[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.

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.


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. 

5. Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R. Preventing chronic 
diseases: taking stepwise action. Lancet 2005; published online Oct 5. 

6. Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of 
chronic diseases in India. Lancet 2005; published online Oct 5. 

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


The Lancet Early Online Publication, 5 October 2005


Preventing chronic diseases: how many lives can we save?

Kathleen Strong a , Colin Mathers b, Stephen Leeder c and Robert Beaglehole a


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.


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.


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.


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


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 

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.


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.


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AD, eds. The global burden of disease, vol 1, global burden of disease and 
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349: 1498-1504. Abstract | Full Text | PDF (58 KB) | MEDLINE | CrossRef

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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:.

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mortality in 4 industrialized countries. Int J Cancer 2005; published online 
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change. Oxford: Oxford University Press for World Bank, 2000:.

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31: 403-423. CrossRef

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taking stepwise action. Lancet 2005; published online Oct 5. 

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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, 

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

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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



Preventing chronic diseases: taking stepwise action

JoAnne E Epping-Jordan a , Gauden Galea b, Colin Tukuitonga a and Robert 
Beaglehole a


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.


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 

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 

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 

Excerpted with permission from WHO. Preventing Chronic Diseases: A Vital 

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 

•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 

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.


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.


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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1. Strong K, Mathers CD, Leeder S, Beaglehole R. Preventing chronic diseases: 
how many lives can we save?. Lancet 2005; published online Oct 5. 

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DC: American Institute for Cancer Research, 1997: 530-534.

3. WHO. Diet, nutrition, and the prevention of chronic diseases: WHO Technical 
Report Series 916. Geneva: World Health Organization, 2002:.

4. Ezzati M, Vander Hoorn S, Lawes CM, et al. Rethinking the "diseases of 
affluence" paradigm: global patterns of nutritional risks in relation to 
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361: 717-725. Abstract | Full Text | PDF (222 KB) | MEDLINE | CrossRef

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in coronary heart disease mortality rates in Auckland, New Zealand, between 
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Epidemiol 2003; 56: 583-590. Abstract | Full Text | PDF (479 KB) | MEDLINE | 

13. Pietinen P, Lahti-Koski M, Vartiainen E, Puska P. Nutrition and 
cardiovascular disease in Finland since the early 1970s: a success story. J 
Nutr Health Aging 2001; 5: 150-154. MEDLINE

14. Zatonski WA, Willett W. Changes in dietary fat and declining coronary heart 
disease in Poland: population-based study. BMJ 2005; 331: 187-188. CrossRef

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http://www.who.int/dietphysicalactivity/strategy/eb1134 (accessed July 14, 

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(accessed July 14, 2005).

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18. WHO. The SURF report 2. Geneva: World Health Organization, 2005:.

19. Duc Son LM, Kusama K, Hung NT, et al. Prevalence and risk factors for 
diabetes in Ho Chi Minh City, Vietnam. Diabet Med 2004; 21: 371-376. MEDLINE | 

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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



Responding to the threat of chronic diseases in India

K Srinath Reddy a , Bela Shah b, Cherian Varghese c and Anbumani Ramadoss d


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 

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 

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 

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 


•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 

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.


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.


We thank Robert Beaglehole (WHO) for his suggestions and Colin Mathers (WHO) 
for providing figure 1.


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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



Preventing chronic diseases in China

Longde Wang a, Lingzhi Kong a, Fan Wu b, Yamin Bai b and Robert Burton c d


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 

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'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 

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 

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 

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.


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.


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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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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