1
Introduction

As the leading cause of death worldwide, cardiovascular disease (CVD) has a major impact on both developed and developing nations. Although the spotlight is more often on the global burden of mortality associated with malaria, tuberculosis, and HIV/AIDS, CVD causes more than three times the annual deaths of these three diseases combined. Indeed, nearly 30 percent of all deaths in low and middle income countries are attributable to CVD, and more than 80 percent of CVD-related deaths worldwide now occur in low and middle income countries (WHO, 2008b). This health burden is accompanied by a deleterious economic impact. However, despite the significant and growing health and economic burden in low and middle income countries, CVD and related chronic diseases are not included by most stakeholders in their investments and commitments to improving the health of the world’s people.

CVD and related chronic diseases were once considered to be diseases of industrialized nations. However, in recent years an increasingly robust body of epidemiological evidence has highlighted the proliferation of CVD risk factors worldwide, including obesity, hypertension, and diabetes. The worsening of cardiovascular health around the world—and most notably in developing countries—reflects significant global changes in behavior and lifestyle. The “westernization” of dietary habits, decreased levels of physical activity, increased childhood obesity, and increased tobacco consumption—accelerated by industrialization, urbanization, and globalization—now threaten once-low-risk regions. In addition, the decline in infectious diseases and improved childhood nutrition have contributed to the aging of populations in many low and middle income countries, resulting in an increasing



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1 Introduction A s the leading cause of death worldwide, cardiovascular disease (CVD) has a major impact on both developed and developing na- tions. Although the spotlight is more often on the global burden of mortality associated with malaria, tuberculosis, and HIV/AIDS, CVD causes more than three times the annual deaths of these three diseases combined. Indeed, nearly 30 percent of all deaths in low and middle income countries are attributable to CVD, and more than 80 percent of CVD-related deaths worldwide now occur in low and middle income countries (WHO, 2008b). This health burden is accompanied by a deleterious economic impact. However, despite the significant and growing health and economic burden in low and middle income countries, CVD and related chronic diseases are not included by most stakeholders in their investments and commitments to improving the health of the world’s people. CVD and related chronic diseases were once considered to be diseases of industrialized nations. However, in recent years an increasingly robust body of epidemiological evidence has highlighted the proliferation of CVD risk factors worldwide, including obesity, hypertension, and diabetes. The worsening of cardiovascular health around the world—and most notably in developing countries—reflects significant global changes in behavior and lifestyle. The “westernization” of dietary habits, decreased levels of physical activity, increased childhood obesity, and increased tobacco consumption— accelerated by industrialization, urbanization, and globalization—now threaten once-low-risk regions. In addition, the decline in infectious diseases and improved childhood nutrition have contributed to the aging of popula- tions in many low and middle income countries, resulting in an increasing 

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0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD number of individuals who survive to the age at which risk factors they accrued throughout childhood and early adulthood manifest as chronic dis- eases. This has resulted in an epidemic that is “old” in its similarity to the rise in CVD that occurred in the developed world in previous decades, yet brings with it new characteristics that are a result of contemporary global circumstances. STUDY CHARGE, APPROACH, AND SCOPE Over the past several decades, a considerable amount has been learned about the determinants of CVD as well as how to reduce CVD incidence and mortality. Building on this knowledge and the emerging evidence of the growing burden of CVD in developing countries, there has been a steady escalation of international reports, declarations, and resolutions calling attention to the growing threat of the global CVD epidemic. These are summarized in Figure 1.1 and Box 1.1 later in this chapter, where they are discussed in more detail to set the historical context for this report. These declarations, reports, and resolutions have resulted in a grow- ing recognition that CVD, and chronic noncommunicable diseases more broadly, are a worldwide problem whose burden is increasingly felt by low and middle income countries. In the past several years, this recognition has begun to translate into guidance for action. However, despite examples from the developed world that demonstrate promise and hope for the reduction of disease burden on a national level, the burden of CVD has continued to grow and concrete steps toward scaling up CVD treatment and prevention efforts in developing countries have been slow to materialize. Recognizing a need to help catalyze progress from guidance and strategies to actions, the National Heart, Lung, and Blood Institute (NHLBI) sponsored this study by the Institute of Medicine (IOM), and an ad hoc committee was convened to study the evolving global epidemic of CVD and offer conclusions and recommendations pertinent to its control. Study Charge The full Statement of Task for the Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries can be found in Appendix A. In summary, the committee was charged with synthesizing and expanding relevant evidence and knowl- edge based on research findings, with an emphasis on developing concepts of global partnership and collaborations, and on recommending actions targeted at global governmental organizations, nongovernmental organiza- tions (NGOs), policy and decision makers, funding agencies, academic and research institutions, and the general public.

