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Tackling the global burden of stroke
Leading Edge
Tackling the global burden of stroke Almost 6 million people worldwide will die from stroke in 2005, and nearly 90% of these deaths will occur in less-affluent countries. Without urgent action, deaths from stroke will increase over the next decade by 12% globally—and by 20% in low-income countries. These stark projections are revealed by WHO as part of its report—Preventing chronic diseases: a vital investment—published on October 5. But even these bleak figures do not capture the full burden of stroke. More than a third of people who survive a stroke will have severe disability. By 2015, over 50 million healthy life-years will be lost from stroke, with 90% of this burden in low-income and middle-income countries. In its report, and in a series of four companion papers published in The Lancet, WHO aims to dispel the myth that stroke—and other chronic diseases such as coronary heart disease, diabetes, and cancer—is a disease of affluence. WHO is calling for global action to halt the rising pandemic of stroke and other chronic diseases by tackling major lifestyle risk factors, such as tobacco smoking, physical inactivity, and poor diet. The agency is proposing a new goal: a reduction in death rates by 2% per year over and above current trends until 2015. To devise this target, WHO looked at countries that have achieved substantial reductions in death rates through population-based interventions; for example, in Poland, the government imposed subsidies on animal fats and made cheaper vegetable oils available. This simple intervention led to a fall in death rates of 6–10% per year. In countries where the impact of stroke is particularly great, tackling the disease will be an enormous challenge. In China, for example—which is home to more than a fifth of the world’s population—stroke rates are five to ten times greater than in other countries such as Australia, Singapore, and Japan. Stroke is the number one vascular killer (mortality 276·9 per 100 000 person-years) in China, way ahead of chronic pulmonary heart disease (137·6), coronary heart disease (85·5), and heart failure (14·5) according to recent figures published in the NEJM. Tackling lifestyle risk factors is undoubtedly important: salt consumption is high; over 50% of adult men smoke; and obesity rates in some wealthy urban areas are soaring. Consequently, hypertension, one of the most important risk factors for stroke, is a major http://neurology.thelancet.com Vol 4 November 2005
problem. About 160 million Chinese people— equivalent to more than half the population of the USA—have hypertension. Over the past two decades, the primary health-care system in China has all but disintegrated, so only a minority of these people are receiving treatment. It will be very difficult to make any inroads into reducing stroke burden until the Chinese primary health-care system is reconstructed. There are signs that the tide may be turning, however. In 2002, the Chinese Ministry of Health established the National Centre for Chronic and Non-communicable Disease Control and Prevention in Shanghai, which is responsible for disease surveillance and populationbased interventions. So far, 1 million people in the Shanghai region have been entered on to a database that tracks their risk factors for chronic disease and how well these risk factors are being controlled. The challenge for China, and indeed for many nations, will be to scale up successful small-scale projects to deliver results on a national level. As a first step, it is imperative for governments to prioritise the prevention of stroke and other chronic diseases. Second, they must ensure that there is a department within the ministry of health that is devoted to this goal. Third, each country must formulate and adopt a comprehensive and integrated national policy that can serve as a framework for action. For some countries, particularly those that are struggling with a double burden of infectious disease and chronic disease, governments will have difficult choices to make. Infectious diseases, such as HIV/AIDS and malaria, have quite rightly received much attention from public-health advocates in recent times. But for too long, chronic diseases have been neglected in the global health arena—even though there are twice as many deaths each year from chronic diseases than from all infectious diseases (including HIV/AIDS, tuberculosis, and malaria), maternal and perinatal conditions, and nutritional deficiencies combined. As Nigerian president Olusegun Obasanjo said in a supportive statement in the WHO report: “We cannot afford to say, ‘we must tackle other diseases first—HIV/AIDS, malaria, tuberculosis— then we will deal with chronic diseases’. If we wait even ten years, we will find that the problem is even larger and more expensive to address.” ■ The Lancet Neurology
See http://www.who.int/chp/ chronic_disease_report/en/ index.html
See Lancet 2005, published online Oct 5 DOI:10.1016/S0140-6736(05) 67454-5
