Johanna Ralston

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

Early-life prevention of non-communicable diseases

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.

The World Heart Federation's vision for worldwide cardiovascular disease prevention

Non-communicable diseases (NCDs) are major causes of death worldwide and underlie almost two-thirds of all global deaths.1 Although all countries face epidemics of these diseases, low-income and middle-income countries, and the poorest and most vulnerable populations within them, are affected the most. There is a global imperative to create and implement effective prevention strategies, because the future costs of diagnosis and treatment are likely to be unaffordable. At the UN High-Level Meeting on the Prevention and Control of Non-Communicable Diseases, held in New York, USA, in September, 2011, the so-called four by four strategy for NCD prevention was proposed. Prevention efforts for the priority NCDs discussed at the meeting (diabetes, cardiovascular disease, cancer, and chronic obstructive pulmonary disease) focus on four, mainly adult, risk factors: poor diet, physical inactivity, tobacco use, and alcohol consumption. Although paragraphs 26 and 28 of the UN Political Declaration refer to the roles of prenatal nutrition, maternal diseases, and household air pollution on NCD risk in later life, these paragraphs only partially describe the full scope of the problem and opportunities for intervention. As scientific knowledge emerges on the role of both nutritional factors and exposures to environmental chemicals in the developmental origins of health and disease, evidence suggests that much more attention is needed on early-life interventions, optimisation of nutrition, and reduction of toxic exposures to curtail the increasing prevalence of NCDs. The present state of the science on the developmental origins of health and disease and NCDs was discussed at the Prenatal Programming and Toxicity III conference, Environmental Stressors in the Developmental Origins of Disease: Evidence and Mechanisms, held in Paris, France in May, 2012, and at a symposium just before the conference.2 Studies in human beings have shown that nutritional deprivation and maternal metabolic status (eg, diabetes) in early intrauterine life increase the risk of metabolic disorders and cardiovascular disease in adulthood.3,4 These effects occur not only in settings of extreme deprivation, but also throughout the normal range of population weights at birth and in early childhood.3 Investigators have also reported associations between in-utero exposures and childhood diseases, including type 2 diabetes.5 In-utero and early-life exposures to environmental toxicants, ranging from heavy metals to endocrine-disrupting chemicals, affect adult metabolism, immune system function, neurodevelopment, and reproductive function.2 Although causal relations have not yet been established, the new science of epigenetics offers insight into mechanisms of early life predisposition to adult disease risk. During development, epigenetic marks, such as DNA methylation, histone modifications, and noncoding RNA expression, undergo substantial changes. These changes affect genes that are essential for both early life development and later life physiological functions. Epigenetic modifications are stable during cell division and can be transmitted transgenerationally.6 An increasing amount of evidence suggests that developmental exposure to nutritional imbalance or environmental contaminants—including metals, pesticides, persistent organic pollutants, and chemicals in drinking water, such as triethyltin, chloroform, and trihalomethanes—can affect epigenetic changes, thus suggesting a mechanism for their effects on adult health.7,8 Similarly, prenatal exposure to air pollutants has been associated with epigenetic changes and subsequent effects on children’s respiratory health.9 Knowledge that in-utero and early childhood experiences affect the risk of NCD development provides an opportunity to target interventions at the time when they have the greatest effect. Because these exposures are not controlled directly by the individual, especially when the exposures might have occurred to the individual’s parents or grandparents, early-life interventions can reduce the perception of blame that the individual’s own lifestyle has caused his or her disease. This notion has policy implications, because the prevailing viewpoint often assumes that NCDs are mainly a matter of individual responsibility, thus obviating societal and governmental responsibility. Substantial reductions of NCD risks could be achieved through the use of existing maternal–child health platforms to educate mothers about both nutritional and environmental exposures and to integrate the health promotion and disease prevention agendas within social and economic development efforts. For example, the Millennium Development Goals (MDGs) address not only maternal and child health problems, but also poverty and malnutrition, sex inequality, and lack of education, all of which are notable drivers of social disadvantage in low-income and middle-income countries and are underlying causes of NCDs.10,11 Poverty alleviation, sustainable food production, and reductions in exposures to toxic chemicals are all key themes emerging from the Rio+20 UN Conference on Sustainable Development12 held in Rio de Janeiro, Brazil, in June, 2012, and the development of Sustainable Development Goals (SDGs) and appropriate environmental, nutritional, and health indicators provides another opportunity to incorporate NCD prevention into broader, multisector programmes. The integration of NCD prevention with the attainment of the MDGs and SDGs could leverage major worldwide investments in health and development.

