The WHO Health for All by the year 2000 program was very ambitious and had a tight deadline. The success of the program may be questionable but it did help many countries to start formulating health goals for the population, rather than planning all health care activities on treatment indicators. The Millennium Development Goals follow this tradition. This time the goals are fewer and less detailed and some of them have a deadline (2015). All the stated goals are related to health, some by targeting health determinants, others more directly by targeting child mortality, maternal health and certain infectious diseases. The health goals will be achieved if social inequalities within and between countries are reduced by improving the conditions for the poor. Some of the health goals can even be reached should that not be the case. [Evans et al, 2005a; Evans et al, 2005b]
The IEA support these goals. Our ideas about the priority may vary but we believe that achieving these goals would be a victory for public health.
How could epidemiologists help and can the IEA do anything to support the program?
We can do something and we are doing something. Epidemiologists are needed to monitor burdens of disease, and should focus their research on areas that shorten life expectancy and contribute to growing social inequalities in health. Epidemiologic training is needed. Formal education in how best to work with epidemiologic problems is unfortunately shortest in supply where it is needed the most. Many universities and schools of public health have trained many epidemiologists from low and middle income countries. Unfortunately, they often remain in the countries were they received their training or they go back home and take administrative jobs, because the conditions for doing epidemiology in their homeland are too poor. We suggest a new research structure that may bring some of these epidemiologist back to the countries where their epidemiologic skills are most needed.
Our WCE and especially our regional meetings in poor countries are important in keeping these people in touch with the health problems they left. The meetings also provide new inputs to these regions and make it possible for epidemiologists from within and outside the regions to meet and establish collaborative work.
We have decided to use of our experience from the Florence EEPE/IEA course to set up an annual summer course on epidemiological research methodology for developing countries. The proposed course will be held in a different region of the world each year. We believe that short term courses not only serve to raise awareness of the importance of epidemiology for developing countries, but are also an effective method for identifying and selecting people who are candidates for more long term training within a university program.
It has been a common belief that we can use causal models and preventive strategies, developed in affluent societies and apply these strategies to countries with a completely different infrastructure, social context and life style factors. Such technology transfer will often fail, even for some of the vaccination programs. Given the contextual importance of “upstream” determinants of chronic disease risk factors, it would be unreasonable to expect technology transfer to work for prevention of cardiovascular diseases or other life style related diseases that more and more will dominate the disease profile in developing countries.[WHO, 2005; Strong et al, 2005]
High quality, large scale evaluation studies will be needed to learn how we best prevent these diseases in developing countries.[Ebrahim & Smeeth, 2005] There is a scientific and public health need that should be met with ambitious research plans. Such plans could make it attractive for skilled epidemiologists to return to their home regions in order for them to make better use of their training. Too much research money in developing countries has been spend on short term projects, performed by people with limited epidemiological skills and with limited logistic support.
We suggest using the model of cancer research to coordinate large scale studies in epidemiology with the capacity to incorporate biological tools with modern epidemiologic methods. We suggest that an International Agency for Epidemiologic Research on Chronic Diseases is established and placed in a developing country. Like IARC (the International Centre for Research on Cancer), this centre should refer to WHO and the donor countries or donor orgnisations. Initially, its main topics for research should be the chronic diseases with the highest impact on quality of life like cardiovascular diseases and mental disorders. The Agency should address these diseases aetiology and the preventive strategies in developing countries. The centre should coordinate research, intervention programmes and maintain databases. It should have a small permanent staff but have room for external experts that will be assigned to specific research programs. The Centre should undertake training programs as well as monitoring tasks.
Such a Centre could play a main role in reaching the millennium goals for health in the year 2015.
Table 1. The goals, targets, and indicators for MDGs
MILLENNIUM DEVELOPMENT GOALS
|ERADICATE EXTREME POVERTY AND HUNGER|
|TARGET FOR 2015: Halve the proportion of people living on less that a dollar a day and those who suffer from hunger.|
|ACHIEVE UNIVERSAL PRIMARY EDUCATION|
|TARGET FOR 2015: Ensure that all boys and girls complete primary school.|
|PROMOTE GENDER EQUALITY AND EMPOWER WOMEN|
|TARGET FOR 2005 AND 2015: Eliminate gender disparities in primary and secondary education preferably by 2005 and at all levels by 2015.|
|REDUCE CHILD MORTALITY|
|TARGET FOR 2015: Reduce by two thirds the mortality rate among children under five.|
|IMPROVE MATERNAL HEALTH|
|TARGET FOR 2015: Reduce by three quarters the ratio of women dying in childbirth.|
|COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES|
|TARGET FOR 2015: Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases.|
|ENSURE ENVIRONMENTAL SUSTAINABILITY|
|Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources.
By 2015, reduce by half the proportion of people without access to safe drinking water.
By 2020, achieve significant Improvement in the lives of at least 100 million slum dwellers.
|DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT|
|Develop further an open trading and financial system that includes a commitment to good governance, development and poverty reduction – nationally and internationally.
Address the least developed countries’ special needs, and the special needs of landlocked and small island developing states.
Deal comprehensively with developing countries’ debt problems
Develop decent and productive work for youth.
In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.
In cooperation with the private sector, make available the benefits of new technologies – especially information and communications technologies.
Adapted from http://ddp-ext.worldbank.org/ext/MDG/homePages.do. (accessed 2/8/05).
More on the goals can be found at:
[Evans, 2005a] David B Evans, Taghreed Adam, Tessa Tan-Torres Edejer, Stephen S Lim, Andrew Cassels, Timothy G Evans, for the the WHO Choosing Interventions that are Cost Effective (CHOICE) Millennium Development Goals Team Achieving the millennium development goals for health: Time to reassess strategies for improving health in developing countries. BMJ 2005;331:1133-1136
[Evans, 2005b] David B Evans, Tessa Tan-Torres Edejer, Taghreed Adam, Stephen S Lim, for the WHO Choosing Interventions that are Cost Effective (CHOICE) Millennium Development Goals Team Achieving the millennium development goals for health: Methods to assess the costs and health effects of interventions for improving health in developing countries. BMJ 2005;331:1137-1140
WHO 2005. World Health Organization. Preventing chronic disease: a vital investment. WHO; Geneva 2005.
Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic disease: How many lives can we save? Lancet 2005; published online Oct 5.
Ebrahim S, Smeeth L. Non-communicable diseases in low and middle-income countries: a priority or a distraction? Int J Epidemiol 2005; 34(5):961-966