|Year : 2016 | Volume
| Issue : 2 | Page : 92-104
Global non-communicable disease prevention: Building on success by addressing an emerging health need in developing countries
Ali H Mokdad
Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
|Date of Web Publication||7-Apr-2016|
Ali H Mokdad
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle, WA 98121
Non-communicable diseases (NCDs) are beginning to dominate the global health landscape. Despite numerous calls to action for chronic disease preventive and control, the response to the urgency is insufficient, especially in terms of their prevention efforts. Worldwide, the total number of people dying from NCDs is twice that of the combined total of all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions and nutritional deficiencies. Cardiovascular disease is the leading cause of death in the world and accounts for about 30% of all deaths. Increased interventions in global NCDs prevention and control programs are needed as a global strategy to improve the current scenario. Specifically, we present this case for the United States to provide leadership in global NCD prevention and control.
Keywords: Centers for Disease Control and Prevention, epidemiology, global health, non.-communicable diseases, population surveillance, training, United States Agency for International Development
|How to cite this article:|
Mokdad AH. Global non-communicable disease prevention: Building on success by addressing an emerging health need in developing countries. J Health Spec 2016;4:92-104
|How to cite this URL:|
Mokdad AH. Global non-communicable disease prevention: Building on success by addressing an emerging health need in developing countries. J Health Spec [serial online] 2016 [cited 2019 Nov 22];4:92-104. Available from: http://www.thejhs.org/text.asp?2016/4/2/92/179820
| Introduction|| |
The 20th century's successful efforts ,, to address the global burdens associated with infectious diseases, maternal and child health and nutritional deficiencies in developing countries ushered in a new era where non-communicable diseases (NCDs) are the major new challenges for governments, organisations and donors aiming to improve global health and well-being. The challenge that these successes have brought to global disease prevention is the shift or 'transition' of disease burden from communicable to NCDs. NCDs such as cardiovascular, lung and liver disease, malignant neoplasms, diabetes and depression are now the major cause of death, disability, reduced quality of life and rising health care costs worldwide.,,,
Recently, a 2% annual reduction in NCD death rates over and above projected declines during the next 10 years has been put forward as a global goal. However, despite numerous calls-to-action for NCD prevention and control, the response to the urgency of chronic diseases is not matched by efforts for their prevention.,,,, In 2008, the 61st World Health Assembly endorsed the World Health Organization (WHO) led action plan for the global strategy for the prevention and control of NCD. In doing so, the World Health Assembly urged its member states to consider and implement the actions in the global strategy for the prevention and control of NCDs and to increase support for the work of the WHO to prevent and control NCDs including implementation of the global strategy. In this report, we present this case for devoting more attention to NCDs in global health by the United States through a global NCD prevention and control program in support of the WHO and its global strategy.
| An Overview of the Epidemiologic Transition in the United States|| |
Many public health achievements and advancements in tobacco control, sanitation, infection control, therapeutic medicine, pharmaceuticals and medical technology in the 20th century have added more than 25 years of life expectancy in the United States. Vaccination and control of infectious diseases are among the most visible of these achievements.,,,,,,, As the burden of infectious diseases fell, the burden of NCDs grew to become the leading cause of death and disability. As a result of these epidemiological shifts, by 2005, NCDs accounted for more than 60% of all deaths in the United States. Unprecedented gains in life expectancy during the 20th century fundamentally changed the patterns of health and disease. The tremendous cost associated with NCDs makes the case for their Centers for Disease Control and Prevention (CDC) even more urgent. In addition, the aging of population resulted in heavy demands on our systems of public health, medical care and aging services, driven in part by disability and increases the need for long-term care., The high cost of treating NCDs ultimately contributes to ever greater health care costs. As a result, many public health professionals have called for greater resources to prevent and control NCDs, emphasising that our health system should place disease prevention and health maintenance at the forefront of our nation's health activities.
The US obesity epidemic reflects the increasing importance of addressing NCDs and their related risk factors. Since 1990, a steady increase in population obesity rates has been observed among both men and women and across all ages, racial groups, education levels and all states. This rapid increase in obesity in all segments of the population and regions of the country reflects broad changes in our society that foster caloric imbalance, such as shifts in food consumption which lead to increased ingestion of calories. At the same time, we have become less active and more reliant on machines to do our physical work, hence, burning fewer calories. The example of increasing obesity rates is closely related to the evidence that health-related behaviors such as smoking, poor diet, physical inactivity, and the harmful use of alcohol are the leading personal behavioral causes of preventable deaths in the United States.,
Resources must be allocated appropriately to plan and develop primary and secondary prevention programs to address the leading causes of morbidity and mortality. Understanding trends in health behaviors, the origins of these behaviors and social influences that reinforce them are critical. For instance, in 2005, about 7% of the US population had diabetes  and an estimated $22.9 billion was spent in 2006 on direct medical costs related to diabetes complications. In 1998, the estimated cost of obesity in US adults was about US$78.5 billion; in 2002, this rose to US$92.6 billion. Cigarette smoking causes more than 400,000 deaths or about 1 of every 5 deaths each year and results in nearly $100 billion in lost productivity annually.,,, Preventing the onset and progression of non-communicable illness through policies and programs that support the adoption and maintenance of healthy behaviors is one of the most effective strategies to improve health, and it is also one of the most efficient; providing health improvement at the lowest cost. Health planners need to prioritise the clear and present damage to the body from the NCD epidemic, just as they prioritise preventing emerging infectious diseases, pandemics and bioterrorism. A clear balance has to be maintained as we weigh these 'immediate,' 'possible' or 'threatening' and 'important' public health priorities.
| The Global Burden of Non-Communicable Diseases and Opportunities to Build on Success|| |
Worldwide, the total number of people dying from NCDs is twice that of the combined total of all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions and nutritional deficiencies., Cardiovascular disease is the leading cause of death in the world and accounts for about 30% of all deaths.
