Chronic disease: preventing the world's next tidal wave—the challenge for Canada 2007?
E-mail: hpi{at}deakin.edu.au
Chronic disease is fast becoming the world's next tsunami, swelled by increasing levels of obesity, unhealthy eating, physical inactivity and tobacco use. Sixty per cent of all deaths worldwide are now due to chronic diseases, principally heart disease, stroke, cancer, chronic respiratory diseases and diabetes. In 2005, chronic diseases accounted for 35 million deaths, which is more than double the number from all infectious diseases (including HIV/AIDS, tuberculosis and malaria). Surprising to many, only 20% of chronic disease deaths happen in high-income countries, the remainder occurring in low- and middle-income countries where most of the world's population live.
A ‘red alert’ has already been sounded by the World Health Organization, which has estimated that deaths from infectious diseases, maternal and perinatal conditions and nutritional deficiencies combined will decline by 3% over the next 10 years. In contrast, deaths due to chronic diseases will increase by 17% over the same period (World Health Organization, 2005
).
Were this not a ‘silent’ epidemic, there would be public demonstrations, protests and petitions. Chronic diseases, however, are slow to develop but still lead to devastating complications, resulting in premature death and poor quality of life. The consequences can also be prohibitively expensive with significant economic impacts on families, communities and societies in general. This growing threat is an under-appreciated cause of poverty and hinders the economic development of many countries. For example, China will forego $558 billion in national income over the next 10 years as a result of premature deaths caused by heart disease, stroke and diabetes. In Australia, medical care costs for a person diagnosed with diabetes are almost double than that for a person without the condition, such that more than $3 billion is spent annually on the health care costs of diabetes—expenditure that could be better spent on conditions which cannot be prevented or treated adequately.
Unfortunately, chronic diseases have generally been neglected in international health and development work; for example, they were not included within the global Millennium Development Goal targets. Nevertheless, there have been some important advances such as the World Health Organization Framework Convention on Tobacco Control, the first legal instrument designed to reduce tobacco-related deaths and disease around the world. Leadership has also been provided by the WHO through its recent publication Preventing Chronic Diseases: A Vital Investment (World Health Organization, 2005) and a series of articles in the Lancet initiated by Horton and Beaglehole (Epping-Jordan et al., 2005; Horton, 2005; Srinath Reddy et al., 2005; Strong et al., 2005; Wang et al., 2005). Major health gains are clearly possible. If the major risk factors for chronic disease were eliminated, at least 80% of heart disease, stroke and type 2 diabetes would be prevented; 40% of cancer would be avoided. The WHO strategy has, therefore, rightly set a goal of an additional 2% reduction in chronic disease death rates worldwide per year, which if achieved would prevent 36 million premature deaths by 2015.
Encouragingly, at a country level, a number of new strategies have also been developed. In Australia, the National Chronic Disease Strategy (National Health Priority Action Council, 2006) and other national initiatives (http://www.healthyactive.gov.au/) are stimulating actions at state and local levels as part of a major National Reform Agenda. Victoria, for example, has recently published a plan to tackle obesity and type 2 diabetes as a whole of government initiative (Department of Premier and Cabinet, 2007), which builds on its high-profile public education campaign Go For Your Life (http://www.goforyourlife.vic.gov.au/). These initiatives have their origins in earlier work of the Australian Government's National Obesity Taskforce and the National Health Priority Action Council.
China's Ministry of Health has also been addressing chronic disease prevention and control. In 2002, it established the National Center for Chronic and Non-Communicable Disease Control and Prevention and introduced a national resource for chronic disease surveillance, the Disease Surveillance Points System. The Ministry is also working to develop and implement the first long-term comprehensive national plan for chronic disease control and prevention from 2005 to 2015 in cooperation with relevant sectors and supported by the WHO. Reducing adult male smoking, hypertension, overweight and obesity and building capacity for chronic disease control are among the plan's highest priorities (Wang et al., 2005). Targets focus on the major risk factors (such as tobacco, diet, physical activity and blood pressure) and chronic diseases (such as cardiovascular and respiratory diseases, cancer and diabetes), which account for 
70% of mortality in China.
Although there may be a perception that a lot of things are happening, the level of investment in prevention is still remarkably low given the scale of the chronic disease epidemic and the rising trends. For example, the Australian health sector probably spends less than $1 on preventing obesity against $70 per capita per year on treating its consequences. Worldwide there are an estimated one billion overweight adults, and without action, this figure will exceed 1.5 billion by 2015. At a global level, 22 million children under 5 years are already overweight and, given the Australian experience of tripling rates over the last 10 years, the situation will also get much worse. This is likely to fuel a massive increase in type 2 diabetes. Prevention is essential, because by the time diabetes is diagnosed, 50% of the people will already have cardiovascular and kidney complications. There is little escape; three quarters of people with diabetes will die prematurely from heart disease.
Against this disturbing backdrop, we as health promoters have a responsibility to ensure that the epidemic of chronic disease is anticipated, understood and acted upon urgently. A new approach by national leaders is needed, which requires responsive and responsible government action, involving all departments. Departments of the Prime Minister or their equivalent should now take the lead role in chronic disease prevention. This is vital as so many different parts of government need to be part of the solution rather than the problem—indeed, health departments cannot do it on their own. Past experience shows that national public health action to build supportive environments and responsive services requires innovation, bold reform and a long-term investment.
