[Paleopsych] The Lancet: The Neglected Epidemic of Chronic Disease
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The Neglected Epidemic of Chronic Disease
http://www.thelancet.com/collections/series/chronic_diseases et seq.
DOI:10.1016/S0140-6736(05)67454-5
The neglected epidemic of chronic disease
Richard Horton, The Lancet, London NW1 7BY, UK
The reduction of chronic disease is not a Millennium Development Goal (MDG).
While the political fashions have embraced some diseases—HIV/AIDS, malaria, and
tuberculosis, in particular—many other common conditions remain marginal to the
mainstream of global action on health. Chronic diseases are among these
neglected conditions.
Chronic diseases represent a huge proportion of human illness. They include
cardiovascular disease (30% of projected total worldwide deaths in 2005),
cancer (13%), chronic respiratory diseases (7%), and diabetes (2%). Two risk
factors underlying these conditions are key to any population-wide strategy of
control—tobacco use and obesity. These risks and the diseases they engender are
not the exclusive preserve of rich nations. Quite the contrary.1 Chronic
diseases are a larger problem in low-income settings. Research into chronic
diseases in resource-poor nations remains embryonic. But what evidence there
is2,3 shows just how critical it will be to intervene early in the epidemic's
course. There is an unusual opportunity before us to act now to prevent the
needless deaths of millions. Do we have the insight and resolve to respond?
With a new series of articles,4-7 for which we thank the superb efforts of
Robert Beaglehole, The Lancet aims to fill a gap in the global dialogue about
disease. It is a surprising and important gap, one that health workers and
policymakers can no longer afford to ignore. The call by Kathleen Strong and
colleagues4 for the world to set a target to reduce deaths from chronic disease
by 2% annually—to prevent 36 million deaths by 2015—deserves to be added to the
existing eight MDGs.
Without concerted and coordinated political action, the gains achieved in
reducing the burden of infectious disease will be washed away as a new wave of
preventable illness engulfs those least able to protect themselves. Let this
series be part of a new international commitment to deny that outcome.
References
1. Yusuf S, Hawken S, Öunpuu S. Effect of potentially modifiable risk factors
associated with myocardial infarction in 52 countries (the INTERHEART Study).
The Lancet 2004; 364: 937-952.
2. Sorensen G, Gupta PC, Pednekar MS. Social disparities in tobacco use in
Mumbai, India: the roles of occupation, education, and gender. Am J Public
Health 2005; 95: 1003-1008.
3. Pampel FC. Patterns of tobacco use in the early epidemic stages: Malawi and
Zambia, 2000-2002. Am J Public Health 2005; 95: 1009-1015.
4. Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases:
how many lives can we save?. Lancet 2005; published online Oct 5.
DOI:10.1016/S0140-6736(05)67341
5. Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R. Preventing chronic
diseases: taking stepwise action. Lancet 2005; published online Oct 5.
DOI:10.1016/S0140-6736(05)67342
6. Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of
chronic diseases in India. Lancet 2005; published online Oct 5.
DOI:10.1016/S0140-6736(05)67343
7. Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in China.
Lancet 2005; published online Oct 5. DOI:10.1016/S0140-6736(05)67344
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The Lancet Early Online Publication, 5 October 2005
DOI:10.1016/S0140-6736(05)67341-2
Preventing chronic diseases: how many lives can we save?
Kathleen Strong a , Colin Mathers b, Stephen Leeder c and Robert Beaglehole a
Summary
35 million people will die in 2005 from heart disease, stroke, cancer, and
other chronic diseases. Only 20% of these deaths will be in high-income
countries—while 80% will occur in low-income and middle-income countries. The
death rates from these potentially preventable diseases are higher in
low-income and middle-income countries than in high-income countries,
especially among adults aged 30-69 years. The impact on men and women is
similar. We propose a new goal for reducing deaths from chronic disease to
focus prevention and control efforts among those concerned about international
health. This goal—to reduce chronic disease death rates by an additional 2%
annually—would avert 36 million deaths by 2015. An additional benefit will be a
gain of about 500 million years of life over the 10 years from 2006 to 2015.
Most of these averted deaths and life-years gained will be in low-income and
middle-income countries, and just under half will be in people younger than 70
years. We base the global goal on worldwide projections of deaths by cause for
2005 and 2015. The data are presented for the world, selected countries, and
World Bank income groups. This is the first in a Series of four papers about
chronic diseases.
Introduction
The neglected epidemic
An appreciation of the rising global burden of chronic, noncommunicable
diseases has been developing for more than 20 years.1-4 Physicians and health
managers have applied effective measures, including behavioural interventions
and pharmaceutical treatment, in the prevention and management of chronic
diseases, but these are neither widely used nor equitably distributed. Further,
a widening gap exists between the reality of the chronic disease burden
worldwide and the response of national governments, civil society, and
international agencies to this burden. In this paper, we review the mortality
and chronic disease burden as estimated for 2005 and projected to 2015. We
respond to the gap between information and action by proposing a global goal
for prevention of chronic diseases. The global goal is designed to rally
partners from all sectors of society to avoid needless suffering and death.
Methods
Projections of mortality for 2005 and 2015 WHO provides consistent estimates of
deaths by age, sex, and cause for all member countries based on a systematic
review and analysis of available evidence from surveys, censuses, sample
registration systems, population laboratories, and vital registration on levels
and trends in child and adult mortality. The most recent regional and global
estimates for mortality by cause are for the year 2002.5 More information on
how these estimates were made is available online.6
WHO has prepared updated projections of future trends for mortality between
2002 and 2015 using methods similar to those applied in the original Global
Burden of Disease study.7 The data inputs for the projection models take into
account the greater number of countries reporting death registration data to
WHO, especially low-income and middle-income countries and the updated
projections for the HIV/AIDS and smoking epidemics. For the projections
reported here, historical death registration data for 107 countries between
1950 and 2002 were used to model the relation between death rates for all major
causes (excluding HIV/AIDS) and three variables: (1) average income per capita,
measured as gross domestic product (GDP) per person; (2) the average number of
years of schooling in adults; and (3) time, a proxy measure for the effect of
technological change on health status. Death rates were then projected using
World Bank projections of GDP per person, WHO projections of average years of
schooling, and smoking intensity based on historical patterns of tobacco
use,8,9 and further adjusted for recent trends in tobacco consumption. Separate
projections for HIV/AIDS mortality were prepared by UNAIDS and WHO, and
tuberculosis mortality projections were modified for the interaction between
HIV and tuberculosis. Further information on the projection methods can be
found online.10
Observed historical relations between indicators of development and mortality
patterns, together with explicit assumptions about future trends in development
indicators, smoking intensity, and body-mass index, were used to produce
"business as usual" projections. The results depend on the assumption that
future mortality trends in low-income and middle-income countries will
generally have the same relation to economic and social development as has
applied in high-income countries recently.
The mortality projections were also used as the basis for projections of the
global burden of disease from 2002 to the year 2015 by use of methods similar
to those of Murray and Lopez.7 The burden of disease is quantified in terms of
disability-adjusted life years (DALYs). One DALY can be thought of as one lost
year of healthy life and the burden of disease as a measurement of the gap
between the current health of a population and an ideal situation where
everyone in the population lives into old age in full health.
A global goal
Projected annual rates of change in age-and-sex-specific death rates for all
chronic disease causes were calculated for the mortality projections from 2005
to 2015 and then adjusted by subtraction of an additional 2% per year. Death
rates for years 2006 to 2015 were then recomputed using the adjusted annual
trends for age-sex-specific rates. The final death rates for chronic diseases
in 2015, assuming that the global goal is achieved, are substantially lower
than the base projections, since the additional 2% annual declines are
cumulative. Population numbers, were the global goal to apply, were projected
using the new death rates.
Years of life gained under the global goal scenario were estimated by
calculating total years of life lost (without discounting or age weights) for
each year between 2005 and 2015 under the global goal scenario and subtracting
these from the years of life lost under the base projections scenario.
Results
Global mortality and burden of disease We estimate that, globally, about 58
million people will die in 2005. This value is projected to rise to 64 million
in 2015. Figure 1 shows the distribution of these deaths across three major
cause groups: communicable, maternal, perinatal conditions, and nutritional
deficiencies (group 1), chronic, non-communicable, diseases (group 2) and
injuries (group 3). At a more detailed cause group level, cardiovascular
disease is the leading single cause of death worldwide.
Figure 1. Projected global distribution of total deaths (58 million) by major
cause, 2005
The table shows the projected number of chronic disease deaths and age-specific
death rates for persons for 2005 and 2015. Just over 15 million chronic disease
deaths will occur in people under 70 years in 2005, rising to 17 million in
2015. Half of these deaths will be in women. The age-specific death rates
between 2005 and 2015 are generally projected to remain the same or decline
slightly between 2005 and 2015 (table). However, ageing populations will result
in an overall increase in chronic disease death rates for all ages combined.
Table Projected global deaths and burden of disease (DALYs) due to chronic
diseases by age, 2005 and 2015
In 2005, all chronic diseases account for 72% of the total global burden of
disease in the population aged 30 years and older. The total lost years of
healthy life due to chronic diseases, as measured by DALYs, are greater in
adults aged 30-59 years than for ages 60 years and older, although the DALY
rates increase with age. More than 80% of the burden of chronic diseases occurs
in people under the age of 70 years. Cardiovascular disease alone accounts for
20% of global total DALYs in those older than 30 years. Projected DALY rates
for 2015 are similar to those for 2005 for the older age groups but are higher
for all ages combined, reflecting global population ageing. Selected
country-level projections taken from a WHO publication11 show that chronic
disease rates are higher in the Russian Federation and low-income and
middle-income countries than in Canada or the UK (figure 2).
