- Email: [email protected]
Combating chronic disease in developing countries
Comment
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Kendler KS, Gallagher TJ, Abelson JM, Kessler RC. Lifetime prevalence, demographic risk factors and diagnostic validity of nonaffective psychosis as assessed in a US community sample. Arch Gen Psychiatry 1996; 53: 1022–31. Haro JM, Arbabzadeh-Bouchez S, Brugha TS, et al. Concordance of the composite international diagnostic interview version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health Surveys. Int J Methods Psychiatr Res 2006; 15: 167–80. Xu MQ, Sun WS, Liu BX, et al. Prenatal malnutrition and adult schizophrenia: further evidence from the 1959–60 Chinese famine. Schizophr Bull 2009; 35: 568–76. WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291: 2581–90. Kessler RC, Ustun TB. The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004; 13: 93–121.
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Booth BM, Kirchner JE, Hamilton G, Harrell R, Smith GR. Diagnosing depression in the medically ill: validity of a lay-administered structured diagnostic interview. J Psychiatr Res 1998; 32: 353–60. Kessler RC, McGonagle KA, Zhao S. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8–19. Williams JBW, Gibbon M, First MB, et al. The structured clinical interview for DSM-III-R (SCID) II: multisite test-retest reliability. Arch Gen Psychiatry 1992; 49: 630–36. Kessler, RC, Abelson J, Demler O, et al. Clinical calibration of DSM-IV diagnoses in the World Mental Health (WMH) version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMHCIDI). Int J Methods Psychiatr Res 2004; 13: 122–39. Mezzich JE, Kirmayer LJ, Kleinman A, et al. The place of culture in DSM-IV. J Nerv Ment Dis; 187: 457–64. Lee S. Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology 2002; 35: 152–57.
Combating chronic disease in developing countries Published Online June 11, 2009 DOI:10.1016/S01406736(09)61074-6
For the 3four50 website see http://www.3four50.com/v2/
For the NHLBI website see www.globalhealth.nhlbi.nih.gov
2004
Globalisation has affected every aspect of modern life, and health and disease are no different. The global health landscape is rapidly shifting away from one dominated by infectious diseases to one characterised by various chronic conditions. These diseases— cardiovascular disease, cancer, type 2 diabetes, and chronic respiratory diseases—now cause more than half of all deaths worldwide, 80% of which occur in low-income and middle-income countries.1–3 If present trends continue unabated, annual deaths from chronic diseases will reach 41 million by 2015, and almost half of these will be in people younger than 70 years.4 Since the major causes of chronic diseases are known, half of these deaths are preventable.2 The health catastrophe provoked by this global surge of chronic disease is also an underappreciated cause of poverty that impedes the economic development of many countries.5,6 Thus, we believe it is vital that the international public health community makes chronic disease prevention a worldwide priority. We believe that a coordinated effort by national leaders will strengthen chronic disease prevention and control efforts.2,3,5,7–10 To address the globalisation of noncommunicable chronic cardiovascular and pulmonary diseases, the National Heart, Lung, and Blood Institute (NHLBI), a component of the US National Institutes of Health, has increased its commitment to reducing the global burden of chronic diseases by fostering collaborations with partners in the public and private sectors. Most recently, the NHLBI and UnitedHealth Group, one of the world’s largest health and wellbeing
companies, have forged a collaboration to counter chronic disease by supporting a collaborative global network of centres of excellence (COEs) in low-income and middle-income countries throughout the world. Our goal is to support research that will generate the evidence needed to inform policy decisions. Rigorous research undertaken at diverse sites will also enrich our basic understanding of disease causation and of the interplay between biological, environmental, and sociocultural contributors to public health. Our strategic, complementary effort grew from the common interests of the NHLBI and the UnitedHealth Group. We recognise that combating chronic disease requires crossing geographical, governmental, and organisational boundaries, and thus collaboration between public and private partners. In September, 2006, the UnitedHealth Group established a strategic priority to raise public and political consciousness about chronic disease in the developing world and to use its competencies to prevent and control chronic disease in those regions.11 From the beginning, the UnitedHealth Group partnered with the Oxford Health Alliance to fulfil that group’s communication objective with the 3four50 website (so named to highlight the three factors of poor diet, physical inactivity, and tobacco that cause the four conditions—cardiovascular disease, diabetes, chronic respiratory disease, some cancers—that account for more than 50% of global mortality).12 This website is a rich online resource for those interested in raising awareness about chronic diseases and in devising www.thelancet.com Vol 373 June 13, 2009