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WHO 20 08 -2013 NCD Action Plan Framework Convention on Tobacco Control IOM Report : U.S. Commitment WHO Assessment of National to Global Health Capacity for Noncommunicable Disease Prevention and Control Lancet Series on Chronic Diseases 20 00 World Health Report Lancet Series on Chronic Diseases WHO World Health Report Catalonia Declaratio n Follow-Up Grand Challenges Report Disease Control Priorities in UN Resolution on Diabetes Milan Declaratio n Developing Countries 20 00 Victoria Declaratio n WHO Preventing Chronic Disease: Victoria Declaratio n Osaka Declaratio n Singapore Declaratio n A Vital Investment 1992 1994 1996 1998 2000 20 02 20 04 2006 20 08 2010 Earth Institute/ OxHA Sydney Challenge World Hear t Federation White Book IC Health Report Catalonia Declaratio n Kampala Statement WHO World Health Report WHO Global Strategy for the World Development Report Prevention and Control of Disease Control Priorities in Noncommunicable Diseases Developing Countries 2nd Ed. IOM Report : Control of CVD in WHO Global Strategy on Diet, Global Burden of Disease: Update Developing Countries Physical Activity, and Health WHO Social Determinants Report 7th JNC Report : Hypertension Towards a WHO Long -Term Strategy for Prevention and Control of Leading Chronic Diseases Figure 1-1 rev.eps FIGURE 1.1 Timeline of major documents related to global CVD. landscape 

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD In response to its charge, the committee undertook an analysis of the current state of efforts to reduce the global epidemic of CVD based on a review of the available literature and of information gathered from vari- ous stakeholders in CVD and global health. In this analysis, the committee evaluated why there has not been more action to address CVD; assessed the available evidence on intervention approaches to prevent and manage CVD, including knowledge and strategies pertinent to their implementation in low and middle income countries; and drew conclusions about the neces- sary next steps to move forward. Prior reports have identified general priorities and recommended a wide range of possible actions for a multitude of stakeholders; indeed, the findings and conclusions of this report reinforce many of those messages and priorities. In this report’s recommendations, however, the committee has emphasized advancing the field beyond messages about broad concep- tual solutions and has identified a limited set of specific actions targeted to specific stakeholders. These actions are intended to encourage a sufficient shift in the global health and development agenda to facilitate critical next steps that will build toward the eventual goal of widespread dissemination and implementation of evidence-based programs, policies, and other tools to address CVD and related chronic diseases in developing countries. Study Approach The committee met four times to deliberate in person, and conducted additional deliberations by teleconference and electronic communications. Public information-gathering sessions were held in conjunction with the second and third meetings; the complete agendas for these sessions can be found in Appendix C. The committee also commissioned several papers that informed the study; these are referenced within the report. The committee reviewed literature and information from a range of disciplines and sources. A comprehensive systematic review of all primary literature relevant to the study’s broad charge was not within the scope of the study. Instead, this report represents a summative description of the key evidence, with illustrative research examples discussed in more detail. In or- der to limit the length of this document and to avoid replication of existing work, the committee sought existing relevant, high-quality systematic and narrative reviews. In content areas where these were available, the report includes summaries of key findings, but otherwise refers the reader to the available resources for more detailed information. For intervention approaches to reduce the burden of disease, the com- mittee reviewed the literature to identify relevant examples of interventions, programs, or policies that target CVD and related CVD-risk factors, as well as to identify areas in which relatively little applicable intervention research has been conducted. The committee’s approach to the analysis

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 INTRODUCTION of intervention evidence is described in full in Chapter 5. In summary, the committee emphasized effectiveness, contextual generalizability, feasibility, and relevance for real-world implementation. Therefore, the focus was on identifying intervention approaches for CVD with evidence in developing countries. Where this evidence was limited, examples were sought that offer generalizable lessons from interventions with evidence from both CVD- specific approaches in developed countries and developing country evidence for non-CVD health outcomes. Using this approach, the report strives to move the field beyond a discussion of general intervention approaches and policy priorities in the broad terms of prior reports, such as “reduce salt consumption,” “improve diets,” “reduce tobacco use,” “increase physical activity,” and “screen and treat biological risk factors and disease.” The report achieves this by offer- ing a pragmatic review of the available evidence in the context of potential for implementation of interventions and strategies, while recognizing the complexities of heterogeneity and variability in capacity among different low and middle income countries. Indeed, the committee’s goal was to go beyond the relatively few well-known intervention examples that appear in many preceding reports to instead gather information of sufficient depth, breadth, and specificity on actual intervention implementation in order to realistically inform resource prioritization in real-world, country-specific decision making. Applying this approach revealed significant gaps in the evidence base and led to greater specificity and clarity in defining the needs to transition from knowledge to action, which has resulted in a research agenda focusing on implementation research and additional economic analysis. However, the committee does not intend that the findings highlighting ongoing research priorities be taken as a suggestion of inaction. A principle throughout the report is one of being action oriented based on available findings. Study Scope and Audiences This committee was tasked by the sponsor to focus on cardiovascular disease, which is the largest contributor to the global burden of chronic disease (WHO, 2008b). This focus was clearly mandated by the Statement of Task, but with the understanding that the report should consider CVD in the context of other related chronic diseases that share common risk fac- tors and intervention approaches, especially diabetes, cancer, and chronic respiratory disease (Nabel, 2009). The term cardiovascular disease can encompass a wide range of diseases, such as coronary heart disease, con- gestive heart failure, vascular diseases of the brain and kidney, peripheral vascular disease, congenital heart defects, and infectious cardiac disease. As evidenced in Chapter 2, the committee focused its attention primarily on the major contributors to global CVD mortality, coronary heart disease

