WORLD HEALTH ORGANIZATION The WORLD HEALTH REPORT 2002 Re educe ag Risks, Promoting Healthy life
educing isks, Promoting Healthy Life he W O RLD HEALTH R EPORT 2002 WORLD HEALTH ORGANIZATION
WHO Library Cataloguing in Publication Data The World health report: 2002: Reducing risks, promoting healthy life Risk assessment 3. Epidemiologic methods 5. Risk management-methods 6 Public policy 7. Quality of life rends ITitle II.Title: Reducing risks, promoting life SBN 92 4 156207 2(NLM Classification: WA 540.1) ISSN1020-3311 o World Health Organization 2002 All rights reserved Publications of the World Health Organization can be obtained from Marketing and Dissemination, Wor Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders(@who. int). Requests for permission to reproduce or translate WHO publications hether for sale or for noncommercial distribution - should be addressed to Publications, at the above address(fax: +41 22 791 4806; email: permissions@who. int) The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal or area or of its authorities, or concerning the delimitation of it frontiers or boundaries Dotted lines on maps represent approximate border lines for which there t be full agreement r of certain manufacturers products does not imply that endorsed or recommended by the World Health Organization in preference to others of a similar that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Information ming this publication can be obtained from World Health Report World Health Organization 1211 Geneva 27, Switzerland Email: whr(@who int Fax:(41-22)7914870 Copies of this publication can be ordered from: bookorders(@who int This report was produced under the overall direction of Christopher Murray ters, and senior policy advisers to the Director-General. and Alan Lopez. The two principal authors were Anthony Rodgers(Chap- The risk assessments in this report were coordinated by Majid Ezzati, ters 2&4)and Patrick Vaughan(Chapters 3&6). The Overview and Chapter Alan Lopez and Anthony Rodgers, with statistical analyses by Stephen 1 were written by Thomson Prentice. All of the above contributed to Chap- Vander Hoom. The assessments are the result of several years'work by many ter 7. Chapter 5 was written by Tessa Tan-Torres Edejer, David Evans and scientists worldwide. These scientists are listed in the Acknowledgements, Julia Lowe as are the many WHO specialists who worked on the cost-effectiveness as The report was edited by Barbara Campanini, with assistance from Hoorn Angela Haden. The figures, maps and tables were coordinated by Michel Valuable input was received from an internal advisory group and a re- Beusenberg. Translation coordination and other administrative and pr gional reference group, the members of which are listed in the Acknowl- duction support for the World Health Report team was provided by shelagh edgements. Additional help and advice were appreciated from regional Probst. Further assistance was given by Patrick Unterlerchner The indexw directors, executive directors and members of their staff at WHO headquar- prepared by Liza Furnival. Cover illustration by Laura de Santis Design by Marilyn Langfeld Layout by WHO Graphics Printed in france 2002/14661- Sadao-2500
ii The World Health Report 2002 Cover illustration by Laura de Santis Design by Marilyn Langfeld. Layout by WHO Graphics Printed in France 2002/14661 – Sadag – 25000 WHO Library Cataloguing in Publication Data. The World health report : 2002 : Reducing risks, promoting healthy life. 1.Risk factors 2.Risk assessment 3.Epidemiologic methods 4.Cost of illness 5.Risk management - methods 6.Public policy 7.Quality of life 8.World health - trends I.Title II.Title: Reducing risks, promoting life. ISBN 92 4 156207 2 (NLM Classification: WA 540.1) ISSN 1020-3311 © World Health Organization 2002 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland Email: whr@who.int Fax: (41-22) 791 4870 Copies of this publication can be ordered from: bookorders@who.int This report was produced under the overall direction of Christopher Murray and Alan Lopez. The two principal authors were Anthony Rodgers (Chapters 2 & 4) and Patrick Vaughan (Chapters 3 & 6). The Overview and Chapter 1 were written by Thomson Prentice. All of the above contributed to Chapter 7. Chapter 5 was written by Tessa Tan-Torres Edejer, David Evans and Julia Lowe. The writing team was greatly assisted by Michael Eriksen, Majid Ezzati, Susan Holck, Carlene Lawes, Varsha Parag, Patricia Priest and Stephen Vander Hoorn. Valuable input was received from an internal advisory group and a regional reference group, the members of which are listed in the Acknowledgements. Additional help and advice were appreciated from regional directors, executive directors and members of their staff at WHO headquarters, and senior policy advisers to the Director-General. The risk assessments in this report were coordinated by Majid Ezzati, Alan Lopez and Anthony Rodgers, with statistical analyses by Stephen Vander Hoorn. The assessments are the result of several years’ work by many scientists worldwide. These scientists are listed in the Acknowledgements, as are the many WHO specialists who worked on the cost-effectiveness assessment section. The report was edited by Barbara Campanini, with assistance from Angela Haden. The figures, maps and tables were coordinated by Michel Beusenberg. Translation coordination and other administrative and production support for the World Health Report team was provided by Shelagh Probst. Further assistance was given by Patrick Unterlerchner. The index was prepared by Liza Furnival
CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL OVERVIEW Introduction Enemies of health, allies of poverty Recommended actions Summary of chapters CHAPTER 1 PROTECTING THE PEOPLE Reducing the risks 3 The risk transition CHAPTER 2 DEFINING AND ASSESSING RISKS TO HEALTH What are risks to health? why focus on risks to health? 799 Development of risk assessment Key goals of global risk assessment Standardized comparisons and common outcome measures Assessing protective as well as hazardous factors Including proximal and distal causes 13 Assessing population-wide risks as well as high-risk individuals Including risks that act together to cause disease Using best available evidence to assess certain and probable risks to health 16 Assessing avoidable as well as attributable burden 17 Overview of risk assessment methods Choosing and defining risks to health Estimating current risk factor levels and choosing counterfactuals Estimating current and future disease and injury burden Estimates of avoidable burden Estimating the joint effects of multiple risks Estimates of uncertainty CHAPTER 3 PERCEIVING RISKS Changing perceptions of risk Emerging importance of risk perceptions Questioning the science in risk assessmen Risk perceptions Defining and describing risks to health 323 raming the information on risks ocial and cultural interpretations of risk Perceptions of health risks in developing countries 37 mportance of risk communications
Overview iii CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL ix OVERVIEW xiii Introduction xiii Enemies of health, allies of poverty xiv Recommended actions xvii Summary of chapters xviii CHAPTER 1 PROTECTING THE PEOPLE 1 Reducing the risks 3 The risk transition 4 CHAPTER 2 DEFINING AND ASSESSING RISKS TO HEALTH 7 What are risks to health? 9 Why focus on risks to health? 9 Development of risk assessment 10 Key goals of global risk assessment 11 Standardized comparisons and common outcome measures 12 Assessing protective as well as hazardous factors 13 Including proximal and distal causes 13 Assessing population-wide risks as well as high-risk individuals 15 Including risks that act together to cause disease 15 Using best available evidence to assess certain and probable risks to health 16 Assessing avoidable as well as attributable burden 17 Overview of risk assessment methods 18 Choosing and defining risks to health 20 Estimating current risk factor levels and choosing counterfactuals 22 Estimating current and future disease and injury burden 22 Estimating risk factor–burden relationships 22 Estimates of avoidable burden 23 Estimating the joint effects of multiple risks 23 Estimates of uncertainty 24 CHAPTER 3 PERCEIVING RISKS 27 Changing perceptions of risk 29 Questioning the science in risk assessment 30 Emerging importance of risk perceptions 31 Risk perceptions 32 Defining and describing risks to health 34 Influences on risk perceptions 35 Framing the information on risks 36 Social and cultural interpretations of risk 36 Perceptions of health risks in developing countries 37 Importance of risk communications 38
The World Health Report 2002 Influence of special interest groups on risk perceptions 39 Importance of mass media in risk perceptions 42 Importance of perceptions in successful risk prevention QUANTIFYING SELECTED MAJOR RISKS TO HEALTH Risks to health and socioeconomic status 49 Rates of poverty across the world Relationships between risk factor levels and poverty Potential impact on risk factor levels of shifting poverty distributions Burden of disease and injury attributable to selected risk factors Childhood and maternal undernutrition 52 52 lodine deficiency Iron deficiency Vitamin a deficiency Zinc deficiency 55 Lack of breastfeeding 56 Other diet-related risk factors and physical inactivity igh blood pressure Obesity, overweight and high body mass Low fruit and vegetable intake 61 Sexual and reproductive health Unsafe sex Lack of contraception Addictive substances Smoking and oral tol acco use Alcohol use 65 Illicit drug u 66 Unsafe water, sanitation and hygiene Urban air pollution Indoor smoke from solid fuels Lead e Climate change Other environmental risks to health Work-related risk factors for injuri Work-related carcinogens Work-related airborne particulates Work-related ergonomic stressors Work-related noise Other risks to health Unsafe health care practices Abuse and violence Global patterns of risks to health 012345万667898888 it all together-what is possibl Estimates of the joint effects of selected risk factors Estimates of avoidable burden The need for cost-effectiveness analyses
iv The World Health Report 2002 Influence of special interest groups on risk perceptions 39 Importance of mass media in risk perceptions 42 Importance of perceptions in successful risk prevention 43 CHAPTER 4 QUANTIFYING SELECTED MAJOR RISKS TO HEALTH 47 Risks to health and socioeconomic status 49 Rates of poverty across the world 50 Relationships between risk factor levels and poverty 50 Potential impact on risk factor levels of shifting poverty distributions 51 Burden of disease and injury attributable to selected risk factors 52 Childhood and maternal undernutrition 52 Underweight 52 Iodine deficiency 54 Iron deficiency 54 Vitamin A deficiency 55 Zinc deficiency 55 Lack of breastfeeding 56 Other diet-related risk factors and physical inactivity 57 High blood pressure 57 High cholesterol 58 Obesity, overweight and high body mass 60 Low fruit and vegetable intake 60 Physical inactivity 61 Sexual and reproductive health 61 Unsafe sex 62 Lack of contraception 63 Addictive substances 64 Smoking and oral tobacco use 64 Alcohol use 65 Illicit drug use 66 Environmental risks 67 Unsafe water, sanitation and hygiene 68 Urban air pollution 68 Indoor smoke from solid fuels 69 Lead exposure 70 Climate change 71 Other environmental risks to health 72 Selected occupational risks 73 Work-related risk factors for injuries 74 Work-related carcinogens 75 Work-related airborne particulates 75 Work-related ergonomic stressors 76 Work-related noise 76 Other risks to health 77 Unsafe health care practices 78 Abuse and violence 79 Global patterns of risks to health 81 Putting it all together – what is possible? 