Figure 2. Age-standardised death rates from chronic disease (per 100000) by
country for ages 30-69 years, estimates for 2005
Standardised to WHO World Standard Population.
Mortality and DALYs by World Bank income group When countries are grouped by
per-person income,12 chronic diseases are projected to be the leading cause of
death in all income groups in 2015 (figure 3). This is already the case in all
but low-income countries for 2005.
Figure 3. Projected crude death rates per 100000 by World Bank income groups
for all ages, 2005 and 2015
Group 1 combines communicable diseases, perinatal and maternal conditions, and
nutritional deficiencies. Group 2 is chronic, noncommunicable diseases. Group 3
is injuries.
Age-specific death rates are projected to decline in all income groups, which
largely reflects projected economic growth over the next decade. However, the
rate of decline is lower for chronic diseases (group 2) than for group 1 causes
other than HIV/AIDS. Because chronic disease death rates rise with age, and
populations are ageing, the overall death rates for chronic diseases are set to
increase in all income groups (figure 3). By 2015, overall deaths due to
chronic diseases will exceed those due to group 1 for all income groups.
The projections suggest that the largest relative increases in chronic disease
death rates will be in high-income countries. However, it is clear from the
high death rates projected for lower-income and upper middle-income countries
for 2015 that these countries also need urgent interventions to control and
prevent chronic diseases.
DALY rates for group 1 conditions are highest in low-income countries in 2005.
This observation reflects the heavy toll that HIV/AIDS is taking in sub-Saharan
African countries. However, by 2015, the DALY rates for chronic disease (group
2) are projected to be slightly higher than those for group 1 conditions in
low-income countries, reflecting the decline of group 1 causes apart from HIV
and tuberculosis, population ageing and a projected increase in tobacco use. In
2005, coronary heart disease and cerebrovascular disease combined are the main
cause of deaths in all income groups and DALYs in all except low-income groups.
This dominance is set to increase in 2015.
Potential achievements of the global chronic disease goal Achieving the global
chronic disease goal would result in an estimated 36 million fewer chronic
disease deaths between 2005 and 2015 worldwide, of which 28 million would be
averted in low-income and middle-income countries (figure 4). For people under
the age of 70 years, achieving the global goal would result in 3 million fewer
deaths in 2015 (figure 5). Averting these deaths would result in a gain of 115
million years of life globally in 2015. 500 million life-years would be saved
cumulatively between 2005 and 2015 for those deaths averted under age 70, and
almost 90% of these saved life-years would be in low-income and middle-income
countries. This supports the overall goal of chronic disease prevention and
control, which is to delay mortality from these diseases to older age groups
and to promote healthy ageing of global populations.
Figure 4. Cumulative number of deaths averted by an additional 2% annual
reduction in death rates from chronic disease from 2006 to 2015, by combined
World Bank income groups
Figure 5. Chronic disease deaths (millions) projected from 2005 to 2015 with
the global goal scenario for people younger than 70 years of age
Discussion
We present the mortality and burden of disease projections for chronic diseases
using the WHO 2002 mortality estimates as a baseline. For regions with limited
death registration data, such as the eastern Mediterranean region, sub-Saharan
Africa, parts of Asia, and the Pacific, there is considerable uncertainty in
estimates of deaths by cause. For some countries, only limited information on
mortality is available from sources such as the Demographic and Health Surveys
and from cause-specific mortality estimates for causes such as HIV/AIDS,
malaria, tuberculosis and vaccine-preventable diseases. The Global Burden of
Disease approach included results for these regions based on the best possible
assessment of the available evidence.13
The mortality and burden of disease projections are less firm than the base
year assessments, and provide "business as usual" projections under specified
assumptions. Furthermore, "business as usual" projections do not take account
of trends in major risk factors apart from tobacco smoking and, to a limited
extent, overweight and obesity in relation to diabetes mortality. If risk
factor prevalence increases, rather than falls, in low-income and middle-income
countries, then our projections of deaths and DALYs in those countries will be
underestimates.
Currently, the serious consequences of chronic diseases and their risk factors
are not recognised by the international health community, at least in terms of
financial commitments by health and development agencies. Chronic diseases are
often characterised as problems of affluent, ageing communities who have
acquired them through indulging in the risk factors for disease (tobacco use,
unhealthy diets, and physical inactivity). This view is inaccurate: chronic
disease is a larger problem in low-income countries, especially among those who
do not have the resources to pursue healthy choices easily. Furthermore, recent
evidence, supported by data presented here, suggests that deaths from heart
disease and lung cancer occur at earlier ages in low-income and middle-income
countries where effective treatments are not widely available and prevention
has not been made a priority.8,14
Myths about chronic disease have serious consequences for the health and
welfare of people in low-income and middle-income countries. The costs of
chronic diseases in these countries are high and often borne by patients as
out-of-pocket payments, contributing directly to family poverty.15,16 The cost
of illness to national governments is also high.11
Another more insidious myth about the chronic disease burden is that we can do
nothing to prevent these conditions because they are caused by unhealthy
behaviours that people choose to have. The reality could hardly be more
different. Human behaviour is shaped by many factors, including environment and
economic pressures, which with increasingly urbanised populations in low-income
and middle-income countries may result in poor diet choices and limited
physical activity. Fortunately, many of these diseases are amenable to
successful intervention.17
The experience of high-income countries clearly shows what can be achieved with
sustained interventions. Death rates from heart disease have fallen by up to
70% in the past three decades in Australia, Canada, Japan, the UK, and the USA.
Between 1970 and 2000, 14 million deaths due to cardiovascular disease were
averted in the USA alone. During the same period, the numbers of deaths averted
in Japan and the UK were 8 million and 3 million, respectively. These data
correspond to a reduction in chronic disease death rates of 1-3% per year over
a 30-year period. Estimates of the joint effects of the leading chronic disease
risk factors (tobacco use, raised blood pressure, and poor diet) indicate that
more than 30% of the burden of chronic diseases and more than 50% of deaths
from chronic disease are attributable to a relatively small number of
modifiable risks.18 In setting out the global goal, we have used a 2% reduction
per year—one which has been typical of the decline in these disorders in
committed high-income countries.
What could we hope to achieve by the year 2015? Meeting the global goal target
would result in 36 million deaths from chronic disease averted during the next
10 years (2006-2015) and a gain of more than 500 million healthy life years
over the next 10 years. Every death averted is a bonus, but the goal contains
an additional, priceless asset: almost half of these averted deaths will be in
men and women younger than 70 years. Extending these lives for the benefit of
the individuals concerned, their families and communities is in itself the
worthiest of goals.
How might this goal be achieved? There are three discrete but overlapping
components to chronic disease prevention and management19 and these can be
approached in a stepwise manner17 including: (1) individual interventions; (2)
population-based interventions; and (3) macroeconomic interventions that align
fiscal realities with health promotion. All three are needed to achieve the
global goal of chronic disease prevention and control.
We have set out a proposal for the establishment of a global health goal that
is both realistic and necessary in light of the serious threat posed by chronic
diseases to global health. Any single organisation or group is unlikely to have
the resources needed to address the complex public health issues related to
chronic diseases. New coalitions that extend beyond the confines of the
traditional health portfolio will need to be built.20 The reason for this lies
in the very nature of the causal, modifiable risks of chronic diseases. These
risks, including tobacco use, poor diet, and physical inactivity, derive from
the structure and function of societies, especially with the process of rapid
urbanisation. If health-promoting change is to occur, then the drivers of these
risks need to be involved in defining the problem as well as the solution.
Sectors of society such as business, labour, and non-governmental organisations
not traditionally included in the development of health policy can be recruited
for prevention efforts. The global goal that we offer is intended to challenge
these sectors to become involved. Our vision for the future extends beyond
measuring risk behaviour and counting the dead, and instead encourages all
sectors of society to contribute to effective ways of reducing health risks and
promoting longer, healthier lives.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
We thank the following for their helpful comments and suggestions, particularly
with regard to the global goal for chronic disease prevention and control: Ruth
Bonita, Debbie Bradshaw, Majid Ezzati, Joanne Epping-Jordan, Jane McElligott,
Thomson Prentice, Serge Resnikoff, Anthony Rodgers, and Theo Vos. The first two
authors would like to dedicate their contributions to this paper to the memory
of Robert Ross Woodrow, who died on July 7, 2005, in Australia, after fighting
cancer for over 10 years. He was 61 years old. This manuscript contains the
views of its authors, and does not necessarily represent the decisions or the
stated policy of WHO.
References
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population change. Milbank Mem Fund Q 1971; XLIX: 509-538.
2. Bulatao RA. Mortality by cause, 1970-2015 In: Gribble JN, Preston SH, eds.
The epidemiological transition. Policy and planning for developing countries.
Washington DC: National Academy Press, 1993:.
3. Murray CJL, Lopez AD. The global burden of disease In: Murray CJL, Lopez
AD, eds. The global burden of disease, vol 1, global burden of disease and
injury series. Cambridge: Harvard University Press, 1996:.
4. Rodgers A, Lawes C, MacMahon S. The global burden of cardiovascular disease
conferred by raised blood pressure: benefits of reversal of blood
pressure-related cardiovascular risk in East Asia. J Hypertens 2000; 18
(suppl): S3-S6.