The epidemiologic shift affects all countries regardless of their stage of economic development. NCDs are no longer just a problem of the affluent. During the next 20 - 30 years, decline in communicable diseases and in conditions related to childbirth and poor nutrition, population aging and changes in lifestyle factors such as diet, alcohol consumption, exercise and smoking mean that the greatest health care needs will be for prevention and treatment of NCDs. During 2005, an estimated 35 million people died from NCDs; 80% of these deaths occurred in low- and middle-income countries. In the same year, NCDs accounted for 43% of total mortality in low-income countries. In 2013, 70% of all global deaths were due to NCDs and increased rapidly from 1990 [Figure 1] and [Figure 2]. They are projected to account for more than half of all deaths and nearly half of the burden of disease in low-income countries by 2030. Cardiovascular disease is the number one cause of death in the developing world with the exception of sub-Saharan Africa  and causes as many deaths in developing countries as HIV, malaria and tuberculosis combined. In fact, 3 times as many cardiovascular disease deaths occur in developing countries as compared to developed countries. The WHO estimates that 36 million deaths from NCDs could be averted by 2015 if NCD death rates were reduced by additional 2% between 2005 and 2015. Of these, 28 million would be averted in low- and middle-income countries.
Despite this evidence, NCDs remain absent from global list of priorities such as the Millennium Development Goals (health is a focus of three of the eight goals) and rarely the focus of governmental, non-governmental and philanthropic donor agency sponsored field work in global health. Rather, the tendency is to prioritise and fund programs for diseases that are the most visible and most often linked with poverty, malaria, HIV/AIDS and tuberculosis – in other words, diseases that disproportionately affect low- and middle-income countries. Because they are not contagious, NCDs are often not viewed by health officials and decision makers as an urgent challenge but rather as an inevitable problem. This is not to suggest that we should reduce attention and resources for communicable diseases. No doubt, this would be counterproductive, as HIV/AIDS, tuberculosis and malaria continue to be leading health problems in many areas. Nonetheless, evidence suggests that communicable diseases – most notably HIV/AIDS – have 'reshaped the population structure and age distribution' in many developing countries, and despite the impact of HIV/AIDS, developing country populations are aging and increasingly will have to deal with a growing burden from NCD.
Donors and international non-governmental organisations seek to maximise the population-level impact of their funds, so they look for 'low hanging fruits' and 'quick wins.' Emphasis is placed on strategies such as immunisation for measles that are relatively inexpensive yet have impressive impact (two doses of measles vaccine provides nearly 100% protection for life) and provide donors with immediate and sustained results. In the case of measles, as a result of systematic immunisation campaigns, it has been eliminated from the Western hemisphere and is rapidly declining elsewhere. If the target developing country has a weak or mismanaged health system, donors simply bypass it and hire non-governmental organisations to conduct the intervention, which allows the donor near-complete control over every stage of the system.
Fortunately, systematic global strategies such as the Millennium Development Goals have led to highly efficient and effective interventions that have reduced child mortality rapidly and dramatically in less than a decade. Future successes, however, may require that health workforces and systems in developing countries be strengthened, which will require major political changes in the health systems of developing countries and sustained investment by donors and international organisations.,,,,, The strategies to further reduce the impact of infectious diseases would be much like those required for NCD control: Build health systems and make sustained changes in population behavior away from unhealthy behaviors to healthy ones. Here, non-communicable and infectious disease control programs can leverage the others' success to identify and rapidly diffuse strategies that work.
Although NCDs are not contagious at the disease level, the adverse risk behaviors that cause them are fundamentally social and readily transferable between societies. Many lifestyles are communicated worldwide through migration, media, the internet and globalisation of world markets. The spread of the 'fast food' concept throughout the world is of growing concern. Indeed, traditional diets, which are usually healthier than Western fast foods, are disappearing in many countries. Increasing urbanisation and industrialisation further contribute to the problem, with more processed food, more lifestyle options, greater stress, more pollution and less physical activity.
Further compounding countries' ability to deal with NCDs is the unequal global capacity for NCD surveillance, prevention and control across countries, particularly in the public health workforce. Many developing countries lack the expertise and resources to conduct the activities necessary to address NCDs and are increasingly turning to outside partners for advice. Although some countries maintain a sense of urgency to enhance their capacity, others lack country-level information on the epidemiology of NCDs necessary to maintain a focus on building capacity. In addition, many health ministers who are appointed for shorter tenures are more likely to pay attention to infectious diseases or high-impact, media-focused events for further political gains at the expense of NCDs. In contrast, a prevention and control program for NCDs will require a long-term commitment, and the resulting health improvements, especially those focusing on youth, may take a longer time to appear. Therefore, it is important to have continuity in the commitment to NCDs and promote interventions against some NCD risk factors where success is measurable in a short time (e.g. coverage of hypertension screening or school physical activity promotion). The public health community must demonstrate the politicians, partners and the private sector that NCD prevention is essential to promote well-being. Because of their prevalence, their prevention has a correspondingly huge potential for cost savings.
Progress in capacity building will require continuity in the commitment to NCDs and short-term successes using interventions to reduce NCD risk. While population impacts are slow to appear, changes in risky behavior are measurable in the short run and provide managers and politicians with indicators that can be used to measure success and build continuing support. Some NCD interventions do provide quick results; for instance, providing insulin for diabetics.
Some countries have begun to confront their increasing burden of NCDs, but most governments of developing countries continue to devote their resources in controlling infectious diseases. We present the situation in five countries at different levels of economic development: China, Brazil, South Africa, Jordan and the Kingdom of Saudi Arabia (KSA) as examples of challenges faced by these countries.