Sustainable Development Goals and the future of cardiovascular health: a statement from the Global Cardiovascular Disease Taskforce.

2but the age-standardised mortality from cardiovascular disease has halved since then, through better prevention (such as lifestyle changes and risk factor control) and wider use of simple but eff ective treatments for acute events and secondary prevention. 3 However, the use of these proven strategies, even in wealthy countries, is far from optimum and more widespread implementation could further reduce the rates of cardiovascular disease in the next two decades in most high-income countries. By contrast, cardiovascular disease was thought to be uncommon in LMICs in the 1950s and 1960s, but increased substantially over the past three decades. Nowadays, more than 80% of the global burden of cardiovascular disease occurs in these countries. 1 This high percentage is partly due to the much larger populations in these countries, progress in avoidance of deaths from childhood diseases so that now more individuals live to older ages when they are at risk of developing cardiovascular disease, and increased tobacco use, decreased physical activity, increased consumption of animal products, and increased obesity (with resultant elevations in blood pressure, cholesterol, and diabetes), 4

Sustainable Development Goals and the Future of Cardiovascular Health: A Statement From the Global Cardiovascular Disease Taskforce

We are on the cusp of a new era in global health policy that could transform the lives of millions worldwide. Whether cardiovascular health is part of this transformation will be largely determined within the next few months, when the United Nations will debate and decide upon Sustainable

Adapting the World Heart Federation Roadmaps at the National Level: Next Steps and Conclusions.

Author(s): Josephson, Scott; Zoghbi, WA; Duncan, T; Antman, E; Barbosa, M; Champagne, B; Chen, D; Gamra, H; Harold, JG; Komajda, M

World Heart Federation Emerging Leaders Program. An Innovative Capacity Building Program to Facilitate the 25× 25 Goal

There is proven value to the implementation of effective strategies for cardiovascular secondary prevention and for tackling hypertension and tobacco control. However, their uptake is currently disappointingly very low, particularly in low- and middle-income countries where mortality rates for cardiovascular diseases (CVD) is much greater than in high-income countries [1]. The widespread deployment of these strategies can reduce both the risk of recurrent CVD events (secondary prevention) and the risk of developing CVD in the first place (primary prevention). Collectively widespread implementation of these three strategies is absolutely essential if we are to reduce CVD

Reducing Premature Cardiovascular Mortality By 2025: The World Heart Federation Roadmap.

Highlights To help achieve the goal of reducing the risk of premature mortality from noncommunicable, chronic diseases by 25% by 2025, the World Heart Federation has developed its Emerging Leaders program. The Emerging Leaders program focuses on implementation science, health systems, and health policy research and action among a target of at least 100 emerging leaders over the next decade to initiate and facilitate cardiovascular disease prevention activities globally and in every region of the world. We describe the rationale for and characteristics of the Emerging Leaders program, including its training objectives, methods, and future directions. The Emerging Leaders program represents a major opportunity for the World Heart Federation, its member organizations, and the emerging leaders themselves to leverage their collective strengths toward achieving the ambitious, yet achievable, “25 × 25” goal through an innovative global collaborative leadership-enhancing experience.

