, erectile dysfunction, and peripheral neuropathy (pain and loss of feeling), particularly in the feet. Women with diabetes are also at higher risk of complications during pregnancy and their children are at risk of adverse health outcomes in later life.
Chronic obstructive pulmonary disease (COPD) is a life-threatening lung condition that interferes with normal breathing (due to a persistent blockage of airflow from the lungs). It is an umbrella term used to describe progressive lung diseases, such as chronic bronchitis and emphysema (these terms are no longer used). The condition is characterized by increasing breathlessness and other symptoms include abnormal sputum, a chronic cough, wheezing, and tightness in the chest. COPD was the third largest cause of death globally in 2012, when more than 3.1 million people died of the condition, representing 6% of all deaths. Of these deaths, more than 90% occur in low- and middleincome countries. In the 2013 Global Burden of Disease study, COPD was the fifth biggest cause of loss of DALYs.3
2.3 Other NCDs
The full NCD burden also includes death and illness caused by non-communicable conditions other than the four main diseases described in section 2.2. They include accidents (globally, road injury was the ninth biggest cause of death in 2012 and falls were ranked 22nd as a cause of DALYs in 2013) and a range of other diseases. These include mental and neurological disorders and renal, oral, and eye diseases.
The death and disability caused by these conditions should not be underestimated or ignored. Mental and behavioural disorders were responsible for over 257,000 deaths in 20121 and depressive disorders were the 11th largest cause of DALYs lost worldwide in 2013.3 Neurological conditions—such as Alzheimer’s disease and other dementias, Parkinson’s disease, epilepsy, and multiple sclerosis—accounted for 1.4 million deaths in 2012. Eye and ear diseases (sense organ diseases) were the 13th largest cause of disability and death (DALYs) in 2013.1 Oral conditions were responsible for 1.57 million deaths in 2012, including over 1.1 million due to dental caries. Digestive diseases accounted, in 2012, for 2.26 million deaths, including over a million due to cirrhosis of the liver.
Musculoskeletal disorders are a major source of disability, with low back and neck pain the fourth leading cause of DALYs in 2013.
For this group of NCDs, many of the risk factors—and the need for prevention, screening, treatment, and care—are linked. Conditions such as dementia and dental caries, for example, have dietary risk factors in common with cardiovascular disease. Cirrhosis of the liver, to take another example, is linked to alcohol use, also a risk factor for certain cancers.
All of these conditions, therefore, can benefit from efforts to tackle the four major NCDs and action on their major risk factors and determinants.
2.4 The burden of NCDs
Globally, NCDs are responsible for death and disability on a massive scale. NCDs are the single biggest cause of death in the world—of 56 million deaths in the world in 2012, 38 million (68%) were due to all NCDs.4
The burden of NCD mortality has risen rapidly in recent decades. The proportion of deaths attributed to all NCDs rose from 57% in 1990 to 65% in 2008.5 The proportion of
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Sandra Drake sat down on the edge of a hard bench and took a deep breath. With her free hand, she rubbed her eyes and pushed the stray hair out of them. Her eyes were red-rimmed and puffed with lack of sleep. She stretched and took a longing look at the surface of the hard bench; one of those looks that was calculating not the hardness of the bench but wondering if she could catch forty winks without having trouble call her away again. She decided not. She knew herself, and she knew that as long as she kept going she could stay awake, but if she slowed down for a moment, she'd drop off and nothing would awaken her. And forty winks would actually make her feel worse than no sleep at all.
Outside of the window, dawn was just breaking. It was a strange dawn, an alien sunrise, but one that was nothing new to Sandra Drake. Sirius II was just above the horizon, but almost lost in the
mists because of its low radiation. Sirius I was not above the horizon yet, but his strong radiation was coloring the sky blue-gray.
Sandra looked out of the window at the graying sky above. Carefully and hopefully she scanned it but she was not surprised that nothing was there for her to see. The idea of doing away with a hundred-mile satellite was too much, even for McBride, Hammond, and the rest of their gang. A hundred miles of celestial body was not large as celestial bodies go, but against man's futile efforts it was simply vast.
In all of the man-made works on Terra, Pluto, Venus, Mars, and Luna, considerably less than the volume of a hundred-mile sphere had been moved. Affected, perhaps, but not man-moved; the pile-up of rivers behind a dam could not be counted.
So man pitting himself against a celestial object seemed almost like sacrilege, though Sandra Drake knew that these men would take a job of analyzing the course-constants of the Star of Bethlehem if they thought they knew where it was now.
