University of Zambia Medical Library

Chronic Disease Epidemics in Developing Countries: Can We Telescope Transition?

By K. Srinath Reddy, Professor of Cardiology, All India Institute of Medical Sciences, New Delhi

The nutrition transition that is rapidly occurring in the developing countries as well as the tobacco toll that is projected to mount menacingly in the next quarter century testify to the validity of these concerns and emphasize the urgency for appropriate and adequate public health responses.

NUTRITION TRANSITION:
A rise in total fat intake and decline in carbohydrate consumption (especially the complex variety), excess energy intake coupled with micronutrient deficiencies, reduced physical activity with energy-activity mismatch leading to obesity as well as excess salt intake, characterize the nutrition transition that is becoming increasingly well documented in many developing countries (5). The falling price of vegetable fat in the international market and the rising price of dietary fiber (fruit and vegetables) in the domestic markets are economic factors propelling this change. The proportion of Chinese citizens consuming >30% fat as an energy source in their daily diet rose steeply across all income classes between 1989 and 1993 (low Income: 19.1% to 36.4% ; middle Income: 19.1% to 51.0%; high Income:22.8% to 66.6%). (5) The forces of urbanization and globalization which shift production from the small farmer to the large corporation, distribution from the shopkeeper to the supermarket, consumption from fresh to processed foods and supply from local to export markets are the dynamos of this change in dietary patterns. (6) Worldover, food is becoming part of a 'common culture' that reflects the dominant forces in globalization.

TOBACCO TOLL:
The tobacco tragedy is of an even greater magnitude. The proportion of all deaths attributable to tobacco is estimated to rise in India, from 1.4% in 1990 to 13.3% in 2020 and from 9.2% to 16.0% in China during the same period. The overall global escalation would be from 6.0% to 12.3% in these 30 years, as per recent WHO projections. (7) The declining tobacco consumption patterns and the tactical, albeit limited, retreat of the tobacco industry in the developed countries are accompanied by aggressive marketing and rising consumption patterns in the developing countries.

The ready revenue and extensive employment offered by tobacco in tobacco growing nations are barriers to governmental action to control tobacco. The lure of export earnings commits these governments to support and subsidize tobacco. However, the steady decline of tobacco consumption in the developed countries and the capture of the hitherto lucrative markets of the former socialist countries by the tobacco multinationals has divested the developing countries of a substantial segment of their tobacco exports. This, in turn, would lead to saturation of the domestic markets with the surplus tobacco and a rise in total tobacco consumption. Even 1994, 61.4% of all manufactured cigarettes exported worldwide came from just four countries - the United States of America, United Kingdom, Germany and Netherlands. (7) The future will be even more bleak for the developing countries as export revenue progressively shrinks and domestic consumption perilously spirals up.

SOCIETAL EFFECTS:
The economic and social consequences of these chronic disease epidemics will be devastating. As the epidemics mature, the social gradient will reverse as has happened in other nations which have experienced their fury in full form. Even at present, several of the risk factors of chronic diseases are showing a reversal of the social gradient in many developing countries. (8, 9) The poor will become progressively vulnerable to the ravages of these diseases and will have little access to the expensive and technology intensive management that clinical care demands. Additionally, the diversion of scarce societal resources to the treatment of these disorders dangerously depletes the resources available for the 'unfinished agenda' of infectious and nutritional disorders which almost exclusively afflict the poor.

NEED FOR GLOBAL AND LOCAL RESPONSES:
These challenges call for coherent and concerted global and local multi-sectoral responses. The prescription for prevention is a combination of an empowered community, enlightened policy and an energetic profession (providers). All of these need to be catalyzed in unison to ensure that the dream of Health For All does not die young in the developing countries due to the tidal wave of chronic diseases following in the wake of the cyclone of infectious diseases.

Goeffrey Rose elegantly enunciated and eloquently espoused the 'population approach' for accomplishing substantive and sustainable reductions in the risk of chronic disease. (10) This was based on distribution shifts within individual populations. It is now time to extend the population approach to the global community as a whole. Over the last thirty years, the global distributions of risk factors like serum cholesterol, blood pressure, body mass index and tobacco consumption have shifted rightwards. This is because the risk reduction in individual countries was more than offset by the risk augmentation in the developing countries. The 'population attributable risk' of the total world population for chronic diseases has, therefore, risen. Risk reduction only in the small group of "high-risk" developed countries without addressing the risk levels of the many and populous "moderate-risk" developing countries will not favorably impact on the global burden of chronic disease. Can we reverse this trend and shift the global distribution leftwards in the next thirty years? Therein lies the challenges of global health transition.

