Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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1 Introduction
1 Introduction
Pages 19-48
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From page 19... ...
However, despite the significant and growing health and economic burden in low and middle income countries, CVD and related chronic diseases are not included by most stakeholders in their investments and commitments to improving the health of the world's people. CVD and related chronic diseases were once considered to be diseases of industrialized nations.
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These are summarized in Figure 1.1 and Box 1.1 later in this chapter, where they are discussed in more detail to set the historical context for this report. These declarations, reports, and resolutions have resulted in a growing recognition that CVD, and chronic noncommunicable diseases more broadly, are a worldwide problem whose burden is increasingly felt by low and middle income countries.
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IOM Report : Control of CVD in WHO Global Strategy on Diet, Global Burden of Disease: Update Developing Countries Physical Activity, and Health WHO Social Determinants Report 7th JNC Report : Hypertension Towards a WHO Long -Term Strategy for Prevention and Control of Leading Chronic Diseases Figure 1-1 rev.eps FIGURE 1.1 Timeline of major documents related to global CVD. landscape
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These actions are intended to encourage a sufficient shift in the global health and development agenda to facilitate critical next steps that will build toward the eventual goal of widespread dissemination and implementation of evidence-based programs, policies, and other tools to address CVD and related chronic diseases in developing countries. Study Approach The committee met four times to deliberate in person, and conducted additional deliberations by teleconference and electronic communications.
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Using this approach, the report strives to move the field beyond a discussion of general intervention approaches and policy priorities in the broad terms of prior reports, such as "reduce salt consumption," "improve diets," "reduce tobacco use," "increase physical activity," and "screen and treat biological risk factors and disease." The report achieves this by offering a pragmatic review of the available evidence in the context of potential for implementation of interventions and strategies, while recognizing the complexities of heterogeneity and variability in capacity among different low and middle income countries. Indeed, the committee's goal was to go beyond the relatively few well-known intervention examples that appear in many preceding reports to instead gather information of sufficient depth, breadth, and specificity on actual intervention implementation in order to realistically inform resource prioritization in real-world, country-specific decision making.
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and HIV. In order to identify steps to prevent and mitigate the growing burden of cardiovascular disease, the committee was charged by the sponsor to study CVD "prevention and management." In the course of its deliberations among experts from a range of disciplines that have a role in addressing cardiovascular disease, such as public health, health communications, and cardiology, the committee found that different fields often use different terms and definitions to categorize similar intervention approaches and that many intervention approaches do not fall into clearly delineated categories.
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global health agenda, along with the international global health agenda, can evolve to be more inclusive of chronic diseases, providing elaboration on a mandate that was issued in the 2009 IOM report The U.S. Commitment to Global Health (IOM, 2009)
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While these new investments and commitments to improving the health of the world's people were unprecedented and have undoubtedly saved millions of lives, the majority of these efforts have largely ignored CVD and other chronic noncommunicable diseases. This extends to the Millennium Development Goals, in which chronic diseases are not explicitly mentioned and are instead relegated to Millennium Development Goal 6, grouped into the catchall category of "other diseases." International Realization of CVD Burden Although not emphasized in most major global health efforts, the increasing burden of CVD in developing countries was first recognized on the international stage at least as long ago as the first international declaration on CVD in 1956, when India proposed a resolution on CVD and hypertension at the Ninth World Health Assembly (WHO, 1956)
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Documentation of the Disease Burden One of the first such publications to highlight the global burden of CVD and chronic diseases was the 1993 World Development Report by the World Bank. This report focused on the critical role that investments in health play in international development, also emphasizing the rising burden of chronic diseases in low and middle income countries.
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. In addition to the declarations of the International Heart Health Conferences, a number of other reports and resolutions highlighted the growing worldwide epidemic of CVD and related chronic diseases and issued additional calls to action for its prevention and control.
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While serving as director general of WHO, Gro Harlem Brundtland elevated the treatment and control of chronic diseases to the same level of urgency as infectious diseases. In 1999, Brundtland presented the WHO Executive Board with a draft Global Strategy for the Prevention and Control of Noncommunicable Diseases, which emphasized improving chronic disease surveillance, addressing common risk factors, and improving primary care services worldwide (Brundtland, 1999)
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These barriers include the perception of CVD as a competitor to other health needs, causing it to remain a low priority and resulting in a lack of financial, individual, and institutional resources; insufficient capacity to meet CVD needs, including health workforce and infrastructure capacity as well as implementation and enforcement capacity for policies and regulatory approaches; insufficient knowledge of the effectiveness and feasibility of programs and policies in contexts similar to those in which they need to be implemented; a high degree of fragmentation of efforts by various players; and a lack of clear leadership and collaboration focused on defined goals and outcomes. Although the prevailing attitudes about the importance of CVD are changing, both global health funders and national governments of low and middle income countries have yet to elevate action to address CVD as a pri
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Without a new approach that includes chronic diseases, the health dividend gained from progress in other areas of global health could be squandered as one set of problems is tackled while a new set is allowed to grow. Recognizing the importance of including CVD in the development and global health agendas of international stakeholders and national governments in low and middle income countries is a crucial factor in increasing the allocation of resources that can be applied to chronic noncommunicable diseases.