85 Estimates of the joint effects of selected risk factors 85 Estimates of avoidable burden 88 The need for cost-effectiveness analyses 92
Contents CHAPTER S SOME STRATEGIES TO REDUCE RISK From health risks to policy 101 What strategies can reduce risks to health? Risk reduction and behaviour Individual-based versus population approaches to risk reduction The role of government and legislation 105 Different ways of attaining the same goal Technical considerations for cost-effectiveness analysis Choosing interventions to reduce specific risks hildhood undernutrition 0 Childhood undernutrition (and breastfeeding 110 Iron deficiency 110 Vitamin a deficient Zinc deficiency 112 Other individual-based interventions ng on children under five of Combined interventions to reduce risks in children under five years of age Blood pressure and cholesterol 114 lood pressur Cholesterol Combining interventions to reduce the risk of cardiovascular events 116 Low fruit and Unsafe sex and HIVIAIDS Addictive substances Environmental risks Unsafe water, sanitation, and hygiene Occupational risk facto Health practices 130 Unsafe health care injections Combining risk reduction strategies CHAPTER 6 STRENGTHENING RISK PREVENTION POLICIES Choosing priority strategies for risk prevention opulation-based interventions or high-risk individual targets? Distal or proximal risks to health? Primary or secondary prevention? 148 managing the risk prevention process Identifying priority risk factors for prevention Assessment and management of highly uncertain risks Ethical considerations in risk prevention Risk communications and the role of govemments strengthening the scientific evidence base Urgent need for international action
Overview v CHAPTER 5 SOME STRATEGIES TO REDUCE RISK 99 From health risks to policy 101 What strategies can reduce risks to health? 103 Risk reduction and behaviour 103 Individual-based versus population approaches to risk reduction 104 The role of government and legislation 105 Different ways of attaining the same goal 106 Technical considerations for cost-effectiveness analysis 106 Choosing interventions to reduce specific risks 108 Childhood undernutrition 109 Childhood undernutrition (and breastfeeding) 110 Iron deficiency 110 Vitamin A deficiency 111 Zinc deficiency 112 Other individual-based interventions focusing on children under five years of age 112 Combined interventions to reduce risks in children under five years of age 113 Blood pressure and cholesterol 114 Blood pressure 115 Cholesterol 116 Combining interventions to reduce the risk of cardiovascular events 116 Low fruit and vegetable intake 118 Sexual and reproductive health 118 Unsafe sex and HIV/AIDS 118 Addictive substances 123 Smoking 123 Environmental risks 127 Unsafe water, sanitation, and hygiene 127 Occupational risk factors 129 Health practices 130 Unsafe health care injections 130 Combining risk reduction strategies 131 Policy implications 137 CHAPTER 6 STRENGTHENING RISK PREVENTION POLICIES 145 Choosing priority strategies for risk prevention 147 Population-based interventions or high-risk individual targets? 147 Distal or proximal risks to health? 148 Primary or secondary prevention? 148 Managing the risk prevention process 149 Identifying priority risk factors for prevention 150 Assessment and management of highly uncertain risks 151 Ethical considerations in risk prevention 153 Risk communications and the role of governments 154 Strengthening the scientific evidence base 155 Urgent need for international action 156 Contents
The World Health Report 2002 CHAPTER 7 PREVENTING RISKS AND TAKING ACTION Focusing on prevention means focusing on risks The world faces some common, large and certain risks to health Effective and affordable preventive interventions are available Narrowing the gap between potential and actual benefit: a key research priority 164 Population-wide prevention strategies: key to risk reduction Government responsibility for health 165 Reducing major risks to health will promote sustainable development 165 Reducing major risks to health can reduce inequities in society Governments need to prioritize and focus on the most important risks 165 Exercising stewardship means fulfilling the government's responsibility to protect its citizens 166 Recommended actions Reducing risks, promoting healthy life 167 STATISTICAL ANNEX 169 Explanatory Notes Annex Table 1 Basic indicators for all Member States 178 Annex Table 2 Deaths by cause, sex and mortality stratum in WHO Regi estimates for 2001 Annex Table 3 Burden of disease in DALYs by cause, sex and mortality stratum in WHO Regions, estimates for 2001 Annex Table 4 Healthy life expectancy (HALE) in all Member States, estimates Annex Table 5 Selected National