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD and stroke, and on the major modifiable risk factors for cardiovascular diseases, especially tobacco use, unhealthy diet, physical inactivity, obesity, hypertension, dyslipidemia, and elevated blood glucose as well as broader determinants associated with risk for CVD. In addition, although not the major emphasis of the report, in some regions there continues to be a high burden of infectious cardiac disease, particularly rheumatic heart disease and Chagas disease (Muna, 1993; WHO, 2003b; WHO Study Group and WHO, 2004). Therefore, these are also reviewed briefly in Chapter 2 of the report, along with pericarditis and cardiomyopathies caused by tuberculosis (TB) and HIV. In order to identify steps to prevent and mitigate the growing burden of cardiovascular disease, the committee was charged by the sponsor to study CVD “prevention and management.” In the course of its deliberations among experts from a range of disciplines that have a role in addressing cardiovascular disease, such as public health, health communications, and cardiology, the committee found that different fields often use different terms and definitions to categorize similar intervention approaches and that many intervention approaches do not fall into clearly delineated categories. The committee felt that it was not in its mandate nor was it feasible within the study scope and timeline to come to consensus definitions of terms and their subcategories. Therefore, to prevent confusion and to avoid detracting from key messages with discussions of nomenclature, the committee refers broadly to health promotion, prevention, treatment, and disease manage- ment, but whenever possible the committee refers to specific intervention approaches descriptively rather than categorically and makes no attempt to assign them to further subcategories. Furthermore, the committee views health promotion, prevention, treat- ment, and disease management as part of a continuous spectrum. The com- mittee interpreted its charge to be inclusive of this spectrum of approaches rather than as a mandate to recommend choices among them, and the committee found that the entire range warrants attention in order to truly address CVD and related chronic diseases. Indeed, the totality of the avail- able intervention and economic evidence supports a balanced approach in which promotion and prevention is emphasized, but which also recognizes the need for effective, appropriate, quality delivery of medical interventions for risk reduction and treatment. The appropriate balance of investment in different intervention approaches across this spectrum is a challenge for evidenced-base policy decisions that is discussed in Chapter 7. The sponsor’s charge to the committee clearly anticipated that the very nature of the problem necessitates concerted action by a wide range of stakeholders. As articulated in the committee’s Framework for Action (Chapter 8), the committee also recognizes the need to be broad in the ap- proach to the problem, and thus the report has messages and recommenda-

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 INTRODUCTION tions aimed at multilateral and bilateral development and health agencies, national and subnational governments in low and middle income countries, nongovernmental organizations, professional societies, research and train- ing institutions, and the private sector (see Figure 8.2 in Chapter 8). However, unlike many of the preceding documents in the field of global chronic diseases, this report was initiated by a specific stakeholder with the will and resources to act upon its recommendations. Therefore, the committee viewed this study as first and foremost an opportunity to provide independent, external guidance to NHLBI to inform and support its emerging investments in global CVD and to help set goals and priorities that will ensure the success of current and future endeavors to incorporate global health into its activities, including its strategic partnerships with other relevant stakeholders within the United States and internationally. The committee also viewed the report as an opportunity to identify ways in which the U.S. global health agenda, along with the international global health agenda, can evolve to be more inclusive of chronic diseases, provid- ing elaboration on a mandate that was issued in the 2009 IOM report The U.S. Commitment to Global Health (IOM, 2009). As a result, the committee focused many of its recommendations on the fundamental goal of identifying actions that could be taken or supported by the study sponsor, NHLBI, and its potential partners within the U.S. government. As the ultimate recommendation language indicates, many of these actions would also be appropriate for other stakeholders, and many are recommended in the context of collaborative strategies. This relative emphasis on the U.S. government as a key target for the report’s messages does not reflect a judgment on the part of the committee that the needed worldwide actions should be centered in the United States, but simply re- flects an emphasis on the logical primary and receptive audience for a report sponsored by a U.S. government agency and conducted by the U.S. Institute of Medicine. This capacity to convey credible messages to the U.S. govern- ment gives this report the potential to have an unprecedented influence compared to prior reports on this topic. This is especially the case given its timely publication during a process of reflection and evolution of U.S. global health priorities, evidenced by the current administration’s emerging Global Health Initiative (U.S. Department of State, 2010). HISTORICAL CONTEXT A Growing Focus on Global Health The past decade has seen increased recognition that the international community must take action to improve the health of all people worldwide. In 1997, the IOM released its report America’s Vital Interest in Global