It is also essential to communicate the latest and most accurate knowledge and information to front-line health professionals and the public at large. Building on our knowledge of health promotion approaches over the last few decades with tobacco, alcohol, road accidents and HIV, we should be optimistic that the chronic disease threat can be overcome and that the solutions can be highly cost-effective. However, it is important to learn from the past and to base our interventions on sound principles and strategies.
There is compelling evidence that children's experiences early in life can strongly impact their health and well-being later in life. Adverse events such as foetal exposure to tobacco smoke, low birthweight, malnutrition, repeated infections and abuse and neglect in the early years of life help establish predispositions to a range of chronic diseases in adulthood. In addition, attitudes and behaviours are formed early in childhood and then track through to adulthood. For example, the seeds of smoking, poor diet, physical inactivity, obesity and even alcohol use are laid down well before a child moves on to secondary school.
Chronic disease prevention, therefore, needs to take account of the impact of cumulative and interactive exposures to the underlying determinants of health and the associated risk factors. Health outcomes are likely to be most optimal when good health is promoted throughout life, beginning with the pre-natal period and infancy. Such a lifecourse approach recognizes the importance of shaping health status by making the most of opportunities in childhood and investing, not only early in life and across the age continuum, but also early in the pathways of children's health and development of particular problems.
In developing programmes of action, special attention should be given to the context and challenges facing communities. Actions should:
- Tackle the underlying determinants by concentrating on solutions not on problems—with a bias for action on health promoting environments;
- Be long term and sustainable by recognizing that behaviour change is complex, difficult and takes time;
- Engage the whole community by emphasizing that healthy living is everybody's business;
- Close the health gap by helping those population groups most in need as a result of geography, ethnicity, socio-economic status, etc.,
- Empower individuals, families and communities by giving people information, opportunities, skills and resources to take action according to their own opportunities and responsibilities;
- Promote the positive benefits of healthy living by presenting immediate rewards, rather than just the avoidance of health problems later in life;
- Reduce stigmatization by avoiding ‘blaming’ or ‘labelling’ those with risk factors or health problems, i.e. children, young people, parents, adults, seniors or carers;
- Employ a range of strategies by integrating information and skills education, community strengthening, environmental support, healthy public policy and health services;
- Work across multiple sectors and settings by linking health services with child care, schools and colleges, workplaces, community organizations, neighbourhoods, prisons, nursing homes, family and community care, food supply, media and marketing;
- Ensure health sector commitment for chronic disease prevention by demonstrating leadership and accountability as a core responsibility of all health services to promote health and reduce risks.
- Ensure that strategies and actions are evidence-based and cost-effective, particularly by integrating approaches at the community level and through various settings and social marketing;
- Value and build on existing efforts and prevent unnecessary duplication by aligning programmes with existing national, state, territory and local plans and strategies;
- Generate new knowledge through innovation, policy and action research and evaluation and have effective mechanisms for translating this evidence about cost-effective interventions into action;
- Strengthen partnerships by combining efforts to build capacity across sectors, levels, issues and all levels of government;
- Recognize that substantial investments of resources are required from both new and existing sources to advance policies, intervention programmes, research and monitoring;
- Ensure accessible and equitable services that are inclusive of ethnicity, culture, religion, linguistics, sexuality, stage of development, age, gender, education, income and geographic diversity;
- Provide high quality and flexible services that can respond to changing priorities and emerging needs;
- Create a workforce that is skilled in health promotion and risk reduction at both the individual and community levels;
- Demonstrate commitment to accountability, efficiency and value for investments.
REFERENCES
Department of Premier and Cabinet. (2007) Victoria's Plan to Address the Growing Impact of Obesity and Type 2 Diabetes(Victorian Government, Melbourne).
Epping-Jordan J. E., Galea G., Tukuitonga C., Beaglehole R. (2005) Preventing chronic diseases: taking stepwise action. Lancet 366:1667–1671.[CrossRef][ISI][Medline]
Horton R. (2005) The neglected epidemic of chronic disease. Lancet 366:1514.[CrossRef][ISI][Medline]
National Health Priority Action Council. (2006) National Chronic Disease Strategy(Australian Government Department of Health and Ageing, Canberra).
Srinath Reddy K., Shah B., Varghese C., Ramadoss A. (2005) Responding to the threat of chronic diseases in India. Lancet 366:1744–1749.[CrossRef][ISI][Medline]
Strong K., Mathers C., Leeder S., Beaglehole R. (2005) Preventing chronic diseases: how many lives can we save? Lancet 366:1578–1582.[CrossRef][ISI][Medline]
Wang L., Kong L., Wu F., Bai Y., Burton R. (2005) Preventing chronic diseases in China. Lancet 366:1821–1824.[CrossRef][ISI][Medline]
World Health Organisation. (2005) Preventing Chronic Diseases: A Vital Investment(World Health Organisation, Geneva).
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