Chapter six Neglected Global Epidemics three growing threats Today, the burden of deaths and disability in developing countries caused by noncommunicable diseases, particularly cardiovascular conditions, outweighs that imposed by long standing communicable diseases. To tackle this well recognized"double burden", this chapter proposes a"double response"which integrates prevention and control of both communicable diseases and noncommunicable diseases within a comprehensive health care system. R The chapter also examines the stealthy but rapid evolution of two other epidemics, and ways to respond to them. The globalization of tobacco-related diseases can be countered through the WHO Framework Convention on Tobacco Control Simultaneously, the hidden epidemic" of road traffic casualties and traffic-related environmental hazards can be reduced if developing countries adapt successful road safety and other improvements from elsewhere to meet their own needs
Neglected Global Epidemics: three growing threats 83 Chapter Six Neglected Global Epidemics: three growing threats Today, the burden of deaths and disability in developing countries caused by noncommunicable diseases, particularly cardiovascular conditions, outweighs that imposed by longstanding communicable diseases. To tackle this wellrecognized "double burden", this chapter proposes a "double response" which integrates prevention and control of both communicable diseases and noncommunicable diseases within a comprehensive health care system. The chapter also examines the stealthy but rapid evolution of two other epidemics, and ways to respond to them. The globalization of tobacco-related diseases can be countered through the WHO Framework Convention on Tobacco Control. Simultaneously, the "hidden epidemic" of road traffic casualties and traffic-related environmental hazards can be reduced if developing countries adapt successful road safety and other improvements from elsewhere to meet their own needs
6 Neglected Global Epidemics three growing threats Cardiovascular diseases, the need to act Twenty-five years ago, when the delegates at the international Alma-Ata conference drew up a list of eight essential elements for primary health care, there was no mention of the treat ment or prevention of conditions such as heart disease and stroke. The priority was to deliver adequate nutrition, safe water and basic sanitation, maternal and child health care, immuni- zation against the major infectious diseases, the prevention and control of local endemic diseases, and the provision of essential drugs to the poorer countries of the world Cardiovascular diseases(CVDs)-heart disease and stroke- and other noncommunicable diseases were considered diseases of the industrialized countries- so-called "Western dis- ases-brought about by ways of life utterly different from those in most of Africa, Asia and many other parts of the developing world. It is noteworthy, however, that as early as 1954 the delegate of India to the World Health Assembly called for steps to be taken towards the pre- vention of CVDs in developing countries The global health agenda is still dominated by the notion that communicable diseases need to be prevented and treated before CVDs receive attention. There is a lingering view that CVDs are mostly confined to wealthy people and are caused by natural ageing and degenera tive processes. There persists a widespread belief that they are "lifestyle diseases", fully under the control of individual decisions The reality is quite different. CVDs have not only emerged in all but the very poorest coun tries, but are already well advanced; this growing burden has real potential to hinder social and economic development. Risk factors are indicators of future health status, and five of the top 10 risks worldwide are specific to noncommunicable diseases(1). These include raised blood pressure, tobacco use, alcohol consumption, cholesterol, and obesity or overweight This is part of the well-documented epidemiological transition called the"double burden that sees the arrival of the whole group of noncommunicable diseases with their shared risk factors on top of the persisting threat of communicable diseases. As a consequence, health systems are now required that can deal comprehensively with all common diseases, irrespe tive of their origin As highlighted in Chapter 1, in today s world most deaths are attributable to noncommunicable iseases(32 million)and just over half of these(16. 7 million)are the result of CVD; more than one-third of these deaths occur in middle-aged adults. In developed countries, heart disease and stroke are the first and second leading causes of death for adult men and women
Neglected Global Epidemics: three growing threats 85 6 Neglected Global Epidemics: three growing threats Cardiovascular diseases: the need to act Twenty-five years ago, when the delegates at the international Alma-Ata conference drew up a list of eight essential elements for primary health care, there was no mention of the treatment or prevention of conditions such as heart disease and stroke. The priority was to deliver adequate nutrition, safe water and basic sanitation, maternal and child health care, immunization against the major infectious diseases, the prevention and control of local endemic diseases, and the provision of essential drugs to the poorer countries of the world. Cardiovascular diseases (CVDs) – heart disease and stroke – and other noncommunicable diseases were considered diseases of the industrialized countries – so-called “Western diseases” – brought about by ways of life utterly different from those in most of Africa, Asia and many other parts of the developing world. It is noteworthy, however, that as early as 1954 the delegate of India to the World Health Assembly called for steps to be taken towards the prevention of CVDs in developing countries. The global health agenda is still dominated by the notion that communicable diseases need to be prevented and treated before CVDs receive attention. There is a lingering view that CVDs are mostly confined to wealthy people and are caused by natural ageing and degenerative processes. There persists a widespread belief that they are “lifestyle diseases”, fully under the control of individual decisions. The reality is quite different. CVDs have not only emerged in all but the very poorest countries, but are already well advanced; this growing burden has real potential to hinder social and economic development. Risk factors are indicators of future health status, and five of the top 10 risks worldwide are specific to noncommunicable diseases (1). These include raised blood pressure, tobacco use, alcohol consumption, cholesterol, and obesity or overweight. This is part of the well-documented epidemiological transition called the “double burden” that sees the arrival of the whole group of noncommunicable diseases with their shared risk factors on top of the persisting threat of communicable diseases. As a consequence, health systems are now required that can deal comprehensively with all common diseases, irrespective of their origin. As highlighted in Chapter 1, in today’s world most deaths are attributable to noncommunicable diseases (32 million) and just over half of these (16.7 million) are the result of CVD; more than one-third of these deaths occur in middle-aged adults. In developed countries, heart disease and stroke are the first and second leading causes of death for adult men and women
