《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2003_Shaping the Future_Chapter6 Neglected Global Epidemics：three growing threats

Chapter six Neglected Global Epidemics three growing threats Today, the burden of deaths and disability in developing countries caused by noncommunicable diseases, particularly cardiovascular conditions, outweighs that imposed by long standing communicable diseases. To tackle this well recognized"double burden", this chapter proposes a"double response"which integrates prevention and control of both communicable diseases and noncommunicable diseases within a comprehensive health care system. R The chapter also examines the stealthy but rapid evolution of two other epidemics, and ways to respond to them. The globalization of tobacco-related diseases can be countered through the WHO Framework Convention on Tobacco Control Simultaneously, the hidden epidemic" of road traffic casualties and traffic-related environmental hazards can be reduced if developing countries adapt successful road safety and other improvements from elsewhere to meet their own needs

Neglected Global Epidemics: three growing threats 83 Chapter Six Neglected Global Epidemics: three growing threats Today, the burden of deaths and disability in developing countries caused by noncommunicable diseases, particularly cardiovascular conditions, outweighs that imposed by long￾standing communicable diseases. To tackle this well￾recognized "double burden", this chapter proposes a "double response" which integrates prevention and control of both communicable diseases and noncommunicable diseases within a comprehensive health care system. The chapter also examines the stealthy but rapid evolution of two other epidemics, and ways to respond to them. The globalization of tobacco-related diseases can be countered through the WHO Framework Convention on Tobacco Control. Simultaneously, the "hidden epidemic" of road traffic casualties and traffic-related environmental hazards can be reduced if developing countries adapt successful road safety and other improvements from elsewhere to meet their own needs

6 Neglected Global Epidemics three growing threats Cardiovascular diseases, the need to act Twenty-five years ago, when the delegates at the international Alma-Ata conference drew up a list of eight essential elements for primary health care, there was no mention of the treat ment or prevention of conditions such as heart disease and stroke. The priority was to deliver adequate nutrition, safe water and basic sanitation, maternal and child health care, immuni- zation against the major infectious diseases, the prevention and control of local endemic diseases, and the provision of essential drugs to the poorer countries of the world Cardiovascular diseases(CVDs)-heart disease and stroke- and other noncommunicable diseases were considered diseases of the industrialized countries- so-called "Western dis- ases-brought about by ways of life utterly different from those in most of Africa, Asia and many other parts of the developing world. It is noteworthy, however, that as early as 1954 the delegate of India to the World Health Assembly called for steps to be taken towards the pre- vention of CVDs in developing countries The global health agenda is still dominated by the notion that communicable diseases need to be prevented and treated before CVDs receive attention. There is a lingering view that CVDs are mostly confined to wealthy people and are caused by natural ageing and degenera tive processes. There persists a widespread belief that they are "lifestyle diseases", fully under the control of individual decisions The reality is quite different. CVDs have not only emerged in all but the very poorest coun tries, but are already well advanced; this growing burden has real potential to hinder social and economic development. Risk factors are indicators of future health status, and five of the top 10 risks worldwide are specific to noncommunicable diseases(1). These include raised blood pressure, tobacco use, alcohol consumption, cholesterol, and obesity or overweight This is part of the well-documented epidemiological transition called the"double burden that sees the arrival of the whole group of noncommunicable diseases with their shared risk factors on top of the persisting threat of communicable diseases. As a consequence, health systems are now required that can deal comprehensively with all common diseases, irrespe tive of their origin As highlighted in Chapter 1, in today s world most deaths are attributable to noncommunicable iseases(32 million)and just over half of these(16. 7 million)are the result of CVD; more than one-third of these deaths occur in middle-aged adults. In developed countries, heart disease and stroke are the first and second leading causes of death for adult men and women

