Rising to the global challenge of the chronic disease epidemic

Lois Quam, Richard Smith & Derek Yach
Lancet, 268; 9453: 1221-1223

Last year, a study published in The Lancet showed how a global goal of reducing deaths from chronic disease by 2% a year, a target already attained in many wealthy countries, would avert 36 million deaths by 2015.¹ Most of the deaths averted would be in the developing world and just under half would be in people aged under 70 years. The journal's editor commented: “There is an unusual opportunity before us to act now to prevent the needless deaths of millions.”² An attempt is now being made to grasp that opportunity.

Of the 58 million deaths in the world in 2005, some 35 million were from heart disease, stroke, cancer, chronic respiratory disease, and other chronic conditions. Chronic disease accounted for almost three-quarters of the burden of disease (measured in disability-adjusted life-years) in those aged 30 years or over. By 2015, deaths from chronic disease will be the commonest cause of death even in the poorest countries.

Despite this burden of chronic diseases, there is no Millennium Development Goal to address them.^{3 and 4} Currently, infectious diseases, perinatal conditions, and nutritional disorders are the major killers of the very poorest people, and that is why so much emphasis has rightly been concentrated on these problems—but we should not neglect chronic disease. Various myths have probably led to their neglect. Many still believe that these are diseases of affluence and are self-inflicted through indulgence in unhealthy lifestyles. In fact, chronic disease is a bigger problem in poor people because they do not have the resources to pursue healthy choices. Another myth is that little can be done about chronic disease, but deaths from heart disease have fallen by up to 70% in the past three decades in Australia, Canada, Japan, the UK, and the USA. About 50% of deaths from chronic disease are attributable to modifiable risks, including tobacco use, raised blood pressure, and poor diet. Raising tobacco taxes and treating people who have had a cardiac event are among the most cost-effective interventions for those in developing countries.⁵

The current Millennium Development Goals are appropriate for the poorest billion people in the world, but action is needed to better manage chronic disease for the 4 billion people living in China, India, Brazil, Egypt, South Africa, Poland, and other low-to-middle income countries. These countries are the global engines of growth. Reduced productivity in workers in these countries caused by early onset and poorly managed chronic disease harms households and nations.To date, the expectation has been that the same international funders of action against infectious diseases would start supporting a broader range of health issues. Realistically, it is unlikely that those funders will provide support for programmes on chronic disease given the pressure for investments in the poorest countries. These funders do provide modest support to tobacco-control programmes,⁶ but different approaches are needed that draw on new resources. The Lancet has argued that: “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 offers is intended to challenge these sectors to become involved.”² The time has come to accept that challenge, but it requires a shift in the role of the corporate sector and in the attitudes of the public sector. Importantly, any shift will build on emerging initiatives by companies that see the gain to both public health and their businesses through the development and promotion of healthier products and lifestyles.

The food companies that have started to market healthier foods see their profits rise faster then those that do not. Further, the health-care companies that provide incentives and practical support to patients at highest risk for chronic diseases increase their profitability while improving population health outcomes. The potential to expand such approaches into other sectors remains largely untapped. Developments could include the reduction of the harm caused by tobacco by use of smokeless or cessation products, the creation of incentives to increase physical activity, or ensuring that people with diabetes or hypertension are diagnosed early and treated effectively.

We urge sceptics to judge partnerships on their ability to improve public health and not on ideological grounds. Policymakers in health tend to regard private-public partnerships as beginning and ending with the pharmaceutical industry. Many remain unconvinced about their benefits on product development, better ways of working, and novel approaches to increasing access to essential drugs. This narrow view has limited the potential to bring about change in a complex system.

Governments need to help if market-led solutions are to flourish. The regulatory system should reward innovative approaches that lead to health gains and penalise laggards who continue with practices that limit progress. Changes in the regulatory system will require a much needed debate about the optimum role of government in promoting health.

This week, at the Clinton Global Initiative,⁷ a spotlight was placed on the need for action on chronic disease. Participants were asked to commit to taking action. PepsiCo described how it is working to prevent diet-related aspects of chronic diseases, the World Health Federation announced plans to develop a polypill for the secondary prevention of cardiovascular disease and diabetes, and WHO outlined new efforts to implement the Framework Convention on Tobacco Control and tackle obesity. The World Diabetes Foundation announced new efforts to prevent diabetes in children and provide better care for those with the disease—starting in South Africa.

Ovations announced that it would lead efforts to develop a network of Centers of Excellence to tackle chronic diseases in developing countries. This work will be initiated in a global summit hosted by Ovations in Washington, DC, in early 2007. These efforts will explore ways to build on the existing efforts in developing countries, to spread the outstanding success of the Finnish and other national experiences, and to partner the Oxford Health Alliance and other chronic disease initiatives. The network will work closely with those involved in addressing infectious chronic diseases such as AIDS and tuberculosis, because such diseases require a similar system-platform for success, and Ovations will contribute its business expertise of how to spread effective practices for chronic disease control to scale.

The commitments made at the Clinton Global Initiative and the enthusiasm of those present from governments, non-governmental organisations, and business suggest that the tide is at last turning in favour of chronic disease prevention and management.

LQ is the chief executive of Ovations and RS is the chief executive of UnitedHealth Europe, a sister company. DY is on the Board of the Oxford Health Alliance.

References

1 K Strong, C Mathers, S Leeder and R Beaglehole, Preventing chronic diseases: how many lives can we save?, Lancet 366 (2005), pp. 1578–1582.
2 R Horton, The neglected epidemic of chronic disease, Lancet 366 (2005), p. 1514.
3 P Boyle, The globalisation of cancer, Lancet 368 (2006), pp. 629–630.
4 V Fuster, Cardiovascular disease and the UN Millennium Development Goals: a serious concern, Nat Clin Pract Cardiovasc Med 3 (2006), p. 401.
5 R Laxminarayan, AJ Mills and JG Breman et al., Advancement of global health: key messages from the Disease Control Priorities Project, Lancet 367 (2006), pp. 1193–1208.
6 S Okie, Global health—the Gates-Buffet effect, N Engl J Med 355 (2006), pp. 1084–1088.
7 Clinton Global Initiative, Clinton Global Initiative NYC 2006