86TheWorldHealthReport2003 These facts are familiar and hardly surprising. What is surprising, however, is that in some developing countries, CVDs have also become the first and second leading causes, responsi- ole for one-third of all deaths(see Figure 6.1) In fact, twice as many deaths from CVD now occur in developing countries as in developed countries. Overall, in developing countries, CVD ranks third in disease burden(after injuries and neuropsychiatric disorders). Even in high-mortality developing countries, CVD is ranked rery high. A particular cause of concern is the relatively early age of Cvd deaths in developing coun tries compared with those in the developed regions(2 ). One in two of the CVD-related deaths in India occur below the age of 70 years, compared with one in five in economically well developed nations. In both rural and urban areas of the United Republic of Tanzania, stroke mortality rates are three times higher than those in England and wales. What is not often recognized is that, globally, CVDs account for as many deaths in young and middle-aged adults as Hiv/aIDs This does not mean that communicable diseases have quietly gone away, require less funding, or are now safely under control. The advent of HIVIAIDS shattered that hope(see Chapter 3). Malaria and tuberculosis are among other enormous threats that remain and are growing In addition, as pointed out in Chapter 5, new infectious diseases have been emerging at the rate of one a year for the last 20 years or more: SARS is the latest. So it is legitimate that public health communities remain vigilant towards infectious diseases, and that this vigilance be- gins with primary health care, in accordance with the Declaration of Alma-Ata. However, the world cannot afford to lose sight of the growing social and economic threats posed by Cvd and other noncommunicable diseases Ironically, CVDs are now in decline in the industrialized countries first associated with them But from that irony stems hope: the decline is largely a result of the successes of primary prevention and, to a lesser extent, treatment. What has worked in the richer nations-and ure 6.1 Deaths attributable to 16 leading causes in developing countries, 2001 Cardiovascular diseases alignant neoplasms Injuries Chronic respiratory diseases HIVIAIDS Diarrhoeal diseases Tuberculosis Digestive diseases Childhood diseases Diabetes mellitus口 Diseases of the genitourinary system n Low-mortality developing countries Neuropsychiatric disorders High-mortality developing countries 12000 Deaths(000)
86 The World Health Report 2003 These facts are familiar and hardly surprising. What is surprising, however, is that in some developing countries, CVDs have also become the first and second leading causes, responsible for one-third of all deaths (see Figure 6.1). In fact, twice as many deaths from CVD now occur in developing countries as in developed countries. Overall, in developing countries, CVD ranks third in disease burden (after injuries and neuropsychiatric disorders). Even in high-mortality developing countries, CVD is ranked very high. A particular cause of concern is the relatively early age of CVD deaths in developing countries compared with those in the developed regions (2). One in two of the CVD-related deaths in India occur below the age of 70 years, compared with one in five in economically welldeveloped nations. In both rural and urban areas of the United Republic of Tanzania, stroke mortality rates are three times higher than those in England and Wales. What is not often recognized is that, globally, CVDs account for as many deaths in young and middle-aged adults as HIV/AIDS. This does not mean that communicable diseases have quietly gone away, require less funding, or are now safely under control. The advent of HIV/AIDS shattered that hope (see Chapter 3). Malaria and tuberculosis are among other enormous threats that remain and are growing. In addition, as pointed out in Chapter 5, new infectious diseases have been emerging at the rate of one a year for the last 20 years or more: SARS is the latest. So it is legitimate that public health communities remain vigilant towards infectious diseases, and that this vigilance begins with primary health care, in accordance with the Declaration of Alma-Ata. However, the world cannot afford to lose sight of the growing social and economic threats posed by CVD and other noncommunicable diseases. Ironically, CVDs are now in decline in the industrialized countries first associated with them. But from that irony stems hope: the decline is largely a result of the successes of primary prevention and, to a lesser extent, treatment. What has worked in the richer nations – and 0 2000 4000 6000 8000 10 000 12 000 Maternal conditions Neuropsychiatric disorders Diseases of the genitourinary system Diabetes mellitus Malaria Childhood diseases Digestive diseases Tuberculosis Diarrhoeal diseases Perinatal conditions HIV/AIDS Chronic respiratory diseases Respiratory infections Injuries Malignant neoplasms Cardiovascular diseases Low-mortality developing countries High-mortality developing countries Deaths (000) Figure 6.1 Deaths attributable to 16 leading causes in developing countries, 2001
Neglected Global Epidemics: three growing threats especially for the most advantaged members of these societies- can be just as effective in their poorer counterparts There is now abundant evidence to initiate effective actions at national and global levels to promote and protect cardiovascular health through population-based measures that focus on the main risk factors shared by all noncommunicable diseases. The population-wide ap- plication of existing knowledge has the potential to make a major, rapid and cost-effective contribution to their prevention and control and to benefit all segments of the population(3) The main issue for policy-makers, at all levels of public health in developing countries, is how to deal with the growing burden of epidemics of noncommunicable diseases in the presence of persisting communicable disease epidemics. Furthermore, this challenge must be faced even where health system resources are already inadequate. Although considerable policy gains can be made very cheaply, especially intersectorally, extra provision must be found This requires a greater share of national resources for health care, better use of existing re- sources,and new sources of funding. A special tax on tobacco products for disease preven tion programmes is a readily available source of new funds for most countries. The causes are known The good news is that an impressive body of research has identified the causes of the CVd epidemics within populations(1). Global trade and marketing developments continue to drive the nutrition transition towards diets with a high proportion of saturated fat, sugar and salt. At the same time, protective elements like fibre and phytochemicals in fresh fruit and vegetables are being progressively depleted in diets. When combined with tobacco use and low levels of physical activity, this diet leads to population-wide atherosclerosis and the wide spread distribution of CVDs. Variations in these same major risk factors explain much of the ajor difference in rates of CVDs between countries. In summary, the major CVD risk factors of tobacco use, inappropriate diet and physical inac tivity(primarily expressed through unfavourable lipid concentrations, high body-mass ir dex, and raised blood pressure)explain at least 75-85% of new cases of coronary heart disease (4 ) In the absence of elevations of these risk factors, coronary heart disease is a rare cause of death. Unfortunately, the vast majority of the populations in almost all countries are at risk of developing CVD because of higher than optimal levels of the main risk factors. Only about 5%of adult men and women in wealthy countries are at low risk with optimal risk factor levels. There are only a few very poor countries in which these factors have not yet emerged as major public health problems. Policies are available One of the most exciting possibilities to emerge in public health in recent years is the integra- tion of communicable disease and CVd prevention and control into comprehensive health systems led by primary care. Bringing this to fruition will mean reshaping the future of pri- mary health care in response to a changing world. It would see all patients being offered across their lifespan-prevention, treatment and long-term management of both sides of the double burden Achieving such integration will not be easy. Apart from other considerations, it will require cooperation between professional rivals, who each regard their side of the double burden to be more important than the other, and who compete for their share of limited resources Such competitiveness has long been entrenched across the battlefields of public health And