Neglected Global Epidemics: three growing threats 85 6 Neglected Global Epidemics: three growing threats Cardiovascular diseases: the need to act Twenty-five years ago, when the delegates at the international Alma-Ata conference drew up a list of eight essential elements for primary health care, there was no mention of the treat￾ment or prevention of conditions such as heart disease and stroke. The priority was to deliver adequate nutrition, safe water and basic sanitation, maternal and child health care, immuni￾zation against the major infectious diseases, the prevention and control of local endemic diseases, and the provision of essential drugs to the poorer countries of the world. Cardiovascular diseases (CVDs) – heart disease and stroke – and other noncommunicable diseases were considered diseases of the industrialized countries – so-called “Western dis￾eases” – brought about by ways of life utterly different from those in most of Africa, Asia and many other parts of the developing world. It is noteworthy, however, that as early as 1954 the delegate of India to the World Health Assembly called for steps to be taken towards the pre￾vention of CVDs in developing countries. The global health agenda is still dominated by the notion that communicable diseases need to be prevented and treated before CVDs receive attention. There is a lingering view that CVDs are mostly confined to wealthy people and are caused by natural ageing and degenera￾tive processes. There persists a widespread belief that they are “lifestyle diseases”, fully under the control of individual decisions. The reality is quite different. CVDs have not only emerged in all but the very poorest coun￾tries, but are already well advanced; this growing burden has real potential to hinder social and economic development. Risk factors are indicators of future health status, and five of the top 10 risks worldwide are specific to noncommunicable diseases (1). These include raised blood pressure, tobacco use, alcohol consumption, cholesterol, and obesity or overweight. This is part of the well-documented epidemiological transition called the “double burden” that sees the arrival of the whole group of noncommunicable diseases with their shared risk factors on top of the persisting threat of communicable diseases. As a consequence, health systems are now required that can deal comprehensively with all common diseases, irrespec￾tive of their origin. As highlighted in Chapter 1, in today’s world most deaths are attributable to noncommunicable diseases (32 million) and just over half of these (16.7 million) are the result of CVD; more than one-third of these deaths occur in middle-aged adults. In developed countries, heart disease and stroke are the first and second leading causes of death for adult men and women

86TheWorldHealthReport2003 These facts are familiar and hardly surprising. What is surprising, however, is that in some developing countries, CVDs have also become the first and second leading causes, responsi- ole for one-third of all deaths(see Figure 6.1) In fact, twice as many deaths from CVD now occur in developing countries as in developed countries. Overall, in developing countries, CVD ranks third in disease burden(after injuries and neuropsychiatric disorders). Even in high-mortality developing countries, CVD is ranked rery high. A particular cause of concern is the relatively early age of Cvd deaths in developing coun tries compared with those in the developed regions(2 ). One in two of the CVD-related deaths in India occur below the age of 70 years, compared with one in five in economically well developed nations. In both rural and urban areas of the United Republic of Tanzania, stroke mortality rates are three times higher than those in England and wales. What is not often recognized is that, globally, CVDs account for as many deaths in young and middle-aged adults as Hiv/aIDs This does not mean that communicable diseases have quietly gone away, require less funding, or are now safely under control. The advent of HIVIAIDS shattered that hope(see Chapter 3). Malaria and tuberculosis are among other enormous threats that remain and are growing In addition, as pointed out in Chapter 5, new infectious diseases have been emerging at the rate of one a year for the last 20 years or more: SARS is the latest. So it is legitimate that public health communities remain vigilant towards infectious diseases, and that this vigilance be- gins with primary health care, in accordance with the Declaration of Alma-Ata. However, the world cannot afford to lose sight of the growing social and economic threats posed by Cvd and other noncommunicable diseases Ironically, CVDs are now in decline in the industrialized countries first associated with them But from that irony stems hope: the decline is largely a result of the successes of primary prevention and, to a lesser extent, treatment. What has worked in the richer nations-and ure 6.1 Deaths attributable to 16 leading causes in developing countries, 2001 Cardiovascular diseases alignant neoplasms Injuries Chronic respiratory diseases HIVIAIDS Diarrhoeal diseases Tuberculosis Digestive diseases Childhood diseases Diabetes mellitus口 Diseases of the genitourinary system n Low-mortality developing countries Neuropsychiatric disorders High-mortality developing countries 12000 Deaths(000)