Health Accounts indicators for all Member States, estimates for 1995 to 2000 Annex Table 6 Summary prevalence of selected risk factors by subregion, 2000 Annex Table 7 Selected population attributable fractions by risk factor, sex and level of development(% DALYs for each cause), 2000 Annex Table8 Distribution of attributable mortality and DALYs by risk factor, anney Annex Annex e50 Attributable mortality by risk factor, level of developI ctor au023 Attributable mortality by risk factor, sex and mortality stratum in WHO Regions, 2000 Annex Table 12 Attributable DALYs by risk factor, sex and mortality stratum in WHO Regions, 2000 Annex Table 13 Attributable years of life lost (YLL) by risk factor, mortality stratum in WHO Regions, 2000 Annex Table 14 Major burden of disease-leading 10 selected risk factors and leading 10 diseases and injuries, high mortality developing countries, 2000 Annex Table 15 Major burden of disease-leading 10 selected risk factors and leading 10 diseases and injuries, low mortality developing countries, 2000 Annex Table 16 Major burden of disease-leading 10 selected risk factors d leading 10 diseases and injuries, developed countries, 2000
vi The World Health Report 2002 CHAPTER 7 PREVENTING RISKS AND TAKING ACTION 159 Focusing on prevention means focusing on risks 161 The world faces some common, large and certain risks to health 162 Effective and affordable preventive interventions are available 163 Narrowing the gap between potential and actual benefit: a key research priority 164 Population-wide prevention strategies: key to risk reduction 164 Government responsibility for health 165 Reducing major risks to health will promote sustainable development 165 Reducing major risks to health can reduce inequities in society 165 Governments need to prioritize and focus on the most important risks 165 Exercising stewardship means fulfilling the government’s responsibility to protect its citizens 166 Recommended actions 166 Reducing risks, promoting healthy life 167 STATISTICAL ANNEX 169 Explanatory Notes 170 Annex Table 1 Basic indicators for all Member States 178 Annex Table 2 Deaths by cause, sex and mortality stratum in WHO Regions, estimates for 2001 186 Annex Table 3 Burden of disease in DALYs by cause, sex and mortality stratum in WHO Regions, estimates for 2001 192 Annex Table 4 Healthy life expectancy (HALE) in all Member States, estimates for 2000 and 2001 198 Annex Table 5 Selected National Health Accounts indicators for all Member States, estimates for 1995 to 2000 202 Annex Table 6 Summary prevalence of selected risk factors by subregion, 2000 218 Annex Table 7 Selected population attributable fractions by risk factor, sex and level of development (% DALYs for each cause), 2000 220 Annex Table 8 Distribution of attributable mortality and DALYs by risk factor, age and sex, 2000 223 Annex Table 9 Attributable mortality by risk factor, level of development and sex, 2000 224 Annex Table 10 Attributable DALYs by risk factor, level of development and sex, 2000 225 Annex Table 11 Attributable mortality by risk factor, sex and mortality stratum in WHO Regions, 2000 226 Annex Table 12 Attributable DALYs by risk factor, sex and mortality stratum in WHO Regions, 2000 228 Annex Table 13 Attributable years of life lost (YLL) by risk factor, sex and mortality stratum in WHO Regions, 2000 230 Annex Table 14 Major burden of disease – leading 10 selected risk factors and leading 10 diseases and injuries, high mortality developing countries, 2000 232 Annex Table 15 Major burden of disease – leading 10 selected risk factors and leading 10 diseases and injuries, low mortality developing countries, 2000 232 Annex Table 16 Major burden of disease – leading 10 selected risk factors and leading 10 diseases and injuries, developed countries, 2000 232
Contents LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM 233 ACKNOWLEdgEmENtS 236 239 TAbLES Table 4.1 Population impact fractions by subregion for counterfactual of population moving from living on US$ 2 per day to USS 2 per day 51 Table 4.2 Selected major risks to health: childhood and maternal undernutrition Table 4.3 Selected major risks to health: other diet-related factors and physical inactivity 57 Table 4.4 Selected major risks to health: sexual and reproductive health Table 4.5 Selected major risks to health: addictive substances Table 4.6 Selected major risks to health: environmental factors Table 4.7 Selected major risks to health: occupational hazards Table 4. 8 Selected other risks to health Table 4.10 Attributable DALYs by risk factor, level of development and sex 20 Table 4.9 Attributable mortality by risk factor, level of development and sex, 200 Table 4.11 Ranking of estimated attributable and avoidable burdens of 10 leading selected risk factors Table 5.1 Leading 10 selected risk factors as percentage causes of disease burden measured in dAlys Table 5.2 Time gains from improved access to water and sanitation in subregions AFR-D and EMR-D Table 5.3 Cost-effective interventions FIGURES Figure 2.1 Example of distributional transitions for blood pressure and for tobacco smoking Figure 2.2 Causal chains of exposure leading to disease Figure 2.3 The importance of population distributions of exposure Figure 2.4 Attributable and avoidable burdens Figure 2.5 Key inputs for assessment of attributable and avoidable burdens Figure 2.6 Determination of attributable burden, taking account of prevalence ure 3.1 Hazards for dread and risk ure 4.1 Prevalence of moderate underweight in children by average daily household income(USS 2 per day), by subregion igure 4.2 Burden of disease attributable to childhood and maternal undemutrition ( DALYs in each subregion) Figure 4.3 Burden of disease attributable to diet-related risk factors and physical inactivity(% DALYs in each subregion) Figure 4.4 Nine examples of continuous associations between risks and disease Figure 4.5 Burden of disease attributable to sexual and reproductive health risks ( DALYs in each subregion) Figure 4.6 Burden of disease attributable to tobacco, alcohol and illicit drug ( DALYs in each subregi