And as small as Soaky was against the giants of the galaxy, it was none the less a celestial object.
So she searched the sky hopefully and was not surprised that nothing was there. Her search was more "Will it happen" instead of "When will it happen?"
And then a Telfan stuck his head in the room and called: "Sandrake! Can you come?"
Sandra shook her head, rubbed her eyes again, and went.
"Now what?" she asked wearily. "We don't have to evacuate another district?"
"No," smiled Theodi, "not that bad this time. But we are going out to Loana—a small town not too far from here—and try out some of this latest stuff."
"Have any hope for it?"
"I must have hope," said Theodi.
"That's selling yourself a bill of goods," said Sandra.
"I know. But unless I play self-deception to the limit, I'll quit from sheer futility. No, Sandrake, I must hope with all my soul and I must force myself to believe that this may work."
"I won't even mention my friends," she said.
"You are beginning to give up?"
"I hate to think of it," said Sandra honestly. "It'll be the first time that they failed to do what they said they could do. I know they planned it, perhaps it takes longer than they think. Or perhaps they came unprepared; their equipment not complete. After all," and Sandra managed a reminiscent smile in spite of her feelings, "I've seen them running some of the haywirest equipment in the world and making it perform. Maybe this time the law of averages caught up with them."
"You think perhaps they are finding that our satellite is too much for them?"
"I hate to think of it. I'd hate to admit that they could fail."
"You have changed, Sandrake."
"Have I? I wonder if it is my hope that they will take me home. No, Theodi, in spite of what I may say about them, they know their potatoes. They're the typical genius-type. Whether they rate as genius I wouldn't know, but they're that kind of people. Give them a situation, and from somewhere in their memory they can bring forth the darnedest things which fit in like jigsaw pieces to complete the whole picture."
"I hope they continue," said Theodi. "Feel up to coming along?"
"Sure."
"Good. We need you."
"Who, me?" asked Sandra.
"Yes."
"Why?"
"Because you are alien. You are impartially alien. Though you have friends on Telfu, they are few, and in your secret mind you class us all
as 'Telfan' and forget about sub-classifications. This experimentation is just that, to you, and we are the subjects. Therefore when you select one hundred victims out of a district, we get a perfect, impartial selection; a true cross-section of the district."
"Any of you could do that."
"No. We'd be biased by our knowledge of who is important, who is the sicker, who is young and who is old. And, though it may seem strange to you, you have absolutely no idea of beauty. Therefore you are impartial among the ugly and the beautiful."
"So what?"
"In experimentation on humans, we are inclined to pick those of less value to the community. We pick the lame and the halt and the ugly. We are inclined to pick those who are likely not to live anyway, and this biases our selection. Come, let's get going."
"O.K. Lead on."
Three hours later, and still without sleep, Sandra strode up the line of Telfans and pointed out one after the other. Those selected followed silently to the auditorium in the center of the village and seated themselves. They looked neither happy nor regretful, but rather a resignation was upon them.
Sandra said: "Is this the best place you could pick?"
"Sorry," smiled Theodi. "I didn't know it made any difference."
"I suppose it is good from a functional standpoint," said Sandra. "Being on the stage permits them to pass before us from one side to the other. It is the only clear place in the auditorium in which to work, and as far as I could see, there isn't any other suitable place in town. But being on the stage sort of makes me ... oh, come on. I'm just tired, I guess. Where's the pills?"
"No pills on this deal," said Theodi, opening a case and removing a set of large hypodermics. "This goes into the vein. Right in the main
line. You'll have to help."
"Me? Look, Theodi, I don't feel well enough to go shoving needles into people."
Theodi looked up sharply. Her brash-sounding statement was made in a hard voice in spite of its humanitarian and pleading sound. Sandrake, to Theodi's opinion, was really feeling ill.
"It must be done," he said simply. "You fill and hand them to me."
Sandra took the first hypo, inserted it into the disinfectant, and then filled it from an ampule. She handed it to Theodi and watched him with fascination as he took the first Telfan in line and thrust the needle into his arm. It went in and in, and Theodi felt around with the needlepoint until he found the vein, and then he emptied the cylinder. "Next!" he called, and so on until the hundred had been inoculated.
"Now," said Theodi, "we'll proceed to Dorana and do likewise."
Sandra was silent all the way to the next village, and as she started down the line of people, picking them out one by one, her face began to whiten.