86 The World Health Report 2003 These facts are familiar and hardly surprising. What is surprising, however, is that in some developing countries, CVDs have also become the first and second leading causes, responsi￾ble for one-third of all deaths (see Figure 6.1). In fact, twice as many deaths from CVD now occur in developing countries as in developed countries. Overall, in developing countries, CVD ranks third in disease burden (after injuries and neuropsychiatric disorders). Even in high-mortality developing countries, CVD is ranked very high. A particular cause of concern is the relatively early age of CVD deaths in developing coun￾tries compared with those in the developed regions (2). One in two of the CVD-related deaths in India occur below the age of 70 years, compared with one in five in economically well￾developed nations. In both rural and urban areas of the United Republic of Tanzania, stroke mortality rates are three times higher than those in England and Wales. What is not often recognized is that, globally, CVDs account for as many deaths in young and middle-aged adults as HIV/AIDS. This does not mean that communicable diseases have quietly gone away, require less funding, or are now safely under control. The advent of HIV/AIDS shattered that hope (see Chapter 3). Malaria and tuberculosis are among other enormous threats that remain and are growing. In addition, as pointed out in Chapter 5, new infectious diseases have been emerging at the rate of one a year for the last 20 years or more: SARS is the latest. So it is legitimate that public health communities remain vigilant towards infectious diseases, and that this vigilance be￾gins with primary health care, in accordance with the Declaration of Alma-Ata. However, the world cannot afford to lose sight of the growing social and economic threats posed by CVD and other noncommunicable diseases. Ironically, CVDs are now in decline in the industrialized countries first associated with them. But from that irony stems hope: the decline is largely a result of the successes of primary prevention and, to a lesser extent, treatment. What has worked in the richer nations – and 0 2000 4000 6000 8000 10 000 12 000 Maternal conditions Neuropsychiatric disorders Diseases of the genitourinary system Diabetes mellitus Malaria Childhood diseases Digestive diseases Tuberculosis Diarrhoeal diseases Perinatal conditions HIV/AIDS Chronic respiratory diseases Respiratory infections Injuries Malignant neoplasms Cardiovascular diseases Low-mortality developing countries High-mortality developing countries Deaths (000) Figure 6.1 Deaths attributable to 16 leading causes in developing countries, 2001

Neglected Global Epidemics: three growing threats especially for the most advantaged members of these societies- can be just as effective in their poorer counterparts There is now abundant evidence to initiate effective actions at national and global levels to promote and protect cardiovascular health through population-based measures that focus on the main risk factors shared by all noncommunicable diseases. The population-wide ap- plication of existing knowledge has the potential to make a major, rapid and cost-effective contribution to their prevention and control and to benefit all segments of the population(3) The main issue for policy-makers, at all levels of public health in developing countries, is how to deal with the growing burden of epidemics of noncommunicable diseases in the presence of persisting communicable disease epidemics. Furthermore, this challenge must be faced even where health system resources are already inadequate. Although considerable policy gains can be made very cheaply, especially intersectorally, extra provision must be found This requires a greater share of national resources for health care, better use of existing re- sources,and new sources of funding. A special tax on tobacco products for disease preven tion programmes is a readily available source of new funds for most countries. The causes are known The good news is that an impressive body of research has identified the causes of the CVd epidemics within populations(1). Global trade and marketing developments continue to drive the nutrition transition towards diets with a high proportion of saturated fat, sugar and salt. At the same time, protective elements like fibre and phytochemicals in fresh fruit and vegetables are being progressively depleted in diets. When combined with tobacco use and low levels of physical activity, this diet leads to population-wide atherosclerosis and the wide spread distribution of CVDs. Variations in these same major risk factors explain much of the ajor difference in rates of CVDs between countries. In summary, the major CVD risk factors of tobacco use, inappropriate diet and physical inac tivity(primarily expressed through unfavourable lipid concentrations, high body-mass ir dex, and raised blood pressure)explain at least 75-85% of new cases of coronary heart disease (4 ) In the absence of elevations of these risk factors, coronary heart disease is a rare cause of death. Unfortunately, the vast majority of the populations in almost all countries are at risk of developing CVD because of higher than optimal levels of the main risk factors. Only about 5%of adult men and women in wealthy countries are at low risk with optimal risk factor levels. There are only a few very poor countries in which these factors have not yet emerged as major public health problems. Policies are available One of the most exciting possibilities to emerge in public health in recent years is the integra- tion of communicable disease and CVd prevention and control into comprehensive health systems led by primary care. Bringing this to fruition will mean reshaping the future of pri- mary health care in response to a changing world. It would see all patients being offered across their lifespan-prevention, treatment and long-term management of both sides of the double burden Achieving such integration will not be easy. Apart from other considerations, it will require cooperation between professional rivals, who each regard their side of the double burden to be more important than the other, and who compete for their share of limited resources Such competitiveness has long been entrenched across the battlefields of public health And

