and the problem is growing. In this context, there is a clear danger that these efforts will prove unsuccessful unless they can be prioritized, aligned, and coordinated in a way that achieves the greatest benefit at a cost that is acceptable to society. Addressing the toll of all chronic diseases, from a population health perspective, is the subject of this report.


Chronic illnesses have always been a great burden not only to those living with them but also to their societies and cultures, taking a tremendous toll on welfare, economic productivity, social structures, and achievements. Individuals with chronic illnesses have historically sought varied healers and healing institutions in their communities to alleviate suffering, but over past centuries there were few management aids for severe and progressive conditions, and survivorship was often modest at best. This problem was exacerbated by frequent lack of access to supportive or palliative care, and death often came quickly. However, even in these unfortunate historical circumstances, the state, along with many nongovernmental organizations, played important roles in the response to chronic diseases, providing almshouses and hospitals for impoverished, disabled, and otherwise sick individuals who may not have had the fiscal or social resources to remain in the community or who had been ostracized from community life because of their conditions.

In the past century, extraordinary advances in developed countries in medicine and public health, as well as economic growth leading to more widely accessible social welfare programs, have changed the chronic disease landscape dramatically. Hygienic and sanitary advances have prevented many previously common diseases. Immunizations and clinical and community interventions have substantially controlled many past causes of chronic illness, such as tuberculosis and syphilis. Good progress in reducing tobacco use has occurred, even if incomplete. Pharmacotherapy has enabled most persons with chronic mental illnesses to be deinstitutionalized, even in the absence of prevention or cure. Although there is more work to do, chronic cardiovascular diseases have been diminished in many important ways. Importantly, additional therapeutic approaches have improved the function and overall health for some persons with chronic illnesses through advances in corrective surgery, new approaches in analgesia, better rehabilitation and physical and occupational therapy, improved nutrition management, and adaptation of home and community environments for functionally impaired persons.

Despite these advances, many community-wide problems with chronic diseases remain major public health concerns. Individuals with congenital

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