strategies to counter their growing global emergence. In May, 2007, the UnitedHealth Group issued a solicitation for COEs that would develop innovative, equitable, transferable programmes to prevent and control chronic diseases and build sustainable individual, institutional, and community capacity to achieve this goal. In parallel, in November, 2007, the NHLBI convened a meeting to develop a strategic approach to global health research. Recommendations that emerged from this meeting emphasised the unique and essential part the institute could and should play in undertaking global cardiovascular health implementation research and in disseminating the results. In September, 2008, the NHLBI issued a solicitation to create COEs that would undertake research into new or improved approaches and measures to prevent or treat chronic disease and to develop clinical research infrastructure and research training programmes. The NHLBI is also establishing a global health office, commissioning a report from the Institute of Medicine on global cardiopulmonary health, and joining with other government funders of research to create the Global Alliance for Chronic Diseases.9 The UnitedHealth Group/NHLBI collaborative effort now consists of a consortium of COEs in Argentina, Bangladesh, China, Guatemala, India-Bangalore, IndiaNew Delhi (including Pakistan), Kenya, Peru, South Africa-Tanzania, Tunisia, and along the US/Mexico border). Each COE includes a research institution in a developing country paired with at least one partner academic institution in a developed country. The research goals span a range of activities tailored to regional needs and disease effect. Projects include health surveillance to garner baseline data on risk prevalence and burden of disease; implementation research to develop and communicate new knowledge into workable, culturally appropriate policies and practices; decisional modelling to compare intervention strategies; and community engagement efforts to raise awareness and enlist the support of local and national leadership. Clearly, not only do chronic diseases know no boundaries, they also travel together. Thus, the consortium aims to broaden study beyond individual diseases, in keeping with WHO’s recommendation to address chronic diseases as they group in a real-world setting.2,12 www.thelancet.com Vol 373 June 13, 2009
Getty Images
Comment
COE consortium research will focus primarily on development of chronic disease prevention programmes, and early results are encouraging. For example, the South Africa-Tanzania and China sites are developing portable tools that can be used in the field to measure risk of chronic disease, and the South Africa site is near completion on simple, yet comprehensive, chronic disease management guidelines that can be used by nurses and community health workers. Some COEs, such as those in India-Bangalore, Guatemala, Tunisia, and along the US/Mexico border, are working with whole communities, including schools and workplaces, to redesign communities so that healthy choices are also simple and practical choices. NHLBI and the UnitedHealth Group encourage collaboration between and among the COEs, as well as with other organisations. Importantly, the COE consortium members are each developing infrastructures for research and training to enhance local capacity, with the goal of long-term sustainability of our seed investment. We are dually committed to identification of workable and effective approaches for implementation and integration of research results, and we will share best practices as appropriate and relevant. To maintain momentum from our effort and that of other organisations, continued strong leadership and coordination is vital. WHO has developed an action plan that encompasses surveillance, research, and implementation to counter chronic disease.12 The Pepsico Foundation is supporting programmes to make communities healthier in China, India, Mexico, and the UK, 2005
Comment
and the World Economic Forum and the World Bank also have projects underway. The NHLBI and the UnitedHealth Group will work in partnership with these other entities to enhance synergy and to avoid duplication. To that end, the NHLBI is a founding member of the Global Alliance for Chronic Disease, a new alliance of six initial national biomedical research funders to address research needs in the chronic non-communicable diseases. Now is the time for sustained and coordinated scientific leadership to focus global efforts on combating the social, economic, and political toll of chronic disease. The NHLBI and UnitedHealth Group collaboration is an important piece of this public health initiative that is so vital for our global citizenry.
1
*Elizabeth G Nabel, Simon Stevens, Richard Smith
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National Heart, Lung, and Blood Institute, Bethesda, MD 20892, USA (EGN); UnitedHealth Group, Minneapolis, MN 55440, USA (SS, RS) [email protected] EGN is the director of the National Heart, Lung, and Blood Institute and SS is a senior executive at UnitedHealth Group, responsible for health reform and global business. RS is the director of the UnitedHealth Chronic Disease Initiative.
