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Preventing Chronic Diseases

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Nepalis are getting overweight and this is not good news, especially because obesity is an important cause of chronic diseases, which killed 98,000 Nepalis in 2002 only. The WORLD HEALTH ORGANIZATION suggests solutions.

Nepalis are getting overweight, says a World Health Organization (WHO) report. About 9 per cent men and 8 per cent women in 2005 were overweight in the country. WHO predicts 14 percent of all men and 13 percent of women will be overweight by 2015.

This is not good news, especially because overweight or obesity is an important cause of chronic diseases.

Already, chronic disease is a major cause of death in the country. According to WHO, chronic disease accounted for 42 per cent of all deaths in Nepal in 2002. Of the 235,000 deaths in 2002, 98,000 people died because of chronic diseases like injuries (9 percent), cardiovascular disease (21 per cent), communicable, maternal and perinatal, nutritional deficiencies (49 per cent), cancer (7 per cent), chronic respiratory disease (5 per cent), diabetes (2 per cent) and other chronic diseases (7 per cent).

But this is a global problem, too. The impact of chronic diseases in many low and middle income countries is steadily growing. It is vital that the increasing importance of chronic disease is anticipated, understood and acted upon urgently. This requires a new approach by national leaders who are in a position to strengthen chronic disease prevention and control efforts, and by the international public health community. It is essential to communicate the latest and most accurate knowledge and information to front-line health professionals and the public at large.

The magnitude of the problem is big. About 80 per cent of chronic disease deaths occur in low and middle income countries and these deaths occur in equal numbers among men and women. The threat is growing – the number of people, families and communities afflicted is increasing. This growing threat is an under-appreciated cause of poverty and hinders the economic development of many countries.

However, there is a solution to the problem. The chronic disease threat can be overcome using existing knowledge. The solutions are effective – and highly cost-effective. Comprehensive and integrated action at country level, led by governments, is the means to achieve success.

The World Health Organization has set a goal. It aims to reduce an additional 2 per cent in chronic disease death rates worldwide, per year, over the next 10 years. This will prevent 36 million premature deaths by 2015. The scientific knowledge to achieve this goal already exists

The fight must begin with dispelling the myths about chronic diseases. Let’s look at ten of the most common misunderstandings and two principal half-truths that have contributed to the neglect of chronic disease. Notions that chronic diseases are a distant threat and are less important and serious than some infectious diseases can be dispelled by the strongest evidence.

A Major Cause of Death
According to WHO, of all the deaths, 60 per cent are due to chronic diseases. 35 000 000 people will die from chronic diseases in 2005. Chronic diseases include heart disease, stroke, cancer, chronic respiratory diseases and diabetes. Visual impairment and blindness, hearing impairment and deafness, oral diseases and genetic disorders are other chronic conditions that account for a substantial portion of the global burden of disease.

From a projected total of 58 million deaths from all causes in 2005, it is estimated that chronic diseases will account for 35 million, which is double the number of deaths from all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and prenatal conditions, and nutritional deficiencies combined.

Poorest countries are the worst affected. About 80 per cent of chronic disease deaths occur in low and middle income countries. Only 20 per cent of chronic disease deaths occur in high income countries – while 80 per cent occur in low and middle income countries, where most of the world’s population lives. Even the least developed countries such as the United Republic of Tanzania are not immune to the growing problem.

The burden of chronic disease: has major adverse effects on the quality of life of affected individuals; causes premature death; creates large adverse – and underappreciated – economic effects on families, communities and societies in general. China alone will forego an estimated amount of $558 billion in national income over the next 10 years as a result of premature deaths caused by heart disease, stroke and diabetes.

The risk factors are widespread. Some 388,000, 000 people will die in the next 10 years of chronic disease. Common, modifiable risk factors underlie the major chronic diseases. These risk factors explain the vast majority of chronic disease deaths at all ages, in men and women, and in all parts of the world. They include: unhealthy diet; physical inactivity; and tobacco use.

Each year at least: 4.9 million people die as a result of tobacco use; 2.6 million people die as a result of being overweight or obese; 4.4 million people die as a result of raised total cholesterol levels; and 7.1 million people die as a result of raised blood pressure.

The threat is growing. Deaths from infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined are projected to decline by 3 per cent over the next 10 years. In the same period, deaths due to chronic diseases are projected to increase by 17 per cent. This means that of the projected 64 million people who will die in 2015, and 41 million will die of a chronic disease – unless urgent action is taken.

Global Response Inadequate
Despite global successes, such as the WHO Framework Convention on Tobacco Control, the first legal instrument designed to reduce tobacco-related deaths and disease around the world, chronic diseases have generally been neglected in international health and development work. Furthermore, chronic diseases – the major cause of adult illness and death in all regions of the world – have not been included within the global Millennium Development Goal (MDG) targets; although as a recent WHO publication on health and the MDGs has recognized, there is scope for doing so within Goal 6 (Combat HIV/AIDS, malaria and other diseases).