Overview vii LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM 233 ACKNOWLEDGEMENTS 236 INDEX 239 TABLES Table 4.1 Population impact fractions by subregion for counterfactual scenario of population moving from living on US$ 2 per day 51 Table 4.2 Selected major risks to health: childhood and maternal undernutrition 52 Table 4.3 Selected major risks to health: other diet-related factors and physical inactivity 57 Table 4.4 Selected major risks to health: sexual and reproductive health 62 Table 4.5 Selected major risks to health: addictive substances 64 Table 4.6 Selected major risks to health: environmental factors 67 Table 4.7 Selected major risks to health: occupational hazards 73 Table 4.8 Selected other risks to health 79 Table 4.9 Attributable mortality by risk factor, level of development and sex, 2000 86 Table 4.10 Attributable DALYs by risk factor, level of development and sex, 2000 87 Table 4.11 Ranking of estimated attributable and avoidable burdens of 10 leading selected risk factors 91 Table 5.1 Leading 10 selected risk factors as percentage causes of disease burden measured in DALYs 102 Table 5.2 Time gains from improved access to water and sanitation in subregions AFR-D and EMR-D 128 Table 5.3 Cost-effective interventions 134 FIGURES Figure 2.1 Example of distributional transitions for blood pressure and for tobacco smoking 12 Figure 2.2 Causal chains of exposure leading to disease 14 Figure 2.3 The importance of population distributions of exposure 17 Figure 2.4 Attributable and avoidable burdens 19 Figure 2.5 Key inputs for assessment of attributable and avoidable burdens 20 Figure 2.6 Determination of attributable burden, taking account of prevalence and relative risk 21 Figure 3.1 Hazards for dread and risk 33 Figure 4.1 Prevalence of moderate underweight in children by average daily household income (US$ 2 per day), by subregion 50 Figure 4.2 Burden of disease attributable to childhood and maternal undernutrition (% DALYs in each subregion) 53 Figure 4.3 Burden of disease attributable to diet-related risk factors and physical inactivity (% DALYs in each subregion) 58 Figure 4.4 Nine examples of continuous associations between risks and disease 59 Figure 4.5 Burden of disease attributable to sexual and reproductive health risks (% DALYs in each subregion) 62 Figure 4.6 Burden of disease attributable to tobacco, alcohol and illicit drugs (% DALYs in each subregion) 65 Contents
The World Health Report 2002 Figure 4.7 Burden of disease attributable to selected environmental risk factors DALYs in each subregion) Figure 4.8 Amount and patterns of burden of disease in developing and developed countries Figure 4.9 Global distribution of burden of disease attributable to 20 leading selected risk factors Figure 4.10 Burden of disease attributable to 10 selected leading risk factors, by level of development and type of affected outcom Figure 4.11 Disease and risk factor burder Figure 4.12 Estimated gain in healthy life expectancy with removal of 20 leading risk factors by subregion Figure 4.13 Attributable DALYs in 2000 and avoidable DALYs in 2010 and 2020 following a 25% risk factor reduction from 2000, for 10 leading selected risk factor Figure 5.1 Distributions of systolic blood pressure in middle-aged men in two populations Figure 5.2 Cost and effects of selected interventions in subregion AFR-D 132 Figure 5.3 Cost and effects of selected interventions in subregion AMR-B Figure 6.1 Case studies of distribution shifting and cardiovascular disease in Finland and Japan 148 Figure 6.2 Implementing risk prevention 149 OXES Box 1.1 Countries endorse the focus on risks to health 6 Box 2.1 What does risk mean? Box 2.2 Protective factors Box 2.3 Risks to health across the life course 15 Box 2.4 Population-wide strategies for prevention 16 Box 2.5 Multiple causes of disease Box 2.6 Estimating the combined effects of cardiovascular disease risk factors Box 3.1 Perceptions of risk by scientists and the general public Box 3.2 Mens sexual behaviour related to risk of HIV infection and pregnancy 35 Box 3.3 Framing risks to health: choosing presentations Box 3. 4 Perceptions of risk in Burkina Fas Box 3.5 The Bovine Spongiform Encephalopathy(BSE) Inquiry, United Kingde Box 3. 6 Strategies for fuelling public controversy 40 Box 3.7 Junking science to promote tobacco 41 Box 4.1 Environmental tobacco smoke ox 4.2 Housing and health Box 4.3 Road traffic Box 4. 4 Sharps injuries among health care workers 74 Box 4.5 Coronary heart disease and work-related stress 75 Box 4.6 Risk factors for tuberculosis 4.7 Genetics and attributable and avoidable burde Box 4.8 Risks in the health care system Box 4.9 Violence 80 Box 4 10 Healthy risk factor transition 88 Box 5.1 Methods for cost-effectiveness analysis Box 5.2 Integrated Management of Childhood Ilness: interventions that interact 114 Box 5.3 Cost-effectiveness of a national nutrition campaign 118 Box 5.4 Reducing injuries from motor-vehicle accidents 130 ox 5.5 Cost-effectiveness of interventions to reduce occupational back pain 131 Box 6.1 Contrasting views of the role of the precautionary principle within Box 6. 2 Important lessons for governments on developing better risk communications 154 Box 6.3 Examples of successful international concerted action 57