China has made great progress in reducing the number of people living in poverty. In addition, the country has experienced tremendous economic growth, which led to an increase in the proportion of people living in urban settings. Unfortunately, the prevalence of risk factors and the NCDs they cause have increased. For example, there are now an estimated 350 million current smokers (60% of men and 3% of women smoke),, 160 million persons with high blood pressure, 160 million persons with dyslipidemia and another 260 million persons who are either obese or overweight. Moreover, the country is experiencing a rapid increase in obesity among its children. Not surprisingly, coronary heart disease mortality is increasing at an estimated rate of 5% per year.,, Lung cancer death rates doubled in men between 1991 and 1995.
The aging Chinese population will continue to suffer from an increasing burden of NCDs. In 2000, about 7% of the Chinese population was aged 65 years or older. This proportion is expected to increase to >20% by 2040 and will lead to a predicted 200% increase in the number of cardiovascular deaths. The burden of NCDs in China will undoubtedly affect its future economic growth and pose serious problems for its future. In 2000, cardiovascular diseases accounted for 6.7 million years of lost productivity for adults aged 35 - 64, at a cost of about US$30 billion. Heart diseases, stroke and diabetes will cost China an estimated US$556 billion from 2005 to 2015. China is now prioritising NCD prevention and control and the country plans to develop a comprehensive response to this emerging burden.
Brazil's health status has improved dramatically in the past 20 years, but the health care system continues to struggle with the challenges of emerging NCDs while tackling diseases associated with poverty. Infant and maternal deaths have decreased by 42% since 1985., Deaths due to vaccine-preventable diseases are negligible now that vaccination coverage has reached the high levels needed for herd immunity. Diarrhoea, the second leading cause of death among children younger than 5 during the 1970s, now contributes to <7% of all deaths in this age group. Much of these improvements are due to public health strategies that increased access, coverage and quality of health care delivery. Moreover, Brazil has implemented comprehensive health reforms to create a unified national health system that makes universal health care coverage a citizen's right under the newly amended constitution. In addition, despite a high incidence and prevalence of HIV/AIDS relative to other Latin American countries, Brazil's incidence has levelled off, and hospitalisations and deaths from the disease are dramatically lower than in the past. These gains have resulted from aggressive prevention education campaigns initiated 20 years ago, improved access to screening, free delivery of medical care and drugs to all HIV/AIDS patients and government-backed local production of HIV/AIDS top-line drugs.
Despite these achievements, deaths from cardiovascular disease, cancer and injuries increased from approximately 24% in 1950 to 60% in 2000, a dramatic 150% increase. This rapid epidemiologic shift is occurring during a major demographic transition. While in 1950, <20% of all deaths occurred among people aged 65 or older, an estimated 60% of all deaths will occur in this age group by 2020, a 200% increase. Between 2002 and 2004, a survey of risk factors for NCDs across 16 capitals showed that the prevalence of overweight and physical inactivity were similar to those of developed countries, at approximately 38% and 40% respectively, while cigarette smoking prevalence was somewhat lower at about 17%.
Despite its small size relative to other programmatic activities, Brazil's Ministry of Health (MOH), Secretariat of Health Surveillance, has made progress in filling the system gaps in the prevention of NCD and injuries., In the past 5 years, Brazil has significantly improved its surveillance of NCDs and related risk factors by enacting laws that created programs and policies that guaranteed their funding. The government also established the Division of Health Surveillance and the Coordination Office for NCD prevention as well as specific programs and funds for surveillance of cancer and risk factors.
Between 2004 and 2006, funds for surveillance of non-communicable, NCDs increased from US$4.5 million to US$32.2 million, a 688% increase. In the next 2 years, Brazil intends to develop a national strategy to prevent NCDs that includes the design and implementation of a more comprehensive surveillance system for NCDs and injury-related risk factors, development of programs to prevent injury and NCDs and promote health and research to identify public health strategies in NCD prevention that are effective and adoptable.
The socio-economic status and urbanisation of South Africa are rising. The percentage of South Africans living in urban areas increased from 36% in 1993 to 43% in 1996. South Africa is suffering from a double burden of diseases. The health system is dealing with poverty-related infectious diseases, including HIV/AIDS, simultaneously with an increase in risk factors for and prevalence of NCDs. For example, prevalence of obesity has increased to about 34% among women, a level similar to that of African-American women in the United States. Moreover, hypertension in South Africa is very common, but adequate treatment is a challenge. The age-adjusted prevalence of hypertension (140/90 mm Hg) was 21% for both genders in 1998. Using an alternative definition of hypertension (>160/95 mm Hg), the prevalence was 11% for men and 14% for women. For men with hypertension, levels of awareness, taking antihypertensive medication and having controlled blood pressure (<160/95 mm Hg) were 41%, 39% and 26%, respectively, while for women, these prevalences were 67%, 55% and 38% respectively.
Mortality from NCDs is increasing as a result of the health transition. In 1990, cerebrovascular diseases were the third leading cause of death, accounting for 7% of mortality. Ischemic heart diseases were the fifth leading cause of death in 1990, accounting for 5% of total mortality., It is likely that the rates in 2008 will be higher in view of the socio-economic advances and urbanisation since these data were collected. Hence, NCDs and their risk factors are placing an increasing burden on health services in South Africa at a time when the country is struggling to control its infectious diseases.