Can human resources for health in the context of noncommunicable disease control be a lever for health system changes

Dr. Perel lead several studies on preventive cardiology for which his institution has received grants. He has no conflicts related to this particular article. Dr. Wood lead several studies on preventive cardiology Reducing Premature Cardiovascular Mortality By 2025 The World Heart Federation Roadmap Pablo Perel*, Eduardo Biancoy, Neil Poulterz, Dorairaj Prabhakaranx, Prem Paisk, Johanna Ralston{, David Wood, Salim Yusuf**

Cardiovascular Diseases on the Global Agenda: The United Nations High Level Meeting, Sustainable Development Goals, and the Way Forward

Major global shifts are shaping health priorities in the wake of new challenges and emerging opportunities. While reaffirming a commitment to accelerate progress on the Millennium Development Goals, discussions on the post-2015 agenda have also focused on the importance of noncommunicable diseases (NCDs).1 Efforts are also under way to enhance countries’ commitment to universal health coverage (UHC) and to overcome the system constraints that are hampering progress towards achieving disease-specific targets. Despite auspicious directions, the journey is fraught with obstacles. A focus on human resources for health (HRH) in the context of NCD control could be a lever for health system change after 2015 by leading to measures designed to improve health systems more broadly. This view is supported by several trends. First, the required shift from the care of acute infectious diseases to chronic conditions entails a reorientation of health systems for which human resources can be an important lever. This effect has been shown in programmes for the control of human immunodeficiency virus (HIV) infection that have relied heavily on changes in the terms and conditions of employment: task sharing and task shifting strategies were designed; information systems, supply chains and service delivery norms were tailored towards chronic disease care; new referral systems and appointment and defaulter tracking methods were introduced; and worker training was focused on the use of new instruments, such as appointment books, patient counselling guidelines, medical records and standardized treatment protocols.2 Besides these measures, HIV programmes have also employed non-traditional human resource strategies in the form of engagement with nongovernmental organizations, service recipients, peer educators, treatment partners and expert clients.3 In the context of NCD management, human resources can be strategically leveraged in similar fashion to reorient systems towards chronic care more broadly. Second, the “health in all policies” approach is gaining appeal with the growing recognition that many paths towards improving health lie outside the health-care system.4 New stewardship capacities are required to ensure appropriate institutional mechanisms and partisan agreements, a collaborative division of labour, a commitment to shared goals and accountability for results. Change is possible only if the right human resource competencies are present at the starting point. The prevention and control of NCDs provide a platform for intersectoral engagement, both through “health in all policies” and through a more issue-centric approach, such as tobacco control.5 Third, NCDs are the focus of most of the information and communication technology-based solutions designed to overcome human resource shortages and geographic access constraints to health care. Among them are health education to promote patient screening for NCDs and cell-phone-enabled medication adherence tools for the management of asthma and diabetes, some of which have shown clinical benefits in trials.6,7 Now that 95% of the world’s population has access to mobile signals, these approaches could help to overcome critical health worker shortages, to the benefit of the one billion people in the world who would otherwise never have access to a health professional. Sim card applications, which can be powered by any type of phone, can provide health service access to patients and communities in settings where health worker shortages are not amenable to quick fixes. These emerging tools for NCD control create opportunities for revising health worker roles and maximizing the effectiveness of health systems. HRH are also an important lever in post-2015 efforts to attain UHC. Of all the resources that factor into the health system – financial, physical, technological and human – human resources are the most strategic. Individually or collectively, they can generate change within the system.8 For example, decentralization of authority from a higher government level to the subnational level can enhance accountability. Outsourcing of health service management and new service delivery arrangements can lead to improved performance. Definition of new rules of engagement between public and private entities in the health system and new recruitment and retention mechanisms, together with empowerment of facilities by granting them increased autonomy, can affect staff incentives and, consequently, morale and performance. As health systems are reoriented towards the control of NCDs, these measures become potential pathways towards health system reform. In summary, human resources for health are vital for mainstreaming changes in health systems and in the broader social system that affects the health of the population. Emerging agendas in the post-2015 landscape offer an opportunity to tap to the fullest the potential of human resources for health.