5. World Health Organization. World Health Report 2004: Changing History.
Geneva: World Health Organization (WHO), 2004:.
6. WHO. The world health report http://www.who.org/whr (accessed July 21,
2005).
7. Murray CJL, Inoue M, Lopez AD. Alternative projections of mortality and
disability by cause 1990-2020: global burden of disease study. Lancet 1997;
349: 1498-1504. Abstract | Full Text | PDF (58 KB) | MEDLINE | CrossRef
8. Ezzati M, Lopez AD. Smoking and oral tobacco use In: Ezzati M, Lopez AD,
Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global
and regional burden of disease attributable to selected major risk factors.
Geneva: WHO, 2004:.
9. Shibuya K, Lopez AD. Statistical modelling and projections of lung cancer
mortality in 4 industrialized countries. Int J Cancer 2005; published online
May 19. DOI:10.1002/ije.21078 .
10. WHO. Burden of disease project http://www.who.int/evidence/bod (accessed
July 21, 2005).
11. WHO. Preventing chronic disease: a vital investment. Geneva: World Health
Organization, 2005:.
12. World Bank. 2003 world development indicators. Washington DC: World Bank,
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13. Murray CJL, Mathers CD, Salomon JA. Towards evidence-based public health
In: Murray CJL, Evans D, eds. Health systems performance assessment: debates,
methods and empiricism. Geneva: World Health Organization, 2003:.
14. Leeder SR, Raymond SU, Greenberg H, Lui H, Esson K. A race against time:
the challenge of cardiovascular diseases in developing countries. New York:
Columbia University, 2004:.
15. Narayan D, Chambers R, Shah M, Petesch P. Voices of the poor crying out for
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16. Hulme D, Shepherd A. 2003, conceptualizing chronic poverty. World Dev 2003;
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17. Epping-Jordan JE, Galea G, Tukuitonga C. Preventing chronic diseases:
taking stepwise action. Lancet 2005; published online Oct 5.
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18. Ezzati M, Lopez AD. Potential health gains from reducing multiple risk
factors In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative
quantification of health risks: global and regional burden of disease
attributable to selected major risk factors. Geneva: World Health Organization,
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19. Greenberg H, Raymond SU, Leeder SR. Cardiovascular disease and global
health: Threat and opportunity. Health Aff (Millwood) 2005; published online
Jan 25. DOI:10.1377/hlthaff.W5.31
20. Raymond SU, Greenberg HM, Lui H, Leeder SR. Civil society confronts the
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Affiliations
a Department of Chronic Diseases and Health Promotion, WHO, 20 Avenue Appia,
CH-1211 Geneva 27, Switzerland b Department of Measurement and Health
Information Systems, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland c
Australian Health Policy Institute, College of Health Sciences, The University
of Sydney, Australia
Correspondence to: Kathleen Strong
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DOI:10.1016/S0140-6736(05)67342-4
Preventing chronic diseases: taking stepwise action
JoAnne E Epping-Jordan a , Gauden Galea b, Colin Tukuitonga a and Robert
Beaglehole a
Summary
The scientific knowledge to achieve a new global goal for the prevention of
chronic diseases—a 2% yearly reduction in rates of death from chronic disease
over and above projected declines during the next 10 years—already exists.
However, many low-income and middle-income countries must deal with the
practical realities of limited resources and a double burden of infectious and
chronic diseases. This paper presents a novel planning framework that can be
used in these contexts: the stepwise framework for preventing chronic diseases.
The framework offers a flexible and practical public health approach to assist
ministries of health in balancing diverse needs and priorities while
implementing evidence-based interventions such as those recommended by the WHO
Framework Convention on Tobacco Control and the WHO Global Strategy on Diet,
Physical Activity and Health. Countries such as Indonesia, the Philippines,
Tonga, and Vietnam have applied the stepwise planning framework: their
experiences illustrate how the stepwise approach has general applicability to
solving chronic disease problems without sacrificing specificity for any
particular country.
This is the second in a Series of four papers about chronic diseases.
Introduction
As described in the first paper of this series,1 from an estimated total of 58
million deaths worldwide this year, heart disease, stroke, cancer, and other
chronic diseases will account for 35 million, more than 15 million of which
will occur in people younger than 70 years. Approximately four out of five of
all deaths from chronic disease now occur in low-income and middle-income
countries, and the death rates are highest in middle-aged people in these
countries (panel 1).
Panel 1: Key messages
Many chronic disease interventions are effective and suitable for
resource-constrained settings
Stepwise implementation of evidence-based interventions will make a major
contribution to the prevention and control of chronic disease
Comprehensive and integrated action at country level, led by governments, is
the means to achieve success
While the age-specific rates of death from chronic diseases are declining in
many high-income countries, the burden of these epidemics is accelerating in
low-income and middle-income countries, driven by both population ageing and
rapid social and environmental changes that are increasing the prevalence of
common risk factors in these countries. This acceleration is alarming
considering that chronic diseases are highly preventable. At least 80% of heart
disease, stroke, and type 2 diabetes, and 40% of cancer could be avoided
through healthy diet, regular physical activity, and avoidance of tobacco
use.2,3 Cost-effective interventions to reduce chronic disease risks exist, and
have worked in many countries (panel 2); the most successful strategies have
used a range of population-wide and individual approaches. Yet the upsurge of
chronic disease risks in many low-income and middle-income countries exposes
the paucity of successfully implemented preventive population-based
interventions. For those at high risk or with established disease, many
medications and other treatments are at best intermittently available in these
countries. The stark consequence is that people are suffering needlessly for
lack of inexpensive and off-patent treatments (panel 3).
Panel 2: Common myths surrounding chronic diseases Myth: "Chronic diseases are
diseases of affluence"
Fact: four out of five deaths from chronic disease are in low-income and
middle-income countries. Recent evidence points to the fact that chronic
disease risks become widespread much earlier in a country's economic
development than is usually realised. For example, population body-mass index
and total cholesterol increase rapidly as the national income of poor countries
rises. They remain steady once a certain level of national income is reached,
before eventually declining.4
Myth: "People must die of something"
Fact: Certainly everyone has to die of something, but death does not need to be
slow, painful, or premature. Most chronic diseases do not result in sudden
death. Rather, they are likely to cause people to become progressively ill and
debilitated, especially if their diseases are not managed correctly. This is
especially true in low-income and middle-income countries, where people tend to
develop disease at younger ages, suffer longer— often with preventable
complications—and die sooner than those in high-income countries. Death is
inevitable, but a life of protracted ill health is not.
Myth: "Chronic diseases develop over a lifetime of exposure to risk and hence
effective prevention will take generations, far beyond political attention
spans"
Fact: It is not necessary to wait decades to reap the benefits of prevention
and control activities. Risk factor reduction can lead to surprisingly rapid
health gains, at both population and individual levels. In the case of tobacco
control, the effect of proactive policies and programmes is almost immediate.
The implementation of tobacco-free policies leads to quick decreases in tobacco
use, rates of cardiovascular disease, and hospital admissions due to myocardial
infarction.5,6
Myth: "Interventions for chronic disease prevention and control are necessarily
less cost-effective than those for acute and infectious diseases"
Fact: A full range of chronic disease interventions has been judged to be very
cost-effective for all regions of the world, including sub-Saharan Africa. Many
of these solutions are not only very cost-effective, they are also inexpensive
to implement.7 Examples of very cost-effective interventions are: salt
reduction through voluntary agreements with the food industry; taxation of
tobacco products, which is not only cost effective but also raises revenues for
governments; comprehensive bans on advertising of tobacco products; and
combination drug therapy based on an overall risk approach to identifying
individuals at high risk.8 The ideal components of a medication to prevent
complications in people with heart disease are no longer covered by patent
restrictions and could be produced for little more than a dollar a month.9
Panel 3: Face to face with chronic diseases Roberto Severino Campos lives in a
shanty town in the outskirts of São Paulo with his seven children and 16
grandchildren. Roberto never paid attention to his high blood pressure, nor to
his drinking and smoking habits. "He was so stubborn", his 31-year-old daughter
Noemia recalls, "that we couldn't talk about his health".
Roberto had his first stroke 6 years ago at the age of 46—it paralysed his
legs. He then lost his ability to speak after two consecutive strokes 4 years
later. Roberto used to work as a public transport agent, but now depends
entirely on his family to survive.
Since Roberto's first stroke, his wife has been working long hours as a cleaner
to earn money for the family. Their eldest son is also helping with expenses as
much of the family's income is used to buy the special diapers that Roberto
needs. "Fortunately his medication and check-ups are free of charge but
sometimes we just don't have the money for the bus to take us to the local
medical centre", Noemia continues.
But the burden is even greater: this family not only lost its breadwinner, but
also a devoted father and grandfather. Roberto is now trapped in his own body
and always needs someone to feed him and see to his most basic needs. Noemia
carries him in and out of the house so he can take a breath of air from time to
time. "We all wish we could get him a wheelchair", she says.
Noemia and four of her brothers and sisters also suffer from high blood
pressure.