Halfway through, Sandra stopped.
"Go on," urged Theodi.
"Go on?" screamed Sandra. "Go on? No!"
"But—"
"Go on and on and on and on and on?" shrieked Sandra in a crescendo that ended in a toneless, inarticulate screech. She stopped the sentence only because her voice had no more range and she had no more breath. "Theodi, I feel like a murderess! I go on selecting people as I would select specimens to be speared with a mounting pin and stuck on a cardboard. I point them out. They follow dumbly with a look of resignation. They come and you try something new on them—every time it is something new, and you don't know whether it'll kill 'em or not! I can't stand it."
"But who can we have to do this?"
"Get one of your own to do your own dirty work! You need me! Bah! Suppose—?"
"Suppose we have the right combination?"
"Suppose you have? You haven't—and you know it."
"I wouldn't say that."
"I would. You're just experimenting." Sandra's lip curled over her perfect teeth in a perfect sneer. "Experimenting on your own kind. And I'm no better You should hate me—and I'm beginning to hate you and every one of you."
"This must go on—"
"It'll go on without me."
"Come on, Sandrake. Buck up. Here, I'll give you a sedative and you sleep for an hour. You're over-tired. Then—"
"Then nothing. I can't go on murdering your people any more."
"It's not murder. It's—"
"It's worse than murder. You go on filling them with colored water and telling them that you think that this is the works—and you know it is just another blind try! Go away!" Sandra whirled and ran blindly. Across the field she ran, out and away from the village. On and on she ran, until she fell breathless beside a small brook.
Thankfully, she dabbled in the brook with her tired feet, and laved the cool water on her wrists and forehead. She drank sparingly, and then stretched on her back to relieve the strained muscles that seemed to make her back arch almost to the breaking point.
Unknowing, Sandra relaxed as the ground supported her back, and with the suddenness of falling night, Sandra slept.
Her dreams were less restful than the sleep. They were filled with a whirling panorama of lights, disembodied faces, grinning, leering faces who watched long, brutal needles find the vitals of mute sufferers whose only visible admission of unbearable pain was the tortured look on their mobile faces. And through the dream, McBride
and Hammond fought against a huge metal barrier against which their mightiest efforts were futile.
The day wore on as Sandra slept, and night came, and in all that time Sandra had hardly moved. As the darkness fell, she aroused enough to drink from the brook and settle herself in a more comfortable position. Afterward she did not recall awakening at all but she did select a thick thatch of soft moss the second time and she wondered about it later. And it was about midnight when Sandra awoke.
She was slept out, rested. But the self-hatred was still vivid. The dream had kept it there, and though her body was rested, her mind was still tired from the furious mental action that went on even as she slept.
She stretched, rolled over on her back, and considered her actions of before with distaste. That had been a spectacle, and she hated spectacles except when they made her appear in a better light. She searched the sky wearily, picking out Garna, which was Telfu's sister planet, and Ordana, the behemoth of the Sirian system, both of which were shining close to the bright Geggenschein of Sirius. Above her, she spotted the place where all Telfans watched—the spot where Soaky should be according to their calculations. It was not a spot, but an area, and Sandra scanned it in a futile manner
Nothing yet.
A minute change in the sky along the horizon made her turn quickly, hopefully. She scanned the sky carefully, and yet she knew that looking at the starry curtain was futile unless the scene became so evident that it could not be missed. She could see nothing, and besides, Soaky was supposed to be above, not on the horizon.
She looked above again, but there was nothing to see. Puzzled at that—that something that had caught her attention along the horizon. She shrugged, and in trying to rationalize she admitted that it might have been a meteorite; and she knew that she was overanxious.
It was the same, she knew.
But was it? Was it?
Was it?
No, but what in the name of—?
Garna and Ordana and Geggenschein were gone from the Telfan sky. What was this? Why should planets disappear?
Planets were about as permanent as—but they must still remain, it was their light that was gone! Sandra shouted. McBride! The lens. In her mind she saw the scaled layout; Sirius, Telfu, the other planets, and Soaky, the satellite that was oh, so close to Telfu. Place two biconvex lenses, one near Sirius and one near Telfu—and any light from Sirius that could normally reach Telfu—and the planets in line from Sirius—would be cut off by the lens, refracted into the energy beam that would ultimately be focused on Soaky.