viii The World Health Report 2002 Figure 4.7 Burden of disease attributable to selected environmental risk factors (% DALYs in each subregion) 69 Figure 4.8 Amount and patterns of burden of disease in developing and developed countries 81 Figure 4.9 Global distribution of burden of disease attributable to 20 leading selected risk factors 82 Figure 4.10 Burden of disease attributable to 10 selected leading risk factors, by level of development and type of affected outcome 83 Figure 4.11 Disease and risk factor burden 89 Figure 4.12 Estimated gain in healthy life expectancy with removal of 20 leading risk factors by subregion 90 Figure 4.13 Attributable DALYs in 2000 and avoidable DALYs in 2010 and 2020 following a 25% risk factor reduction from 2000, for 10 leading selected risk factors 91 Figure 5.1 Distributions of systolic blood pressure in middle-aged men in two populations 105 Figure 5.2 Cost and effects of selected interventions in subregion AFR-D 132 Figure 5.3 Cost and effects of selected interventions in subregion AMR-B 138 Figure 6.1 Case studies of distribution shifting and cardiovascular disease in Finland and Japan 148 Figure 6.2 Implementing risk prevention 149 BOXES Box 1.1 Countries endorse the focus on risks to health 6 Box 2.1 What does risk mean? 11 Box 2.2 Protective factors 13 Box 2.3 Risks to health across the life course 15 Box 2.4 Population-wide strategies for prevention 16 Box 2.5 Multiple causes of disease 18 Box 2.6 Estimating the combined effects of cardiovascular disease risk factors 24 Box 3.1 Perceptions of risk by scientists and the general public 31 Box 3.2 Men’s sexual behaviour related to risk of HIV infection and pregnancy 35 Box 3.3 Framing risks to health: choosing presentations 36 Box 3.4 Perceptions of risk in Burkina Faso 38 Box 3.5 The Bovine Spongiform Encephalopathy (BSE) Inquiry, United Kingdom 40 Box 3.6 Strategies for fuelling public controversy 40 Box 3.7 Junking science to promote tobacco 41 Box 4.1 Environmental tobacco smoke 66 Box 4.2 Housing and health 70 Box 4.3 Road traffic injuries 72 Box 4.4 Sharps injuries among health care workers 74 Box 4.5 Coronary heart disease and work-related stress 75 Box 4.6 Risk factors for tuberculosis 77 Box 4.7 Genetics and attributable and avoidable burden 78 Box 4.8 Risks in the health care system 79 Box 4.9 Violence 80 Box 4.10 Healthy risk factor transition 88 Box 5.1 Methods for cost-effectiveness analysis 107 Box 5.2 Integrated Management of Childhood Illness: interventions that interact 114 Box 5.3 Cost-effectiveness of a national nutrition campaign 118 Box 5.4 Reducing injuries from motor-vehicle accidents 130 Box 5.5 Cost-effectiveness of interventions to reduce occupational back pain 131 Box 6.1 Contrasting views of the role of the precautionary principle within different world views of regulation 151 Box 6.2 Important lessons for governments on developing better risk communications 154 Box 6.3 Examples of successful international concerted action 157
MESSAGE FROM THE DIRECTOR-GENERAL hese are dangerous times for the well-being of the world. In many regions, some of the most formidable enemies of health are joining forces with the allies of poverty to impose a double burden of disease, disability and premature death on many millions of people. It is time for us to close ranks against this growing threat Reducing risks to health, the subject of this years World health report, has been a preoc- cupation of people and their physicians and politicians throughout history. It can be traced ack at least 5000 years to some of the world's earliest civilizations. But it has never been more relevant than it is today. Virtually every major advance in public health has involved the redt on or the elimination of risk. Improvements in drinking-water sup- plies and sanitation during the 19th and 20th centuries were directly related to the control of the organisms that cause cholera and other diarrhoeal diseases Mass immunization programmes eradicated the scourge of small ox from the planet and have reduced the risk to individuals and whole populations of infectious diseases such as poliomyelitis, yellow fever, measles and diphtheria by providing protection against the causative agents. Countless millions of premature deaths have been avoided as a result egislation enables risks to health to be reduced in the workplace and on the roads, whether through the wearing of a safety helmet in a factory or a seat belt in a car. Sometimes laws, education and persuasion combine to diminish risks, as with health warnings on cigarette packets, bans on tobacco advertising, and restrictions on the sale of alcohol Dr Gro harlem brundtland The result is that, in many ways, the world is a safer place to- day. Safer from what were once deadly or incurable diseases. Safer from daily hazards of waterborne and food-related illnesses. Safer from dangerous consumer goods, from acci dents at home, at work or in hospital i. But in many other ways the world is becoming more dangerous. Too many of us are ving dangerously whether we are aware of that or not. I believe that this World health eport is a wake-up call to the global community. In one of the largest research projects WHO has ever undertaken, it tries to quantify some of the most important risks to health and to assess the cost-effectiveness of some of the measures to reduce them The ultimate goal is to help governments of all countries lower these risks and raise the healthy life expectancy of their populations The picture that is taking shape from our research gives an intriguing -and alarming insight into current causes of disease and death and the factors underlying them. It shows how the lifestyles of whole populations are changing around the world, and the impact of