Neglected Global Epidemics: three growing threats 87 especially for the most advantaged members of these societies – can be just as effective in their poorer counterparts. There is now abundant evidence to initiate effective actions at national and global levels to promote and protect cardiovascular health through population-based measures that focus on the main risk factors shared by all noncommunicable diseases. The population-wide application of existing knowledge has the potential to make a major, rapid and cost-effective contribution to their prevention and control and to benefit all segments of the population (3). The main issue for policy-makers, at all levels of public health in developing countries, is how to deal with the growing burden of epidemics of noncommunicable diseases in the presence of persisting communicable disease epidemics. Furthermore, this challenge must be faced even where health system resources are already inadequate. Although considerable policy gains can be made very cheaply, especially intersectorally, extra provision must be found. This requires a greater share of national resources for health care, better use of existing resources, and new sources of funding. A special tax on tobacco products for disease prevention programmes is a readily available source of new funds for most countries. The causes are known The good news is that an impressive body of research has identified the causes of the CVD epidemics within populations (1). Global trade and marketing developments continue to drive the nutrition transition towards diets with a high proportion of saturated fat, sugar and salt. At the same time, protective elements like fibre and phytochemicals in fresh fruit and vegetables are being progressively depleted in diets. When combined with tobacco use and low levels of physical activity, this diet leads to population-wide atherosclerosis and the widespread distribution of CVDs. Variations in these same major risk factors explain much of the major difference in rates of CVDs between countries. In summary, the major CVD risk factors of tobacco use, inappropriate diet and physical inactivity (primarily expressed through unfavourable lipid concentrations, high body-mass index, and raised blood pressure) explain at least 75–85% of new cases of coronary heart disease (4). In the absence of elevations of these risk factors, coronary heart disease is a rare cause of death. Unfortunately, the vast majority of the populations in almost all countries are at risk of developing CVD because of higher than optimal levels of the main risk factors. Only about 5% of adult men and women in wealthy countries are at low risk with optimal risk factor levels. There are only a few very poor countries in which these factors have not yet emerged as major public health problems. Policies are available One of the most exciting possibilities to emerge in public health in recent years is the integration of communicable disease and CVD prevention and control into comprehensive health systems led by primary care. Bringing this to fruition will mean reshaping the future of primary health care in response to a changing world. It would see all patients being offered – across their lifespan – prevention, treatment and long-term management of both sides of the double burden. Achieving such integration will not be easy. Apart from other considerations, it will require cooperation between professional rivals, who each regard their side of the double burden to be more important than the other, and who compete for their share of limited resources. Such competitiveness has long been entrenched across the battlefields of public health. And
The World Health Report 2003 yet, as the chapter of this report on SARS has shown, cross-disciplinary collaboration is not only possible but can be enormously rewarding to all concerned. In the case of this new pidemic, the worlds best scientists, clinicians and public health experts were willing to se aside academic competition and work together for the public good- because the circum- stances so clearly required it. Paradoxically, a matching policy response to tackle public health challenges of even greater magnitude is lacking: the mounting menace of the global CVD epidemic is evolving rapidly Another critical policy issue, especially for poor countries, concerns the appropriate balance between primary and secondary prevention and between the population and high-risk ap- proaches to primary prevention. If the goal is to increase the proportion of the population at low risk and to ensure that all groups benefit, the strategy with the greatest potential is the one directed at the whole population, not just people with high levels of risk factors or estab- lished disease(5). All other strategies will, at best, only blunt the epidemics and likely in- crease inequalities; they will not prevent the epidemics. Even so, with ageing populations, health systems will continue to face the unrelenting demands of costly care, both acute and chronic(see Box 1.3 in Chapter 1) The ultimate public health policy goal is the reduction of population risk, and since most of the population in most countries is not at the optimal risk level, it follows that the majority of prevention and control resources should be directed towards this goal in the entire popula tion. Evidence is available in support of the cost-effective policies required for the task of making the small-but powerful and surprisingly rapid -shifts in risk distributions in entire populations in a favourable direction (1). Similarly, management decisions based on meas- ures of overall risk are more cost-effective than those based on single risk factors Untold lives lost are lost unnecessarily because of inadequate acute and long-term manage- ment of CVD. Relatively cheap interventions for CVD are available(6), and single combina tion pills including aspirin and drugs for blood pressure and cholesterol lowering for possible use in chronic care are under development. Even in wealthy countries, however, the potential of these and other interventions for secondary prevention is far from fully utilized. The situ ation in poorer countries is even less satisfactory. There are many opportunities for coordi- nated CVD risk reduction, care and long-term management. Smoking cessation and the identification and management of diabetes, for example, are just two priorities. Cost-effec tive interventions, such as the use of aspirin in people with symptoms of chest pain, would prevent a quarter of the deaths associated with heart attacks and are much more cost-effe tive than more radical interventions such as revascularization procedures, which are inevita bly restricted to a minority of patients with CVD. Acting now and measuring progress There have been striking and rapid reductions in Cvd death rates in wealthy countries especially benefiting the wealthiest and most educated -because of comprehensive approaches including both improved prevention and the management of high-risk people. Policy inter ventions in developed and developing countries can lead to a surprisingly rapid response. In Mauritius, government action to encourage consumption of healthy oils resulted in a rapid decrease in population levels of blood cholesterol In Finland, government agricultural sub sidies were used to reduce dairy farming and increase berry production. And in Poland, in- creased consumption of fresh fruit and vegetables, consequent to changes in the polio environment, were associated with a sharp decline in CVD death rates. A WHO/FAO expert onsultation report on diet, nutrition and the prevention of chronic diseases reviewed the