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Health, which emphasized that the United States has a vital and direct stake in the health of people around the globe and that it should increase investments in foreign aid to improve health (IOM, 1997). Since then, the U.S. government has significantly increased its development spending on health. U.S. Agency for International Development (USAID) and U.S. State Department global health program funding grew by 350 percent between 2001 and 2008, and by 2006 health aid made up 23 percent of total U.S. allocable aid (IOM, 2009; OECD, 2008). This pattern of increased fund- ing for global health by the United States can be expected to continue for the next 6 years as President Obama requested that Congress allocate $63 billion to global health between 2009 and 2014 for his new Global Health Initiative (U.S. Department of State, 2010). At the international level, the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunizations; and the Millennium Development Goals were examples of important steps in bringing global health issues to the forefront. Finally, the establishment of major private funders such as the Bill & Melinda Gates Foundation and the William J. Clinton Foundation infused significant new capital into the fight against the causes of disease and suffering. While these new investments and commitments to improving the health of the world’s people were unprecedented and have undoubtedly saved mil- lions of lives, the majority of these efforts have largely ignored CVD and other chronic noncommunicable diseases. This extends to the Millennium Development Goals, in which chronic diseases are not explicitly mentioned and are instead relegated to Millennium Development Goal 6, grouped into the catchall category of “other diseases.” International Realization of CVD Burden Although not emphasized in most major global health efforts, the increasing burden of CVD in developing countries was first recognized on the international stage at least as long ago as the first international declaration on CVD in 1956, when India proposed a resolution on CVD and hypertension at the Ninth World Health Assembly (WHO, 1956). The growing burden of chronic diseases was further highlighted by the World Bank’s 1984 report China: Health Sector, which noted the increas- ing burden of CVD among China’s health challenges (World Bank, 1984). However, evidence of the growing chronic disease burden more broadly in low and middle income countries did not begin to gain significant notice until the early 1990s. At this time, advances in epidemiological methods and metrics as well as more accurate data allowed for novel analyses of worldwide disease burden (Jamison et al., 1993). These analyses shed light on the truly global impact of CVD and other chronic diseases and helped

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 INTRODUCTION instigate a number of international reports, declarations, and resolutions calling attention to the growing threat of the global CVD epidemic. These efforts from the past two decades are described briefly here and summarized in Figure 1.1 and Box 1.1. Documentation of the Disease Burden One of the first such publications to highlight the global burden of CVD and chronic diseases was the 1993 World Development Report by the World Bank. This report focused on the critical role that investments in health play in international development, also emphasizing the rising burden of chronic diseases in low and middle income countries. The report also introduced the Global Burden of Disease study, which definitively es- tablished that chronic diseases are responsible for more deaths worldwide than any other cause (Murray and Lopez, 1996; WHO, 2003b). As the realization of the true global burden of CVD began to grow among the international public health community, several major reports examined national capacities to implement CVD prevention and treatment programs. These reports, most notably the 1999 World Heart Federation White Book on the Impending Global Pandemic of Cardiovascular Diseases (Achutti et al., 1999) and the 2001 World Health Organization (WHO) As- sessment of National Capacity for Noncommunicable Disease Prevention and Control (Alwan et al., 2001), found that the majority of countries did not have chronic disease control policies, programs, funding, or the will to take action. As a result, there was little prevention or control under way. A series of reports from multilateral organizations further examined the growing burden of CVD and other chronic diseases in developing countries. These included the 2000, 2002, and 2005 World Health Reports and the Global Burden of Disease Reports from 1996, 2006, and 2008 (Lopez and Disease Control Priorities Project, 2006; Murray and Lopez, 1996; WHO, 2000, 2002, 2008b, 2008c). In addition, the 2004 Earth Institute/IC Health Report, which examined the social and macroeconomic impact of the grow- ing CVD epidemic, concluded that the burden of cardiovascular mortality and disability was likely to drastically affect working-age adults in develop - ing countries, leading to substantial reductions in productivity and ensuing economic losses (Leeder et al., 2004). Taken together, these reports established that CVD is the number one cause of death worldwide, that about 80 percent of these deaths occur in low and middle income countries, that the disease burden will only increase in the coming decades, that it will likely have detrimental economic impacts on low and middle income countries, and that control efforts are not suf- ficient to address the disease burden. These data and projections forced the realization that the global health agenda must expand beyond infectious