NCDs are the leading cause of death in Jordan, with 38% of deaths attributed to cardiovascular diseases and 14% to cancers in 2003. The Jordan MOH, with assistance from the United States CDC, established a behavioral surveillance program to monitor the risk factors associated with these diseases in 2002. In 2004, the MOH conducted a national representative survey of adults aged >18 years which revealed a high prevalence of NCD risk factors. For example, the prevalence of obesity among Jordanian adults was 20% in 2004, a 50% increase in 2 years from 13% in 2002. In 2004, 55% of adult Jordanians (52% of men and 57% of women) were overweight (body mass index [BMI] ≥25), up from 45% in 2002. The prevalence of diagnosed diabetes was 8% in 2004, a 17% increase in 2 years from 6% in 2002. About 25% of Jordanians aged >65 years had been diagnosed with diabetes. Among people with diabetes, 63% reported they had not had their feet checked for sores or irritations and 45% had not had an eye examination in the last 12 months. Among people with diabetes who ever had an eye examination, 36% were diagnosed with eye complications.
Cancer screening was very low among women during 2004, with only about 15% of married women reporting having had a Pap test during the past 3 years. Only 9% of women aged >40 years reported having had a mammogram in the past 2 years. Screening for high blood pressure and cholesterol were also low; about 70% and 40% of Jordanians reported ever having been tested for high blood pressure and high blood cholesterol, respectively. Perhaps, the most striking finding was the low intake of fruits and vegetables: Only about 19% of the respondents reported consuming three or more cups of fruits, fresh juices or vegetables the previous day.
The high levels of modifiable risk factors, coupled with their rapid increase since 2002, call for immediate development and implementation of a national NCD prevention and control plan. Based on findings from the 2004 survey, the Jordanian cabinet recently allocated $2.9 million to launch such a plan. The CDC is currently helping the MOH to create a plan that represents a collaborative effort involving multiple parties and that will target the primary behaviors associated with NCDs.
Kingdom of Saudi Arabia
The KSA has made tremendous improvements in its health systems in a short period of time through extensive investments., However, KSA is facing a rising burden of NCDs as a result of rapid changes in behaviors. Cardiovascular diseases are currently the leading cause of death in KSA, with ischemic heart diseases and strokes accounting for 14% and 11% of the total deaths in 2010, respectively. Elevated BMI was the leading risk factor for burden (11.8% for males and 11.1% for females). High glucose levels were the second leading disease risk factor (10.5% for males and 7.9% for females).
Obesity, diabetes, high blood pressure, high cholesterol and smoking are among the leading issues that affect a growing number of people in the Kingdom of Saudi Arabia. The prevalence of obesity, as measured by BMI over 30 kg/m 2, was 28.7%. It was higher among females than males, 33.5% and 24.1% respectively. Morbid obesity, defined as a BMI > 40 kg/m 2 was 2.5% in men and 4.7% in women. Almost half of women are physically inactive while 29% had low levels of physical activity. For men, 23% are physically inactive and the same percentage had low levels of physical activity. At the same time, only 7.6% of adults consumed more than five daily servings of fruits or vegetables. The total prevalence of diabetes was 14.8% for males and 11.7% for females in 2013. Borderline diabetes was present in 17% (1.17 million) of men and 15.5% (0.95 million) of women. The prevalence of hypertension was 17.7% for males and 12.5% for females. It increased with age and was highest among those aged 65 and above (65.2%). Borderline hypertension was noted in 46.5% (3.04 million) of men and 34.3% (2.18 million) of women. About 1.16 million Saudi men and 795,000 Saudi women, or 15.1% combined, are hypertensive. The prevalence of hypercholesterolemia was 9.5% for males and 7.3% for females. It increased by age and was highest among those aged 65 and above (28.7%). Borderline hypercholesterolemia was found in 19.5% (1.25 million) of men and 20.6% (1.18 million) of women. Almost 215,000 men and 116,000 women were on medication, but only 7.4% of them had uncontrolled hypercholesterolemia. Smoking is also on the rise among men in KSA. Overall 21.5% of men currently smoke. Of all Saudi males, 20.9% smoke shisha. Despite the increase of NCD and smoking, three-quarters of Saudis reported never having a routine medical check-up. Moreover, only about 7% of Saudi women aged 50 or older reported having a mammogram.
In September 2012, the MOH in KSA in collaboration with the WHO regional office for the Eastern Mediterranean (EMRO) organised an international conference that aimed to address the topic of NCD in the area. The conference released the Riyadh Declaration that included ten recommendations to combat NCD at the regional level. The MOH has worked with WHO/EMRO and the declaration was adopted by EMRO during the regional committee meeting in October 2012. Indeed, this step will amount to a major impact on health in KSA and the region.
| The New Challenge|| |
As many countries struggle to improve their health infrastructures, NCDs present a considerable challenge, both in human and economic terms. In addition, many developing countries are simultaneously facing both communicable and NCDs. Thus, a critical health challenge in the 21st century would be to enhance capacity for NCD surveillance, prevention and control while maintaining and advancing gains made in infectious diseases control.
What can be done?
Global agencies such as the WHO should continue their efforts to prevent and control NCDs while individual countries need to devote further attention to NCDs and their risk factors in global health; one method is to create global NCD prevention and control programs. Such programs could reduce morbidity and mortality, improve quality of life and economic conditions  and strengthen the stability and prosperity of many countries, particularly those which have struggle with diseases of poverty beforehand. Indeed, such a plan will have a tremendous impact on the economies of high-income countries since it will free up resources that its partners now spend on treating preventable NCD or resources lost due to premature death of productive workers. Partners will likely choose to spend some of these savings on trading with high-income countries. The key components of such a plan are to develop (1) a strategy to make partners more aware of the burden of NCDs, (2) improved NCDs surveillance, (3) standard training for public health professionals and increased capacity at the national and global levels, (4) feasible and achievable goals to prevent NCDs and promote health and (5) effective NCD prevention and control policies and programs.