Excerpted with permission from WHO. Preventing Chronic Diseases: A Vital
Investment.9
To address the divergence between escalating numbers of deaths from chronic
disease on one hand, and the existence of effective interventions on the other
hand, a global goal for preventing chronic diseases has been proposed.1 The
target is a 2% annual reduction in chronic disease death rates over and above
projected declines during the next 10 years. This reduction would result in 36
million deaths averted over this period, of which 28 million would be averted
in low-income and middle-income countries. The target is based on the
achievements of several countries over the past three decades in which
comprehensive chronic disease prevention programmes have been introduced.10-14
Subsequently, a vast amount of published work has accumulated to show that
health gains can be obtained over a relatively short period of time, especially
in the area of tobacco control, in which benefits accrue almost immediately.
Although the scientific knowledge to achieve the global goal exists now, many
low-income and middle-income countries must deal with the practical realities
of limited resources and a double burden of infectious and chronic diseases.
The WHO Global Strategy on Diet, Physical Activity and Health15 and the WHO
Framework Convention on Tobacco Control16 describe the actions needed to reduce
tobacco use and support the adoption of healthy diets and regular physical
activity. Yet policies to encourage these actions might seem out of reach for
some ministries of health, who are charged with the task of putting such
approaches into practice in the face of pressing, competing priorities. Here,
we propose a novel planning framework that can be used in these contexts: the
stepwise framework for preventing chronic diseases.
Taking action
Creative solutions are necessary to address the escalating demands of chronic
diseases and their common risk factors in countries with limited or stressed
health systems, such as Vietnam, where annual health expenditures amount to
Intl$148 per person (Intl$1 has the same purchasing power as US$1 has in the
USA). With this limited funding, the country must contend with a high
prevalence of chronic malnutrition of children, relatively high maternal and
neonatal mortality, an unfinished agenda around infectious diseases, and a
steady increase in cardiovascular diseases, cancer, and other chronic
diseases.17 In urban areas near Hanoi, 15% of adults are overweight (body-mass
index >25);18 in Ho Chi Minh City, 7% of adults have diabetes.19
Within contexts such as these, ministries of health are faced with a seemingly
daunting task: to rally support for chronic disease prevention and control; to
provide a unifying vision and action plan to ensure that intersectoral action
is emphasised at all stages of policy formulation and implementation; and to
make certain that actions at all levels and by all sectors are mutually
supportive. Additionally, actions need to be prioritised in keeping with the
specific population needs for chronic disease prevention and control, range of
possible interventions, and availability of human and financial resources to
implement them.
Stepwise framework for preventing chronic diseases The stepwise framework
offers a flexible and practical approach to assist ministries of health in
balancing diverse needs and priorities while implementing evidence-based
interventions. The framework is guided by a set of principles based on a public
health approach to chronic disease prevention and control:
•The national level of government provides the unifying framework for chronic
disease prevention and control, so that actions at all levels and by all
stakeholders are mutually supportive.
•Intersectoral action is necessary at all stages of policy formulation and
implementation because major determinants of the chronic disease burden lie
outside the health sector.
•Policies and plans focus on the common risk factors and cut across specific
diseases.
•As part of comprehensive public-health action, population-wide and individual
interventions are combined.
•In recognition that most countries will not have the resources to immediately
do everything implied by the overall policy, activities that are immediately
feasible and likely to have the greatest impact for the investment are selected
first for implementation. This principle is the heart of the stepwise approach.
•Locally relevant and explicit milestones are set for each step and at each
level of intervention with a particular focus on reducing health inequalities.
Detail of the stepwise framework
The figure outlines the key steps of the stepwise framework, which includes
three main planning steps and three main implementation steps.
Figure. WHO stepwise framework for preventing chronic diseases
The first planning step is to assess the current risk factor profile and burden
of chronic diseases of a country or sub-population. The distribution of risk
factors among the population is the key information required by countries in
their planning of prevention and control programmes, and can be assessed using
WHO's stepwise surveillance approach.20 This information must then be
synthesised and disseminated in a way that successfully argues the case for the
adoption of relevant policies. This is a key aspect of making the case for
action.
Indonesia's experience illustrates the importance of this first step. For many
years the scale of the chronic disease problem in Indonesia went unrecognised
because of a shortage of reliable information. Prevention and control
activities were scattered, fragmented, and lacked coordination. Periodic
household surveys later revealed that the proportion of deaths from chronic
diseases doubled between 1980 and 2001 (from 25% to 49%). The economic
implications and the pressing need to establish an integrated prevention
platform at national, district, and community level became clear. In 2001,
Indonesia's Ministry of Health initiated a broad consultative process that
resulted in a national consensus on chronic disease policy and strategy. A
collaborative network for chronic disease prevention and control was
established, involving health programmes, professional organisations,
non-governmental organisations, educational institutions, and other partners
from both the public and private sectors (including those not directly
concerned with health). This enterprise was followed by further action that
ultimately led to a national policy and strategy document in 2004.
The second planning step is to formulate and adopt a chronic disease policy
that sets out the vision for prevention and control of the major chronic
diseases and provides the basis for action in the next 5-10 years. In all
countries, a national policy is essential to give chronic diseases appropriate
priority and to organise resources efficiently. For example, China's Ministry
of Health, with the support of WHO and the cooperation of relevant sectors, has
been developing a national plan for chronic disease prevention and control that
focuses on cardiovascular diseases, stroke, cancer, chronic obstructive
pulmonary disease, and diabetes. It will include an action plan for 3-5
years.21 Depending on the configuration of each country's governance,
complementary policies also can be developed at the state, province, district,
or municipal levels. In these cases, it is vital that subnational policies are
fully integrated and aligned with national policies.
The third planning step is to identify the most effective means of implementing
the adopted policies. The comprehensive approach requires a range of
interventions to be implemented in a stepwise manner, depending on their
feasibility and likely impact in the local conditions, and taking into account
potential constraints and barriers to action. Some of the selected
interventions might be primarily under the control of the health ministry, such
as realigning health systems for chronic disease prevention and control. Others
might be primarily the responsibility of other government sectors or the
legislative branch, such as health financing, laws and regulations, and
improving the built environment. In these cases, the ministry of health must
ensure coordination and cooperation with all government partners, civil
society, and the private sector.
Planning is followed by a series of implementation steps: core, expanded, and
desirable. The chosen combination of interventions for core implementation
forms the starting point and the foundation for further action. Each country
must consider a range of factors in deciding the package of interventions that
constitute the first, core implementation step, including capacity for
implementation, likely impact, acceptability, and political support. Selecting
a smaller number of activities and doing them well is likely to have more
effect than tackling a large number haphazardly. Countries should also try to
ensure that any new activities complement those already underway locally,
provincially, or nationally.
Putting the framework into action
A number of countries, such as Vietnam and Tonga (panel 4) have successfully
used the stepwise framework for policy formulation and implementation. They
show how the stepwise approach has general applicability to solving chronic
disease problems without sacrificing specificity for any given country.
Panel 4: Vietnam and Tonga
Vietnam and Tonga could not be less alike, yet both are early adopters of the
stepwise approach to planning in their region. The former is a large Asian
country of 80 million people, with a double burden of infectious and chronic
disease, and a rapidly growing economy. The latter is a Pacific country of
100000 people, with a fully established chronic disease epidemic and an economy
strongly dependent on remittances and foreign aid.
When the stepwise approach to planning was first introduced, Vietnam and Tonga
faced very different challenges. Tonga had no national chronic disease plan but
was committed to developing one,22 whereas Vietnam had an ambitious national
programme23 but no means to monitor its implementation.
In both countries, resource scarcity was a major impediment. In Tonga, the
scarcity, especially of human resources, is absolute, with a very small number
of professionals available to work in the field of chronic disease. In Vietnam
that scarcity is compounded by specialisation into a series of vertical
institutes and some degree of fragmentation.
The consequence for both countries was similar. In Tonga, there was a need to
reach consensus on a prioritised list of possible actions, making most
effective use of its scarce human resources. In Vietnam, there was a need to
agree on a common set of measures and indicators that would be used to monitor
the effect of the work of several diverse institutes.
An ineffective planning model could have distorted the outcome for both
countries. In Tonga, improper planning might have resulted in a national
programme peppered with the pet projects of influential proponents. In Vietnam,
the danger would have been of producing a surveillance system overburdened with
the research projects of specialist interests.
A series of consultations were held in both countries, in 2003 in Tonga, and in
2004 in Vietnam—large formal meetings involving multiple partners, including
international development agencies, and smaller, more direct, negotiations
between parties. In all these meetings, the stepwise approach was explicitly
used as a planning and recording tool.
In both countries, the planning model led to results that went beyond the
production of a consensus document. In Tonga, the action plan24 that was
produced by the end of 2003 was rapidly adopted by government and became an
instrument for coordinating the work of different sectors as well as for
channeling the disparate inputs of development agencies. In Vietnam, the
model25 produced by the stepwise process has been endorsed by the Ministry of
Health and is now being tested in pilot provinces.
These examples show that the stepwise approach can rapidly translate
evidence-based standards on the prevention and control of chronic disease into
coherent action programmes that are relevant to the resource constraints and
political realities of developing countries.
Across these and other countries, the following factors have been associated
with successful implementation:
•A high-level political mandate to develop a national policy framework.
•A committed group of advocates who are often involved with estimating need,
advocating for action, and developing the national policy and plan.
•International collaboration providing political and technical support.
•Wide consultation in the process of drafting, consulting, reviewing, and
re-drafting the policy until endorsement is achieved.
•Development and implementation of a consistent and compelling communication
strategy for all stages of the process.
•Clarity of vision on a small set of outcome-oriented objectives.