88 The World Health Report 2003 yet, as the chapter of this report on SARS has shown, cross-disciplinary collaboration is not only possible but can be enormously rewarding to all concerned. In the case of this new epidemic, the world’s best scientists, clinicians and public health experts were willing to set aside academic competition and work together for the public good – because the circumstances so clearly required it. Paradoxically, a matching policy response to tackle public health challenges of even greater magnitude is lacking: the mounting menace of the global CVD epidemic is evolving rapidly. Another critical policy issue, especially for poor countries, concerns the appropriate balance between primary and secondary prevention and between the population and high-risk approaches to primary prevention. If the goal is to increase the proportion of the population at low risk and to ensure that all groups benefit, the strategy with the greatest potential is the one directed at the whole population, not just people with high levels of risk factors or established disease (5). All other strategies will, at best, only blunt the epidemics and likely increase inequalities; they will not prevent the epidemics. Even so, with ageing populations, health systems will continue to face the unrelenting demands of costly care, both acute and chronic (see Box 1.3 in Chapter 1). The ultimate public health policy goal is the reduction of population risk, and since most of the population in most countries is not at the optimal risk level, it follows that the majority of prevention and control resources should be directed towards this goal in the entire population. Evidence is available in support of the cost-effective policies required for the task of making the small – but powerful and surprisingly rapid – shifts in risk distributions in entire populations in a favourable direction (1). Similarly, management decisions based on measures of overall risk are more cost-effective than those based on single risk factors. Untold lives lost are lost unnecessarily because of inadequate acute and long-term management of CVD. Relatively cheap interventions for CVD are available (6), and single combination pills including aspirin and drugs for blood pressure and cholesterol lowering for possible use in chronic care are under development. Even in wealthy countries, however, the potential of these and other interventions for secondary prevention is far from fully utilized. The situation in poorer countries is even less satisfactory. There are many opportunities for coordinated CVD risk reduction, care and long-term management. Smoking cessation and the identification and management of diabetes, for example, are just two priorities. Cost-effective interventions, such as the use of aspirin in people with symptoms of chest pain, would prevent a quarter of the deaths associated with heart attacks and are much more cost-effective than more radical interventions such as revascularization procedures, which are inevitably restricted to a minority of patients with CVD. Acting now and measuring progress There have been striking and rapid reductions in CVD death rates in wealthy countries – especially benefiting the wealthiest and most educated – because of comprehensive approaches including both improved prevention and the management of high-risk people. Policy interventions in developed and developing countries can lead to a surprisingly rapid response. In Mauritius, government action to encourage consumption of healthy oils resulted in a rapid decrease in population levels of blood cholesterol. In Finland, government agricultural subsidies were used to reduce dairy farming and increase berry production. And in Poland, increased consumption of fresh fruit and vegetables, consequent to changes in the policy environment, were associated with a sharp decline in CVD death rates. A WHO/FAO expert consultation report on diet, nutrition and the prevention of chronic diseases reviewed the
Neglected Global Epidemics: three growing threats evidence and provided recommendations for nutrient intake goals for the prevention of CVD and other noncommunicable diseases(7) A coherent policy framework, encompassing legislation, regulation and mass education is critical for CVD prevention and control, since individual behaviour change is difficult in the absence of conducive environmental alterations. A suggested stepwise framework for a com prehensive response to CVD prevention and control is outlined in Table 6. 1 and can be modi- fied according to national needs, goals and targets Table 6.1 A stepwise approach for prevention and control of noncommunicable diseases Individual high-risk approach Resource level National level Community level Step 1 WHO Framework Convention on Local infrastructure plans indude the Context-specific management guide Tobacco Control (FCTC)is ratified in the provision and maintenance of accessible lines for noncommunicable diseases and safe sites for physical activity (such have been adopted and are used at all Tobacco control legislation consistent as parks and pedestrian-only areas). health care levels. with the elements of the FCTC is Health-promoting community projects A sustainable, accessible and affordable enacted and enforced include participatory actions to cope supply of appropriate medication is Anational nutrition and physical activity, predispose to risk of noncommunicable asele for priority noncommunicable with the environmental factors that policy consistent with the Globa trategy is developed and endorsed at diseases: inactivity, unhealthy diet, A system exists for the consi Cabinet level: sustained multisectoral tobacco use, alcohol use, etc. uality application of clinica action is evident to reduce fat intake, Active health promotion programmes and for the clinical audit reduce salt (with attention to iodized focusing on noncommunicable diseases offered salt where appropriate), and promote are implemented in different settings fruit and vegetable consumption. villages, schools and workplaces. for recall of patients with hypertension is Health impact assessment of publi y is carried out(for example ort, urban planning, taxation, and Tobacco legislation provides for Sustained, well-designed programmes ms are in place for selective and Expanded incremental increases in tax on tobacco, are in place to promote ted prevention aimed at high-risk and a proportion of the revenue is tobacco-free lifestyles, e.g. smoke. lations, based on absolute levels earmarked for health promotion ee public places, smoke-free sports; Food standards legislation is enacted and enforced: it includes nutrition healthy diets, e.g. low-cost, low-fat lab foods, fresh fruit and vegetables; Sustained, well-designed, national hysical activity, e.g. "movement"in fferent domains occupational and programmes (counter-advertising) are in place to promote non-smoking Step 3: Country standards are established that Recreational and fitness centres are Opportunistic screening, case-finding Optimal regulate marketing of unhealthy food available for community use. and management programmes are to children Capacity for health research is built Support groups are fostered for tobacco within countries by encouraging studies cessation and overweight reduction on noncommunicable diseases Appropriate diagnostic and therapeutic interventions are implemented Adapted from: (8)
Neglected Global Epidemics: three growing threats 89 evidence and provided recommendations for nutrient intake goals for the prevention of CVD and other noncommunicable diseases (7). A coherent policy framework, encompassing legislation, regulation and mass education is critical for CVD prevention and control, since individual behaviour change is difficult in the absence of conducive environmental alterations. A suggested stepwise framework for a comprehensive response to CVD prevention and control is outlined in Table 6.1 and can be modified according to national needs, goals and targets. Table 6.1 A stepwise approach for prevention and control of noncommunicable diseases Resource level Step 1: Core Step 2: Expanded Step 3: Optimal Context-specific management guidelines for noncommunicable diseases have been adopted and are used at all health care levels. A sustainable, accessible and affordable supply of appropriate medication is assured for priority noncommunicable diseases. A system exists for the consistent, highquality application of clinical guidelines and for the clinical audit of services offered. A system for recall of patients with diabetes and hypertension is in operation. Systems are in place for selective and targeted prevention aimed at high-risk populations, based on absolute levels of risk. Opportunistic screening, case-finding and management programmes are implemented. Support groups are fostered for tobacco cessation and overweight