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD diseases and maternal and child health to include CVD and other chronic diseases. These reports also recognized that global CVD is a complex prob- lem, influenced by interdependent factors that involve many sectors and stakeholders extending far beyond the realm of health and public health systems. Calls for Action As the new disease burden data were making the true worldwide toll of CVD increasingly clear, calls for action were issued from a number of sources. In 1998 the IOM released a report titled Control of Cardiovascular Diseases in Developing Countries: Research, Development, and Institu- tional Strengthening. It offered recommendations to better document the magnitude of cardiovascular disease burden, use case-control studies to develop prevention strategies, address risk factors such as hypertension and tobacco use, evaluate low-cost drug regimens, improve the affordability of care for CVD, build research and development capacity, and develop institutional mechanisms to facilitate CVD prevention and control (IOM, 1998). In a series of declarations from the International Heart Health Con- ferences, the cardiovascular community called on multinational organi- zations, governments, civil society, and communities to take immediate action on CVD prevention and control. The first of these was the Victoria Declaration in 1992, which was subsequently followed by the Catalonia Declaration (released in 1995 with a follow-up in report in 1997), the Singapore Declaration in 1998, the second Victoria Declaration in 2000, the Osaka Declaration in 2001, and most recently the Milan Declaration in 2004 (Advisory Board of the Fifth International Heart Health Con- ference, 2004; Advisory Board of the First International Conference on Women, Heart Diseases, and Stroke, 2000; Advisory Board of the Fourth International Heart Health Conference, 2001; Advisory Board of the In- ternational Heart Health Conference, 1992; Advisory Board of the Second International Heart Health Conference, 1995; Grabowsky et al., 1997; Pearson et al., 1998). In addition to the declarations of the International Heart Health Con- ferences, a number of other reports and resolutions highlighted the grow- ing worldwide epidemic of CVD and related chronic diseases and issued additional calls to action for its prevention and control. These included the United Nations (UN) Resolution on Diabetes announced in 2007, the 2008 Sydney Resolution and Sydney Challenge from the Oxford Health Alliance Summit, and the 2009 Kampala Statement (Chronic Disease Summit, 2009; The Sydney Resolution, 2008; United Nations General Assembly, 2006). In

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 INTRODUCTION 2009, the IOM report The U.S. Commitment to Global Health also rec- ognized the need to apply resources to chronic diseases in the developing world as part of the global health agenda (IOM, 2009). Taken together, these publications shone a brighter spotlight on the burden of CVD, placed increasing pressure on national governments and the international community, and offered recommendations to tackle the issue of CVD. However, despite these calls for action, implementation of CVD prevention and control programs in developing countries has been slow to materialize. New Strategies, Policies, and Partnerships To try to initiate implementation of these calls for action, the inter- national community has begun to take steps to develop strategies and plans for action. While serving as director general of WHO, Gro Harlem Brundtland elevated the treatment and control of chronic diseases to the same level of urgency as infectious diseases. In 1999, Brundtland pre- sented the WHO Executive Board with a draft Global Strategy for the Pre- vention and Control of Noncommunicable Diseases, which emphasized improving chronic disease surveillance, addressing common risk factors, and improving primary care services worldwide (Brundtland, 1999). This Global Strategy was later discussed at the Fifty-Third World Health As- sembly, where the Assembly called on the Director General to continue prioritizing chronic diseases and urged Member States to redouble their noncommunicable disease surveillance, prevention, and control efforts (WHA, 2000). In 2003, after 5 years of unprecedented negotiation, the Member States of WHO unanimously adopted the Framework Convention on Tobacco Control, the first and only legally binding treaty ever adopted by WHO. This treaty called for the implementation of tobacco reduction strategies and new regulatory policies, and a formal reporting mechanism on progress is being implemented (WHO, 2003a). This was followed by the 2004 WHO Global Strategy on Diet, Physical Activity, and Health as well as the 2007 Grand Challenges in Global Health report in Nature (Daar et al., 2007; WHO, 2004), which outlined research and policy priorities for chronic dis- eases. The 2008 release of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (WHO, 2008a) established a policy framework for action, with specific recommendations for WHO, Member States, and civil society. However, this action plan does not specify who will act on specific recommendations, what resources they need, and to whom governments would be accountable for inaction.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 1.1 Continued community from vertical, disease-specific initiatives to a more horizontal, health systems strengthening emphasis. Furthermore, the report estimated that non- communicable diseases together contributed to almost 60 percent of global mortality (33.5 million deaths) and 43 percent of the global burden of disease in 1999 (WHO, 2000). 2001 The Osaka Declaration: Health, Economics and Political Action: Stemming the Global Tide of Cardiovascular Disease This declaration furthered the process started by previous heart health declara- tions by reviewing the factors outside of the health sector, specifically social, economic, and political factors, that have contributed to the lack of progress in CVD prevention and promotion globally. It also argued for the crucial advocacy role for health professionals and their organizations to influence health system governance and address systemic barriers to achieving health. The declaration also examined global forces beyond the health system that affect the awareness, understanding, and commitment to take global action on CVD prevention (Advi- sory Board of the Fourth International Heart Health Conference, 2001). 2001 WHO Assessment of National Capacity for Noncommunicable Disease Prevention and Control This report described the national capacity for noncommunicable disease pre- vention and control in WHO Member States based on a survey conducted in 2001. The survey found that fewer than half the WHO Member States had chronic disease policies and that only about two-thirds of the countries had tobacco or food and nutrition legislation. Furthermore, fewer than two-thirds of the countries had a chronic disease unit in their ministries of health, and fewer than 40 percent had a specific chronic disease budget line. The report highlights the traditional lack of attention that chronic diseases receive in many coun- tries around the world despite their increasing prevalence and responsibility for morbidity and mortality. The report identifies a number of areas in which WHO could provide technical support and emphasized the need for countries and the international community to strengthen their capacity to prevent and treat chronic diseases (Alwan et al., 2001). 2002 2002 World Health Report The 2002 World Health Report focused on reducing risks and promoting healthy lives. The report highlighted the world’s 10 leading risk factors that account for more than one-third of deaths worldwide. It went on to suggest effective and efficient strategies governments and the international community can employ to reduce the prevalence of these risk factors, thus saving millions of lives. Five of the risk factors highlighted in the report—hypertension, tobacco consumption, alcohol consumption, high cholesterol, and obesity—are key cardiovascular risk factors. The report emphasizes the increasing global burden of CVD, especially its rise in low and middle income countries, citing the dual epidemics of infec- tious and noncommunicable diseases that many developing countries are now facing. The report’s focus on risk-factor reduction and its prominent use of key