Civil society and the private sector
Any single organisation or group is unlikely to have enough resources to
address the complex public health issues related to the prevention and
management of chronic diseases. The stepwise framework initiated by governments
allows all health and non-health sectors to see how their role is an integral
part of an overall framework. It becomes quickly apparent that it can be best
implemented by working with the private sector, civil society, and
international organisations. In the Philippines, for example, the Department of
Health has assumed a coordination and advocacy role in the development of a
response to chronic disease, marshalling the multiple inputs of local
governments, non-governmental associations, and the Philippine Health Insurance
Corporation. Using the stepwise framework as a basis for planning, a Philippine
Coalition for the Prevention of Noncommunicable Diseases has been formed and a
Memorandum of Understanding for action between these parties was signed in
2004.26 The relations between government, civil society, and the private sector
also apply at the international level, where WHO collaborates with a range of
partners on chronic disease prevention and control.
Conclusion
Every country, regardless of the level of its resources, has the potential to
make substantial improvements in chronic disease prevention and control, and to
take steps towards contributing towards the global goal for preventing chronic
diseases by 2015. A 2% annual reduction in chronic disease death rates, above
and beyond currently projected declines, will result in 36 million fewer deaths
by 2015, half of which will be in people younger than 70 years.1
A range of effective interventions for chronic disease prevention and control
exist, and many countries-mostly those with high income-have already made major
reductions in chronic disease deaths through their implementation. Yet more
focused action and political commitment is needed in many parts of the world,
especially low-income and middle-income countries.
In low-income countries, it is vital that supportive policies are in place now
to reduce risks and curb epidemics before they take hold. In countries with
established chronic disease problems, additional measures will be useful not
only to prevent diseases through risk reduction but also to manage illness and
prevent complications. Everyone has a role to play in advancing the agenda. As
a starting point, the full WHO publication, Preventing Chronic Diseases: A
Vital Investment, supplementary information, and an online advocacy toolkit,
can be downloaded from WHO's website.9
This publication describes a comprehensive public health approach for
implementing chronic disease policies and programmes in an integrated and
stepwise manner. As there cannot be a universal prescription for
implementation, the feasibility of the stepwise approach is that it allows each
country to consider a range of factors in priority setting. Stepwise
implementation of evidence-based interventions will make a major contribution
to prevention and control of chronic disease, and will assist countries to
contribute towards achieving the global goal by 2015.
Taking up the challenge for chronic disease prevention and control, especially
in the context of competing priorities, requires a certain amount of courage
and ambition. On the other hand, the failure to use available knowledge about
chronic disease prevention and control is unjustified, and recklessly endangers
future generations. There is simply no excuse for chronic disease to continue
taking millions of lives each year when the scientific understanding for how to
prevent these deaths is available now. The agenda is broad and bold, but the
way forward is clear.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
We thank Ruth Bonita, Serge Resnikoff, and Kathleen Strong for their helpful
comments and suggestions on draft versions of this paper. We also thank the
numerous contributors to and reviewers of the related WHO publication:
Preventing Chronic Diseases: A Vital Investment. This manuscript contains the
views of its authors, and does not necessarily represent the decisions or the
stated policy of WHO.
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Affiliations
a Department of Chronic Diseases and Health Promotion, WHO, 20 Avenue Appia,
CH-1211 Geneva 27, Switzerland b Regional Office for the Western Pacific, WHO,
Manila, Philippines
Correspondence to: JoAnne E Epping-Jordan
-----------------
DOI:10.1016/S0140-6736(05)67343-6
Responding to the threat of chronic diseases in India
K Srinath Reddy a , Bela Shah b, Cherian Varghese c and Anbumani Ramadoss d
Summary
At the present stage of India's health transition, chronic diseases contribute
to an estimated 53% of deaths and 44% of disability-adjusted life-years lost.
Cardiovascular diseases and diabetes are highly prevalent in urban areas.
Tobacco-related cancers account for a large proportion of all cancers. Tobacco
consumption, in diverse smoked and smokeless forms, is common, especially among
the poor and rural population segments. Hypertension and dyslipidaemia,
although common, are inadequately detected and treated. Demographic and
socioeconomic factors are hastening the health transition, with sharp
escalation of chronic disease burdens expected over the next 20 years. A
national cancer control programme, initiated in 1975, has established 13
registries and increased the capacity for treatment. A comprehensive law for
tobacco control was enacted in 2003. An integrated national programme for the
prevention and control of cardiovascular diseases and diabetes is under
development. There is a need to increase resource allocation, coordinate
multisectoral policy interventions, and enhance the engagement of the health
system in activities related to chronic disease prevention and control.
This is the third in a Series of four papers about chronic diseases.
Burden of chronic diseases: the rising tide
India is experiencing a rapid health transition, with large and rising burdens
of chronic diseases, which are estimated to account for 53% of all deaths and
44% of disability-adjusted life-years (DALYs) lost in 2005 (figure 1). Earlier
estimates, from the Global Burden of Disease Study, projected that the number
of deaths attributable to chronic diseases would rise from 3·78 million in 1990
(40·4% of all deaths) to 7·63 million in 2020 (66·7% of all deaths).1
Figure 1. Estimated proportions of total deaths and DALYs lost by cause in
India (all ages, 2005)
Many of these deaths occur at relatively early ages. Compared with all other
countries, India suffers the highest loss in potentially productive years of
life, due to deaths from cardiovascular disease in people aged 35-64 years (9·2
million years lost in 2000). By 2030, this loss is expected to rise to 17·9
million years-940% greater than the corresponding loss in the USA, which has a
population a third the size of India's.2
The burden of cardiovascular disease is rising in India. The estimated
prevalence of coronary heart disease is around 3-4% in rural areas and 8-10% in
urban areas among adults older than 20 years, representing a two-fold rise in
rural areas and a six-fold rise in urban areas over the past four decades.
About 29·8 million people were estimated to have coronary heart disease in
India in 2003; 14·1 million in urban areas and 15·7 million in rural areas.3
The prevalence of stroke is thought to be 203 per 100000 population among
people older than 20 years.4
Data on cancer mortality are available from six centres across the country,
which are part of the National Cancer Registry Programme of the Indian Council
of Medical Research (ICMR). About 800000 new cases of cancer are estimated to
occur every year. The age-adjusted incidence rates in men vary from 44 per
100000 in rural Maharashtra to 121 per 100000 in Delhi.5 The major cancers in
men are mostly tobacco-related (lung, oral cavity, larynx, oesophagus, and
pharynx). In women, the leading cancer sites include those related to tobacco
(oral cavity, oesophagus, and lung), and cervix, breast, and ovary cancer.
India has the largest number of oral cancers in the world, due to the
widespread habit of chewing tobacco.
India also has the largest number of people with diabetes in the world, with an
estimated 19·3 million in 1995 and projected 57·2 million in 2025.6 The
prevalence of type 2 diabetes in urban Indian adults has been reported to have
increased from less than 3·0% in 1970 to about 12·0% in 2000.7 On the basis of
recent surveys, the ICMR estimates the prevalence of diabetes in adults to be
3·8% in rural areas and 11·8% in urban areas.
The prevalence of hypertension has been reported to range between 20-40% in
urban adults and 12-17% among rural adults.8 The number of people with
hypertension is expected to increase from 118·2 million in 2000 to 213·5
million in 2025, with nearly equal numbers of men and women.9
Risk factor levels: grim portents
These advancing epidemics are propelled by demographic, economic, and social
factors, of which urbanisation, industrialisation, and globalisation, are the
main determinants. The Indian economy is growing at 7% per year. With
increasing life expectancy, the proportion of the population older than 35
years is expected to rise from 28% in 1981 to 42% in 2021.10 The proportion of
people in urban residence, presently around 30%, is expected to rise to about
43% in 2021. During the decade 1991-2001, the population grew by 18% in the
rural areas and 31% in urban regions.11 Urbanisation and industrialisation are
changing the patterns of living in ways that increase behavioural and
biological risk factor levels in the population. Substantial variations exist
between different regions, but risk levels are rising across the country, most
notably in urban areas of demographically and economically more advanced states
of India.
An excess risk of death from coronary disease has been observed in men and
women of south-Asian origin, by comparison with other ethnic groups, and there
is a progressive rise in risk from rural to urban to migrant environments.12,13
The increased risk of cardiovascular problems noted in Indian migrants is a
portent of the further rise in risk that Indians are likely to experience
alongside the developmental transition of their country.
A high frequency of diabetes, central obesity, and other features of the
metabolic syndrome (especially the characteristic dyslipidaemia of reduced HDL
cholesterol and raised triglycerides) have been reported in migrant and urban
Indian population groups.14,15 Comparisons between migrant and non-migrant
groups and rural and urban populations have also highlighted the importance of
conventional risk factors like smoking, blood pressure, plasma cholesterol, and
body-mass index (BMI).10,12 The INTERHEART study16 found that the cluster of
nine coronary risk factors identified in the global population was also
applicable to south Asians as a group.
Nationally representative distribution data are available for a few risk
factors. Several community-based surveys, done in different parts of India at
different times, have contributed to a patchwork profile of risk in segments of
the population, but there have been very few multicentre studies with
standardised methodology. In the past few years, two surveillance systems have
been established to provide risk factor data from different parts of the
country, using WHO's STEPS methodology.17 In 2002, ICMR, with technical
assistance from WHO, established a community-based surveillance system
involving five centres. During 2000-04, another WHO-assisted project
established a sentinel surveillance system for cardiovascular risk factors and
events in ten large industries across the country, involving the employees and
their family members.