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The current emphasis in the global health community on developing health systems capacity also provides a window of opportunity to improve capacity for delivery of preventive and therapeutic care for chronic diseases. In addition, policies in nonhealth sectors of government and the private sector need to be developed synergistically to reduce, or at least not adversely affect, risk for CVD.
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Chapters 2 and 3 describe the determinants of global CVD and its increasing impact, along with related chronic diseases, on the health, welfare, and economies of low and middle income countries, thus providing a clear mandate for action. Chapter 4 describes measurement and evaluation as a fundamental element for the framework and as a means to develop, implement, and sustain effective approaches to reduce the burden of disease.
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PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Dr iv er s 2 Epidemiology D evelo pm en t 3 A p pr oa c h es Barriers 4 I n te rven ti on A p pr oa c h es 5 Measurement 6 Health Promotion Early in Life o Lack of Awareness of CVD Burden 7__P r io ri ti za ti on o Competing Priorities o Limited Funding o Insufficient Health Workforce Capacity R e s p on s e o Insufficient Health Infrastructure o Fragmentation of Efforts F r am ew or k f o r A c ti on 8 o Lack of Clear Leadership Essential Functions o Advocacy and Leadership o Insufficient Knowledge – o Policy Feasibility and o Program Implementation Transferability of o Capacity Building Interventions o Research o Monitoring and Evaluation o Funding Organizing for Action o International o Regional o National Barriers o Local FIGURE 1.2 Report organization. Figure 1-2 rev.eps
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It recommended that basic public health interventions including chronic disease prevention could be a part of low and middle income countries' essential clinical package (World Bank, 1993)
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invest ment to control CVD in developing countries and offered recommendations for R&D investment in several broad areas for the control of CVD. These areas included determining the magnitude of CVD burden in low and middle income countries; developing targeted and effective prevention strategies using case control studies; reducing tobacco use; detecting and treating hypertension; start ing pilot studies to evaluate essential vascular packages of effective and low-cost drugs; developing algorithms for affordable clinical CVD care; building R&D capacity; and developing institutional mechanisms that facilitate CVD prevention and control (IOM, 1998)
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. 1999 Global Strategy for the Prevention and Control of Noncommunicable Diseases: Report by the Director-General This report by WHO Director-General Gro Harlem Brundtland called attention to the growing burden of noncommunicable diseases in low and middle income countries and cited the increasingly strong epidemiological evidence linking these diseases to common risk factors.
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Five of the risk factors highlighted in the report -- hypertension, tobacco consumption, alcohol consumption, high cholesterol, and obesity -- are key cardiovascular risk factors. The report emphasizes the increasing global burden of CVD, especially its rise in low and middle income countries, citing the dual epidemics of infec tious and noncommunicable diseases that many developing countries are now facing.
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The treaty represents a major milestone in the global fight to reduce chronic disease risk factors and has prompted previously unseen international collaboration around tobacco control (WHO, 2003a, 2010)
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The declara tion stressed that a comprehensive range of treatment and prevention strategies is essential to control the global CVD epidemic and that treatment technology options need to be effective but also sustainable and affordable (Advisory Board of the Fifth International Heart Health Conference, 2004)
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The series noted that chronic diseases were not listed in the Millennium Development Goals and warned that if they continue to be ignored by the global health community, the progress gained from reducing the burden of infectious diseases would be eclipsed by a rising burden of chronic diseases in developing countries (Epping-Jordan et al., 2005; Fuster and Voûte, 2005; Horton, 2005; Reddy et al., 2005; Strong et al., 2005; Wang et al., 2005)
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The Sydney Resolution and Challenge were the outcomes of the 2008 Oxford Health Alliance Summit and served as a call to action for the international community to make healthier choices to turn back the rising tide of preventable chronic diseases. The resolution explained that 50 percent of the world's deaths are caused by four preventable chronic diseases: CVD, diabetes, chronic lung disease, and cancer.
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financial com mitments to global health; and setting an example of engaging in partnerships. The report also included an emphasis on the rising tide of noncommunicable diseases in low and middle income countries, specifically recommending that the United States increase attention to chronic diseases and adopt a leadership role in reducing deaths from chronic diseases and tobacco-related illnesses (IOM, 2009)
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Advisory Board of the Fifth International Heart Health Conference.
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1997. America's vital interest in global health: Protecting our people, enhancing our economy, and advancing our international interests.
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2010. Implementation of the global health initiative: Consultation document.
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2008a. 00-0 action plan for the global strategy for the prevention and control of noncommunicable diseases.
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