Developing effective and affordable models for non-communicable disease prevention and control

Franklin White

Community Health Sciences, The Aga Khan University, Karachi, Pakistan.

Sir—The editorial on ‘Exporting failure? Coronary heart disease and stroke in developing countries’, although provocative, is stronger on rhetoric than on scientific reasoning.1 For example, just because ‘one enthusiast’ made an inaccurate and refutable statement, this should not be a cause célebre. Critical reviews should be more constructive than this.

An assessment of trends reveals that non-communicable diseases (within which cardiovascular disease is a major category) are increasingly important, and indeed most public health professionals would agree that something should be done about it. The Burden of Disease study concluded that by 1990 non-communicable diseases (NCD) had overtaken communicable diseases as the leading cause of mortality worldwide (56% of all deaths, not including injuries which accounted then for 10%, the remaining 34% attributable to communicable diseases). By year 2020, NCD were projected to account for 73% of global mortality, with communicable diseases declining to 15%. The only region not yet heavily affected by this double burden is sub-Saharan Africa. This analysis of trends, incorporating the DALYS methodology, has been widely disseminated.2

Other questionable assertions are also made, for example: ‘The prevention of cardiovascular disease traditionally relies on the control of risk factors among individuals as a major element of any strategy. Such approaches—generally termed health promotion—are well illustrated by ... the Ottawa Charter’. On the contrary, the Ottawa Charter (1986) was ground breaking in its advocacy of healthy public policy, which the editorial later extols as the preferred approach. The Charter makes no mention anywhere of ‘risk factors’. The following is a brief extract: ‘The fundamental conditions and resources for health are peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity’.3

The editorial later digresses into the central role of poverty in determining health and disease. Most public health professionals would agree that addressing the root causes of poverty would likely do more for the health of the poor in all countries, than any number of specific health programmes. However, beyond advocacy, our role requires that we must also develop and test a variety of options for disease control and prevention. The decision framework must be evidence-based, and take into account disease burden, prevention effectiveness, cost effectiveness and affordability.

Regarding the North Karelia project, the editorial takes pains to show that similar declines occurred in the comparison county. However, readers also might like to know more about what happened in Finland, in particular the important finding that the majority (about 75%) of the major decline in heart disease mortality (73% reduction over 25 years in North Karelia itself) was explained by reductions in three risk factors: smoking cholesterol and blood pressure.4 While a more positive account is given of the Mauritius project (one of the few documented efforts at integrated NCD intervention in a developing country), these two examples should be viewed as complementary and mutually supportive, especially in their recognition of the public policy element. The historical importance of the North Karelia project (initiated in 1972) is that it was the earliest attempt to organize NCD interventions for a large population (an entire province), which eventually influenced a whole country, and spawned the international CINDI network (Country-wide Integrated Non-communicable Disease Interventions) a decade later (1982). To be fair, intervention efforts should be considered in their historical and geographical context, not only with the exaggerated wisdom of hindsight. For example, if it would serve a useful purpose, one could promote flaws in the work of John Snow.

Under the heading ‘So, what do we do?’ the editorial cites the 53rd World Health Assembly resolution on the need for a national policy framework. However, the resolution is fully consistent with principles outlined in several earlier statements, including the Alma Ata Declaration (1978). Coincident with the Ottawa Charter (1986), for example, Canada released a policy framework entitled ‘Achieving Health for All’. According to its website, CINDI provides participating countries with such a framework.5 Frameworks themselves of course are only a beginning, and a scientifically sound and managerially feasible approach is essential in order to transform them into practical actions.6 While the CINDI network process has been ongoing for many years (and now includes 24 countries), since 1995, the Pan American Health Organization (PAHO/WHO) has been promoting a similar integrated model for NCD programming (CARMEN), piloted by Chile. CARMEN differs in emphasis from CINDI, in the context-appropriate inclusion of diabetes, cervical cancer and injury prevention, which are important issues for Latin America and the Caribbean.7,8 Similarly, the Mauritius project is a member of the INTERHEALTH group of projects, another supportive network, similar conceptually and linked to the other networks.9 The first step in all these models is a policy framework.

The potential of such frameworks for NCD prevention and control is broader than the editorial suggests: many risk factors and underlying determinants for coronary heart disease and stroke are equally applicable to other NCD outcomes. Measures such as tobacco control, dietary and physical fitness approaches, education regarding care seeking and even promoting quality of care where service is already being provided, are scientifically sound and potentially feasible in many developing countries. Lessons from the now many CINDI, CARMEN and INTERHEALTH projects around the world are valuable in helping to find a way forward in the prevention and control of NCD.

References

1 Ebrahim S, Davey Smith G. Exporting failure: coronary heart disease and stroke in developing countries. Int J Epidemiol 2001;30:201–05.[Free Full Text]

2 Murray CJL, Lopez AD (eds). The Global Burden of Disease—Summary. Geneva: World Health Organization, 1996.

3 The Ottawa Charter for Health Promotion; an international conference on health promotion. Health Promotion 1986;1:iii–v.

4 Vaartiainen, E, Puska P, Pekkanen J, Tuomilheto J, Jousilahti P. Do changes in risk factors in Finland explain the changes in ischemic heart disease mortality? In: Puska P, Tuomilehto J, Nissinen A, Vartiainen E (eds). The North Karelia Project: 20 Year Results and Experiences. Helsinki: National Public Health Institute, 195, pp.241–54.

5 Noncommunicable diseases and their control: CINDI programme.http:/www.who.dk/zoro/inv/cindi01.htm

6 White F. Epidemiology in health promotion: a Canadian perspective. Bull Pan Am Health Organ 1989;23:384–96.[Medline]

7 World Health Report 1997. Executive Summary. Geneva: World Health Organization, 1997.

8 Peruga A. Conjunto de Acciones para la Reducion Multifactorial de las Enfermedades non Transmissibles. In: Worldwide Efforts to Improve Heart Health: a follow up to the Catalonia Declaration selected program descriptions. Washington: US Department of Health and Human Services, Centers for Disease Control and Prevention and Health Promotion, June 1997.

9 Khaltaev NG. INTERHEALTH. In: Worldwide Efforts to Improve Heart Health: a follow up to the Catalonia Declaration selected program descriptions. Washington: US Department of Health and Human Services, Centers for Disease Control and Prevention and Health Promotion, June 1997.





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