The prevalence of tobacco use, in myriad smoked and smokeless forms, has been
estimated in the National Sample Survey and the National Family Health Survey
(figure 2).18 In the Indian component of the Global Youth Tobacco Survey
(2000-04), 25·1% of the students aged 13-15 years reported that they had ever
used tobacco, whereas current use was reported by 17·5%.19 A national survey in
2002, reported that the overall prevalence of current tobacco use in men and
boys aged 12-60 years was 55·8%, ranging from 21·6% in those aged 12-18 years
to 71·5% in the 51-60 year age group.20
Figure 2. Prevalence of tobacco chewing, smoking, and alcohol habits in men and
women older than 15 years in rural and urban India (1998-99)18
Many cross-sectional surveys, as well as the industrial surveillance project,
recorded a high urban prevalence of central obesity and overweight (especially
when the lower thresholds recommended by WHO for Asian people are used). Though
the prevalence of obesity (BMI 30) is usually lower than that observed in the
western population, the overweight category (BMI 25) includes almost a third to
half the population in every survey. Women and men are equally affected.21,22
Small birth size, with rebound obesity in early childhood, predicted diabetes
and glucose intolerance in adulthood, in an Indian cohort.23
The few available standardised studies of physical activity revealed low levels
in urban areas (compared with rural) and in the upper-income and middle-income
groups (compared with low-income). Low levels of physical activity have been
reported in 61-66% of men and 51-75% of women, in urban surveys.22,24
Most surveys have also shown higher mean concentrations of plasma cholesterol
in urban population groups (4·6-5·2 mmol/L) compared with rural groups (4·3-4·6
mmol/L), with a low mean concentration of HDL cholesterol.25 The ICMR
surveillance project observed that the prevalence of dyslipidaemia (ratio of
total cholesterol to HDL cholesterol 4·5) was 37·5% in individuals aged 15-64
years. Even in a relatively young industrial population (20-59 years), 62·0%
had dyslipidaemia.26 Levels of awareness, treatment, and adequate control are
low for hypertension, diabetes, and dyslipidaemia, especially in rural
areas.26,27
With advancing health transition, the poor are increasingly affected by chronic
diseases and their risk factors. Low levels of education and income now predict
not only higher levels of tobacco consumption, but also increased risk of
coronary heart disease.19,28 Since India's daily consumption of fruits and
vegetables is 130 g per person per day, poor people may also have deficiencies
of protective phytonutrients. Urban slums in Delhi have high rates of diabetes
and dyslipidaemia.29 Lack of awareness of risk factors and diseases, and
inadequate access to health care, increase the risk of early death or severe
disability in such disadvantaged groups.
The policy response: current scenario
The advancing epidemics of chronic diseases require a comprehensive policy
response that caters to the varied needs of population-based prevention and
essential clinical care. The health systems are presently geared to provide
prioritised care for communicable diseases and services related to maternal and
child health. The agenda of health promotion and chronic disease prevention has
not yet been adequately incorporated. Clinical services, too, are not currently
designed to provide the required level of care for these diseases in primary
and secondary health-care settings.
As in other developing countries, public health advocacy has been mostly
devoted to communicable diseases, nutritional deficiencies, population
stabilisation, and recently to HIV/AIDS. Clinical health-care providers, on the
other hand, were more focused on developing advanced health-care facilities for
treatment of established chronic diseases. Policymakers have been impeded,
until recently, by inadequacy of data on the burdens of chronic diseases.
Perceptions that these diseases mainly affect the rich, who can purchase
private health care, also prevented public sector resources from flowing into
chronic disease prevention and control. The limited health budgets were not
ready to take on the additional costs of treating chronic diseases at state
expense. The huge expenditure that the state and society are incurring on the
tertiary care of advanced chronic diseases has only been recently recognised.
The cost of treating three tobacco-related diseases (cancers, coronary heart
disease, and chronic obstructive pulmonary disease) was an estimated US$7·2
billion in the year 2002-03.19
Over the past 20 years, policies related to tobacco control have been
strengthened, culminating in the Indian Parliament unanimously enacting a
comprehensive national law for tobacco control in April, 2003 (panel 1). India
has also ratified the WHO Framework Convention on Tobacco Control. Many factors
cumulatively contributed to the emergence of this national consensus:
increasing knowledge of the health, environmental, and developmental damages
caused by tobacco; growing global support for tobacco control; WHO's catalytic
role in developing policies and programmes for effective action; national
research on tobacco-related burdens; vigorous advocacy by Indian civil society
groups; decisive interventions by the Indian judiciary and increasing
policymaker support across the political spectrum. Implementation of the
national law, however, needs to gather strength, through effective mobilisation
of central and state level enforcement agencies and community groups.
Panel 1: Key provisions of the Indian Tobacco Control Act, 2003
•Ban on smoking in public places
•Ban on direct and indirect advertisement of cigarettes and other tobacco
products in print, electronic and outdoor media (ban on tobacco use in films to
be implemented from October, 2005)
•Ban on sales to and by people younger than 18 years
•Tobacco products cannot be sold near educational institutions
•Mandatory depiction of statutory health warning (in one or more Indian
languages) and pictorial warning, on all tobacco products
•Product regulation: tar and nicotine levels to be declared on tobacco product
packages
India is the world's second largest producer as well as consumer of tobacco. As
a source of excise revenue, export earnings, and employment, tobacco occupies
an important place in the Indian economy. The strong measures initiated by the
Government of India for tobacco control have overcome fierce resistance from
the tobacco industry. In this respect, India becomes an excellent role model
for other developing countries.
The policy framework needed to implement the WHO Global Strategy on Diet,
Physical Activity and Health is still evolving. Although several nutrition
programmes exist for correction of nutritional deficiencies, especially among
vulnerable groups, they do not incorporate the dietary elements needed for
prevention of chronic disease. Coordinated multisectoral initiatives,
recommended by the Global Strategy, have not yet been designed. However,
efforts have recently been initiated to address these needs. A
multi-stakeholder national consultation was held in April, 2005, at the behest
of the Indian Health Ministry, to identify action pathways and partnerships for
implementing the Global Strategy in the context of India.
Recently the Health Ministry has decided to initiate an integrated national
programme for prevention and control of diabetes and cardiovascular diseases
(including stroke) and is now developing models. Some state governments, such
as Tamil Nadu and Kerala, have identified chronic disease prevention and
control as a high priority. The former has incorporated this component into its
recently launched statewide health-systems project, which is supported by the
World Bank.
Existing chronic disease prevention and control programmes
Although several national programmes for prevention and control of communicable
diseases exist, there are very few such programmes for chronic diseases. The
National Cancer Control Programme was the first programme dedicated to a
chronic disease. The National Blindness Control Programme has helped to reduce
the backlog of cataract operations through wide coverage (about 4.3 million
cataract operations per year at the moment). The National Programme on Speech
and Hearing provides services related to prevention and control of deafness.
The other programmes relevant to chronic diseases are National Iodine
Deficiency Disorders Control Programme and National Mental Health Programme.
New programmes that are being initiated this year are likely to have a
substantial effect on chronic diseases. The National Rural Health Mission is a
country-wide programme for upscaling rural health services, and can be designed
to include key elements of health promotion and chronic disease prevention.
Special outpatient services for elderly people in all hospitals and two
National Institutes of Ageing are also proposed.
In general, most national health programmes have been structured around a
technological response and focused on specific targets. The need for
multi-component interventions, affecting several behaviours, posed difficulties
in designing programmes related to chronic diseases. However, the fact that
programmes for population stabilisation and HIV prevention also have major
behaviour modification components should open the way for programmes related to
chronic disease.
India was one of the first countries to develop a National Cancer Control
Programme. Cancer control received early recognition because of strong advocacy
from health professionals, emotive appeal to people, and the realisation that
the disease affected the poor in large numbers. The programme, which was
started in 1975, was initially focused on setting up ten regional cancer
centres and procuring cobalt therapy units. It was reformulated in 1984 (panel
2).
Panel 2: National cancer control programme Objectives
•Primary prevention of tobacco-related cancers
•Early diagnosis and treatment of cervical cancer
•Extension and strengthening of therapeutic services including pain relief, on
a national scale, through regional cancer centres and medical and dental
colleges
Schemes
•Financial assistance to voluntary organisations
•District cancer control scheme
•Financial assistance for Cobalt Unit installation
•Development of oncology wings in Government Medical College hospitals
•Assistance for regional research and treatment centres
Current status
•205 cancer treatment centres; 22 regional cancer centres; 325 teletherapy
units; 113 remote brachytherapy machines
•Availability of oral morphine tablets in registered medical institutions since
1991
Although no separate national programme has, as yet, been established for
tobacco control, a National Tobacco Control Cell has been established in the
central Health Ministry, with assistance from WHO. Its activities currently
extend from supporting civil society initiatives for anti-tobacco education and
advocacy to operation of tobacco cessation clinics in selected health-care
facilities. A National Programme for Tobacco Control, linked with state-level
programmes, has now become necessary for effective implementation of the Indian
law and adherence to the WHO Framework Convention on Tobacco Control.
State-subsidised health care is available for treatment of chronic diseases.
However, such clinical care facilities are mostly concentrated in large urban
centres. There has been a rapid growth of private tertiary-care hospitals,
which cater to the urban affluent sections and are now vying to attract
international medical tourism. Facilities for both acute and long-term care of
chronic diseases are inadequate in rural primary-care settings, and even in
secondary-care settings of smaller towns and cities. Essential drugs for
treatment of cardiovascular disease and diabetes are available at lower than
global prices, but are still too expensive for many people.