reduction. Appropriate diagnostic and therapeutic interventions are implemented. Population approaches Individual high-risk approach Adapted from: (8). National level WHO Framework Convention on Tobacco Control (FCTC) is ratified in the country. Tobacco control legislation consistent with the elements of the FCTC is enacted and enforced. A national nutrition and physical activity policy consistent with the Global Strategy is developed and endorsed at Cabinet level; sustained multisectoral action is evident to reduce fat intake, reduce salt (with attention to iodized salt where appropriate), and promote fruit and vegetable consumption. Health impact assessment of public policy is carried out (for example: transport, urban planning, taxation, and pollution). Tobacco legislation provides for incremental increases in tax on tobacco, and a proportion of the revenue is earmarked for health promotion. Food standards legislation is enacted and enforced; it includes nutrition labelling. Sustained, well-designed, national programmes (counter-advertising) are in place to promote non-smoking lifestyles. Country standards are established that regulate marketing of unhealthy food to children. Capacity for health research is built within countries by encouraging studies on noncommunicable diseases. Community level Local infrastructure plans include the provision and maintenance of accessible and safe sites for physical activity (such as parks and pedestrian-only areas). Health-promoting community projects include participatory actions to cope with the environmental factors that predispose to risk of noncommunicable diseases: inactivity, unhealthy diet, tobacco use, alcohol use, etc. Active health promotion programmes focusing on noncommunicable diseases are implemented in different settings: villages, schools and workplaces. Sustained, well-designed programmes are in place to promote: • tobacco-free lifestyles, e.g. smokefree public places, smoke-free sports; • healthy diets, e.g. low-cost, low-fat foods, fresh fruit and vegetables; • physical activity, e.g. “movement” in different domains (occupational and leisure). Recreational and fitness centres are available for community use
The World Health Report 2003 Unfortunately, in most countries the response to CVd prevention and control is still based on the infectious disease paradigm. Consequently, the global and national capacity to re- spond to CVd epidemics is woefully inadequate. Few countries have implemented compre hensive prevention and control policies(9)and development of capacity, especially for policy research, has not kept pace with the epidemiological transition. The gaps between the needs for CVd prevention and control and the capacity to meet them will grow even wider unless urgent steps are taken. Global norms are needed to balance the otherwise unrestrained influences of powerful ac tors. To promulgate such norms, public health professionals need to learn how to influence the deliberations of bodies such as the World Trade Organization- where health issues are Increasins gly considered-and to develop stronger ways of dealing with products with health impacts. A combination of multistakeholder and intergovernmental codes and other non- binding measures may be required. The Framework Convention on Tobacco Control, de- scribed in the following section, is one example of a legally binding global norm. WHO and governments cannot confront the challenges of CVD prevention and control alone. As with tobacco control, partnerships and interactions with international consumer groups and global commercial multinationals are essential. WHO is developing a Global Strategy on Diet, Physical Activity and Health as a strategic framework within which WHO and Member States can work together across sectors in preventing CVD and other noncommunicable dis eases. This population-wide prevention strategy is based on extensive consultations with stakeholders: Member States, the United Nations and intergovernmental organizations, civil society and the private sector Globally, there is still only limited advocacy for the CVd prevention and control agenda. What there is tends to be fragmented. The lack of unified advocacy for health promotion Box 6.1 Measuring progress: integrated surveillance of noncommunicable disease risk factors The goal of surveillance is to monitor emerging patterns and trends in get started in surveillance and prevention activities for noncommunicable major cardiovascular disease(CVD)and other noncommunicable dis- diseases. By increasing local capacity, STEPS aims to achieve data com- ease(NCD)risk factors and to measure the effectiveness of prevention parability over time and between countries. Many Member States have interventions in countries. Two tools have now been trained in the STEPS methodology developed for this purpose The approach is designed to build on existing STEPwise approach to Surveillance(STEPS)of surveillance activities, but can also be intro- noncommunicable disease risk factors(10) duced as a new methodology to countries where there are no surveillance systems cur STEPS is a sequential process, starting rently in place. Data collected using the STEPwise approach is fed into the WHO Glo- haviours by the use of questionnaires (Step bal NCD InfoBase 1), then moving to simple physical measure- The WHO Global NCD InfoBase is a da ments(Step 2), and only then recommending tabase designed to hold existing country-level the collection of blood samples for biochemi- data on risk factors of noncommunicable dis. cal assessment(Step 3). This framework builds eases Its strength is that the data can be dis a common approach to defining core variables played and used to derive a single best for surveys, surveillance and monitoring sys Core prevalence estimate for any given country. This ms. The goal is to achieve data comparabil. approach allows transparency in the use of y over time and between countries. The country data sources. It is a major improve methodology has been developed in close collaboration with WHO re. ment on previous WHO estimates, which, in the absence of such a rela- gional offices and is easily adaptable to the needs of Member States. It tional database, relied on selected studies which may have excluded offers an entry point for low-income and middle-income countries to many available sources and lacked transparency
90 The World Health Report 2003 Unfortunately, in most countries the response to CVD prevention and control is still based on the infectious disease paradigm. Consequently, the global and national capacity to respond to CVD epidemics is woefully inadequate. Few countries have implemented comprehensive prevention and control policies (9) and development of capacity, especially for policy research, has not kept pace with the epidemiological transition. The gaps between the needs for CVD prevention and control and the capacity to meet them will grow even wider unless urgent steps are taken. Global norms are needed to balance the otherwise unrestrained influences of powerful actors. To promulgate such norms, public health professionals need to learn how to influence the deliberations of bodies such as the World Trade Organization – where health issues are increasingly considered – and to develop stronger ways of dealing with products with health impacts. A combination of multistakeholder and intergovernmental codes and other nonbinding measures may be required. The Framework Convention on Tobacco Control, described in the following section, is one example of a legally binding global norm. WHO and governments cannot confront the challenges of CVD prevention and control alone. As with tobacco control, partnerships and interactions with international consumer groups and global commercial multinationals are essential. WHO is developing a Global Strategy on Diet, Physical Activity and Health as a strategic framework within which WHO and Member States can work together across sectors in preventing CVD and other noncommunicable diseases. This population-wide prevention strategy is based on extensive consultations with stakeholders: Member States, the United Nations and intergovernmental organizations, civil society and the private sector. Globally, there