Health more broadly, including chronic disease prevention, contributes to poverty reduction and hence Goal (Eradicate extreme poverty and hunger, Health and the Millennium Development Goals, Geneva, WHO, 2005). In response to their needs, several countries have already adapted their MDG targets and indicators to include chronic diseases and/or their risk factors; a selection of these countries is featured in Part Two.

Chronic diseases hinder economic growth and reduce the development potential of countries, and this is especially true for countries experiencing rapid economic growth, such as China and India. However, it is important that prevention is addressed within the context of international health and development work even in least developed countries such as the United Republic of Tanzania, which are already undergoing an upsurge in chronic disease risks and deaths.

The 10 Myths
It is assumed that chronic diseases mainly affect high income countries (Myth #10, in reverse order). The reality is that four out of five chronic disease deaths are in low and middle income countries.

Many people believe that low and middle income countries should control infectious diseases before they tackle chronic diseases (Myth #9). In reality, low and middle income countries are at the centre of both old and new public health challenges. While they continue to deal with the problems of infectious diseases, they are in many cases experiencing a rapid upsurge in chronic disease risk factors and deaths, especially in urban settings. These risk levels foretell a devastating future burden of chronic diseases in these countries.

Many people think that chronic diseases mainly affect rich people (Myth # 8). The truth is that in all but the least developed countries of the world, poor people are much more likely than the wealthy to develop chronic diseases, and everywhere are more likely to die as a result. Moreover, chronic diseases cause substantial financial burden, and can push individuals and households into poverty.

Chronic diseases are often viewed as primarily affecting old people (Myth #7). We now know that almost half of chronic disease deaths occur prematurely, in people under 70 years of age. One quarter of all chronic disease deaths occur in people under 60 years of age. In low and middle income countries, middle-aged adults are especially vulnerable to chronic disease. People in these countries tend to develop disease at younger ages, suffer longer – often with preventable complications – and die sooner than those in high income countries.

Childhood overweight and obesity in children is a rising global problem. About 22 million children aged under five years are overweight. In the United Kingdom, the prevalence of overweight in children aged two to 10 years rose from 23 per cent to 28 per cent between 1995 and 2003. In urban areas of China, overweight and obesity among children aged two to six years increased substantially from 1989 to 1997. Reports of type 2 diabetes in children and adolescents – previously unheard of – have begun to mount worldwide.

Certain chronic diseases, especially heart disease, are often viewed as primarily affecting men (Myth #6). The truth is that chronic diseases, including heart disease, affect women and men almost equally.

Many people believe that if individuals develop chronic disease as a result of unhealthy "lifestyles", they have no one to blame but themselves (Myth #5). The truth is that individual responsibility can have its full effect only where individuals have equitable access to a healthy life, and are supported to make healthy choices. Governments have a crucial role to play in improving the health and well-being of populations, and in providing special protection for vulnerable groups.

This is especially true for children, who cannot choose the environment in which they live, their diet and their passive exposure to tobacco smoke. They also have a limited ability to understand the long-term consequences of their behavior. Poor people also have limited choices about the food they eat, their living conditions, and access to education and health care. Supporting healthy choices, especially for those who could not otherwise afford them, reduces risks and social inequalities.

Adopting a pessimistic attitude, some people believe that there is nothing that can be done, anyway (Myth #4). In reality, the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80 per cent of all heart disease, stroke and type 2 diabetes would be prevented; over 40 per cent of cancer would be prevented. In fact, 80 per cent of premature heart disease, stroke and diabetes can be prevented

Some people believe that the solutions for chronic disease prevention and control are too expensive to be feasible for low and middle income countries (Myth #3). In reality, a full range of chronic disease interventions are very cost-effective for all regions of the world, including sub-Saharan Africa. Many of these solutions are also inexpensive to implement. The ideal components of a medication to prevent complications in people with heart disease, for example, are no longer covered by patent restrictions and could be produced for little more than one dollar a month.

Another set of misunderstandings arises from kernels of truth . In these cases, the kernels of truth are distorted to become sweeping statements that are not true. Because they are based on the truth, such half-truths are among the most ubiquitous and persistent misunderstandings. Let’s refute two principal half-truths.

One example (Half-truth #2) is “My grandfather smoked and was overweight – and he lived to 96.” In any population, there will be a certain number of people who do not demonstrate the typical patterns seen in the vast majority. For chronic diseases, there are two major types: people with many chronic disease risk factors, who nonetheless live a healthy and long life; people with no or few chronic disease risk factors, who nonetheless develop chronic disease and/or die from complications at a young age.

These people undeniably exist, but they are rare. The vast majority of chronic disease can be traced back to the common risk factors, and can be prevented by eliminating these risks.

Another example (Half-truth #1) is: "Everyone has to die of something." 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 illness is not managed correctly. Death is inevitable, but a life of protracted ill-health is not. Chronic disease prevention and control helps people to live longer and healthier lives.

