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Global response to non-communicable diseases (NCDs): the role of epidemiologists

It is well documented that NCDs carry an increasing burden of diseases and mortality in affluent as well as poor countries. NCDs amount to 63 % of all deaths in the world, and 80 % of these occur in low and middle income countries (LMICs). Cardiovascular diseases and chronic obstructive diseases are expected to increase rapidly in many LMICs, and NCDs are a major cause of poverty, loss of productivity and quality of life worldwide.

The global fight against communicable diseases is still important, and it has been successful in many areas. The concern is that many still act as if health problems in LMICs are mainly related to communicable diseases. Most of the research and prevention efforts have been devoted to the fight against “tropical diseases”, which may appear to be the main health problems for foreigners working (and doing medical research) in LMICs. Tropical diseases may, in fact, never have been the major health problem for these populations as a whole; certainly, they are accounting for a smaller and smaller proportion of the global health burden worldwide with expanding life expectancies in many LMICs.

Except for the International Agency for Research on Cancer (IARC), we do not have many international organizations devoted to the fight against NCDs on a global scale. Time has come to change that, and epidemiologists should consider how they may contribute.

The first step may be to argue for more epidemiologic research. Many prominent people say we know enough, and now is the time for action, not research. We believe it is time for both action and research. We need to reduce smoking, improve diet, reduce salt intake and get people to exercise more. Research in affluent countries has clearly demonstrated that lifestyle factors are important drivers of NCDs, but research also shows that these factors are more modifiable in well educated populations with good personal resources. How this is done in less affluent countries and less educated populations is not well known. There is a need for epidemiologic research to examine if risk factors for NCDs are the same in LMICs as seen in Europe and the US. Lifestyle factors and physiological risk factors for NCDs may be rather similar all over the world, but their “upstream” causes are different, and prevention without taking upstream causes into consideration may be a recipe for failure. There is a need for research in how we best implement these preventive efforts both at the individual level and at the societal level, and our research findings from affluent countries may not help much.

Better monitoring is also of importance, and the experience from setting up cancer registers all over the world should be used. The existing monitoring of lung cancer and other tobacco related diseases is of course important, as well as monitoring of other cancers. Specific monitoring of mortality and specific morbidities should be developed for selected NCDs and selected risk factors like smoking, blood pressure and obesity.

Setting up new monitoring systems should take into consideration the costs involved in terms of time and money. We know from monitoring of infectious diseases that even grossly incomplete systems pick up rapid changes in incidence. Monitoring of NCDs may require better quality data, and using new technologies should be considered, especially web-based or cell phone technologies which may work well in LMICs. Monitoring programs can use the experience from monitoring the Millennium Development goals – although none of these goals unfortunately addressed NCDs. Surveillance systems have to be used to identify areas in need of action or in order to monitor effects of interventions. Monitoring without available plans and funding for action is a waste of time and resources.

Reducing the burden of NCDs is under the mandate of the UN and the WHO, but they will need the input of skilled experts who can set up the monitoring systems and support the research. Expanding IARC to include NCDs is one option that will benefit from the experience built up in Lyon on cancer research and prevention. Establishing a similar structure for NCDs is another option. Any model will require some independence from the WHO to avoid conflicts of interests related to the political structure of the WHO.

We expect some of the large industrial and agricultural companies to seek influence by slowing down the monitoring and research capacity building process or by modifying it to serve their interests.  There is evidence that this is already well underway.  It is also becoming clearer that the commercial and trade interests of developed countries, particularly the USA and Europe, are at odds with taking rational action on reducing the harmful effects of tobacco, alcohol and processed foods high in sugar, fat and salt in LMICs.

We believe independent and experienced epidemiologists have an important role to play. First, in training epidemiologists in LMICs. We know that there are only a few epidemiologists in the areas where they are needed the most. We know that their epidemiologic training is insufficient and outdated, especially for studying NCDs.

Many universities in Europe and the US now establish departments or centers in global health. Rapid international action may help getting these resources coordinated and tuned into reducing the burden of NCDs.

We know that access to data is often difficult in many countries. International organizations may help giving access to data and funding to monitor health and to implement research programs. Although we know much about the etiology of NCDs, we also expect to find new risk factors in LMICs and to find the strength of risk factors to differ from what we have seen so far. For example, the effects of obesity may be much larger in people who suffered from undernutrition in utero or in the first years of life. The research questions related to the potential role of fetal programming needs more attention in LMICs.

We know that strong commercial interests will try to influence the work. The food industry, the health industry, and all industries producing products that promote or interfere with healthy living will try to influence the process, and huge financial interests will be at stake. It is important that those who make the decisions have no conflicts of interest. The International Epidemiological Association (IEA), being an organization of independent epidemiologists, should have a role to play by suggesting ways to prevent NCDs and to monitor its progress. We could also play a much larger role in helping to develop the proper tools and training needed in LMICs.

Much of the work that needs to be done is epidemiology, within public health and also within the fields of genetic research and clinical research. The IEA is the only society that links epidemiologists from all over the world, and the IEA has a long tradition of hosting conferences, running training courses, producing books and publishing epidemiologic research from all over the world. The IEA should take this initiative together with the WHO to help the process of fighting NCDs worldwide, based on evidence rather than commercial interests.

This draft is the first version of a policy document that we hope will have your interest. Your comments and suggestions are welcome.

 

Jørn Olsen, Cesar Victora, Neil Pearce, Patricia Buffler, Shah Ebrahim


References

Stuckler D, Basu S, McKee M. Commentary: UN high level meeting on non-communicable diseases: an opportunity for whom? BMJ 2011;343:d5336. doi: 10.1136/bmj.d5336

UnitedHealth, National Heart, Lung, and Blood Institute Centers of Excellence, Cerqueira MT, Cravioto A, Dianis N, Ghannem H, Levitt N, Yan LL, Kimaiyo S, Koehlmoos T, Miranda J, Niessen L, Prabhakaran D, Ramirez-Zea M, Rubinstein A, Wu Y, Xavier D, Smith R. Global response to non-communicable disease. BMJ 2011;342:d3823. doi: 10.1136/bmj/d3823

Cohen D. Will industry influence derail UN summit? BMJ 2011;343:d5328. doi: 10.1136/bmj.d5328

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