George Alleyne

Priority actions for the non-communicable disease crisis

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US

Global health 2035: a world converging within a generation

9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Expansion of cancer care and control in countries of low and middle income: a call to action

Prompted by the 20th anniversary of the 1993 World Development Report a Lancet Commission revisited the case for investment in health and developed a new investment frame work to achieve dramatic health gains by 2035. The report has four key messages each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. Conclusion 1: there is a very large payoff from investing in health. Conclusion 2: a grand convergence is achievable within our lifetime. Conclusion 3: scale-up of low-cost packages of interventions can enable major progress in NCDs and injuries within a generation. Conclusion 4: progressive universalism is an effi cient way to achieve health and fi nancial protection.

UN High-Level Meeting on Non-Communicable Diseases: addressing four questions

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health communitys assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.

Advancement of global health: key messages from the Disease Control Priorities Project

Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes, and chronic respiratory diseases, are a global crisis and require a global response. Despite the threat to human development, and the availability of affordable, cost-effective, and feasible interventions, most countries, development agencies, and foundations neglect the crisis. The UN High-Level Meeting (UN HLM) on NCDs in September, 2011, is an opportunity to stimulate a coordinated global response to NCDs that is commensurate with their health and economic burdens. To achieve the promise of the UN HLM, several questions must be addressed. In this report, we present the realities of the situation by answering four questions: is there really a global crisis of NCDs; how is NCD a development issue; are affordable and cost-effective interventions available; and do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities. A successful outcome of the UN HLM depends on the heads of states and governments attending the meeting, and endorsing and implementing the commitments to action. Long-term success requires inspired and committed national and international leadership.

Renal metabolic response to acid base changes: I. Enzymatic control of ammoniagenesis in the rat

The Disease Control Priorities Project (DCPP), a joint project of the Fogarty International Center of the US National Institutes of Health, the WHO, and The World Bank, was launched in 2001 to identify policy changes and intervention strategies for the health problems of low-income and middle-income countries. Nearly 500 experts worldwide compiled and reviewed the scientific research on a broad range of diseases and conditions, the results of which are published this week. A major product of DCPP, Disease Control Priorities in Developing Countries, 2nd edition (DCP2), focuses on the assessment of the cost-effectiveness of health-improving strategies (or interventions) for the conditions responsible for the greatest burden of disease. DCP2 also examines crosscutting issues crucial to the delivery of quality health services, including the organisation, financial support, and capacity of health systems. Here, we summarise the key messages of the project.In June 2004 six fighters from the Congolese Rally for Democracy-Goma gang-raped a woman in the presence of her husband and children while another soldier raped her three-year-old daughter according to Human Rights Watch. In June 2005 a 17-year-old boy was arrested by a Mai-Mai officer after he refused to draw water for the military stationed there and was severely tortured while he was held in detention in the camp. A local non-governmental organization (NGO) reported that the boy was released only after a large fine was paid. In November 2005 three soldiers from the United Congolese forces tied an 11-year-old girl with an electric cable and repeatedly raped her in a military camp according to the United Nations Organization Mission in the Democratic Republic of the Congo (MONUC). These cases are examples of the brutal violations against Congolese children as documented by the Watchlist on Children and Armed Conflict in its April 2006 report Struggling to Survive: Children in Armed Conflict in the Democratic Republic of the Congo. The country continues to endure the worlds deadliest humanitarian crisis and according to the International Rescue Committee more than 38000 people die every month as a direct and indirect consequence of the armed conflict in the Democratic Republic of the Congo (DRC). As many as 45 per cent of these deaths occurred among children who fell victim to intolerable human rights violations committed in an atmosphere of almost complete impunity. (excerpt)

Embedding non-communicable diseases in the post-2015 development agenda

Experiments were done on rats to investigate the nature of the renal response to metabolic acidosis and the changes in enzyme activity associated with increased ammoniagenesis. When metabolic acidosis was induced with oral feeding of ammonium chloride for 48 hr, there was an increase of activity of the enzyme phosphoenolpyruvate carboxykinase (PEPCK) in whole kidneys as well as in the kidney cortex. There was no change in PEPCK in liver, and glucose-6-phosphatase showed no change in kidney or liver in response to metabolic acidosis. The increase in PEPCK activity in kidney cortex varied with the degree of acidosis and there was a close correlation between cortical PEPCK activity and urinary ammonia. Kidney cortex mitochondrial PEPCK did not change in response to metabolic acidosis. An increase in PEPCK occurred as early as 6 hr after NH(4)Cl feeding, before there was any increase in kidney glutaminase I activity. Rats fed sodium phosphate, or given triamcinolone intramuscularly, developed a metabolic alkalosis, but there was increased urinary ammonia and an increase in activity of renal cortical PEPCK. Triamcinolone plus ammonium chloride induced a greater increase of PEPCK activity than triamcinolone by itself; on the contrary, the rise of glucose-6-phosphatase induced by triamcinolone was not enhanced by acidosis. Glucose-6-phosphatase from control and acidotic rats had identical kinetic characteristics. The results indicate that increased PEPCK activity is constantly related to increases of urinary ammonia. It is proposed that the increase of PEPCK activity is the key event in the ammoniagenesis and gluconeogenesis which follow on metabolic acidosis.