Reducing Deaths, Improving Lives
The rapid changes that threaten global health require a rapid response that must above all be forward-looking. The great epidemics of tomorrow are unlikely to resemble those that have previously swept the world, thanks to progress in infectious disease control. While the risk of outbreaks, such as a new influenza pandemic, will require constant vigilance, it is the "invisible" epidemics of heart disease, stroke, diabetes, cancer and other chronic diseases that for the foreseeable future will take the greatest toll in deaths and disability. However, it is by no means a future without hope. For another of today's realities, equally well supported by the evidence, is that the means to prevent and treat chronic diseases, and to avoid millions of premature deaths and an immense burden of disability, already exist.

In several countries, the application of existing knowledge has led to major improvements in the life expectancy and quality of life of middle-aged and older people. For example, heart disease death rates have fallen by up to 70 per cent in the last three decades in Australia, Canada, the United Kingdom and the United States. Middle income countries, such as Poland, have also been able to make substantial improvements in recent years.

Such gains have been realized largely as a result of the implementation of comprehensive and integrated approaches that encompass interventions directed at both the whole population and individuals, and that focus on the common underlying risk factors, cutting across specific diseases. The cumulative total of lives saved through these reductions is impressive. From 1970 to 2000, WHO has estimated that 14 million cardiovascular disease deaths were averted in the United States alone. The United Kingdom saved 3 million people during the same period.

The challenge is now for other countries to follow suit.

Encouraged by achievements in countries such as Australia, Canada, Poland, the United Kingdom and the United States, we can anticipates more such gains in the years ahead. But realistically, how much is possible by the year 2015? After carefully weighing all the available evidence, the WHO study on chronic diseases offers the health community a new global goal: to reduce death rates from all chronic diseases by 2 per cent per year over and above existing trends during the next 10 years. This bold goal is thus in addition to the declines in age-specific death rates already projected for many chronic diseases, and would result in the prevention of 36 million chronic disease deaths by 2015, most of these being in low and middle income countries. Achievement of the global goal would also result in appreciable economic dividends for countries.

Every death averted is a bonus, but the goal contains an additional positive feature: almost half of these averted deaths would be in men and women under 70 years of age and almost nine out of 10 of these would be in low and middle income countries. Extending these lives for the benefit of the individuals concerned, their families and communities is in itself the worthiest of goals.

This global goal is ambitious and adventurous, but it is neither extravagant nor unrealistic. Countries that have made improvements can serve as examples. As many as 36, 000, 000 lives can be saved

Every country, regardless of the level of its resources, has the potential to make significant improvements in chronic disease prevention and control, and to take steps towards achieving the global goal. Resources are necessary, but a large amount can be achieved for little cost, and the benefits far outweigh the costs. Leadership is essential, and will have far more impact than simply adding capital to already overloaded health systems. There is important work to be done in countries at all stages of development. In the poorest countries, many of which are experiencing upsurges in chronic disease risks, it is vital that supportive policies are in place to reduce risks and curb the epidemics before they take hold. In countries with established chronic disease problems, additional measures will be required, not only to prevent disease, but also to manage illness and disability.

Part Four of the WHO study details the stepwise framework for implementing recommended measures. The framework offers a flexible and practical public health approach to assist ministries of health to balance diverse needs and priorities while implementing evidence-based interventions. While there cannot be a "one size fits all" prescription for implementation – each country must consider a range of factors in establishing priorities – using the stepwise framework will make a major contribution to the prevention and control of chronic disease, and will assist countries in their efforts to achieve the global goal by 2015.

A Final Word
In many ways, we are the heirs of the choices that were made by previous generations: politicians, business leaders, financiers and ordinary people. Future generations will in turn be affected by the decisions that we make today. Each of us has a choice: whether to continue with the status quo, or to take up the challenge and invest now in chronic disease prevention.

Without action, an estimated 388 million people will die from chronic diseases in the next 10 years. Many of these deaths will occur prematurely, affecting families, communities and countries. The macroeconomic impact will be substantial. Countries such as China, India and the Russian Federation could forego between $200 billion and $550 billion in national income over the next 10 years as a result of heart disease, stroke and diabetes.

With increased investment in chronic disease prevention, it will be possible to prevent 36 million premature deaths in the next 10 years. Some 17 million of these prevented deaths would be among people under 70 years of age. These averted deaths would also translate into substantial gains in countries' economic growth.

For example, achievement of the global goal would result in an accumulated economic growth of $36 billion in China, $15 billion in India and $20 billion in the Russian Federation over the next 10 years. The failure to use available knowledge about chronic disease prevention and control needlessly endangers future generations. There is simply no justification for chronic diseases to continue taking millions of lives prematurely each year while being overlooked on the health development agenda, when the understanding of how to prevent these deaths is available now. Taking up the challenge of chronic disease prevention and control requires a certain amount of courage and ambition. The agenda is broad and bold, but the way forward is clear.

Excerpted from the Preventing Chronic Diseases: A Vital Investment, a report by World Health Organization, released in Kathmandu on July 18, 2006. This article reflects minor editorial modifications and some additional reporting on Nepal’s status on chronic diseases.

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Brihát Śhānti Sámjhautā, 2006
(Comprehensive Peace Agreement)

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