Author + information
- K. Srinath Reddy, MD, MSc, Associate Editor, Journal of the American College of Cardiology∗ ( )()
- Public Health Foundation of India, New Delhi, India; and the World Heart Federation, Geneva, Switzerland
- ↵∗Address correspondence to:
Prof. K. Srinath Reddy, ISID Campus, Vasantkunj Institutional Area, New Delhi, India 110070.
The year 2014 is pivotally positioned between 2 years of great significance for global health. In the preceding year, 2013, the World Health Assembly adopted the Global Action Plan for Prevention and Control of Non-Communicable Diseases (NCDs). In the coming year, 2015, the whole world will adopt the Sustainable Development Goals (SDGs), which will be framed at the United Nations (U.N.) to guide global development initiatives during 2015 to 2030, including education, access to water, and health. NCDs will be an important component of the health SDG that is likely to be framed in 2015, unlike in 2000, when they were curiously omitted from the 3 health-specific goals that were a major part of the Millennium Development Goals adopted at the United Nations to set the development agenda for the first 15 years of the new millennium (1).
How has this change occurred? Even by 2000, it was very clear from the 1994 Global Burden of Disease Study that NCDs had already become the leading cause of global mortality and disability by 1990, with the low- and middle-income countries (LMICs) becoming the new epicenter of this rapidly expanding pandemic (2). Yet, there was a false perception by the leading international development agencies and high-income country donors that NCDs were only a health problem of rich countries and the wealthy individuals in poor countries, and this led to their exclusion from what was intended to be a development agenda of the poor. Indeed, an opinion piece by a group of influential World Bank economists in 1999 specifically cautioned that “under an accelerated rate of overall decline in NCDs, the poor-rich gap would widen” (3).
However, by 2007, even the World Bank changed its position in the face of compelling evidence that “in all countries and by any metric, NCDs account for a large enough share of the disease burden of the poor to merit a serious policy response” (4). It also was clear that NCDs accounted not only for high absolute mortality burdens and rising proportional mortality rates in LMICs but also for higher age-standardized mortality rates in comparison with rich countries. In 2008, more than 25% of the 35 million global deaths due to NCDs occurred in individuals younger than the age of 60 years. Of these very untimely midlife deaths, 90% were in LMICs. Further, the vulnerability of the poor to NCDs was very visible in the form of adverse risk profiles, poor access to health information and services, higher case fatality rates, and health care–related impoverishment. The world could no longer deny that NCDs were, indeed, a threat to development and to the goal of poverty reduction. Cardiovascular diseases (CVDs) not only were the leading NCD, but also provided the best evidence of how severely NCDs affected poor and young people in LMICs.
This recognition culminated in the U.N. high-level meeting of September 2011, where it was declared that NCDs were a major public health challenge and threat to development and where the United Nations called for national and global responses that would require health system interventions and multisectoral actions. By this time, an economic case also was formulated by a report published by Harvard University and the World Economic Forum, which showed that NCDs and mental illnesses would cost the world $47 trillion between 2011 and 2030 (5). The World Economic Forum even listed NCDs among the top 5 threats to the global economy. Loss of productivity due to premature deaths or disability, escalating health care costs that strained national health budgets, and catastrophic health expenditures that resulted in devastating poverty made NCDs an economic nightmare. Attention and action had to replace the apathy of 2000.
In May 2013, the World Health Assembly of the World Health Organization (WHO) adopted 9 targets for NCD prevention and control to be reached by 2025, in comparison with the rates of mortality and risk factor prevalence estimated for 2010. The overarching target was a 25% reduction in NCD-related mortality in the age group of 30 to 70 years, yielding the catchy slogan of “25 × 25”. The enabling targets are related to specific percent reductions in the prevalence of tobacco and alcohol consumption, physical inactivity, salt consumption, diabetes, and obesity prevalence, as well as improved insurance coverage for individuals with a high risk of CVD, with proven lifesaving drugs and increased access to essential drugs and technologies (6).
Recently modeled estimates suggest that the goal of 25 × 25 is achievable for CVD if the previously mentioned 6 known risk factors are acted upon as proposed in the enabling targets. For the 4 major NCDs combined (CVD, cancer, diabetes, and chronic respiratory disease), the overall mortality reduction would be 22% for men and 19% for women (7). A 25% reduction in NCD mortality can still be achieved if the prevalence of tobacco consumption is reduced by 50%, instead of 30% as proposed by the WHO. If effective risk reduction treatments also are implemented to the target of at least 50% coverage of high-risk individuals, the gains would be even more. About 37 million premature deaths would be prevented by 2025 even if the more modest risk factor reduction of the basic model is accomplished, with maximum gains in LMICs.
It is clear that if the overall NCD goal is to be achieved, CVD prevention and control must lead the way. We do have evidence derived from rigorous research that currently available knowledge, appropriate policies, clinical interventions, drugs, and technologies can accomplish the task if properly deployed. This requires a combination of political will and professional skill to utilize the full potential of evidence-based interventions on a global scale. There is still the challenge of supporting this with adequate financial resources. Most LMICs have not yet set in motion well-funded NCD prevention and control programs. International financial assistance is still miniscule as well. This calls for further advocacy to include NCDs in the health SDG of 2015.
Presently, the ongoing discussion on a potential health SDG has narrowed down to 2 possible candidates. The WHO and the World Bank are strongly advocating for universal health coverage (UHC) as the final choice, whereas several others prefer a broader goal such as maximizing healthy life expectancy, with UHC as a pathway rather than the goal. Whichever the winner is, NCDs have to be a part of the goal. UHC must provide for NCD prevention and control as part of any essential health package, and substantial increases in healthy life expectancy cannot be achieved without an effective proposal to combat NCDs.
The case for inclusion of NCDs in the sustainable development framework is also strong because of the common determinants between NCDs and environment, apart from the obvious link with poverty reduction. There are several links, from urban air pollution and nonsustainable patterns of production and consumption of unhealthy foods to the environmental effects of tobacco. Action against these common determinants will benefit the overall objective of protecting sustainable development through better health and a safer environment. It is now time for the world to correct the error of 2000 and place cardiovascular health, along with other NCDs, at the heart of global development.
- American College of Cardiology Foundation
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