See N Engl J Med 2005; 353: 1124–34 DOI:10.1056/NEJMsa050467
689
Tackling the global burden of stroke Almost 6 million people worldwide will die from stroke in 2005, and nearly 90% of these deaths will occur in less-affluent countries. Without urgent action, deaths from stroke will increase over the next decade by 12% globally—and by 20% in low-income countries. These stark projections are revealed by WHO as part of its report—Preventing chronic diseases: a vital investment—published on October 5. But even these bleak figures do not capture the full burden of stroke. More than a third of people who survive a stroke will have severe disability. By 2015, over 50 million healthy life-years will be lost from stroke, with 90% of this burden in low-income and middle-income countries. In its report, and in a series of four companion papers published in The Lancet, WHO aims to dispel the myth that stroke—and other chronic diseases such as coronary heart disease, diabetes, and cancer—is a disease of affluence. WHO is calling for global action to halt the rising pandemic of stroke and other chronic diseases by tackling major lifestyle risk factors, such as tobacco smoking, physical inactivity, and poor diet. The agency is proposing a new goal: a reduction in death rates by 2% per year over and above current trends until 2015. To devise this target, WHO looked at countries that have achieved substantial reductions in death rates through population-based interventions; for example, in Poland, the government imposed subsidies on animal fats and made cheaper vegetable oils available. This simple intervention led to a fall in death rates of 6–10% per year. In countries where the impact of stroke is particularly great, tackling the disease will be an enormous challenge. In China, for example—which is home to more than a fifth of the world’s population—stroke rates are five to ten times greater than in other countries such as Australia, Singapore, and Japan. Stroke is the number one vascular killer (mortality 276·9 per 100 000 person-years) in China, way ahead of chronic pulmonary heart disease (137·6), coronary heart disease (85·5), and heart failure (14·5) according to recent figures published in the NEJM. Tackling lifestyle risk factors is undoubtedly important: salt consumption is high; over 50% of adult men smoke; and obesity rates in some wealthy urban areas are soaring. Consequently, hypertension, one of the most important risk factors for stroke, is a major http://neurology.thelancet.com Vol 4 November 2005
problem. About 160 million Chinese people— equivalent to more than half the population of the USA—have hypertension. Over the past two decades, the primary health-care system in China has all but disintegrated, so only a minority of these people are receiving treatment. It will be very difficult to make any inroads into reducing stroke burden until the Chinese primary health-care system is reconstructed. There are signs that the tide may be turning, however. In 2002, the Chinese Ministry of Health established the National Centre for Chronic and Non-communicable Disease Control and Prevention in Shanghai, which is responsible for disease surveillance and populationbased interventions. So far, 1 million people in the Shanghai region have been entered on to a database that tracks their risk factors for chronic disease and how well these risk factors are being controlled. The challenge for China, and indeed for many nations, will be to scale up successful small-scale projects to deliver results on a national level. As a first step, it is imperative for governments to prioritise the prevention of stroke and other chronic diseases. Second, they must ensure that there is a department within the ministry of health that is devoted to this goal. Third, each country must formulate and adopt a comprehensive and integrated national policy that can serve as a framework for action. For some countries, particularly those that are struggling with a double burden of infectious disease and chronic disease, governments will have difficult choices to make. Infectious diseases, such as HIV/AIDS and malaria, have quite rightly received much attention from public-health advocates in recent times. But for too long, chronic diseases have been neglected in the global health arena—even though there are twice as many deaths each year from chronic diseases than from all infectious diseases (including HIV/AIDS, tuberculosis, and malaria), maternal and perinatal conditions, and nutritional deficiencies combined. As Nigerian president Olusegun Obasanjo said in a supportive statement in the WHO report: “We cannot afford to say, ‘we must tackle other diseases first—HIV/AIDS, malaria, tuberculosis— then we will deal with chronic diseases’. If we wait even ten years, we will find that the problem is even larger and more expensive to address.” ■ The Lancet Neurology
See http://www.who.int/chp/ chronic_disease_report/en/ index.html
See Lancet 2005, published online Oct 5 DOI:10.1016/S0140-6736(05) 67454-5
See N Engl J Med 2005; 353: 1124–34 DOI:10.1056/NEJMsa050467
689