A strategy to promote NCD surveillance, prevention and control at the national and global levels will require greater awareness of the emerging burden of NCDs and their potential impact on health and economy worldwide. Because such a strategy is essential for obtaining continued funding for NCD projects and programs, it must (a) be derived from evidence-based programs, (b) clearly illustrate the potential public health and economic gains, (c) involve multiple stakeholders in the plan's development, (d) communicate NCD messages and surveillance results to various key audiences, such as policy makers and the public through multiple channels.
Improvements are needed in accuracy, timeliness, accessibility and global comparability of surveillance information. These improvements will facilitate planning and policy creation. Further development of high-quality surveillance systems based on routine databases such as vital statistics is urgently needed. Data in a surveillance system must be collected in a standardised and ongoing manner if relevant changes and trends are to be noted quickly enough to be useful. Collecting data and defining epidemiological measures and other indicators of program progress allow comparability between and within countries over time. Standardising surveillance methods will allow different parties to share knowledge and benefit from experiences in surveillance reporting, prevention and control of NCDs. The use of common indicators is necessary to maximise inter-regional comparability such as definitions, data sources, extraction procedures, standardisation of rates or inclusion/exclusion criteria. Moreover, use of a common analytic methodology is needed to combine various indicators – such as mortality, morbidity, economy, quality of life and health care utilisation – that will produce a good summary measure for easy use by decision makers.
In addition, new thinking is required to meet the latest challenges in data collection, such as the increasing popularity of mobile cellular telephones and the increasing interest of governments in protecting the privacy and confidentiality of their citizens' health information. The usefulness of the traditional telephone survey may be nearing an end in some areas, and new ways to conduct surveillance must be explored. In the near future, instruments currently limited to small samples and specialised studies may be used more widely in population health surveys, especially when the cost, availability and accuracy are optimised. For example, new developments in highly-reliable surveys using personal digital assistants equipped with global positioning services allow rapid and accurate sampling and analysis at affordable prices.,
Strengthening the capacity of surveillance systems refers not only to the scientific process of collecting, analysing, interpreting and publishing data but also to the translation of these data to practical applications. Technical methods for surveillance are well developed, but its ultimate purpose – utilisation in the field – is not. The need to translate surveillance findings into prevention and control activities and bridge the gap between scientists and policy makers, is urgent.
Develop training for capacity building
Further development of appropriate training for all levels of current and future health workers, including those on the frontlines and in academia, is needed. Standard practitioners' training that could be tailored to the needs of trainees and their organisations is currently lacking in many countries. Ideally, such training could be designed to involve all of a country's public health professionals in its first stage. For example, a short and focused joint basic training in epidemiology, biostatistics, public health surveillance and management of public health programs could be provided to all professionals and further training could be tailored for specific topics (e.g., non-communicable or infectious disease). This approach has been effective in Egypt, Brazil and elsewhere. Workforce development will also require greater political support, changes in personnel systems to reward and keep competent health workers and training for epidemiologists who will collect and analyse the data and policy makers who will use this data. This strategy will be much cheaper and will ensure better collaboration in the future among the trained health professionals.
For those in the formative phase of their public health career, a student practicum placement in a governmental or international non-governmental public health agency can be a good way to raise awareness and interest of students in public health. Alternatively, it may be useful to establish 'teaching health units' within these international and national health agencies to consistently recruit medical and other graduate students to learn about the operation and application of public health and to use health agency databases for thesis research. Medical schools should include in their pre- and post-graduate physician training programs education about the urgency of surveillance, prevention and control of NCDs and should switch from the traditional acute health care model to a carefully planned non-communicable health care model. Other university programs should be similarly oriented. Partnering professionals and institutions in low- and middle-income countries with those in high-income countries is another way to address the resource capacity issue, and one that could lead to sustainable improvements. Regular meetings will allow this global network of NCD professionals to get continuing medical education and share knowledge.
Launch Worldwide and country-specific objectives
Comprehensive, feasible and achievable health objectives to prevent NCDs should be launched in cooperation with health and non-traditional partners (i.e., education, justice, labor, transportation, environmental and private-sector). These objectives should be designed to serve as a roadmap for improving the health of all people in the world and could be adapted using a similar framework as the Healthy People program in the United States. Although the majority of goals in such a program should address the important public health challenges of NCDs and focus on the quality of life, years of healthy life and elimination of health disparities, much attention is needed on the development of robust indicators to facilitate evaluation and monitoring. Such indicators should be chosen based on their ability to motivate action, the availability of data to measure their progress and their relevance to broad public health issues.
Implement and evaluate evidence-based prevention policies and programs
NCD prevention and control programs – their design, implementation, effectiveness, adoptability and utility – must be assessed. Programs should produce evidence that leads to effective public health policies and actions to prevent or reduce the burden of NCD while promoting health. It is important to coordinate across partnering agencies and countries to evaluate the effectiveness of promising public health strategies. This coordination could be expanded to support further field evaluation of evidence-based strategies. Many effective public health strategies to prevent NCDs in the United States or Europe could be replicated in other countries with appropriate adaptation and carefully designed evaluation approaches. The US Guide to Community Preventive Services provides a good starting point for identifying and selecting effective strategies.