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Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global burden of disease and risk factors. Washington, DC: Oxford University Press and World Bank, 2006. WHO. Preventing chronic diseases: a vital investment. Geneva: World Health Organization, 2005. Adeyi O, Smith O, Robles S. Public policy and the challenge of chronic noncommunicable diseases. Washington, DC: World Bank, 2007. Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: how many lives can we save? Lancet 2005; 366: 1578–82. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007; 370: 1929–38. Suhrcke M, Nugent RA, Stuckler D, Rocco L. Chronic disease: an economic perspective. London: Oxford Health Alliance, 2006. Jamison DT, Breman JG, Measham AR, et al, eds. Disease control priorities in developing countries. Washington, DC: World Bank and Oxford University Press, 2006. Horton R. Chronic diseases: the case for urgent global action. Lancet 2007; 370: 1881–82. Daar A, Singer PA, Persad DL, et al. Grand challenges in chronic non-communicable diseases: the top 20 policy and research priorities for conditions such as diabetes, stroke and heart disease. Nature 2007; 450: 494–96. Beaglehole R, Ebrahim S, Reddy S, Voûte J, Leeder S, on behalf of the Chronic Disease Action Group. Prevention of chronic disease: a call to action. Lancet 2007; 370: 2152–57. Quam L, Smith R, Yach D. Rising to the global challenge of the chronic disease epidemic. Lancet 2006; 368: 1221–23. WHO. 2008–2013 Action plan for the global strategy for the prevention and control of non-communicable diseases. Geneva: World Health Organization, 2008.
Lives to save: PEPFAR, HIV, and injecting drug use in Africa
Getty Images
The US President’s Emergency Plan for AIDS Relief (PEPFAR) is credited with provision of antiretroviral therapy to 2·1 million people with HIV, almost all of whom live in sub-Saharan Africa, and has spent more than US$18 billion on the continent.1 The achievements
2006
of this programme have, unfortunately, not reached thousands of injecting drug users in PEPFAR countries in Africa, many of whom have HIV. Outside Africa, the gateway to antiretroviral therapy for people who inject illicit drugs is usually through drug-dependency treatment, an HIV-prevention service such as needle exchange, or in some cases through legal services. In almost all countries of sub-Saharan Africa, including those most affected by HIV, affordable drug-dependency treatment is out of reach, needle exchange does not exist, and legal services are unavailable or unaffordable.2 As many as 3 million people who inject drugs could be living in sub-Saharan Africa, with more than 200 000 in Kenya and at least 250 000 in South Africa.3 In a growing number of sub-Saharan African countries, prevalence of HIV is higher in injecting drug users than in other people. In a 2004 rapid assessment,4 HIV prevalence in injecting drug users from Kenya was estimated at 68–88%. Data from other studies have shown rates to be 58% in women and 27% in men in Tanzania; 28% in all injecting www.thelancet.com Vol 373 June 13, 2009
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5
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8
Kendler KS, Gallagher TJ, Abelson JM, Kessler RC. Lifetime prevalence, demographic risk factors and diagnostic validity of nonaffective psychosis as assessed in a US community sample. Arch Gen Psychiatry 1996; 53: 1022–31. Haro JM, Arbabzadeh-Bouchez S, Brugha TS, et al. Concordance of the composite international diagnostic interview version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health Surveys. Int J Methods Psychiatr Res 2006; 15: 167–80. Xu MQ, Sun WS, Liu BX, et al. Prenatal malnutrition and adult schizophrenia: further evidence from the 1959–60 Chinese famine. Schizophr Bull 2009; 35: 568–76. WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291: 2581–90. Kessler RC, Ustun TB. The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004; 13: 93–121.
9
10
11
12
13 14
Booth BM, Kirchner JE, Hamilton G, Harrell R, Smith GR. Diagnosing depression in the medically ill: validity of a lay-administered structured diagnostic interview. J Psychiatr Res 1998; 32: 353–60. Kessler RC, McGonagle KA, Zhao S. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8–19. Williams JBW, Gibbon M, First MB, et al. The structured clinical interview for DSM-III-R (SCID) II: multisite test-retest reliability. Arch Gen Psychiatry 1992; 49: 630–36. Kessler, RC, Abelson J, Demler O, et al. Clinical calibration of DSM-IV diagnoses in the World Mental Health (WMH) version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMHCIDI). Int J Methods Psychiatr Res 2004; 13: 122–39. Mezzich JE, Kirmayer LJ, Kleinman A, et al. The place of culture in DSM-IV. J Nerv Ment Dis; 187: 457–64. Lee S. Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology 2002; 35: 152–57.
