Elite Panel Prescribes Tough Medicine for Noncommunicable Chronic Disease

A set of 20 "grand challenges" for a worldwide crusade against chronic but noncommunicable diseases has been proposed by an international panel.
The 20 challenges, detailed in the Nov. 22 issue of Nature, form a "global roadmap to try to do something serious about reducing the burden of chronic disease," said Stig Pramming, M.D., executive director of the Oxford Health Alliance here.
The project is similar to the 2003 Grand Challenges in Global Health initiative, spearheaded by the Bill and Melinda Gates Foundation, which was aimed at infectious diseases.
That chronic-disease strategy was developed by a panel of 155 health experts from 50 countries, who used a so-called Delphi process to agree on 20 of the most serious problems standing in the way of lowering the toll of chronic but noncommunicable diseases, Dr. Pramming and colleagues reported.
Such diseases -- including type 2 diabetes, cardiovascular disease, some cancers, and chronic respiratory conditions -- account for 60% of all deaths worldwide, Dr. Pramming said.
That's double the number of deaths arising from the combination of infectious diseases (including HIV/AIDS, tuberculosis, and malaria), maternal and perinatal conditions, and nutritional deficiencies, he and colleagues said.
And the toll is likely to rise, he said. For instance, Dr. Pramming said, type 2 diabetes affects about 190 million people, but that is expected to hit 400 million in 15 years.
The traditional approach to such diseases has been to try to find cures, but that's unlikely to make a dent in the problem before it's too late.
"We can't sit and wait for a tablet to cure obesity or diabetes, because it ain't going to happen in the next 20 years," he said. "We need to take measures now."
Luckily, for many of the diseases targeted by the panel, effective prevention methods are known, he said.
The difficulty, Dr. Pramming said, is that prevention has been treated as an individual responsibility, rather than a social goal. The 20 grand challenges -- intended to change that approach -- are grouped into six areas:
Raising public and political awareness of chronic disease.
Enhancing economic, legal, and environmental policies.
Modifying the risk factors -- for instance, by reducing tobacco use.
Engaging businesses and communities.
Mitigating the health impacts of poverty and urbanization.
And re-orienting health systems toward prevention.
The researchers, led by Abdallah Daar, D.Phil., of the McLaughlin-Rotman Center for Global Health in Toronto, also propose a range of research projects intended to find ways of solving the 20 challenges.
For instance, under the heading of modifying risk factors, they suggest prospective cohort studies to identify risk factors, nail down the size of their effects, and find the factors that reduce risk.
"This study has the potential to galvanize more effective action against chronic diseases," Dr. Daar said.
The study is likely to find broad agreement among those involved in global public health issues, commented Gerard Anderson, Ph.D., of the Bloomberg School of Public Health at Johns Hopkins, who was not involved in the study.
"I'm totally in consort with these ideas," said Dr. Anderson, noting that emphasis on chronic noncommunicable diseases is part of a health care cycle that started with infectious diseases in the early 1900s and moved on to acute disease in the latter half of the century.
"For the 21st century, we've added chronic disease," he said.
But Dr. Anderson said the high-level roadmap outlined by the researchers is only a first step and the major difficulty will be translating the proposed directions into specific programs tailored to different places and peoples.
"One size doesn't fit all," he said
In the Nature report, the researchers outlined the medical and economic costs of inaction, noting that 388 million people worldwide will die of one or more of the chronic illnesses in the next 10 years.
Over that time, China, India, and Great Britain are projected to lose $558 billion, $237 billion, and $33 billion, respectively, in national income because of lost economic activity because of heart disease, stroke, and diabetes, they said.
As many as four in every five of those deaths could be prevented by known interventions if critical barriers to their widespread use were removed, Dr. Pramming and colleagues said.
Those barriers form the 20 grand challenges identified in the study, the researchers said.
Unlike the Gates-inspired infectious diseases project, the chronic-disease initiative does not have the benefit of nearly $500 million in philanthropic support, the researchers noted. "It would be nice to find a good sponsor," Dr. Pramming said.
The project does have support from several government institutions, including the NIH, the Canadian Institutes of Health Research, the Medical Research Council of the United Kingdom, and the Indian Council of Medical Research.
But Dr. Anderson said moving the research from the high-level concepts of the Nature study to specific programs is going to require support from some of the big players, including the World Bank, the Gates Foundation, and USAID.
"Discovering what works in specific localities is the critical missing piece," he said, "and that's going to take money."