is still only limited advocacy for the CVD prevention and control agenda. What there is tends to be fragmented. The lack of unified advocacy for health promotion Box 6.1 Measuring progress: integrated surveillance of noncommunicable disease risk factors The goal of surveillance is to monitor emerging patterns and trends in major cardiovascular disease (CVD) and other noncommunicable disease (NCD) risk factors and to measure the effectiveness of prevention interventions in countries. Two tools have been developed for this purpose: the WHO STEPwise approach to Surveillance (STEPS) of noncommunicable disease risk factors (10) and the WHO Global NCD InfoBase (11). STEPS is a sequential process, starting with gathering information on key health behaviours by the use of questionnaires (Step 1), then moving to simple physical measurements (Step 2), and only then recommending the collection of blood samples for biochemical assessment (Step 3). This framework builds a common approach to defining core variables for surveys, surveillance and monitoring systems. The goal is to achieve data comparability over time and between countries. The methodology has been developed in close collaboration with WHO regional offices and is easily adaptable to the needs of Member States. It offers an entry point for low-income and middle-income countries to get started in surveillance and prevention activities for noncommunicable diseases. By increasing local capacity, STEPS aims to achieve data comparability over time and between countries. Many Member States have now been trained in the STEPS methodology. The approach is designed to build on existing surveillance activities, but can also be introduced as a new methodology to countries where there are no surveillance systems currently in place. Data collected using the STEPwise approach is fed into the WHO Global NCD InfoBase. The WHO Global NCD InfoBase is a database designed to hold existing country-level data on risk factors of noncommunicable diseases. Its strength is that the data can be displayed and used to derive a single best prevalence estimate for any given country. This approach allows transparency in the use of country data sources. It is a major improvement on previous WHO estimates, which, in the absence of such a relational database, relied on selected studies which may have excluded many available sources and lacked transparency. Biochemical measurements Physical measurements Questionnaires Core Expanded Option 1 Option 3 Option 2 Step 1 Step 3 Step 2
Neglected Global Epidemics: three growing threats compares poorly with the growing dominance of commercial and consumer groups who have placed treatment at the centre of health policy debates and funding priorities. Broader alliances of major health professional bodies, consumer groups and others are needed to promote the prevention of major risk factors for CVD and to track progress to agreed na- tional and global goals- perhaps modelled on the Millennium Development Goals(see Box 6.1). Since the determinants of CVD are multisectoral, advocacy and action, too, must extend well beyond the health sector. The involvement of nongovernmental organizations in articu lating the demand for speedy implementation of policies and programmes relevant to CVD control is critical for catalysing policy change and for mobilizing communities to ensure that he benefits flow to the entire population. While the pace of globalization of the major risks for CVDs is increasing, progress towards CVD prevention and control is slow. Sustained progress will occur only when governments, international agencies, nongovernmental organizations and civil society acknowledge that the scope of public health activities must be rapidly broadened to include CVDs and their tors The challenge is to work towards the integration of prevention and control of both commu- nicable diseases and CVDs, while acknowledging the different time scales of these epidemics and the competition for limited resources. a place must be found for the prevention and control of CVD on the agenda of health systems led by primary care At Alma-Ata 25 years ago it was deemed unnecessary. Today, it is indispensable Tobacco control: strengthening national efforts The consumption of cigarettes and other tobacco products and exposure to tobacco smoke are the worlds leading preventable cause of death, responsible for about 5 million deaths a year, mostly in poor countries and poor populations. Latest estimates reveal that, of the nearly 4 million men and l million women who died. over 2 million men and 380 000 w in developing countries (12). The toll will double in 20 years unless available and effective interventions are urgently and widely adopted. Globalization of the tobacco epidemic can undermine even the best national control pro gramme. The epidemic is being spread and reinforced worldwide by a complex mix of factors with cross-border effects, including trade liberalization, foreign direct investment, and other factors such as global marketing, transnational tobacco advertising, promotion and sponsor ship, and the international movement of contraband and counterfeit cigarettes. Recognition of this situation led to the adoption by 192 Member States at the World Health Assembly in May 2003 of the WHO Framework Convention on Tobacco Control(WHO FCTC). This, the first treaty negotiated under the auspices of WHO, constitutes a major turning point in tack- ling a major global killer: it signals a new era in global and national tobacco control activities. The FCTC is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. It represents a paradigm shift in developing a regulatory strategy for ad- dictive substances: in contrast to previous drug control treaties, the FCTC asserts the impor tance of demand reduction strategies as well as supply issues. Major challenges lie ahead as WHO works with Member States to implement the agreement in countries. The process of the FCTC's creation also reveals the price paid for delay between vision and action. It has taken almost 10 years to bring the idea of such an instrument to fruition. During that time, more than 30 million people have died of tobacco-related ill- nesses, 70% of them in low-income and middle-income countries and half before the age of 70
Neglected Global Epidemics: three growing threats 91 compares poorly with the growing dominance of commercial and consumer groups who have placed treatment at the centre of health policy debates and funding priorities. Broader alliances of major health professional bodies, consumer groups and others are needed to promote the prevention of major risk factors for CVD and to track progress to agreed national and global goals – perhaps modelled on the Millennium Development Goals (see Box 6.1). Since the determinants of CVD are multisectoral, advocacy and action, too, must extend well beyond the health sector. The involvement of nongovernmental organizations in articulating the demand for speedy implementation of policies and programmes relevant to CVD control is critical for catalysing policy change and for mobilizing communities to ensure that the benefits flow to the entire population. While the pace of globalization of the major risks for CVDs is increasing, progress towards CVD prevention and control is slow. Sustained progress will occur only when governments, international agencies, nongovernmental organizations and civil society acknowledge that the scope of public health activities must be rapidly broadened to include CVDs and their risk factors. The challenge is to work towards the integration of prevention and control of both communicable diseases and CVDs, while acknowledging the different time scales of these epidemics and the competition for limited resources. A place must be found for the prevention and control of CVD on the agenda of health systems led by primary care. At Alma-Ata 25 years ago it was deemed unnecessary. Today, it is indispensable. Tobacco control: strengthening national efforts The consumption of cigarettes and other tobacco products and exposure to tobacco smoke are the world’s leading preventable cause of death, responsible for about 5 million deaths a year, mostly in poor countries and