'We Are Still Challenged to be Dissatisfied'
These words from Dr Martin Luther King, Jr. ring true in today's global quest for equity and a greater measure of social justice in every field, no less so when it comes to disease prevention and access to health care itself. The time is long past when chronic non-communicable diseases (NCDs) were a problem mainly for the well-to-do and the industrialized nations. With longer life expectancies in most countries and the globalization of "Western" diets and sedentarism, the main burden of disease and death from these conditions is falling on already-disadvantaged developing countries and poor communities everywhere. Over 80% of chronic disease deaths occur in low- and middle-income countries.
For years, public health workers have sounded the alarm about an approaching health tsunami-mainly from cardiovascular diseases, cancer, diabetes and chronic respiratory diseases-that could bring down entire health systems, wreck already fragile economies, and kill poor people by the millions. Today, the NCD pandemic is already upon us: it causes over 36 million deaths annually, more than from all other causes combined, and demands a systemic and global response.
This September, the UN High-Level Meeting on NCDs was called to discuss the crisis and its implications for human development. The meeting was rightly hailed as an historic opportunity to focus global policy attention and mobilize concrete actions-and needed resources-to address the NCD wave worldwide. As Cuba's Public Health Vice Minister, Dr Luis Estruch, said when he addressed the meeting: "No single country can avoid the lethal and economically unsustainable effect of non-communicable diseases, but we can fight them if we unite around clear policies."
Yet, the sessions' results met such expectations only partially. As expressed by the NCD Alliance-an advocacy network of some 2000 nongovernmental organizations from 170 countries-the meeting "made the world sit up and take notice," but its declaration stopped disappointingly short of setting specific targets. It is now up to regional initiatives and national governments to build on the meeting's momentum, set ambitious yet feasible goals, draft plans of action and find the resources to make them work effectively.
For this issue of MEDICC Review, we are pleased to have as guest editor Dr Pedro Ordúñez, a leading public health expert who advises PAHO and the WHO on chronic disease prevention and control. Dr Ordúñez coordinated the recent PAHO multi-country consultation to develop priorities for cardiovascular health in the Americas. His Policy & Practice opens this issue (Cardiovascular Health in the Americas: Facts, Priorities and the UN High-Level Meeting on Non-Communicable Diseases), describing the regional complexities of the crisis and the active search for solutions.
'Complex' may be too lean a word to describe the conditions in which pioneering community-based research is being conducted by Dr Orantes and colleagues in El Salvador's poorest rural areas (Chronic Kidney Disease and Associated Risk Factors in the Bajo Lempa Region of El Salvador). The communities that joined in the study are under water, hit by torrential rains that have provoked a national state of emergency. It is unclear what primary data may have been lost in this vital study to determine the role of agricultural chemicals and other risk factors in an epidemic that has made chronic kidney disease the number two cause of death among men in Salvadoran hospitals. The research adapted methodology from Cuba's Isle of Youth Study (ISYS) on vascular NCDs and their risk factors (see MEDICC Review, Fall 2007).
In Cuba, cardiovascular diseases remain the leading cause of death and premature death. This has prompted efforts to develop a more robust and comprehensive monitoring system for these NCDs and their risk factors, based on longitudinal followup in national, provincial and now municipal studies (Interview with Dr Mariano Bonet: New Survey Results Enhance Cuba's NCD Surveillance). The interview also furnishes the first preliminary results from the 2010 National Survey on Risk Factors and Chronic Diseases, revealing trends over the last 15 years.
One gap identified in NCD monitoring in Cuba is the lack of a national registry for acute myocardial infarction-similar to the National Cancer Registry developed as far back as 1964-to support comprehensive epidemiologic analysis and progress assessment. Laying the foundation for such an AMI registry are local studies such as the one published in this issue by Dr Morales (Acute Myocardial Infarction Incidence, Mortality and Case Fatality in Santa Clara, Cuba, 2007-2008).
Dr Llibre's research (Dementia and Other Chronic Diseases in Older Adults in Havana and Matanzas: The 10/66 Study in Cuba) presents key results for shaping public health policy in Cuba, a country with one of the fastest aging populations in the Americas.
Finally, three articles in this issue address risk factors identified as essential to NCD control by both the regional strategy for the Americas and the UN High-Level Meeting: Dr González's Perspective (Alcohol: Friend or Foe?), examining evidence for both potential benefit and harm of alcohol consumption; Dr Varona's research on Tobacco and Alcohol Use in Cuban Women, and Dr Suárez's Viewpoint (Women & Smoking: Becoming Part of the Solution). The last two also foreshadow our April 2012 issue devoted to A Gender Perspective in Cuban Health.
We dedicate this issue of MEDICC Review to former contributing editor Debra Evenson, who died of cancer in August. An authority on Cuban law and labor relations, Debra also published on human rights and health. She was a long-time collaborator of the journal and cherished friend of our staff. Her grace, keen mind, spirit and courage will continue to inspire us all.
1. Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA. 2004;291:2616-22.
2. World Health Organization. Global Status Report on Non-communicable Diseases 2010 [Internet]. Geneva: World Health Organization; 2011 May [cited 2011 Oct 21]. 176 p. Available from: http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf
3. The NCD Alliance. UN High-Level Meeting Puts NCDs on the Map, Falls Short of Setting Goals or Targets. Press Release. 19 September 2011 [cited 2011 Oct10]. Available from: http://www.ncdalliance.org/node/3517