Combating chronic disease in developing countries Published Online June 11, 2009 DOI:10.1016/S01406736(09)61074-6
For the 3four50 website see http://www.3four50.com/v2/
For the NHLBI website see www.globalhealth.nhlbi.nih.gov
2004
Globalisation has affected every aspect of modern life, and health and disease are no different. The global health landscape is rapidly shifting away from one dominated by infectious diseases to one characterised by various chronic conditions. These diseases— cardiovascular disease, cancer, type 2 diabetes, and chronic respiratory diseases—now cause more than half of all deaths worldwide, 80% of which occur in low-income and middle-income countries.1–3 If present trends continue unabated, annual deaths from chronic diseases will reach 41 million by 2015, and almost half of these will be in people younger than 70 years.4 Since the major causes of chronic diseases are known, half of these deaths are preventable.2 The health catastrophe provoked by this global surge of chronic disease is also an underappreciated cause of poverty that impedes the economic development of many countries.5,6 Thus, we believe it is vital that the international public health community makes chronic disease prevention a worldwide priority. We believe that a coordinated effort by national leaders will strengthen chronic disease prevention and control efforts.2,3,5,7–10 To address the globalisation of noncommunicable chronic cardiovascular and pulmonary diseases, the National Heart, Lung, and Blood Institute (NHLBI), a component of the US National Institutes of Health, has increased its commitment to reducing the global burden of chronic diseases by fostering collaborations with partners in the public and private sectors. Most recently, the NHLBI and UnitedHealth Group, one of the world’s largest health and wellbeing
companies, have forged a collaboration to counter chronic disease by supporting a collaborative global network of centres of excellence (COEs) in low-income and middle-income countries throughout the world. Our goal is to support research that will generate the evidence needed to inform policy decisions. Rigorous research undertaken at diverse sites will also enrich our basic understanding of disease causation and of the interplay between biological, environmental, and sociocultural contributors to public health. Our strategic, complementary effort grew from the common interests of the NHLBI and the UnitedHealth Group. We recognise that combating chronic disease requires crossing geographical, governmental, and organisational boundaries, and thus collaboration between public and private partners. In September, 2006, the UnitedHealth Group established a strategic priority to raise public and political consciousness about chronic disease in the developing world and to use its competencies to prevent and control chronic disease in those regions.11 From the beginning, the UnitedHealth Group partnered with the Oxford Health Alliance to fulfil that group’s communication objective with the 3four50 website (so named to highlight the three factors of poor diet, physical inactivity, and tobacco that cause the four conditions—cardiovascular disease, diabetes, chronic respiratory disease, some cancers—that account for more than 50% of global mortality).12 This website is a rich online resource for those interested in raising awareness about chronic diseases and in devising www.thelancet.com Vol 373 June 13, 2009
strategies to counter their growing global emergence. In May, 2007, the UnitedHealth Group issued a solicitation for COEs that would develop innovative, equitable, transferable programmes to prevent and control chronic diseases and build sustainable individual, institutional, and community capacity to achieve this goal. In parallel, in November, 2007, the NHLBI convened a meeting to develop a strategic approach to global health research. Recommendations that emerged from this meeting emphasised the unique and essential part the institute could and should play in undertaking global cardiovascular health implementation research and in disseminating the results. In September, 2008, the NHLBI issued a solicitation to create COEs that would undertake research into new or improved approaches and measures to prevent or treat chronic disease and to develop clinical research infrastructure and research training programmes. The NHLBI is also establishing a global health office, commissioning a report from the Institute of Medicine on global cardiopulmonary health, and joining with other government funders of research to create the Global Alliance for Chronic Diseases.9 The UnitedHealth Group/NHLBI collaborative effort now consists of a consortium of COEs in Argentina, Bangladesh, China, Guatemala, India-Bangalore, IndiaNew Delhi (including Pakistan), Kenya, Peru, South Africa-Tanzania, Tunisia, and along the US/Mexico border). Each COE includes a research institution in a developing country paired with at least one partner academic institution in a developed country. The research goals span a range of activities tailored to regional needs and disease effect. Projects include health surveillance to garner baseline data on risk prevalence and burden of disease; implementation research to develop and communicate new knowledge into workable, culturally appropriate policies and practices; decisional modelling to compare intervention strategies; and community engagement efforts to raise awareness and enlist the support of local and national leadership. Clearly, not only do chronic diseases know no boundaries, they also travel together. Thus, the consortium aims to broaden study beyond individual diseases, in keeping with WHO’s recommendation to address chronic diseases as they group in a real-world setting.2,12 www.thelancet.com Vol 373 June 13, 2009
Getty Images
Comment
COE consortium research will focus primarily on development of chronic disease prevention programmes, and early results are encouraging. For example, the South Africa-Tanzania and China sites are developing portable tools that can be used in the field to measure risk of chronic disease, and the South Africa site is near completion on simple, yet comprehensive, chronic disease management guidelines that can be used by nurses and community health workers. Some COEs, such as those in India-Bangalore, Guatemala, Tunisia, and along the US/Mexico border, are working with whole communities, including schools and workplaces, to redesign communities so that healthy choices are also simple and practical choices. NHLBI and the UnitedHealth Group encourage collaboration between and among the COEs, as well as with other organisations. Importantly, the COE consortium members are each developing infrastructures for research and training to enhance local capacity, with the goal of long-term sustainability of our seed investment. We are dually committed to identification of workable and effective approaches for implementation and integration of research results, and we will share best practices as appropriate and relevant. To maintain momentum from our effort and that of other organisations, continued strong leadership and coordination is vital. WHO has developed an action plan that encompasses surveillance, research, and implementation to counter chronic disease.12 The Pepsico Foundation is supporting programmes to make communities healthier in China, India, Mexico, and the UK, 2005
Comment
and the World Economic Forum and the World Bank also have projects underway. The NHLBI and the UnitedHealth Group will work in partnership with these other entities to enhance synergy and to avoid duplication. To that end, the NHLBI is a founding member of the Global Alliance for Chronic Disease, a new alliance of six initial national biomedical research funders to address research needs in the chronic non-communicable diseases. Now is the time for sustained and coordinated scientific leadership to focus global efforts on combating the social, economic, and political toll of chronic disease. The NHLBI and UnitedHealth Group collaboration is an important piece of this public health initiative that is so vital for our global citizenry.