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 INTRODUCTION CVD risk factors provides further validation of the gravity of the worldwide CVD epidemic and signals the growing recognition from the global health community of the importance of addressing CVD in developing countries (WHO, 2002). 2003 Framework Convention on Tobacco Control This treaty, adopted by the World Health Assembly on May 21, 2003, was the first negotiated under the auspices of the World Health Organization and has since become one of the most rapidly adopted international treaties in his- tory, having been ratified by nearly 170 countries. The treaty was developed in response to the global tobacco epidemic and represents a shift in the way the world addresses regulation of addictive substances by stressing the importance of reducing demand for tobacco. The treaty encourages countries to strengthen their tobacco control policies by enacting price, tax, regulatory, and social mea- sures to reduce demand. The treaty represents a major milestone in the global fight to reduce chronic disease risk factors and has prompted previously unseen international collaboration around tobacco control (WHO, 2003a, 2010). 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The JNC7 report summarized the available scientific evidence on hypertension and offers guidance to primary care clinicians. The report specified hyperten- sive risk thresholds for adults and offered guidelines for appropriate treatment with antihypertensive medication. The report cited the significant success in awareness and reduction of hypertension in the United States, with awareness increasing from 51 to 70 percent by 1999-2000. It also reported that since 1972, age-adjusted death rates from stroke and coronary heart disease (CHD) had de- clined by approximately 60 and 50 percent, respectively. This provides evidence that CVD mortality can be significantly reduced with comprehensive treatment and prevention programs (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2003). 2004 Towards a WHO Long-Term Strategy for Prevention and Control of Leading Chronic Diseases This report recommended seven strategic initiatives for action by WHO. It de- scribed the health and economic impacts of chronic diseases and the long-term drivers underlying their spread, and it analyzed the deeply entrenched policy responses to the epidemic of chronic diseases. The resulting strategy builds on the existing efforts of the WHO noncommunicable disease cluster and takes a long-term, strategic global view (Yach and Hawkes, 2004). 2004 WHO Global Strategy on Diet, Physical Activity and Health The goal of this report was to guide the development of environments that en- able sustainable actions at individual, community, national, and global levels that, when taken together, will lead to reduced rates of disease and death that are related to unhealthy diet and physical inactivity. These actions would have potential for public health gains worldwide and would support the UN Millen- continued

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0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 1.1 Continued nium Development Goals. The Global Strategy sought to help reduce chronic disease risk factors stemming from poor diet and lack of physical activity through essential health action; increase overall awareness of the influences of diet and physical activity on health; encourage the development, strengthening, and implementation of policies and action plans to improve diets and increase physical activity; and monitor scientific data and support research on diet and physical activity (WHO, 2004). 2004 The Milan Declaration: Positioning Technology to Serve Global Heart Health This declaration followed up on the previous International Heart Health Declara- tions by calling for the international community to mobilize new and existing technologies to improve heart health. The declaration examined a range of technologies—including health promotion and disease prevention, informa- tion and communication technology, food technology, medical technology, and biotechnology—and their potential to reduce the burden of CVD. A key consider- ation identified for all governments was balancing highly technical and expensive technologies that benefit a small number of individuals and population-level strategies that enhance the health status of the entire population. The declara- tion stressed that a comprehensive range of treatment and prevention strategies is essential to control the global CVD epidemic and that treatment technology options need to be effective but also sustainable and affordable (Advisory Board of the Fifth International Heart Health Conference, 2004). 2004 Earth Institute/IC Health Report This report examined the social and economic impact of CVD, now and for the next 40 years, in one low income and four middle income countries. It also re- viewed existing data on the costs and benefits of strategies for the prevention of CVD. The report offered six conclusions emphasizing the need to put CVD in low and middle income countries on the international health and development agen- das, more accurately document the prevalence and costs of CVD worldwide, develop partnerships at the macroeconomic level with national governments in key developing countries, establish health worker training programs about CVD, undertake trial treatment and prevention interventions, and establish a long-term research base for CVD interventions (Leeder et al., 2004). 2005 WHO Preventing Chronic Disease: A Vital Investment This report made the case for urgent action to halt and reverse the course of the growing chronic disease epidemic worldwide. It sought to dispel the mispercep- tion that chronic diseases are diseases of the affluent and do not affect those in low and middle income countries. It estimated 80 percent of chronic disease- related deaths in 2005 to be in low and middle income countries and in younger people than in high income countries. The report stressed that the growing threat of chronic diseases can be overcome using existing knowledge and highly cost- effective interventions and provided suggestions for how countries can imple- ment interventions to reduce and prevent chronic diseases (WHO, 2005a).