Overview ix hese are dangerous times for the well-being of the world. In many regions, some of the most formidable enemies of health are joining forces with the allies of poverty to impose a double burden of disease, disability and premature death on many millions of people. It is time for us to close ranks against this growing threat. Reducing risks to health, the subject of this year’s World health report, has been a preoccupation of people and their physicians and politicians throughout history. It can be traced back at least 5000 years to some of the world’s earliest civilizations. But it has never been more relevant than it is today. Virtually every major advance in public health has involved the reduction or the elimination of risk. Improvements in drinking-water supplies and sanitation during the 19th and 20th centuries were directly related to the control of the organisms that cause cholera and other diarrhoeal diseases. Mass immunization programmes eradicated the scourge of smallpox from the planet and have reduced the risk to individuals and whole populations of infectious diseases such as poliomyelitis, yellow fever, measles and diphtheria by providing protection against the causative agents. Countless millions of premature deaths have been avoided as a result. Legislation enables risks to health to be reduced in the workplace and on the roads, whether through the wearing of a safety helmet in a factory or a seat belt in a car. Sometimes laws, education and persuasion combine to diminish risks, as with health warnings on cigarette packets, bans on tobacco advertising, and restrictions on the sale of alcohol. The result is that, in many ways, the world is a safer place today. Safer from what were once deadly or incurable diseases. Safer from daily hazards of waterborne and food-related illnesses. Safer from dangerous consumer goods, from accidents at home, at work or in hospital. But in many other ways the world is becoming more dangerous. Too many of us are living dangerously – whether we are aware of that or not. I believe that this World health report is a wake-up call to the global community. In one of the largest research projects WHO has ever undertaken, it tries to quantify some of the most important risks to health and to assess the cost-effectiveness of some of the measures to reduce them. The ultimate goal is to help governments of all countries lower these risks and raise the healthy life expectancy of their populations. The picture that is taking shape from our research gives an intriguing – and alarming – insight into current causes of disease and death and the factors underlying them. It shows how the lifestyles of whole populations are changing around the world, and the impact of Dr Gro Harlem Brundtland MESSAGE FROM THE DIRECTOR-GENERAL
The World Health Report 2002 these changes on the health of individuals, families, communities and whole populations These are issues that deeply concern us all. This was reflected in the in-depth discus- sions involving ministers of health from almost all of WHO's Member States during the World Health Assembly in Geneva in May of this year. These discussions helped shape this report, and are summarized in the opening chapter. They provided invaluable assessments of the risks to health that countries around the world today regard as most important These risks, and some additional ones, are systematically investigated in this report hey include some familiar enemies of health and allies of poverty, such as underweight, unsafe water, poor sanitation and hygiene, unsafe sex(particularly related to HIVIAIDS ron deficiency, and indoor smoke from solid fuels The list also includes risks that are more commonly associated with wealthy societies, such as high blood pressure and high blood cholesterol, tobacco and excessive alcohol consumption, obesity and physical inactivity. These risks, and the diseases linked to them are now dominant in all middle and high income countries. The real drama now being played out is that they are becoming more prevalent in the developing world, where they create a double burden on top of the infectious diseases that still afflict poorer countries In my address to the World Health Assembly in May of this year, I warned that the world living dangerously, either because it has little choice or because it is making the wrong hoices about consumption and activity I repeat that warning now Unhealthy choices are not the exclusive preserve of indust alized nations. We all need to confront them Many of the risks discussed in this report concern consumption-either too little, in the ase of the poor, or too much, in the case of the better-off. Two of the most striking findings in this report are to be found almost side by side. One is that in poor countries today there are 170 million underweight children, over three mil- lion of whom will die this year as a result. The other is that there are more than one billion