1
*Elizabeth G Nabel, Simon Stevens, Richard Smith
10
National Heart, Lung, and Blood Institute, Bethesda, MD 20892, USA (EGN); UnitedHealth Group, Minneapolis, MN 55440, USA (SS, RS) [email protected] EGN is the director of the National Heart, Lung, and Blood Institute and SS is a senior executive at UnitedHealth Group, responsible for health reform and global business. RS is the director of the UnitedHealth Chronic Disease Initiative.
2 3 4 5
6 7
8 9
11 12
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global burden of disease and risk factors. Washington, DC: Oxford University Press and World Bank, 2006. WHO. Preventing chronic diseases: a vital investment. Geneva: World Health Organization, 2005. Adeyi O, Smith O, Robles S. Public policy and the challenge of chronic noncommunicable diseases. Washington, DC: World Bank, 2007. Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: how many lives can we save? Lancet 2005; 366: 1578–82. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007; 370: 1929–38. Suhrcke M, Nugent RA, Stuckler D, Rocco L. Chronic disease: an economic perspective. London: Oxford Health Alliance, 2006. Jamison DT, Breman JG, Measham AR, et al, eds. Disease control priorities in developing countries. Washington, DC: World Bank and Oxford University Press, 2006. Horton R. Chronic diseases: the case for urgent global action. Lancet 2007; 370: 1881–82. Daar A, Singer PA, Persad DL, et al. Grand challenges in chronic non-communicable diseases: the top 20 policy and research priorities for conditions such as diabetes, stroke and heart disease. Nature 2007; 450: 494–96. Beaglehole R, Ebrahim S, Reddy S, Voûte J, Leeder S, on behalf of the Chronic Disease Action Group. Prevention of chronic disease: a call to action. Lancet 2007; 370: 2152–57. Quam L, Smith R, Yach D. Rising to the global challenge of the chronic disease epidemic. Lancet 2006; 368: 1221–23. WHO. 2008–2013 Action plan for the global strategy for the prevention and control of non-communicable diseases. Geneva: World Health Organization, 2008.
Lives to save: PEPFAR, HIV, and injecting drug use in Africa
Getty Images
The US President’s Emergency Plan for AIDS Relief (PEPFAR) is credited with provision of antiretroviral therapy to 2·1 million people with HIV, almost all of whom live in sub-Saharan Africa, and has spent more than US$18 billion on the continent.1 The achievements
2006
of this programme have, unfortunately, not reached thousands of injecting drug users in PEPFAR countries in Africa, many of whom have HIV. Outside Africa, the gateway to antiretroviral therapy for people who inject illicit drugs is usually through drug-dependency treatment, an HIV-prevention service such as needle exchange, or in some cases through legal services. In almost all countries of sub-Saharan Africa, including those most affected by HIV, affordable drug-dependency treatment is out of reach, needle exchange does not exist, and legal services are unavailable or unaffordable.2 As many as 3 million people who inject drugs could be living in sub-Saharan Africa, with more than 200 000 in Kenya and at least 250 000 in South Africa.3 In a growing number of sub-Saharan African countries, prevalence of HIV is higher in injecting drug users than in other people. In a 2004 rapid assessment,4 HIV prevalence in injecting drug users from Kenya was estimated at 68–88%. Data from other studies have shown rates to be 58% in women and 27% in men in Tanzania; 28% in all injecting www.thelancet.com Vol 373 June 13, 2009