Action needed
The need to provide an effective public-health response to the growing
challenge of chronic diseases in India can no longer be ignored without
imperilling India's development. A comprehensive strategy must integrate
actions to minimise exposure to risk factors at the population level, and
reduce risk in individuals at high risk, to provide early, medium-term, and
long-term effects.
Interventions that can prevent or reduce the risk of chronic diseases include:
policy measures, such as those related to tobacco control, production and
supply of healthy foods, regulation of unhealthy foods, and urban planning that
promotes physical activity; empowerment of communities through health promotion
programmes that can effectively enhance knowledge, motivation, and skills to
foster awareness and adoption of healthy behaviours; early detection of
individuals at high risk of developing a chronic disease and those with an
early manifestation of disease, for imparting effective protection; secondary
prevention in people who have developed chronic diseases; and provision of
cost-effective and life-saving acute care.
While India is simultaneously experiencing several disease burdens due to old
and new infections, nutritional deficiencies, chronic diseases, and injuries,
individual interventions for clinical care are unlikely to be affordable on a
large scale. Although community empowerment for health promotion is essential,
health education alone would be insufficient in the absence of supportive
environmental changes. Health messages on chronic disease prevention also have
to compete for public attention with many other messages on polio,
tuberculosis, HIV, family planning, and other health problems. In such a
scenario, policy interventions related to tobacco, food supply, and urban
design are likely to have a far greater and quicker effect on chronic disease
prevention through their population-wide effect. WHO's stepwise approach to
prevention and control provides practical pathways for staged implementation.30
The initiatives taken for tobacco control must be consolidated, by establishing
a national regulatory authority for tobacco control to steer the national
programme. A national coordinating body, representing multiple stakeholder
groups, should be set up to strengthen implementation. The existing food-based
dietary guidelines should be revised to reflect the principles of chronic
disease prevention and health promotion and, thereafter, widely disseminated in
various Indian languages. Through amendments to the Prevention of Food
Adulteration Act of 1954, limitations can be placed on the levels of salt,
sugar, and saturated fats in manufactured food products. Food labelling also
needs to be introduced to facilitate informed choice by consumers. Policies
related to urban design and urban transport also need to be formulated to
facilitate safe and pleasurable physical activity as a routine component of
daily life.
Such multi-sectoral policies can only be implemented when other relevant
government departments, civil society, and private sector act in concert with
the departments of health at central and state levels. To enable this action, a
broad based intersectoral coordinating group would need to be established at
the Planning Commission of India.
Data obtained from simple and sustainable surveillance systems would help to
guide future policy. The Integrated Disease Surveillance Programme, launched by
the Government of India in 2004, incorporates key elements of chronic disease
risk factor surveillance and has the potential to yield such nationally
representative data.
Demonstration projects of health promotion and chronic disease risk reduction
are in progress, in both community and industrial settings. School-based
projects have evolved successful models of health promotion.31 Experience from
these projects will strengthen the design and delivery of a national programme
for chronic disease prevention and control. This programme will also benefit
from capacity enhancement in public health, which the government proposes to
achieve by establishing a network of new and old schools of public health.
Cost-effective clinical interventions to reduce risk also need to be introduced
in primary and secondary health-care settings. India has a strong
pharmaceutical industry, which is able to provide many of the drugs needed for
chronic disease management at low cost. Inexpensive drugs for treatment of
individuals at high risk could be made widely available to the poor through the
government health system, and to others through health insurance schemes.
Conclusion
As chronic disease epidemics gather pace in India and threaten harm to
individuals, families, and the society at large, a comprehensive strategy for
their prevention and control is needed. Some of the required elements are
already in place, such as control programmes for tobacco use and cancer. These
efforts need to be upscaled. In other areas, such as diet and physical
activity, the process must move from contemplation to action. Health systems
need to be reoriented to accommodate the needs of chronic disease prevention
and control, by enhancing the skills of health-care providers and equipping
health-care facilities to provide services related to health promotion, risk
detection, and risk reduction.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
We thank Robert Beaglehole (WHO) for his suggestions and Colin Mathers (WHO)
for providing figure 1.
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3. Gupta R. Rapid response to Ghaffar A, Reddy KS, Singhi M. Burden of
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people from the Indian subcontinent living in west London and their siblings in
India. Lancet 1995; 345: 405-409. MEDLINE
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heart disease risk factors: comparison of Gujaratis in Britain and their
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Affiliations
a Department of Cardiology, All India Institute of Medical Sciences, New Delhi
110029, India b Division of Non-Communicable Diseases, Indian Council of
Medical Research, New Delhi, India c Office of the WHO Representative to India,
New Delhi, India d Minister of Health and Family Welfare, Government of India,
New Delhi, India
Correspondence to: Professor K Srinath Reddy
-----------------
DOI:10.1016/S0140-6736(05)67344-8
Preventing chronic diseases in China
Longde Wang a, Lingzhi Kong a, Fan Wu b, Yamin Bai b and Robert Burton c d
Summary
Chronic diseases now account for an estimated 80% of deaths and 70% of
disability-adjusted life-years lost in China. Cardiovascular diseases and
cancer are the leading causes of both death and the burden of disease, and
exposure to risk factors is high: more than 300 million men smoke cigarettes
and 160 million adults are hypertensive, most of whom are not being treated. An
obesity epidemic is imminent, with more than 20% of children aged 7-17 years in
big cities now overweight or obese. The government of the People's Republic of
China must confront these major challenges. The national cancer prevention and
control plan (2004-10) is being implemented, and a national chronic disease
prevention and control plan is due to be completed this year. Encouraging
progress has been made in some areas, with current smoking prevalence in men
declining at about 1% per year for a decade, and even better results in large
demonstration programmes. Much remains to be done, and resources and
sustainability are major issues. However, the surveillance and intervention
mechanisms needed to ameliorate the increasing burden of chronic diseases are
developing rapidly, taking account of the lessons learned over the past two
decades.
This is the last in a Series of four papers about chronic diseases.
Chronic, non-communicable diseases now account for an estimated 80% of total
deaths and 70% of total disability-adjusted life-years (DALYs) lost in China
(figure 1). The major causes of death in China are cardiovascular disease,
cancer, and chronic respiratory disease. Rates of death from chronic disease in
middle-aged people are higher in China than in some high-income countries.1
Figure 1. Estimated proportions of total deaths and DALYs lost for all ages in
China, 2005
In China, as in many other parts of the world, the government has focused on
communicable diseases-however, China now has a double burden of disease (figure
1). The prevention of chronic diseases is now receiving a national response
commensurate with the burden. In this paper, we outline China's developing
comprehensive response to these chronic disease challenges.