Neglected Global Epidemics: three growing threats 87 especially for the most advantaged members of these societies – can be just as effective in their poorer counterparts. There is now abundant evidence to initiate effective actions at national and global levels to promote and protect cardiovascular health through population-based measures that focus on the main risk factors shared by all noncommunicable diseases. The population-wide ap￾plication of existing knowledge has the potential to make a major, rapid and cost-effective contribution to their prevention and control and to benefit all segments of the population (3). The main issue for policy-makers, at all levels of public health in developing countries, is how to deal with the growing burden of epidemics of noncommunicable diseases in the presence of persisting communicable disease epidemics. Furthermore, this challenge must be faced even where health system resources are already inadequate. Although considerable policy gains can be made very cheaply, especially intersectorally, extra provision must be found. This requires a greater share of national resources for health care, better use of existing re￾sources, and new sources of funding. A special tax on tobacco products for disease preven￾tion programmes is a readily available source of new funds for most countries. The causes are known The good news is that an impressive body of research has identified the causes of the CVD epidemics within populations (1). Global trade and marketing developments continue to drive the nutrition transition towards diets with a high proportion of saturated fat, sugar and salt. At the same time, protective elements like fibre and phytochemicals in fresh fruit and vegetables are being progressively depleted in diets. When combined with tobacco use and low levels of physical activity, this diet leads to population-wide atherosclerosis and the wide￾spread distribution of CVDs. Variations in these same major risk factors explain much of the major difference in rates of CVDs between countries. In summary, the major CVD risk factors of tobacco use, inappropriate diet and physical inac￾tivity (primarily expressed through unfavourable lipid concentrations, high body-mass in￾dex, and raised blood pressure) explain at least 75–85% of new cases of coronary heart disease (4). In the absence of elevations of these risk factors, coronary heart disease is a rare cause of death. Unfortunately, the vast majority of the populations in almost all countries are at risk of developing CVD because of higher than optimal levels of the main risk factors. Only about 5% of adult men and women in wealthy countries are at low risk with optimal risk factor levels. There are only a few very poor countries in which these factors have not yet emerged as major public health problems. Policies are available One of the most exciting possibilities to emerge in public health in recent years is the integra￾tion of communicable disease and CVD prevention and control into comprehensive health systems led by primary care. Bringing this to fruition will mean reshaping the future of pri￾mary health care in response to a changing world. It would see all patients being offered – across their lifespan – prevention, treatment and long-term management of both sides of the double burden. Achieving such integration will not be easy. Apart from other considerations, it will require cooperation between professional rivals, who each regard their side of the double burden to be more important than the other, and who compete for their share of limited resources. Such competitiveness has long been entrenched across the battlefields of public health. And

The World Health Report 2003 yet, as the chapter of this report on SARS has shown, cross-disciplinary collaboration is not only possible but can be enormously rewarding to all concerned. In the case of this new pidemic, the worlds best scientists, clinicians and public health experts were willing to se aside academic competition and work together for the public good- because the circum- stances so clearly required it. Paradoxically, a matching policy response to tackle public health challenges of even greater magnitude is lacking: the mounting menace of the global CVD epidemic is evolving rapidly Another critical policy issue, especially for poor countries, concerns the appropriate balance between primary and secondary prevention and between the population and high-risk ap- proaches to primary prevention. If the goal is to increase the proportion of the population at low risk and to ensure that all groups benefit, the strategy with the greatest potential is the one directed at the whole population, not just people with high levels of risk factors or estab- lished disease(5). All other strategies will, at best, only blunt the epidemics and likely in- crease inequalities; they will not prevent the epidemics. Even so, with ageing populations, health systems will continue to face the unrelenting demands of costly care, both acute and chronic(see Box 1.3 in Chapter 1) The ultimate public health policy goal is the reduction of population risk, and since most of the population in most countries is not at the optimal risk level, it follows that the majority of prevention and control resources should be directed towards this goal in the entire popula tion. Evidence is available in support of the cost-effective policies required for the task of making the small-but powerful and surprisingly rapid -shifts in risk distributions in entire populations in a favourable direction (1). Similarly, management decisions based on meas- ures of overall risk are more cost-effective than those based on single risk factors Untold lives lost are lost unnecessarily because of inadequate acute and long-term manage- ment of CVD. Relatively cheap interventions for CVD are available(6), and single combina tion pills including aspirin and drugs for blood pressure and cholesterol lowering for possible use in chronic care are under development. Even in wealthy countries, however, the potential of these and other interventions for secondary prevention is far from fully utilized. The situ ation in poorer countries is even less satisfactory. There are many opportunities for coordi- nated CVD risk reduction, care and long-term management. Smoking cessation and the identification and management of diabetes, for example, are just two priorities. Cost-effec tive interventions, such as the use of aspirin in people with symptoms of chest pain, would prevent a quarter of the deaths associated with heart attacks and are much more cost-effe tive than more radical interventions such as revascularization procedures, which are inevita bly restricted to a minority of patients with CVD. Acting now and measuring progress There have been striking and rapid reductions in Cvd death rates in wealthy countries especially benefiting the wealthiest and most educated -because of comprehensive approaches including both improved prevention and the management of high-risk people. Policy inter ventions in developed and developing countries can lead to a surprisingly rapid response. In Mauritius, government action to encourage consumption of healthy oils resulted in a rapid decrease in population levels of blood cholesterol In Finland, government agricultural sub sidies were used to reduce dairy farming and increase berry production. And in Poland, in- creased consumption of fresh fruit and vegetables, consequent to changes in the polio environment, were associated with a sharp decline in CVD death rates. A WHO/FAO expert onsultation report on diet, nutrition and the prevention of chronic diseases reviewed the