Protein Malnutrition in Children: Advances in Knowledge in the Last Ten Years

The post-2015 development agenda will build on the Millennium Development Goals (MDGs), in which health is a core component. This agenda will focus on human development, incorporate the components of the Millennium Declaration, and will be made sustainable by support from the social, economic, and environmental domains of activity, represented graphically as the strands of a triple helix. The approaches to prevention and control of non-communicable diseases (NCDs) have been elaborated in the political declaration of the UN high-level meeting on NCDs and governments have adopted a goal of 25% reduction in relative mortality from NCDs by 2025 (the 25 by 25 goal), but a strong movement is needed based on the evidence already available, enhanced by effective partnerships, and with political support to ensure that NCDs are embedded in the post-2015 human development agenda. NCDs should be embedded in the post-2015 development agenda, since they are leading causes of death and disability, have a negative effect on health, and, through their effect on the societal, economic, and the environmental domains, impair the sustainability of development. Some drivers of unsustainable development, such as the transport, food and agriculture, and energy sectors, also increase the risk of NCDs.

Renal metabolic response to acid-base changes: II. The early effects of metabolic acidosis on renal metabolism in the rat

Publisher Summary This chapter discusses the characteristics of protein malnutrition in children, with an emphasis on the biochemical and metabolic changes. It focuses on the nutritional processes, the study of which has been stimulated by disease protein malnutrition, and which have a wider relevance in medicine and biology. It is clear that in the last ten years a great deal of new knowledge has been gained about the effects of protein deficiency and protein-calorie imbalance in human beings. It is, however, more than ever apparent that the major problem is not treatment but prevention. Scientific interest is concentrated less on the acute and severe deficiency state, and more on the mild and marginal forms of protein malnutrition. These early stages can be recognized with more sensitive and specific biochemical measurements. The interpretation of the biochemical findings depends upon an understanding of the metabolic adjustments to different levels of protein intake. Only in this way it is possible to distinguish between the changes that are trivial and changes that are significant from the metabolic point of view.

From the Earth Summit to Rio+20: integration of health and sustainable development

The early renal metabolic response was studied in rats made acidotic by oral feeding of ammonium chloride. 2 hr after feeding of ammonium chloride there was already significant acidosis. Urinary ammonia also increased after ammonium chloride ingestion and at 1(1/2) hr was significantly elevated. In vitro gluconeogenesis by renal cortical slices was increased at 2 hr and thereafter increased steadily. Ammonia production by the same slices was also increased at 2 hr, but thereafter fell and at 6 hr had decreased to levels which, although higher than those of the control, were lower than those obtained from the rats acidotic for only 2 hr. There was no correlation between in vitro gluconeogenesis and ammonia production by kidney slices from rats during the first 6 hr of acidosis, but after 48 hr of ammonium chloride feeding, these two processes were significantly correlated. The early increase in renal gluconeogenesis was demonstrable with both glutamine and succinate as substrates. The activity of the enzyme phosphoenolpyruvate carboxykinase was increased after 4-6 hr of acidosis. During this time there was a decrease in renal RNA synthesis as shown by decreased uptake of orotic acid-(5)H into RNA. Metabolic intermediates were also measured in quick-frozen kidneys at varying times after induction of acidosis. There was an immediate rise in aspartate and a fall in alpha-ketoglutarate and malate levels. There was never any difference in pyruvate or lactate levels or lactate:pyruvate ratios between control and acidotic rats. Phosphoenolpyruvate rose significantly after 6 hr of acidosis. All the data indicate that increased gluconeogenesis is an early response to metabolic acidosis and will facilitate ammonia production by utilization of glutamate which inhibits the glutaminase I enzyme. The pattern of change in metabolic intermediates can also be interpreted as showing that there is not only enhanced gluconeogenesis, but also that there may be significant increase of activity of glutaminase II as part of the very early response to metabolic acidosis.