The success of such a global NCD program will of course be a function of the components above as well as governmental and non-governmental agency commitments (a) to improve sustainable global research capacity and technology and knowledge transfer; (b) to build strong, stable public health infrastructures with trained and qualified public health workers engaged in providing essential public health services in every country; (c) to develop and implement global and regional risk factor surveillance initiatives; and (d) to innovate, develop and enhance surveillance systems and intervention strategies. Perhaps most importantly, a more collaborative paradigm will be necessary to identify and control disease in every country. New partnerships must be forged among all countries to build a global capability to respond to the emerging threat of NCDs. The public health community will need to actively engage and build bridges to critical non-health sectors, such as the agriculture, transportation and commercial sectors to share information and engage in coordinated action to control these diseases and their risk factors.
| Positioned to Build on Success: The Centers for Disease Control and Prevention and the United States Agency for International Development|| |
The CDC, the primary federal agency for conducting and supporting public health activities in the United States, has led many successful global efforts for disease eradication, control and prevention and has a long history of success in the same. The CDC has been a key player in global efforts to eradicate smallpox and polio and to prevent and control malaria. The CDC's Global AIDS Program, active in 25 countries with over 100 CDC staff assigned to the field, collaborates with international health organisations, non-governmental organisations, other donor countries and the private sector with a focus on prevention, care and treatment as well as surveillance and infrastructure development. The CDC also supports the Field Epidemiology Training Program (FETP), established in 1975 and modelled after CDC's Epidemic Intelligence Service, to strengthen international public health capacity by supporting networking for field-based training programs that enhance competencies in applied epidemiology and public health practice. To date, more than 7000 trainees have graduated the FETP with the vast majority working in the public health sector in their respective countries. 63 FETPs in 88 countries cover more than half of the world's population. The FETP is a shining example of CDC's Office of Global Health efforts to support capacity building globally.
| Centers for Disease Control and Prevention's Global Goals|| |
During 2005, CDC established a series of goals – Global Health Promotion, Global Health Protection and Global Health Diplomacy – to provide a framework for its global health activities.
CDC's Global Health Promotion Goal recognises the critical role CDC plays in sharing knowledge, tools and other resources with people and partners to promote health and prevent disease around the world. CDC addresses critical global public health challenges by working with a diverse set of partners to support culturally appropriate public health interventions. Through health promotion activities, CDC will contribute to reductions in global morbidity and mortality.
CDC's Global Health Protection Goal seeks to ensure that Americans at home and abroad are protected from health threats through a transnational prevention, detection and response network. Given the clear relationship between the health status of a country's population and its economic and political performance, it is in the best interest of the United States to begin addressing the broad range of diseases affecting the world's population. To this end, CDC works with international partners to achieve rapid and accurate detection, diagnosis and verification of emerging global public health threats and works to contain threats at their source preventing international spread. For example, CDC is a partner for surveillance and monitoring activities within the Bloomberg Initiative to Reduce Tobacco Use, one of the largest efforts to date committed to the scaling up of tobacco control efforts in developing countries where the health burden from tobacco use is highest. In addition to making the world a safer and healthier place for all, CDC's health protection activities play a critical role in ensuring the health of Americans living in America and traveling abroad as well as protecting US economic interests.
CDC's Global Health Diplomacy Goal recognises the importance of benefits that accrue to both the United States and the world through investments in public health capacity development and partnerships with the developing world. Through health diplomacy activities, CDC and the US government will be trusted with effective resources for health development and health protection around the globe.
As the new global health challenge of NCD emerges, CDC has a clear role to play in supporting a global NCD program by enhancing its own capacity to prevent and control NCDs and their risk factors and by assisting other countries in improving surveillance systems, the development of tools, knowledge generation and transfer and development of expertise to promote health in relevant, affordable and sustainable ways. Meeting the Global Goals described above requires a clear vision and plan to handle NCDs. CDC maintains a distinct expertise in each of the global NCD program components and in collaboration with its partners is well positioned to lead such an effort.
One of its partners is the United States Agency for International Development (USAID). USAID, the primary federal agency for international development, provides economic, development and humanitarian assistance around the world in support of the foreign policy goals of the United States. In conjunction with its partners, USAID has been at the forefront of successful efforts to address the global burden of infectious diseases, maternal and child health and nutritional deficiencies in developing countries. USAID supports numerous field programs in global health focused on environmental health, family planning, health systems, HIV/AIDS, tuberculosis, malaria and other infectious diseases, maternal and child health and nutrition.
Together, CDC and USAID along with other US agencies are well positioned to build on the success and infrastructures put into place during the past 10 - 20 years to prepare for the health challenges that will emerge as the process of 'epidemiologic transition' continues globally. Indeed, if the United States starts investing in NCD in the same manner as it invested in communicable disease, many countries and donors would follow.
| Summary|| |
NCDs are emerging as the leading cause of death, disability, reduced quality of life and rising health care costs worldwide. This burden of NCD will worsen as the worldwide population ages, the epidemiologic transition under way in most countries advances and the effects of globalisation are felt throughout the world. The objective must be to improve the on-the-ground response to disease and risk factors as they relate to both communicable and NCD. The goal is to not only achieve reductions in mortality and disability but also to reduce morbidity for all diseases and not limited to those which are the most visible. Finally, we call for a global program for preventing and controlling NCDs, with special emphasis on interventions that will:
- Increase the public and professional awareness of the burden of NCDs
- Improve local, national and global surveillance of NCDs
- Improve the training and education of frontline public health practitioners
- Provide standard training and capacity building for public health professionals from developing countries and
- Use specific programs of proven effectiveness to prevent and control NCDs and their major risk factors.
Poverty, longer life expectancy, adverse changes in risk behavior patterns and significant social changes all contribute to a heavy and increasing burden for the health and well-being of the global community. The global burden of NCD with its profound human and economic costs requires a globally unified response. Against the backdrop of momentum and success achieved during the past several decades, we must continue to look forward and anticipate emerging health needs of those in developing countries in order to ensure they will live safer, healthier and longer lives.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Levine R. Case Studies in Global Health: Millions Saved. Boston, Massachusetts: Jones and Bartlett Publishers; 2007.
World Health Organization. Health of the People: The Africa Regional Health Report. Geneva, Switzerland: WHO Press; 2006.
Levine R. Millions Saved: Proven Successes in Global Health. Boston, Massachusetts: Jones and Bartlett Publishers; 2004.