They'd started at last! Sandra looked upward into the area containing Soaky
And as she looked, a mite of colored pinpoint appeared in the sky above. It did not rise into the incandescence, it leaped. It passed upward through the red, the orange, the yellow, and the blue with lightning-flash speed, and then settled down in color to an intolerable white. It seared the eyes, that microscopic speck, and its brightness made it appear huge.
Sandra shook her head and looked down. The darkness was fading, and sharp shadows of the low bushes and herself marked the ground. The stars beside Soaky began to fade to the eye, and as the brightness took on solar brilliance, it was like the sudden return of daylight.
A flicker of the light caused Sandra to look into that intolerable light again. No, Soaky was still going strong. But it was scintillating, now, and there were streamers of incandescent vapor leaving the coruscating nucleus that was Soaky.
Full against Soaky the Sirian beam drove, and the surface vaporized. The streamers were the high-temperature vapors of incandescent
metal, being driven away from the tortured satellite by the radiation pressure of that intolerable brilliance. The vapors condensed in finely divided droplets of metal, but still floated away in lines and whorls.
The landscape around Sandra was in full light, now, and the shadows were no longer sharp. The boiling, blue-white vapors were rushing from the satellite at high velocity, and they spoiled the point-source of light. They danced and flickered in the sky, and as Sandra watched, a slight twinge of terror crossed her, and she caught her breath.
This was not right. This was—was defying God Himself. And Sandra, never awed by the men themselves, fell in fear before the visible evidence of their ability. It was not right, this utter destruction of a celestial body by man. Men were supposed to be motes—bacterium on the skin of an apple—not mighty motes capable of almost literally eating the apple that—not eating but destroying ruthlessly—the apple that was spoiling their barrel.
And Sandra, not even awed by the God of her people, prayed to Him in fear. Fear, because people of her race dared to tamper with the universe.
But then the light passed away, and no omnipotent lightning flashed across the universe to destroy it. The night fell again, and darkness, unspoiled, crowded the landscape leaving Sandra light-blind. She fumbled aimlessly in the darkness that was by contrast the utter blackness of no-light.
Sandra Drake was not alone in that. Half of the people on the planet of Telfu were blinking in the darkness; silently groping their way into their houses. Their tongues were stilled by the awesome sight.
Sandra brushed her tattered skirt and smiled. She was a long way from Indilee and she wanted to be there as soon as she could. She was beginning to feel the pinch of the months of loneliness; before, it was futility to lie awake at night and think of the touch of a human hand and the sound of a human voice. Yes, she even admitted to the desire for a bit of admiration, after all, it had been her meat and drink.
But now it was a dream about to come true. There would be people of her own kind. People who could laugh at the hardy jokes of her race, and appreciate the casual acceptance of doing absolutely nothing for periods of time. The verbal sparring and blocking would be there, too; the nice trick of forcing someone into a trap of his own making and springing it with—not double talk—but triple talk. The sound of people who could discuss both downright earthy things and high theory with the same words but with slightly different inflections in their voices, and be understood by others who knew both lines of talk.
She gave a short laugh. They would never know whether she did it from sheer altruism or because she was scared to death at the idea
of being exposed to andryorelitis.
She blinked. The sky flared briefly ahead of her in a brilliant and colorful display of some auroral discharge. It illuminated one full quarter of the celestial hemisphere in flowing color. Sandra thought and remembered a man saying: "The charge on Station One is so great that at twenty thousand feet it would arc a million miles or more." The words and the distances were forgotten, and probably wrong due to her faulty memory for those details, but she did remember something of that nature.
Obviously, one of the Stations had landed with a load of Siliconacetyldiethyl-sulfanomid. The not-quite-perfectly neutralized electronic charge must have ionized the upper air in a sprinkling corona.
From another corner of the sky, a similar flare of color flashed, and it was followed by flashes from near and far, each one creating a streaking display of celestial fireworks.
At the sight of that auroral display, Sandra's head went up, her shoulders went back, and there returned to her step a bit of that lilting walk. She smiled crookedly and then broke into that saucy grin. She set her foot on the road to Dorana, from where she could get a ride back to Indilee.
There were Terrans here, all right. Her Terrans that nothing ever stopped. They came—and brought the goods with them.
But—who brought them?
Sandra Drake.
Throughout the night, the flashing of the celestial fireworks told the whole planet that Terrans were bringing the needed drug to Telfu. And with each flash, as with each mile, a bit of the old Sandra Drake returned.
There were a lot of miles back to the Haywire Queen. THE END.
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