Over the last two years, signs have steadily emerged that chronic diseases
in developing countries are at last being taken seriously. For decades, evidence
has shown that the epidemiological transition was well under way in low- and
middle-income countries but that it was taking a form not seen in developed
countries. Julio Frenk, former Mexican Minister of Health, characterised this
almost 20 years ago as “protracted polarised epidemiological transition” to
emphasise that these countries suffered simultaneously from infectious and non-infectious
chronic diseases as well as from injuries. (1) However, the problem of chronic
diseases has historically received little attention from governments and even
less from those funding health research and interventions.
Many reasons for the neglect have been proposed (2) and are addressed elsewhere
in this edition. This article highlights significant recent developments that
suggest the tide might be turning in favour of sustainable support for chronic
disease prevention and control. They include publication of major new reports;
establishment of new alliances and partnerships; and the announcement of significant
funding for chronic disease prevention by players previously not involved in
global health.
Solid and indisputable evidence
There has been a steady production of academic journal articles since 2004
that have provided new global and national estimates of the burden of disease
attributable to the risk factors – poor diet, tobacco use, lack of physical
activity – driving the epidemic of chronic disease. The evidence has been used
in three major reports: the WHO report Preventing Chronic Diseases: A Vital
Investment (2005) (3); the report of the Developing Country Priorities project
DCP2 (2006) (4); and the World Bank report on Public Policy and the Challenge
of Chronic Noncommunicable Diseases (2007). (5) Between them, these reports
now provide solid and indisputable evidence of the epidemiological and economic
impact of chronic diseases in developing countries. Each report was subject
to intense review within agencies with complementary roles in addressing the
problem: the WHO has lead responsibility for policy and strategy development;
the World Bank is key to providing financial support and economic advice to
governments; and the U.S. National Institutes of Health (one of the primary
players in the Developing Country Priorities project work) and more particularly
its International Fogarty Center, has a key role in setting priorities for,
and supporting, global health research.
It is anticipated that these reports will stimulate these agencies to step
up their investment, advocacy and general support for chronic disease prevention
and control. This is evident within WHO with the increased focus on implementation
of the WHO Framework Convention on Tobacco Control (6) and the development of
an action plan for the Global Strategy for Diet, Physical Activity and Health.
(7) The latter is to be discussed at the World Health Assembly in May 2008.
In addition to these global reports, there has been progress at country level,
a recent example being the publication by the South African Medical Research
Council of an extensive national effort to quantify the contribution of major
risks to health. In the Medical Research Council report, 17 major risks were
analysed, with hypertension, tobacco use, increased body mass, physical inactivity
and other risks for chronic diseases ranking among the top-ten contributors
to the burden of disease. (8) This is particularly significant in a low-middle-income
country beset with HIV/AIDS and high levels of violence.
Advocating for funding and action
While these research and policy documents are necessary, without supportive
financial investment and the creation of human and institutional capacity there
can be no action at country level. This has been recognised by non-governmental
organisations that have started to work together to advocate for funding and
action. An example of this is the establishment of the Global Alliance for the
Prevention of Obesity and Chronic Disease, which includes the World Heart Federation,
the International Obesity Task Force, the International Diabetes Federation,
the International Association for the Study of Obesity, the International Pediatric
Association and the International Union of Nutritional Science. (9)
Three new investments were recently announced with the potential to have global
impact:
First, in mid-2006, Michael Bloomberg, mayor of the city of New York and head
of the Bloomberg Foundation, announced the award of 125 million US$ for global
tobacco control to be administered through a web of NGOs and the WHO. (10) This
grant will significantly contribute to accelerated action in implementing the
provisions of the Framework Convention on Tobacco Control in selected countries.
If programmed wisely, it will also lead to the development of a stronger cadre
of tobacco-control policy experts within those countries.
Secondly, Lois Quam announced in 2006 that Ovations, a UnitedHealth Group company,
would provide 15 million US$ to support development of centres of excellence
to address chronic diseases in developing countries. (11) The hope is that these
centres will work with established groups in developed countries to create a
much-needed pool of expertise in developing countries, capable of leading development
of chronic disease prevention and management systems. Ms Quam’s announcement
was made during the 2006 Clinton Global Initiative in a special session devoted
to chronic diseases – in itself an important milestone in the growing acceptance
of the need for action. (12)
Thirdly, the PepsiCo Foundation announced a grant of 5.2 million US$ in September
2007 to support an Oxford Health Alliance community-based research initiative
to be initiated by groups in India, China, Mexico and the United Kingdom. The
project, Community Interventions for Health, will evaluate how best to reduce
chronic disease risks (tobacco use, poor diet and physical inactivity) through
interventions in schools, workplaces, communities and health-care centres in
developing countries and communities. (13)
These are not the only ongoing chronic disease initiatives – they build on
years of work undertaken by Salim Yusuf from McMaster University in Canada,
Stephen MacMahon from the George Institute in Sydney, Sir Richard Peto from
Oxford University and Stig Wall from Umeå University in Sweden. Further, it
should be recognised that these are still only modest investments when compared
to the size of the burden of disease today and the emerging burden based on
current levels of risk, or the level of financial and political support given
to AIDS, malaria or tuberculosis. But they represent an important start.