dults worldwide who are overweight and at least 300 million who are clinically obese Among these, about half a million people in North America and Western Europe combined will have died this year from obesity-related diseases Could the contrast between the haves and the have-nots ever be more starkly ill trated? WHO is determined to tackle specific nutrient deficiencies in vulnerable populations and to promote good health through optimal diets, particularly in countries undergoing rapid nutritional transition. At the same time, we are developing new guidelines for healthy eating. When these are omplete, key players in the food industry will be invited to work with us in combating the rising incidence of obesity, diabetes and vascular diseases in developing countries Our actions will be vital. The rapidly growing epidemic of noncommunicable diseases, already responsible for some 60% of world deaths, is clearly related to changes in glob dietary patterns and increased consumption of industrially processed fatty, salty and sugary foods. In the slums of todays megacities, we are seeing noncommunicable diseases caused unhealthy diets and habits, side by side with undemutrition As I said at the World Food Summit in Rome in June of this year, economic development and globalization need not be associated with negative health consequences. On the con- trary, we can harness the forces of globalization to reduce inequity, to diminish hunger and prove health in a more just glow Whatever the particular risks to health, whether they are related to consumption or not, every country needs to be able to adapt risk reduction policies to its own needs
x The World Health Report 2002 these changes on the health of individuals, families, communities and whole populations. These are issues that deeply concern us all. This was reflected in the in-depth discussions involving ministers of health from almost all of WHO’s Member States during the World Health Assembly in Geneva in May of this year. These discussions helped shape this report, and are summarized in the opening chapter. They provided invaluable assessments of the risks to health that countries around the world today regard as most important. These risks, and some additional ones, are systematically investigated in this report. They include some familiar enemies of health and allies of poverty, such as underweight, unsafe water, poor sanitation and hygiene, unsafe sex (particularly related to HIV/AIDS), iron deficiency, and indoor smoke from solid fuels. The list also includes risks that are more commonly associated with wealthy societies, such as high blood pressure and high blood cholesterol, tobacco and excessive alcohol consumption, obesity and physical inactivity. These risks, and the diseases linked to them, are now dominant in all middle and high income countries. The real drama now being played out is that they are becoming more prevalent in the developing world, where they create a double burden on top of the infectious diseases that still afflict poorer countries. In my address to the World Health Assembly in May of this year, I warned that the world is living dangerously, either because it has little choice or because it is making the wrong choices about consumption and activity. I repeat that warning now. Unhealthy choices are not the exclusive preserve of industrialized nations. We all need to confront them. Many of the risks discussed in this report concern consumption – either too little, in the case of the poor, or too much, in the case of the better-off. Two of the most striking findings in this report are to be found almost side by side. One is that in poor countries today there are 170 million underweight children, over three million of whom will die this year as a result. The other is that there are more than one billion adults worldwide who are overweight and at least 300 million who are clinically obese. Among these, about half a million people in North America and Western Europe combined will have died this year from obesity-related diseases. Could the contrast between the haves and the have-nots ever be more starkly illustrated? WHO is determined to tackle specific nutrient deficiencies in vulnerable populations and to promote good health through optimal diets, particularly in countries undergoing rapid nutritional transition. At the same time, we are developing new guidelines for healthy eating. When these are complete, key players in the food industry will be invited to work with us in combating the rising incidence of obesity, diabetes and vascular diseases in developing countries. Our actions will be vital. The rapidly growing epidemic of noncommunicable diseases, already responsible for some 60% of world deaths, is clearly related to changes in global dietary patterns and increased consumption of industrially processed fatty, salty and sugary foods. In the slums of today’s megacities, we are seeing noncommunicable diseases caused by unhealthy diets and habits, side by side with undernutrition. As I said at the World Food Summit in Rome in June of this year, economic development and globalization need not be associated with negative health consequences. On the contrary, we can harness the forces of globalization to reduce inequity, to diminish hunger and to improve health in a more just and inclusive global society. Whatever the particular risks to health, whether they are related to consumption or not, every country needs to be able to adapt risk reduction policies to its own needs
