IJE Advance Access originally published online on January 30, 2006
International Journal of Epidemiology 2006 35(2):494-495; doi:10.1093/ije/dyi316
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Letter to the Editor |
Non-communicable diseases in low-income and middle-income countries: a debate?
London School of Hygiene & Tropical Medicine, London, UK
E-mail: Shah.ebrahim{at}lshtm.ac.uk
There is little difference between Strong et al.'s1 position on the prevention of chronic diseases and our own views. The purpose of our editorial was to highlight some the issues and areas of contention that have been brought up by our colleagues, funders, and policy makers in recent years.2 We did not seek, nor do we believe we have promulgated, misunderstandings about the burden of chronic diseases, their causes, or their prevention. We do understand that for the World Health Organization (WHO) and other agencies, which have a role in advocacy, debate may not be perceived as helpful. The issues we tackled—expectations associated with the increase in chronic diseases, the value of aetiological studies in low-income and middle-income countries, the need for locally derived evidence on the cost-effectiveness of interventions, and the importance of integration of chronic disease programmes into existing primary and secondary care systems—are legitimate topics for debate and, paradoxically perhaps, may help engage policy makers who seem relatively immune to exhortations from international agencies.
Contrary to the view of Strong and colleagues, we do not dispute DALYs as a burden of disease measure or their methodology. However, the global burden of disease project does not make explicit how much data is estimated or the absence of much needed epidemiological surveillance. WHO continues to set examples of good practice here with the MONICA studies—sadly now abandoned—and the more recent STEPS project that we described as positive examples.
The WHO Global Infobase uses the best available estimates of health statistics, but the user is not warned of the potential hazards of combining data from different WHO regions. In our example, the ASEAN countries belong to the WHO South East Asian and Western Pacific Regions. We presented our figure, prior to publication, to the WHO staff responsible for the Global Infobase and were told that the estimates are not directly comparable across regions. Our surprise was not that countries in the ASEAN region had estimates that were broadly credible, but that countries of similar socioeconomic development, such as Cambodia and Laos (in the same WHO Western Pacific region), had estimates that differed by two orders of magnitude. A recent well-conducted random survey of diabetes and cardiovascular risk factors in Cambodia has provided an adult prevalence of obesity (BMI 30+ kg/m2) of 1% in a rural area and 3.4% in a semi-urban area, which compares with a Global Infobase estimate of 0.1%.3 We think it is perfectly reasonable to draw the attention of end-users to such marked variability in estimation as it is only through use and revision that information is improved.
We welcome and agree with WHO's strategy for the prevention of chronic diseases and did cite it positively in our editorial.4 While Strong and colleagues think the time for debate is over, it is perfectly clear that in most low-income and middle-income countries the issues we discuss are far from clarified—hence the need for WHO's Preventing Chronic Diseases document. The most important tool for action—resources focused on chronic disease control and prevention—is lacking in virtually all low-income and most middle-income countries. Getting the resources in place involves debate with those who have competing priorities and are selling different visions of the future. As scientists, we would emphasize the importance of relevant and robust evidence of the effectiveness, and where possible, the cost-effectiveness, of population and high-risk strategies for the prevention of chronic diseases.
References
1 Strong K, Mathers C, Epping-Jordan J, Beaglehole R. Preventing chronic diseases. A priority for global health. Int J Epidemiol 2006:35:492–94.
2 Ebrahim S, Smeeth L. Non-communicable diseases in low and middle income countries: a priority or a distraction? Int J Epidemiol 2005;34:961–66.
3 King H, Keuky, Seng S, Khun T, Roglic G, Pinget M. Diabetes and associated disorders in Cambodia: two epidemiological surveys. Lancet 2005;366:1633–39.[CrossRef][ISI][Medline]
4 World Health Organisation. Preventing Chronic Disease: A Vital Investment. Geneva: WHO, 2005.
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