Skolnik R, editor. Non-communicable diseases. In: Essentials of Global Health. Boston, Massachusetts: Jones and Bartlett Publishers; 2008.
World Health Organization. Preventing Chronic Diseases: A Vital Investment. Geneva, Switzerland: WHO Press; 2005.
GBD Risk Factors Collaborators, Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, et al.
Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:2287-323.
GBD Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-71.
GBD DALYs and HALE Collaborators, Murray CJ, Barber RM, Foreman KJ, Abbasoglu Ozgoren A, Abd-Allah F, et al.
Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: Quantifying the epidemiological transition. Lancet 2015;386:2145-91.
Beaglehole R, Ebrahim S, Reddy S, Voûte J, Leeder S; Chronic Disease Action Group. Prevention of chronic diseases: A call to action. Lancet 2007;370:2152-7.
Centers for Disease Control and Prevention (CDC). Ten great public health achievements – United States, 1900-1999. MMWR Morb Mortal Wkly Rep 1999;48:241-3.
Centers for Disease Control and Prevention. Changes in public health system. MMWR Morb Mortal Wkly Rep 1999;48:1141-7.
Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th
century. JAMA 1999;281:61-6.
Simonsen L, Conn LA, Pinner RW, Teutsch S. Trends in infectious disease hospitalizations in the United States, 1980-1994. Arch Intern Med 1998;158:1923-8.
Centers for Disease Control and Prevention (CDC). Control of infectious diseases. MMWR Morb Mortal Wkly Rep 1999;48:621-9.
Centers for Disease Control and Prevention (CDC). Status report on the childhood immunization initiative: Reported cases of selected vaccine-preventable diseases – United States, 1996. MMWR Morb Mortal Wkly Rep 1997;46:665-71.
Centers for Disease Control and Prevention (CDC). Influenza and pneumococcal vaccination levels among persons aged ≥ 65 years – United States, 2001. MMWR Morb Mortal Wkly Rep 2002;51:1019-24.
Centers for Disease Control and Prevention (CDC). Vaccination coverage among children enrolled in head start programs and licensed child care centers and entering school – United States and selected reporting areas, 1999-2000 school year. MMWR Morb Mortal Wkly Rep 2001;50:847-55.
Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: Final data for 2005. Natl Vital Stat Rep 2008;56:1-120.
Schneider EL, Guralnik JM. The aging of America. Impact on health care costs. JAMA 1990;263:2335-40.
Clark DO. US trends in disability and institutionalization among older blacks and whites. Am J Public Health 1997;87:438-40.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-45.
Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-22.
Murray CJ, Atkinson C, Bhalla K, Birbeck G, Burstein R, Chou D, et al.
The state of US health, 1990-2010: Burden of diseases, injuries, and risk factors. JAMA 2013;310:591-608.
Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity: How much, and who's paying? Health Aff (Millwood) 2003;Suppl Web Exclusives:W3-219-26.
Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, years of potential life lost, and productivity losses – United States, 1997-2001. MMWR Morb Mortal Wkly Rep 2005;54:625-8.
McGinnis JM, Foege WH. The immediate vs the important. JAMA 2004;291:1263-4.
World Health Organization. World Health Statistics 2007. Geneva, Switzerland: WHO Press; 2007.
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.
Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349:1498-504.
Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: How many lives can we save? Lancet 2005;366:1578-82.
Gaziano TA. Reducing the growing burden of cardiovascular disease in the developing world. Health Aff (Millwood) 2007;26:13-24.
World Health Organization. World Health Report 2003: Shaping the Future. Geneva, Switzerland: WHO Press; 2003.
Bygbjerg IC, Meyrowitsch DW. Global transition in health. Dan Med Bull 2007;54:44-5.
National Research Council. Aging in sub-Saharan Africa: Recommendations for furthering research. Panel on policy research and data needs to meet the challenge of aging in Africa. In: Cohen B, Menken J, editors. Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press; 2006.
Countdown Coverage Writing Group; Countdown to Core Group, Bryce J, Daelmans B, Dwivedi A, Fauveau V, Lawn JE, et al.
Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on tracking coverage of interventions. Lancet 2008;371:1247-58.
Ackland M, Choi BC, Puska P. Rethinking the terms non-communicable disease and chronic disease. J Epidemiol Community Health 2003;57:838-9.
Moore M, Gould P, Keary BS. Global urbanization and impact on health. Int J Hyg Environ Health 2003;206:269-78.
McQueen DV, Puska P, editors. Global Behavioral Risk Factor Surveillance. New York: Kluwer Academic/Plenum Publishers; 2003.
Yang G, Ma J, Liu N, Zhou L. Smoking and passive smoking in China. Chin J Epidemiol 2005;26:77-83.
Zhou M, Wang H, Zhu J, Chen W, Wang L, Liu S, et al.
Cause-specific mortality for 240 causes in China during 1990-2013: A systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016;387:251-72.
Li X, Zheng C, Rosenthal RJ. The new concept of bariatric surgery in China – Reevaluation of surgical indications and criteria of therapeutic effect of laparoscopy for treatment of obesity. Obes Surg 2008;18:1180-2.
Ji CY, Chen TJ, Sun X. Secular changes on the distribution of body mass index among Chinese children and adolescents, 1985-2010. Biomed Environ Sci 2013;26:520-30.
Critchley J, Liu J, Zhao D, Wei W, Capewell S. Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999. Circulation 2004;110:1236-44.
Yang L, Parkin DM, Li LD, Chen YD, Bray F. Estimation and projection of the national profile of cancer mortality in China: 1991-2005. Br J Cancer 2004;90:2157-66.
Wang L, Kong L, Wu F, Bai Y, Burton R. Preventing chronic diseases in China. Lancet 2005;366:1821-4.