88 The World Health Report 2003 yet, as the chapter of this report on SARS has shown, cross-disciplinary collaboration is not only possible but can be enormously rewarding to all concerned. In the case of this new epidemic, the world’s best scientists, clinicians and public health experts were willing to set aside academic competition and work together for the public good – because the circum￾stances so clearly required it. Paradoxically, a matching policy response to tackle public health challenges of even greater magnitude is lacking: the mounting menace of the global CVD epidemic is evolving rapidly. Another critical policy issue, especially for poor countries, concerns the appropriate balance between primary and secondary prevention and between the population and high-risk ap￾proaches to primary prevention. If the goal is to increase the proportion of the population at low risk and to ensure that all groups benefit, the strategy with the greatest potential is the one directed at the whole population, not just people with high levels of risk factors or estab￾lished disease (5). All other strategies will, at best, only blunt the epidemics and likely in￾crease inequalities; they will not prevent the epidemics. Even so, with ageing populations, health systems will continue to face the unrelenting demands of costly care, both acute and chronic (see Box 1.3 in Chapter 1). The ultimate public health policy goal is the reduction of population risk, and since most of the population in most countries is not at the optimal risk level, it follows that the majority of prevention and control resources should be directed towards this goal in the entire popula￾tion. Evidence is available in support of the cost-effective policies required for the task of making the small – but powerful and surprisingly rapid – shifts in risk distributions in entire populations in a favourable direction (1). Similarly, management decisions based on meas￾ures of overall risk are more cost-effective than those based on single risk factors. Untold lives lost are lost unnecessarily because of inadequate acute and long-term manage￾ment of CVD. Relatively cheap interventions for CVD are available (6), and single combina￾tion pills including aspirin and drugs for blood pressure and cholesterol lowering for possible use in chronic care are under development. Even in wealthy countries, however, the potential of these and other interventions for secondary prevention is far from fully utilized. The situ￾ation in poorer countries is even less satisfactory. There are many opportunities for coordi￾nated CVD risk reduction, care and long-term management. Smoking cessation and the identification and management of diabetes, for example, are just two priorities. Cost-effec￾tive interventions, such as the use of aspirin in people with symptoms of chest pain, would prevent a quarter of the deaths associated with heart attacks and are much more cost-effec￾tive than more radical interventions such as revascularization procedures, which are inevita￾bly restricted to a minority of patients with CVD. Acting now and measuring progress There have been striking and rapid reductions in CVD death rates in wealthy countries – especially benefiting the wealthiest and most educated – because of comprehensive approaches including both improved prevention and the management of high-risk people. Policy inter￾ventions in developed and developing countries can lead to a surprisingly rapid response. In Mauritius, government action to encourage consumption of healthy oils resulted in a rapid decrease in population levels of blood cholesterol. In Finland, government agricultural sub￾sidies were used to reduce dairy farming and increase berry production. And in Poland, in￾creased consumption of fresh fruit and vegetables, consequent to changes in the policy environment, were associated with a sharp decline in CVD death rates. A WHO/FAO expert consultation report on diet, nutrition and the prevention of chronic diseases reviewed the