poor populations. Latest estimates reveal that, of the nearly 4 million men and 1 million women who died, over 2 million men and 380 000 women were in developing countries (12). The toll will double in 20 years unless available and effective interventions are urgently and widely adopted. Globalization of the tobacco epidemic can undermine even the best national control programme. The epidemic is being spread and reinforced worldwide by a complex mix of factors with cross-border effects, including trade liberalization, foreign direct investment, and other factors such as global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contraband and counterfeit cigarettes. Recognition of this situation led to the adoption by 192 Member States at the World Health Assembly in May 2003 of the WHO Framework Convention on Tobacco Control (WHO FCTC). This, the first treaty negotiated under the auspices of WHO, constitutes a major turning point in tackling a major global killer: it signals a new era in global and national tobacco control activities. The FCTC is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. It represents a paradigm shift in developing a regulatory strategy for addictive substances: in contrast to previous drug control treaties, the FCTC asserts the importance of demand reduction strategies as well as supply issues. Major challenges lie ahead as WHO works with Member States to implement the agreement in countries. The process of the FCTC’s creation also reveals the price paid for delay between vision and action. It has taken almost 10 years to bring the idea of such an instrument to fruition. During that time, more than 30 million people have died of tobacco-related illnesses, 70% of them in low-income and middle-income countries and half before the age of 70
The World Health Report 2003 Those who died before 70 years of age lost, on average, 28 years of life(13). As entry into force of the Convention draws nearer, strengthening national capacity in tobacco control becomes an important public health priority in all countries This section looks forward to the timely ratification, entry into force, and implementation of the FCTC and the opportunities thus presented for further progress in national tobacco con trol. It also examines the challenges of building and strengthening national political, m genial and technical tobacco control capacit Guiding tobacco control Total tobacco consumption is on the rise. The number of smokers in the world, estimated at 1.3 billion today, is expected to rise to 1.7 billion by 2025 if the global prevalence of tobacco use remains unchanged (14). Every second smoker will die of a tobacco-caused disease Until recently, the global response to this major public health challenge had been inadequate. In May 2003 the World Health Assembly adopted by consensus the WHo Framework Con vention on Tobacco Control(FCTC) Negotiated among WHO Member States over four years, this international legal instrument is designed to limit the harm to health caused by tobacco products. It comprises many diverse aspects of tobacco control, including: advertising, pro- motion and sponsorship; packaging and labelling: price and tax measures; sales to and by young persons; passive smoking and smoke-free environments; and treatment of tobacco dependence. The Convention represents a global minimum standard, and the future Parties to the Convention are encouraged by provisions in the treaty to go further and implement stricter measures. Furthermore, the negotiation of future protocols to the Convention by the Conference of the Parties will result in a treaty regime that will continue to evolve and to provide for more specific obligations on certain topics. The FCTC is a delicately balanced instrument adopted after vigorous negotiations, which took into account relevant scientific, economic, social and political considerations The FCTC's adoption by the World Health Assembly opens the treaty for signature and rati- fication by individual Member States. The Convention is available for signature from 16 June 2003 until 29 June 2004, and from 30 June 2004 for ratification. The signing of the Convention indicates a Member State's intention to ratify the treaty but does not carry substantial obligations other than agreeing not to undermine the objective of the Convention; it provides, however, an important political commitment by a country to move towards ratification. Ratification provides the consent of a country to become legally bound by the treaty and commits it to implement the provisions of the treaty in good faith once the treaty enters into force. The Convention will come into force of law 90 days after the treaty has been ratified by 40 Member States. At that time, countries that have ratified it will be legally bound by its provisions. Countries that do not ratify the treaty are not obliged to implement its provisions. Not all treaties provide for funding and technical assistance for the implementation of the instrument. The FCTC, however, belongs to the unique family of international agreements that undertakes to provide for such resources. The Convention commits Parties to provide funding for their national tobacco control measures, encourages the use of innovative na tional, regional and international funding mechanisms to provide additional resources for tobacco control, and leaves the question of the possible establishment of a voluntary global fund or other appropriate financial mechanisms to be determined in the future by the Con- ference of the Parties. As evidence of the power of the FCTC process, the issue of tobacco control has been placed firmly on the agenda of development funding as a priority
92 The World Health Report 2003 Those who died before 70 years of age lost, on average, 28 years of life (13). As entry into force of the Convention draws nearer, strengthening national capacity in tobacco control becomes an important public health priority in all countries. This section looks forward to the timely ratification, entry into force, and implementation of the FCTC and the opportunities thus presented for further progress in national tobacco control. It also examines the challenges of building and strengthening national political, managerial and technical tobacco control capacity. Guiding tobacco control Total tobacco consumption is on the rise. The number of smokers in the world, estimated at 1.3 billion today, is expected to rise to 1.7 billion by 2025 if the global prevalence of tobacco use remains unchanged (14). Every second smoker will die of a tobacco-caused disease. Until recently, the global response to this major public health challenge had been inadequate. In May 2003 the World Health Assembly adopted by consensus the WHO Framework Convention on Tobacco Control (FCTC). Negotiated among WHO Member States over four years, this international legal instrument is designed to limit the harm to health caused by tobacco products. It comprises many diverse aspects of tobacco control, including: advertising, promotion and sponsorship; packaging and labelling; price and tax measures; sales to and by young persons; passive smoking and smoke-free environments; and treatment of tobacco dependence. The Convention represents a global minimum standard, and the future Parties to the Convention are encouraged by provisions in the treaty to go further and implement stricter measures. Furthermore, the negotiation of future protocols to the Convention by the Conference of the Parties will result in a treaty regime that will continue to evolve and to provide for more specific obligations on certain topics. The FCTC is a delicately balanced instrument adopted after vigorous negotiations, which took into account relevant scientific, economic, social and political considerations. The FCTC’s adoption by the World Health Assembly opens the treaty for signature and ratification by individual Member States. The Convention is available for signature from 16 June 2003 until 29 June 2004, and from 30 June 2004 for ratification. The signing of the Convention indicates a Member State’s intention to ratify the treaty but does not carry substantial obligations other than agreeing not to undermine the objective of the