Driving forces
The ageing of the population is the major force driving the epidemic of chronic
diseases. In 2000, 7% of the Chinese population were aged 65 years or older,2
and more than 400 million Chinese adults are now aged 20-39 years. If current
trends continue, by 2040 the group aged 65 years and older will have increased
to almost 20% of the population.3 The ageing of the population alone is
predicted to produce a 200% increase in deaths from cardiovascular disease in
China between the years 2000 and 2040.3
In addition to the ageing of the population, China is experiencing dramatic
transformations in many social and economic conditions that will continue to
increase the incidence of major chronic diseases. For example, the country has
recorded spectacular economic growth since 1978 and, on average, people's
standard of living is far higher than ever before in the rapidly expanding
urban areas. From 1990 to 2000, the proportion of people living in urban
settings in China increased from 26% to 36%, the number of cities increased to
663, and the number of towns also soared.2 It is expected that urbanisation in
China will reach 45% by 2010, and 60% by 2030, with an extra 200 million more
people expected in the urban areas before 2010.3 This growth comes at a cost in
health terms. For example, a clear relation exists between urbanisation and the
prevalence of diabetes in China (diabetes defined as diabetic symptoms and a
random blood glucose concentration of 11·1 mmol/L or more, a fasting blood
glucose of 7·0 mmol/L or more, or an abnormal result of 2-h oral glucose
tolerance test; figure 2).4
Figure 2. Prevalence of diabetes in China, 2002
The rapid environmental changes that follow urbanisation are increasing the
prevalence of the major risk factors for chronic disease. Tobacco use,
unhealthy nutrition, and physical inactivity leading to obesity and
hypertension are already common, and physical inactivity is increasing.4,5 The
prevalence of current cigarette smoking in men (smoked in the past 30 days) was
57% in 2002, but had fallen from 63% in 1996; less than 3% of women are current
smokers.5 This favourable trend must be continued, because lung cancer death
rates are calculated to have more than doubled in men between 1991 and 1995,
and are increasing at 2-5% per year in urban and rural working men aged 15-54
years.6 The decrease in smoking is the only encouraging risk factor trend, and
is consistent with the plateau of tobacco consumption over this same period in
the face of a rising adult population, as has occurred in other countries where
tobacco taxes have been raised sharply (figure 3). In 1999 the first Global
Youth Tobacco Survey in China showed that 22% of students aged 13-15 years had
ever tried to smoke; the current smoking rate was only 5%.7
Figure 3. Total tobacco consumption and the effects of tobacco taxation in
China
China's first comprehensive survey in the fields of nutrition and health was
done in 2002. 71971 households were chosen from 132 counties of 31 provinces,
autonomous regions, and the municipalities, using the Central Government
household census, and 243479 people were included in the survey.4 The
prevalence of hypertension (blood pressure 140/90 or higher) in people aged 18
years or older was 19%-a 30% increase since 1991. The prevalence of adult
overweight (23%) and obesity (7%) had increased by 39% and 97%, respectively,
over a 10-year period.4
Of particular note is the rapidly developing epidemic of obesity in Chinese
children. The overall prevalence rates of overweight plus obesity in 2000 among
students in six sites (Beijing, Tianjin, and Shanghai cities and Hebei,
Liaoning, and Shandong provinces) increased from 1-2% in 1985 to 25% for boys
aged 7-9 years, 25% for boys aged 10-12 years, 17% for girls aged 7-9 years,
and 14% for girls aged 10-12 years.8 In 2002, prevalence rates in children aged
7-17 years varied from 13% overweight and 8% obese in a range of big cities to
2% overweight and less than 1% obese in a range of rural sites (figure 4).4
Figure 4. Percentages of children aged 7-17 years who were overweight and obese
in China, 2002
Economic consequences of chronic diseases
Over the past 25 years, China has made extraordinary progress in reducing the
number of people living in poverty from 250 million at the start of its reform
process in 1978 to 29 million in 2001 (the Chinese poverty income standard is
lower than the US$1 per day standard). Chronic diseases are threatening this
progress and exposing individuals and their families and communities to
stresses. Some citizens newly emerged from poverty may find their families
plunged again into it as one of their members falls victim to catastrophic
illness such as stroke or cancer. In a 2003 survey, 30% of poor households
attributed their poverty to health-care costs.9 Overall, 79% of rural dwellers
and 45% of urban citizens have no health insurance, and the prevalence of
citizens who could not afford medical treatment rose from 32% to 39% in rural
areas, and from 32% to 36% in urban areas, between 1993 and 2003.10
The economic consequences of chronic diseases for China are serious. For
cardiovascular disease alone, Chinese people aged 35-64 years lost 6·7 million
years of productive life during the year 2000 at a cost to the country of
around US$30 billion.3 Only a quarter of this cost was estimated to be direct
health-care costs.3 If current trends continue the total of years of productive
life lost in this age range in China is estimated to increase to 10·5 million
by 2030.3 It is estimated that in 2005 China will lose about $18 billion in
national income from the effects of heart disease, stroke, and diabetes on
labour supplies and savings. The cumulative loss over the period 2005-2015
would be about $556 billion.11
Progress in chronic disease prevention and control: examples of successful
projects
The establishment of Chinese cancer registries began in 1963 in Shanghai, and
data from registries led to some of the first programs that addressed chronic
diseases in China. For example, mortality from cervical cancer in the Jing'an
county of Jiangxi province decreased to 9·6 per 100000 in 1985 from 42·0 per
100000 in 1974, at least in part a result of the introduction of the "early
detection, early diagnosis and early treatment" of cervical cancer (Kong L,
unpublished). Cancer has led the way in chronic disease control initiatives. In
2003, the Ministry of Health of the People's Republic of China, which is
responsible for health policy, completed a national cancer control plan on the
basis of expert opinions in diverse fields. Some elements of the Program of
Cancer Prevention and Control in China (2004-2010) are now being implemented,
for example with rapid diagnosis and screening trials for cervical cancer.12
Between 1991 and 2000, a community-based intervention trial on management of
diabetes and hypertension was done in an urban population of 300000 in three
cities (Beijing, Shanghai, and Changsha). The most notable outcomes were that
the incidence of stroke decreased by 52% in men and 53% in women, and the
mortality rate of stroke fell by 54% overall.13,14
In 1995, the World Bank Loan Health VII: China Disease Prevention
Project-health promotion component (1996-2002) began in seven cities: Beijing,
Tianjin, Shanghai, Chengdu, Luoyang, Liuzhou and Weihai, and some regions of
Yunnan province. The programme covered about 90 million people. To date, among
the chronic diseases outcomes reported are an overall reduction of 15% in the
prevalence of male adult cigarette smokers, and in Beijing substantial
increases in hypertension detection and treatment with a fall in cardiovascular
disease death rates of more than 15% in the last year of the project (Wu Z,
Director, Beijing Institute of Heart, Lung and Blood Vessel Diseases, personal
communication).15
Based on the experience of this project, the Ministry Of Health began
establishing demonstration sites for chronic disease prevention and control
nationwide in 1997. There are currently 32 community-based sites and the major
activities include community diagnosis, community mobilisation, development of
integrated community interventions (smoking control, healthy diet, physical
activity, hypertension prevention, mental health, prevention and control of
cardiovascular disease, diabetes, cancer, chronic respiratory disease),
training, and evaluations of interventions.
Current policy activities
Risk factor patterns and demographic trends show that the most important
priorities for chronic disease prevention in China are to control blood
pressure in the 160 million hypertensive adults, and help more than 300 million
adult male smokers to quit. Although no current data are available about
smokers' intentions to quit, the Health VII project achieved an overall quit
rate of 25% in men over a 6-year period.16 Progress is also being made with the
control of hypertension, and the mortality rate from cardiovascular disease
halved in hypertensive patients over a 3-year period in the Shangai
demonstration sites (Kong L, unpublished).
China has just ratified the Framework Convention of Tobacco Control. During the
past two decades, action has included: in-depth dissemination of tobacco
control information and health education; the development of a series of
tobacco control laws, regulations and rules; the formation of a tobacco control
network; the organisation of workshops and symposiums; the progressive
limitation and banning of tobacco advertisements; mass campaigns on tobacco
control; tobacco control in youth; and support for and participation in the
negotiation of the WHO Framework Convention of Tobacco Control. The 2008
Olympics will be smoke free.
To improve the nutrition and health condition of the Chinese people, the
government has been developing and promulgating a series of policies, and
implementing many projects. A major focus is on primary schools, and
demonstration projects are achieving encouraging reductions in the prevalence
of childhood obesity. For example, in a project in four Chinese cities, the
prevalence of obesity in grade 3 and 4 boys (aged 8-14 years) was reduced from
21% to 14% in 1 year (Tian B, National Health Education Institute, personal
communication).
To meet the huge challenge of chronic diseases the Ministry of Health of China,
with the support of WHO, and in cooperation with relevant sectors, has been
developing the first medium and long-term high level national plan for chronic
disease control and prevention (2005-15). This plan will mandate an integrated
and comprehensive approach to the control and prevention of cardiovascular
disease, cancer, chronic respiratory disease, and diabetes. There will be
priority actions in at least four areas: adult male smoking, hypertension,
overweight and obesity, and capacity building for chronic disease control.
Surveillance and information systems
The National Centre for Chronic and Non-communicable Disease Control and
Prevention (NCNCD) was established in 2002, under the leadership of the Chinese
Centre for Disease Prevention and Control (CDC), which is the technical
counterpart of the Ministry of Health. NCNCD is the institution for chronic
disease prevention and control at the national level and is responsible for
surveillance and population based interventions. A national chronic disease
control network is being built. At present, almost all provincial-level CDCs
have a specified chronic disease responsibility and mission with the
development of personnel and financing. Prefecture-level CDCs have been
established in most provinces, and CDC staff are being appointed at lower
regional levels-eg, in counties.
Comprehensive disease surveillance has been done in China through the National
Disease Surveillance Points System, which was founded in 1978, primarily to
report on communicable diseases, with some chronic disease responsibilities.
The system was expanded and adjusted to improve its representativeness of China
as a whole in 2004. The revised system includes 150 disease surveillance sites.
Current initiatives of the system include upgrading cause of death registration
so each disease surveillance point will function as a population mortality
register for its designated site. The NCNCD is now responsible for the Disease
Surveillance Points System, which will be the major national resource for
surveillance of chronic disease.
Following the framework of the WHO STEPs Surveillance system,16 the first
National Risk Factor Surveillance Survey was done in August, 2004, with a
sample size of 33180 individuals from 942 villages or sub-communities, 314
towns or communities in 79 counties or districts in the Disease Surveillance
Points System. The data are being analysed, and a complete report will be
published in late 2005. A national system of risk factor surveillance is being
developed, in which regional risk factor surveys, carried out by trained
provincial and regional CDC staff according to national standards, will be an
important component.
Conclusion
The most pressing problems in the prevention of chronic disease in China relate
to tobacco use and high blood pressure. Although the current generation of
adults is at relatively low risk of the diseases associated with obesity, the
rapid growth of obesity in the next generation will affect Chinese morbidity
and mortality in the second half of this century, unless action is taken now.
The social and economic consequences will be very serious if China fails to
achieve control of these risk factors as soon as possible. Demonstration
projects have shown that chronic disease risk factors can be controlled in
China. The challenge for the national government is to scale up these
interventions, and build capacity for effective national chronic disease
control programmes.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
The authors acknowledge the reading of drafts of this manuscript and the
helpful suggestions offered by Robert Beaglehole, Henk Bekedam, Cristobal
Tunon, and Yanwei Wu. Colin Mathers kindly provided figure 1.
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Affiliations
a Ministry of Health of the People's Republic of China, Beijing, China b
National Centre for Chronic and Non-communicable Disease Control and Prevention
of the Chinese Centre for Disease Control and Prevention, Beijing, China c WHO
Centre for Health Development, Kobe, Japan d Office of the Representative of
the World Health Organization, Beijing, China
Correspondence to: Prof Robert Burton
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