Ministerio da Saude – Brasilia. A vigilancia, o controle e a prevencao das doencas cronicas nao-transmissiveis: DCNT no contexto do Sistema Unico de Saude Brasileiro/Brasil. Ministerio da Saude – Brasilia, Organizacao Pan Americana da Saude; 2005.
Departamento de Analise de Situacao de saude/SVS/MS. Vigilancia em Saude: Dados e indicadores selecionados. Vol. 3; 2005.
The World Bank Aid Memoir “Brazil Projeto de Modernizacao do Sistema nacional de Vigilancia de Saude (Vigisus II)”, Missao de Supervisao 30 de janeiro a 16 de fevereiro de; 2006.
Politica Nacional de Promocao de Saude, Ministerio da Saude. Documento Preliminar; 09 February, 2006.
Anonymous. Health and related indicators. In: Ntuli A, Crisp N, Clarke E, Barron P, editors. South African Health Review. Durban, South Africa: Health System Trust; 2000. p. 467-77.
Walker AR, Adam F, Walker BF. World pandemic of obesity: The situation in Southern African populations. Public Health 2001;115:368-72.
Steyn K, Gaziano TA, Bradshaw D, Laubscher R, Fourie J; South African Demographic and Health Coordinating Team. Hypertension in South African adults: Results from the demographic and health survey, 1998. J Hypertens 2001;19:1717-25.
Bradshaw D, Masiteng K, Nannan N. Health status and determinants. In: Ntuli A, Crisp N, Clarke E, Barron P, editors. South African Health Review. Durban, South Africa: Health System Trust; 2000. p. 89-124.
Ministry of Health (Information Directorate), Hashemite Kingdom of Jordan [Mortality Statistics, 2003]. Unpublished Raw Data; 2004.
Centers for Disease Control and Prevention (CDC). Prevalence of selected risk factors for chronic disease – Jordan, 2002. MMWR Morb Mortal Wkly Rep 2003;52:1042-4.
Centers for Disease Control and Prevention (CDC). Assessing risk factors for chronic disease – Jordan, 2004. MMWR Morb Mortal Wkly Rep 2006;55:653-5.
Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: An overview. East Mediterr Health J 2011;17:784-93.
Memish ZA, Jaber S, Mokdad AH, AlMazroa MA, Murray CJ, Al Rabeeah AA; Saudi Burden of Disease Collaborators. Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990-2010. Prev Chronic Dis 2014;11:E169.
Memish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al.
Obesity and associated factors – Kingdom of Saudi Arabia, 2013. Prev Chronic Dis 2014;11:E174.
El Bcheraoui C, Tuffaha M, Daoud F, Kravitz H, Al Mazroa MA, Al Saeedi M, et al
. On your mark, get set, go: Levels of physical activity in the Kingdom of Saudi Arabia, 2013. J Phys Act Health. [In press].
El Bcheraoui C, Tuffaha M, Daoud F, Al Saeedi M, Basulaiman M, Memish ZA, et al
. Fruit and vegetable consumption among adults in Saudi Arabia, 2013. Nutr Diet Suppl. [In press].
El Bcheraoui C, Basulaiman M, Tuffaha M, Daoud F, Robinson M, Jaber S, et al.
Status of the diabetes epidemic in the Kingdom of Saudi Arabia, 2013. Int J Public Health 2014;59:1011-21.
El Bcheraoui C, Memish ZA, Tuffaha M, Daoud F, Robinson M, Jaber S, et al.
Hypertension and its associated risk factors in the Kingdom of Saudi Arabia, 2013: A national survey. Int J Hypertens 2014;2014:564679.
Basulaiman M, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al.
Hypercholesterolemia and its associated risk factors-Kingdom of Saudi Arabia, 2013. Ann Epidemiol 2014;24:801-8.
Moradi-Lakeh M, El Bcheraoui C, Tuffaha M, Daoud F, Al Saeedi M, Basulaiman M, et al.
Tobacco consumption in the Kingdom of Saudi Arabia, 2013: Findings from a national survey. BMC Public Health 2015;15:611.
El Bcheraoui C, Tuffaha M, Daoud F, AlMazroa MA, Al Saeedi M, Memish ZA, et al.
Low uptake of periodic health examinations in the Kingdom of Saudi Arabia, 2013. J Family Med Prim Care 2015;4:342-6.
El Bcheraoui C, Basulaiman M, Wilson S, Daoud F, Tuffaha M, AlMazroa MA, et al.
Breast cancer screening in Saudi Arabia: Free but almost no takers. PLoS One 2015;10:e0119051.
Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38.
McQueen DV, Campostrini S. Monitoring behavioural change in the population: A continuous data collection approach. In: Boulton M, editor. Challenge and Innovation: Methodological Advances in Social Research on HIV/AIDS. London, United Kingdom: Taylor and Francis; 1994. p. 39-55.
Vanden Eng JL, Wolkon A, Frolov AS, Terlouw DJ, Eliades MJ, Morgah K, et al.
Use of handheld computers with global positioning systems for probability sampling and data entry in household surveys. Am J Trop Med Hyg 2007;77:393-9.
Krishnamurthy R, Frolov A, Wolkon A, Vanden Eng J, Hightower A. Application of pre-programmed PDA devices equipped with global GPS to conduct paperless household surveys in rural Mozambique. AMIA Annu Symp Proc 2006:991.
Choi BC, McQueen DV, Rootman I. Bridging the gap between scientists and decision makers. J Epidemiol Community Health 2003;57:918.
Zaza S, Briss PA, Harris KW. Task force on community preventive services. The Guide to Community Preventive Services. New York: Oxford University Press; 2005.
White ME, McDonnell SM, Werker DH, Cardenas VM, Thacker SB. Partnerships in international applied epidemiology and service, 1975-2001. Am J Public Health 2001;154:993-9.
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