Convention; it provides, however, an important political commitment by a country to move towards ratification. Ratification provides the consent of a country to become legally bound by the treaty and commits it to implement the provisions of the treaty in good faith once the treaty enters into force. The Convention will come into force of law 90 days after the treaty has been ratified by 40 Member States. At that time, countries that have ratified it will be legally bound by its provisions. Countries that do not ratify the treaty are not obliged to implement its provisions. Not all treaties provide for funding and technical assistance for the implementation of the instrument. The FCTC, however, belongs to the unique family of international agreements that undertakes to provide for such resources. The Convention commits Parties to provide funding for their national tobacco control measures, encourages the use of innovative national, regional and international funding mechanisms to provide additional resources for tobacco control, and leaves the question of the possible establishment of a voluntary global fund or other appropriate financial mechanisms to be determined in the future by the Conference of the Parties. As evidence of the power of the FCTC process, the issue of tobacco control has been placed firmly on the agenda of development funding as a priority
Neglected Global Epidemics: three growing threats As in the negotiation of the FCTC, tobacco control activists in health professions, concerned nongovernmental organizations and grass-roots groups have an important role on the inter national stage during the ratification process. They can continue to promote the ratification nd implementation of the FCTC and the introduction of effective national legislation in support of the Convention National policies and programmes A comprehensive public health approach to tobacco control effectively prevents the begin ning of tobacco use and promotes its cessation, through a range of measures including tax and price policy, restrictions on tobacco advertising, promotion and sponsorship, packaging and labelling requirements, educational campaigns, restrictions on smoking in public places and cessation support services. A comprehensive approach must include young people and women and reach the entire population. National policies must also confront fresh challenges such as regulatory frameworks for new tobacco products that are just beginning to appear on the market. Moreover, with the adop- redefined to include the transnational components of tobacco control, as a o has now been tion of the FCTC, the definition of a comprehensive tobacco control strat national and local measures Few countries have implemented the comprehensive measures needed to create a significant decline in tobacco use. The policy measures known to have the biggest impact on individual levels of consumption, cessation rates and initiation rates require sustained political will and engagement, and above all effective and well-enforced legislation The capacity for effective tobacco control is lacking in most countries. Most do not have the necessary infrastructure or human resources to sustain a basic tobacco control programme. As an example, few national governments have people working full-time on tobacco control In many countries, civil society has not yet been mobilized around the issue, so even when governments have adequate political will to propose tobacco control measures, tobacco com panies can easily oppose and weaken policies. Even where the ministry of health is supportive of action it may be unable to make its case successfully above the voices of other more influ- ntial ministries Building national capacity The success of the Convention largely depends on countries ratifying the treaty and imple menting effective tobacco control measures. Building and strengthening national capacity in political, managerial and technical aspects of tobacco control is the key to a systematic multisectoral approach. Only this approach will ensure sustainable community and govern nental action for comprehensive tobacco control efforts at the local, national and global levels Many countries have not yet developed national plans of action for tobacco control, largely because of lack of consensus and political commitment. Where such plans exist, policy in truments may remain ineffective because of weak enforcement. Governments and civil soci ety need to be convinced that investing resources to prepare for tobacco control will reap benefits in the medium and longer term. Continuous monitoring of tobacco industry activi ties and strategies will be required to counteract the industry's manoeuvres to undermine tobacco control efforts. Strong political commitment and engagement are essential
Neglected Global Epidemics: three growing threats 93 As in the negotiation of the FCTC, tobacco control activists in health professions, concerned nongovernmental organizations and grass-roots groups have an important role on the international stage during the ratification process. They can continue to promote the ratification and implementation of the FCTC and the introduction of effective national legislation in support of the Convention. National policies and programmes A comprehensive public health approach to tobacco control effectively prevents the beginning of tobacco use and promotes its cessation, through a range of measures including tax and price policy, restrictions on tobacco advertising, promotion and sponsorship, packaging and labelling requirements, educational campaigns, restrictions on smoking in public places and cessation support services. A comprehensive approach must include young people and women and reach the entire population. National policies must also confront fresh challenges such as regulatory frameworks for new tobacco products that are just beginning to appear on the market. Moreover, with the adoption of the FCTC, the definition of a comprehensive tobacco control strategy has now been redefined to include the transnational components of tobacco control, as a complement to national and local measures. Few countries have implemented the comprehensive measures needed to create a significant decline in tobacco use. The policy measures known to have the biggest impact on individual levels of consumption, cessation rates and initiation rates require sustained political will and engagement, and above all effective and well-enforced legislation. The capacity for effective tobacco control is lacking in most countries. Most do not have the necessary infrastructure or human resources to sustain a basic tobacco control programme. As an example, few national governments have people working full-time on tobacco control. In many countries, civil society has not yet been mobilized around the issue, so even when governments have adequate political will to propose tobacco control measures, tobacco companies can easily oppose and weaken policies. Even where the ministry of health is supportive of action it may be unable to make its case successfully above the voices of other more influential ministries. Building national capacity The success of the Convention largely depends on countries ratifying the treaty and implementing effective tobacco control measures. Building and strengthening national capacity in political, managerial and technical aspects of tobacco control is the key to a systematic multisectoral approach. Only this approach will ensure sustainable community and governmental action for comprehensive tobacco control efforts at the local, national and global levels. Many countries have not yet developed national plans of action for tobacco control, largely because of lack of consensus and political commitment. Where such plans exist, policy instruments may remain ineffective because of weak enforcement. Governments and civil society need to be convinced that investing resources to prepare for tobacco control will reap benefits in the medium and longer term. Continuous monitoring of tobacco industry activities and strategies will be required to counteract the industry’s manoeuvres to undermine tobacco control efforts. Strong political commitment and engagement are essential