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 INTRODUCTION 2005 2005 World Health Report This World Health Report highlighted maternal and child health issues. One of the major foci of the report was achieving universal access to health services, which the report stressed could be achieved through health systems strength- ening. The report emphasized that this strengthening needed to occur at the infrastructure, workforce, and health systems funding levels. The report also tied maternal and child health efforts to chronic diseases by recognizing that the antecedents of many of these diseases occur in early life, and, as such, improving health early in life is an important component of preventing the early onset of chronic diseases (WHO, 2005b). 2005 Lancet Series on Chronic Diseases The first of two Lancet series on chronic diseases, this set of articles called attention to the major gap in the global health discourse regarding chronic dis- eases. The series noted that chronic diseases were not listed in the Millennium Development Goals and warned that if they continue to be ignored by the global health community, the progress gained from reducing the burden of infectious diseases would be eclipsed by a rising burden of chronic diseases in developing countries (Epping-Jordan et al., 2005; Fuster and Voûte, 2005; Horton, 2005; Reddy et al., 2005; Strong et al., 2005; Wang et al., 2005). 2006 Disease Control Priorities in Developing Countries 2nd Edition (DCP2) This follow-up to the original Disease Control Priorities in Developing Countries brought together 350 specialists from diverse fields and proposed context- sensitive policy recommendations to significantly reduce the burden of disease in developing countries. The book included a chapter that specifically discussed CVD and further called into focus the sizable burden of the disease in devel- oping countries. It estimated the economic burden of CVD in low and middle income countries and updated and expanded the cost-effectiveness estimates for prevention and treatment interventions from the 1993 report (Jamison et al., 2006; World Bank, 2006). 2007 Lancet Series on Chronic Diseases The second Lancet series on chronic diseases noted the increasing recognition of the importance of chronic diseases within the global health community. It also provided a deeper, more nuanced examination of the burden of chronic diseases and predicted the reductions in burden at the population and individual level that could be achieved through prevention and treatment interventions (Abegunde et al., 2007; Asaria et al., 2007; Beaglehole et al., 2007; Gaziano et al., 2007; Horton, 2007; Lim et al., 2007). 2007 UN Resolution on Diabetes In January 2007, the United Nations established November 14 World Diabetes Day, as an official United Nations Day. The resolution recognized diabetes as a widespread and serious chronic disease that threatens international develop- ment and the achievement of the Millennium Development Goals. It also recog- nized that diabetes prevention and control should be included in health-system continued

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 1.1 Continued strengthening efforts. The resolution is important because it was an additional sign that the international health community was increasingly recognizing the threat posed by noncommunicable diseases and the necessity to invest in their prevention and control (United Nations General Assembly, 2006). 2007 Grand Challenges in Chronic Non-communicable Diseases This article identified the top 20 policy and research priorities for chronic non- communicable diseases. These grand challenges are intended to guide policy and research in an evidence-based manner and make the case for worldwide debate, support, and funding. The authors asserted that with concerted ac- tion following the blueprint outlined in the article, 36 million premature deaths from chronic noncommunicable diseases can be averted by 2015 (Daar et al., 2007). 2008 Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the WHO Commission on Social Determinants of Health This report of the Commission on Social Determinants of Health examined how health-damaging experiences are unequally distributed within and across societies as a result of unfair economic arrangements, poor social policies, and discriminatory politics. The report calls on the international community to close the health gap in a generation, setting out key areas—daily living conditions, social and cultural inequalities, and the need for governments committed to equity—in which action is needed. It provided analysis of these social deter- minants of health and concrete examples of types of action that have proven effective in improving health and health equity in countries at all levels of socio- economic development (CSDH, 2008). 2008 Oxford Health Alliance Sydney Resolution and Sydney Challenge (The Sydney Resolution) The Sydney Resolution and Challenge were the outcomes of the 2008 Oxford Health Alliance Summit and served as a call to action for the international community to make healthier choices to turn back the rising tide of preventable chronic diseases. The resolution explained that 50 percent of the world’s deaths are caused by four preventable chronic diseases: CVD, diabetes, chronic lung disease, and cancer. The resolution stressed that these four diseases place immense costs on society, threaten economic stability, and push individuals fur- ther into poverty. The resolution challenged the international community to take urgent action and prioritize health-promoting decisions in urban planning, food manufacturing and policy, business decisions, and public policy (The Sydney Resolution, 2008). 2008 Global Burden of Disease 2004 Update This update to the Global Burden of Disease report, based on 2004 data, revised previous estimates of the burden of ischemic heart disease (IHD) and diabetes

