“We are dealing now with a problem of huge magnitude. These are health problems increasing in all six regions of the world,” said Ala Alwan, a WHO assistant director general.
The devastating effects of this epidemic have prompted the U.N. General Assembly to convene a two-day session next week on “noncommunicable diseases,” as this vast territory of human affliction is known. It’s a global focus comparable to the two big international health efforts of the past decade — providing anti-retroviral therapy to people with HIV in poor countries, and accelerating the decline of maternal and child deaths.
The attention on noncommunicable diseases and on a short list of ways to combat them pushes the global health community into a messy world of hard-to-change human behavior, powerful commercial interests and political debate about how much governments should do to protect people from themselves.
Whether it will slow progress against those glaring health inequalities is a question just starting to be debated. But the problem is too big to ignore.
“Every year that passes, the noncommunicable diseases get bigger,” said Christopher J.L. Murray, a co-author of the landmark 1993 “Global Burden of Disease” report, which was the first to rigorously catalogue the toll. “The trends are all pretty clear, the message has been repeated over and over, and it has slowly gotten traction.”
The WHO report summarizes two decades of research challenging the view that people in poor countries die of infections, and people in rich countries die of diseases brought on by the effects of overeating, smoking and a sedentary lifestyle. While not entirely untrue, that stereotype masks an overlooked and growing number of “rich-people’s diseases” in the developing world.
Noncommunicable diseases cause 36 million of 57 million deaths each year, or nearly two-thirds of global mortality, based on 2008 statistics, the most recent available. Most of the victims live in low- and middle-income countries — places such as Kenya, Indonesia and Poland. More than 80 percent of deaths from cardiovascular disease and diabetes occur outside industrialized nations such as the United States, France and Japan.
Particularly troubling, say the authors of the report, is the amount of “premature death” — defined in this case as death before age 60 — occurring in places where the incidence of the diseases is rising rapidly.
In low-income countries, 41 percent of people dying of heart attacks, strokes and cancer are younger than 60. In middle-income countries, the fraction is 25 to 28 percent; in high-income countries, it’s 13 percent.
Premature death is especially common in Africa, the only continent where infectious diseases, childbirth-related deaths, malnutrition and fatal injury as a group still cause most deaths.
In Mali, a nation of 15 million people in northwest Africa, noncommunicable diseases account for only 20 percent of deaths. However, of the men dying from them, half are younger than 60; of the women, that number is 43 percent. This is happening despite a good “risk-factor profile” overall: Only one-quarter of men and virtually no women smoke; one-third of people have hypertension (about the same as in rich countries); and the average cholesterol level is below 160 milligrams per deciliter, deep in the “desirable” range. Mali’s death toll is almost certainly the consequence of very poor medical care for the small — but growing — number of victims of these diseases.
Cognizant of asking countries to do too much in too many areas, the WHO experts are emphasizing a menu of “best buys” to prevent, delay and treat chronic illnesses.
They advocate population-wide interventions such as raising taxes on tobacco and alcohol; banning tobacco advertising; reducing salt in processed food; replacing trans-fats with less hazardous oils; and promoting physical activity through mass media campaigns.
The medical interventions include providing a combination of drugs to people with a calculated 30 percent chance of suffering a heart attack or stroke in 10 years; giving aspirin to people having a heart attack; and screening for cervical cancer (which is the leading cause of cancer death for women in sub-Saharan Africa).
Estimates of how much it would cost to put the interventions into effect will be provided in a second document to be released Sunday in New York, on the eve of the General Assembly meeting. Regardless of cost, there is considerable opposition in many places to policies viewed as intrusive or restrictive. But public health experts pushing the noncommunicable disease agenda say that without action by governments, significant prevention won’t occur.
“Government has a responsibility to make the healthy options the easiest options,” said Robert Beaglehole, a physician and epidemiologist at the University of Auckland in New Zealand. “Governments do that all the time.”
The new WHO report provides a one-page profile of each of more than 190 countries, depicting the share of mortality caused by noncommunicable diseases, and rates and trend lines for risk factors such as blood glucose, smoking and body mass index. It also displays an abbreviated score card for recommended interventions. All countries have much room for improvement, according to the report.
For example, there are five recommended strategies for tobacco control. No country has implemented all of them; only one country, Iran, has implemented four. Many countries have implemented none.
The U.S. Department of Health and Human Services announced a campaign Tuesday called “Million Hearts” aimed at preventing 1 million heart attacks and strokes over the next five years. Those diseases cause one-third of American deaths and consume 17 percent of national health spending, roughly $275 billion a year.
The project seeks to focus more attention, not more money, on improving the care of people who have heart disease and lowering the risk for people who don’t. It will do so by incorporating specific targets into activities already underway, including the government’s efforts to get physicians to adopt electronic medical records and to report certain measures of quality care, as well as numerous community-based interventions designed to improve health. Some private companies, such as pharmacies, will be enlisted to screen and educate people.
The U.S. targets are: increasing aspirin use for high-risk people from 47 percent now to 65 percent in 2017; increasing the percentage of people whose high blood pressure is controlled from 46 percent to 65 percent; the same with people with high cholesterol, from 33 percent to 65 percent; cutting the national smoking rate from 19 percent to 17 percent; and reducing daily salt consumption by 20 percent.
“These are simple, low-cost measures,” said Thomas Frieden, director of the Centers for Disease Control and Prevention.
Spending on heart disease and stroke in the United States is expected to triple by 2030. Whether “Million Hearts” will save money is uncertain, but it’s unlikely to increase costs, Frieden said. “What it will do is shift cost from sick care to health care.”
WHO Assistant Director General Alwan and health experts from around the globe will be discussing the crisis in noncommunicable diseases Wednesday at a Washington Post Live conference, which can be viewed starting at 8:30 a.m. at washingtonpostlive.com.