New partnerships and alliances
The development of new partnerships and alliances is the third major development.
As mentioned above, the Oxford Health Alliance (OxHA) is the first private-public
partnership with resources to convene major players and to carry out the strategic
research required to provide clear evidence for why chronic diseases demand
more attention. (14) It receives its core funding from Novo Nordisk – a Danish-based
global pharmaceutical company with a deep and proven commitment to tackling
diabetes and related health conditions globally. OxHA’s annual meetings have
brought together people from a range of NGOs, international health agencies,
private food, pharmaceutical and insurance companies and academia to foster
a better understanding of each group’s role in addressing chronic diseases.
What has emerged is a growing sense that profits and public health goals can
coincide, and that market forces could be a far more effective tool in tackling
chronic diseases then previous models of philanthropy or public-sector actions.
A major article in The Economist very recently called for a greater focus on
chronic disease. (15) The same publication not too long ago opposed action,
saying that chronic diseases are due to a failure of personal responsibility,
are mainly the concern of the affluent and the old, and do not warrant special
attention. (16) This reversal of attitude may well represent a realisation that
failure to address chronic diseases is bad for profits – a theme so well documented
in recent World Bank and Oxford Health Alliance reports (17), and discussed
in depth at the first-ever meeting between the World Health Organization and
the World Economic Forum in Dalian, China during September 2007. That meeting
highlighted the cost-effectiveness of workplace interventions to address chronic
diseases and called for implementation of what works – with a greater focus
on adapting knowledge from developed countries to workplaces in developing countries.
Future progress will require that serious investment be made by governments;
that corporations carefully review how they could contribute more tangibly to
the health of their employees and, where their core business involves products
or marketing practice that influence public health, that they seek ways of advancing
both their profitability and public health.
The initiatives described here are, on the whole, modest and fragmentary. If
they work together and are able to attract funding and political support, there
is great potential to scale up these efforts.
*Dr. Derek Yach is Director Global Health Policy PepsiCo in New York.. Until
2004, he worked at the World Health Organisation where he established the Tobacco
Free Initiative and where he was responsible for developing a new global “Health
For All” policy, which was adopted by all governments in May 1998. From 2005
to early 2007, he was at the Rockefeller Foundation, heading its global health
programmes. Prior to that, he was Professor of Global Health at Yale University.
Contact: derek.yach@pepsico.com.
Dr. Stig Pramming is Executive Director Oxford Health Alliance in London.
He worked in the Danish National Health Service and also in Norway and Sweden.
He is a widely published author with over 50 papers to his name, and several
coauthorships of professional textbooks. He is a fellow of Harris-Manchester
College, Oxford, an honorary consultant to the UK NHS, and a professor of the
University of Oxford. Contact: stig.pramming@oxha.org
References
- Frenk et al. (1989) Health transition in middle-income countries: new challenges
for health care. Health Policy Plan 4(1): 29–39.
- Yach D, Hawkes C, Gould CL, Hofman KJ (2004). The global burden of chronic
diseases: overcoming impediments to prevention and control. JAMA 291(21):
2616–2622.
- World Health Organization (2005). Preventing Chronic Diseases: A Vital Investment.
Geneva.
- World Bank (2006). Disease Priorities in Developing Countries. Washington,
DC.
- Adeyi O, Smith O, Robles S. (2007). Public Policy and the Challenge of Chronic
Noncommunicable Diseases. World Bank. Washington, DC.
- World Health Organization (2003). Framework Convention on Tobacco Control.
Geneva.
- World Health Organization (2004). The Global Strategy on Diet, Physical
Activity and Health. Geneva.
- South African Comparative Risk Assessment. SAMJ 2007; 97 (8), Part 2: 635-790.
- Global Alliance for the Prevention of obesity and related chronic disease.
www.preventionalliance.net/index.htm
- WHO named as one of five partners to implement Michael Bloomberg’s 125 US$
million initiative to promote freedom from smoking: www.who.int/mediacentre/news/statements/2006/s16/en/index.html
- Quam L, Smith R, Yach D (2006). Rising to the global challenge of chronic
diseases. The Lancet 368(9543): 1221–1223.
- See ‘Request for proposals announced’ (24 July 2007),
www.oxha.org/alliance-alert/
- Community Interventions for Health: www.oxha.org/initiatives/cih
- See www.oxha.org and www.3four50.com.
- The maladies of affluence/ The Economist, 11 August 2007: www.economist.com/world/international/displaystory.cfm?story_id=9616897
- Less Mary Poppins, The Economist, 9 November 2006: www.economist.com
- Adeyi et al., op cit. Suhrcke et al. (2006), Chronic Disease: An Economic
Perspective. Oxford Health Alliance.