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 INTRODUCTION based on more accurate data, resulting in a significantly increased estimate of the global burden of these chronic diseases. These revisions increased the es- timated disability-adjusted life years for IHD by 7 percent. The report also used new data to recalibrate the long-term case fatality rates for cerebrovascular dis- ease, decreasing the prevalence of stroke survivors and, as a result, decreasing the estimate of global years lost to disability due to cerebrovascular disease by 30 percent. The report stressed that of every 10 deaths globally 6 are caused by noncommunicable diseases and that CVD was the leading cause of death worldwide. CVD was responsible for 32 percent of global deaths in women and 27 percent of the deaths in men in 2004. The report also affirmed that IHD and cerebrovascular disease were the number one and two causes of death in high and middle income countries, and that IHD was the number two cause of death in low income countries. Furthermore, the update projected that CVD burden would continue to increase in low and middle income countries (WHO, 2008b). 2008 WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases This action plan, directed at the international development community as well as government and civil society, makes the case for urgent action to enact chronic disease prevention and control programs. The document provides a policy framework for action, outlining a series of objectives and action items for key stakeholder groups at varying levels of the global health system. It further urges WHO Member States to develop national policy frameworks, establish prevention and control programs, and share their experiences and build capacity internationally to address chronic diseases. Recognizing that 80 percent of the chronic disease burden is in developing countries and that the disease burden is projected to increase over the next 10 years, the plan places particular focus on low and middle income countries. The action plan was endorsed by all 193 Member States during the World Health Assembly in May 2008 (WHO, 2008a). 2009 The IOM Report: The U.S. Commitment to Global Health This report examined the U.S. commitment to global health and articulated a vision for future U.S. investments and activities in this area. Coinciding with the U.S. presidential transition, the report outlined how the U.S. global health enter- prise, which includes both government agencies and nongovernmental organiza- tions, can improve global health under the leadership of a new administration. The report identified five key areas for action by the U.S. global health enterprise: scaling up existing interventions; generating and sharing knowledge to address health problems endemic to the global poor; investing in people, institutions, and capacity building with global partners; increasing the U.S. financial com- mitments to global health; and setting an example of engaging in partnerships. The report also included an emphasis on the rising tide of noncommunicable diseases in low and middle income countries, specifically recommending that the United States increase attention to chronic diseases and adopt a leadership role in reducing deaths from chronic diseases and tobacco-related illnesses (IOM, 2009). continued

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 1.1 Continued 2009 Kampala Statement This statement was a product of a summit, Preparing Communities: Chronic Diseases in the Developing Regions of Africa and Asia hosted by the Aga Khan Development Network, in Kampala, Uganda. In the Statement the As- sembly of Kampala agreed: “1) to implement the WHO Action Plan . . . and create the basis for a multisectoral chronic disease alliance in Asia-Africa, and to accelerate progress by sharing resources, expertise, and experi- ences to promote an integrated and evidence-based approach to reducing the health and economic burdens of chronic diseases; 2) that governments and multisectoral partners at all levels will provide the leadership vital to further refine and advance the directions developed during this summit; and 3) to build upon and expand the momentum generated at this summit and monitor and report back on progress in 2011 in New Delhi, India” (Chronic Diseases Summit, 2009). REFERENCES Abegunde, D. O., C. D. Mathers, T. Adam, M. Ortegon, and K. Strong. 2007. The bur- den and costs of chronic diseases in low-income and middle-income countries. Lancet 370(9603):1929-1938. Achutti, A., I. Balaguer-Vintro, A. B. d. Luna, J. Chalmers, A. Chockalingam, E. Farinaro, R. Lauzon, I. Martin, J. G. Papp, A. Postiglione, and K. S. Reddy. 1999. The world heart federation’s white book: Impending global pandemic of cardiovascular diseases: Challenges and opportunities for the prevention and control of cardiovascular diseases in developing countries and economies in transition. Edited by A. Chockalingam and I. Balaguer-Vintro. Spain: Prous Science. Advisory Board of the Fifth International Heart Health Conference. 2004. The Milan Dec- laration: Positioning technology to serve global heart health. http://www.international hearthealth.org/Publications/milan_declaration.pdf (accessed February 5, 2009). Advisory Board of the First International Conference on Women, Heart Diseases, and Stroke. 2000. The 000 Victoria Declaration—women, heart disease and stroke: Science and pol- icy in action. http://www.internationalhearthealth.org/Publications/victoria_eng_2000. pdf (accessed February 5, 2009). Advisory Board of the Fourth International Heart Health Conference. 2001. The Osaka Declaration: Health, economics and political action: Stemming the global tide of cardio- vascular disease. http://www.internationalhearthealth.org/Publications/Osaka2001.pdf (accessed February 5, 2009). Advisory Board of the International Heart Health Conference. 1992. The Victoria Decla- ration on Heart Health. http://www.internationalhearthealth.org/Publications/victoria_ eng_1992.pdf (accessed February 5, 2009). Advisory Board of the Second International Heart Health Conference. 1995. The Cata- lonia Declaration: Investing in heart health. http://www.internationalhearthealth.org/ Publications/catalonia1995.pdf (accessed February 5, 2009). Alwan, A. D., David Maclean, and Ahmed Mandil. 2001. Assessment of national capacity for noncommunicable disease prevention and control: The report of a global survey. Geneva: World Health Organization.

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