The recent UN adoption of the Political Declaration of the High Level Meeting on the Prevention and Control of Non-Communicable Diseases (NCDs) puts NCDs squarely on the global community’s priority list. Currently, the UN has called for a 25% reduction by 2025 in mortality from NCDs in persons between 30-70 years old from 2010-2015. This “25 by 25” initiative will drequire innovation, government commitment, and sustained community mobilization—but has the distinct advantage of being able to draw from the extensive efforts in NCD control in high-income countries (HIC). While there are significant differences between the NCD epidemics in countries of varying socio-economic development, there are many similarities. Lessons learned from our experiences in HIC can, and should, be applied to low- and middle-income countries (LMICs).
The four main behavioral drivers of NCDs include
- tobacco abuse
- alcohol abuse
- poor diet
- lack of physical activity.
These remain the basis for public health interventions. The patterns of these behavioral risk factors can help to predict the presence and development of various NCDs. For example, about 80% of tobacco use is now in LMICs, a major factor in the rise in lung and cardiovascular disease (CVD). Obesity rates and sedentary lifestyles are increasing problems globally, particularly in urban areas, and regions with the highest rates frequently suffer proportional levels of diabetes and other obesity-related NCDs.
Experience in HICs has shown that overall decreases in NCD mortality rates can be achieved through a combination of risk-factor reduction (e.g., smoking, high blood pressure) and improved treatment and access to treatment. Thomas Frieden, the director of the U.S. CDC, introduced a five-tier health impact pyramid that shows that successful public health interventions should have as their foundations means for addressing social determinants of health (e.g. poverty, low education levels) and changing the environmental context to make health options the default choice (e.g., clean air, nutritious foods). However, behavioral risk factors are also examples of public health problems shared across all countries: harmful habits that stubbornly resist public health measures, shaped in part by national and global food production and a variety of marketing forces.
The affordability and effectiveness of risk factor reduction strategies are essential criteria, particularly when health care expenditures per capita are less than $50 in many LICs. WHO has outlined a number of cost effective and scalable interventions it calls the “Best Buys”. Of many potential strategies, the “Best Buys” are most appropriate for the constraints of LMIC health systems and provide the greatest health impact.
Two population-wide interventions that would be especially effective in LMIC are tobacco control and dietary salt-reduction measures. A smoking ban combined with salt reduction efforts could lead to the reduction of 14 million premature deaths over the coming 10 years at estimated implementation costs of less than $.40 person/year in LMICs. The implementation of more comprehensive NCD prevention strategies aimed at reducing all four of the main risk factors has estimated costs per person/year of as little as 0.62 USD (India), 1USD (Brazil) and 1.77 USD (Mexico). These measures offer tremendous value, especially when compared to the personal burden and broad economic losses of NCDs in LMIC.
There are numerous effective strategies to address the dire NCDs trends, and evidence from HIC has shown that risk reduction should be the foundation of NCD public health initiatives. Risk factor reduction requires behavior modification — most effectively addressed through structural interventions. Effective and economical, the implementation of “Best Buy” strategies can serve as the foundation for public health interventions across all countries. Now that NCDs have moved to the forefront of the global agenda, the breadth of effective strategies and of high income countries’ NCD experiences can be combined to mobilize public health efforts, international funders, and global and local communities.