Is it inevitable that the epidemics of chronic disease should track their course form the rich to the poor amongst countries and from the rich to the poor within countries? Eradication of disease requires the abolition of poverty as a prerequisite. This truism is equally applicable to chronic diseases as to infectious diseases. Whether recognition of the common developmental needs of the global community, across and within countries, would lead to a resurgence of liberal thought and the pursuit of equitable economic policies in the next century is difficult to predict. However the realization that wide disparities are incompatible with the common well-being of a closely integrated and interdependent world should provide impetus for greater equity in the allocation of resources for human development.

Equity, education and empowerment are critical components of any health strategy that aims to succeed. The universal availability and application of these principles will be determined by global as well as national initiatives. Global surveillance systems, for example are needed for monitoring and regulation of the production, marketing and safety of food products. These need to be supplemented by national nutritional goals and programs which will ensure that health promoting diets are available, affordable and acceptable to all sections of the community.

Similarly tobacco too requires a global agency (a Health Interpol?) to monitor the production, pricing and promotion of tobacco products. If addictive attributes and unethical enticement of young persons are confessed crimes in one country, as the recent US tobacco deal reveals, how can the offender operate unchecked elsewhere in the world? International policy maker consensus must be evolved to progressively phase out tobacco from all national economies. A Global Convention Against Tobacco, akin to the global conventions against chemical and biological weapons, would be entirely appropriate given the dimensions and the dangers of the global tobacco epidemic. This global action needs to be supported by national programs to curb tobacco consumption through both health education and regulatory restraint as well as a phased program of agro-industrial restructuring to usher in tobacco-free societies.

OPPORTUNITIES OF GLOBALISATION:
Surely the Pandora's box of globalization must contain Hope at its bottom. Despite its many negative effects, globalization also offers valuable opportunities and potential benefits. The globalization of knowledge regarding the determinants of disease, demonstrated successes of risk modification strategies and the availability of cost-effective interventions for prevention and therapy will facilitate the evolution and implementation of chronic disease control programs in the developing countries.

The progressive integration of the global economy and its growth into an interdependent entity is likely to usher in global investor concerns about the health and stability of the labor and consumer markets in the developing countries. The premature loss or lay off of productive person power spells ill for trans-national employers and the depletion of purchasing power of the consuming classes by the enfeebling financial demands of chronic disease healthcare will limit the markets available to the merchants of global goods. This reality may spur the global investor to seek and support strategies to reduce the risk of chronic diseases on a global plane and especially in the developing countries. Just-as the second phase of colonialism witnessed concerted campaigns against infectious diseases so that the colonies could be rendered safe for the colonizer, the second phase of globalization may witness corporate crusades against the risk factors of chronic disease to render the health environment of the international financial market place safe and secure for the global investor. There will, of course, be divergent interests of those who capitalize on human ill health (tobacco trade, certain sections of food & medical care industries) and those whose profit is linked to the health of human capital. The latter, however, are likely to represent the dominant global economic interests and will also occupy the high moral ground in this conflict.

The globalization of travel too could catalyze desirable health promoting developments. The peripatetic American traveler, who hitherto sought the comfort of a MacDonald burger and cola to provide a home away from home on his travels through developing countries, may increasingly seek smoke-free airports and low fat foods as he tries to sustain his newly acquired healthy lifestyle in foreign lands. The market responses to these demands of the dollar may usher in changes that find acceptance and adoption in the host communities.

The globalization of culture through the communications revolution also provides a window of opportunity. The old stereotypes of indolent self-indulgent fat guzzling role models hallooed by their smoke rings are being rapidly replaced, in the Western media, by health conscious, physically active, salad-savoring and smoke free images. The wide-ranging discussion on risk factors and healthy lifestyles now finds a global audience. These cultural influences, if appropriately utilized may disseminate health information and promote health consciousness in transitional societies at a more rapid pace than hitherto anticipated.

DECENTRALISED DECISION MAKING BY COMMUNITIES:
Even as globalization offers opportunities that may offset its harmful effects, it must be recognized that the power for determining the desirability and the direction of change rests with the people. Markets are not autonomous entities and can be molded by consumer consciousness. Creating and cultivating such consciousness is clearly the responsibility of all stockholders in health at the community level.

The power of the people to determine their destinies must also extend to health promoting behavior. Rural communities, for example, should be able to attain and retain self-sufficiency in the production, distribution and local consumption of nutrient-rich foods like fresh fruit and vegetables. National food policies must encourage and enable such decentralization. Urban planning should create environments friendly to physical activity like protected cycle lanes. The process of disease prevention and health promotion can only be participative, not prescriptive. Community empowerment is the key element in the strategy for chronic disease control and decentralization is indispensable even in the era of globalization.

TELESCOPING THE TRANSITION:
It would be unrealistic to urge the developing countries to retain their traditional ("primitive") rural lifestyles. Urbanization and globalization are inexorable forces and modernization has an irresistible appeal. Development has its own health rewards in the form of augmented life expectancy and better health care. However, if the fruits of development are not to be frittered away by the costs of chronic disease, the goal has to be development without distortions and progress without perils. To achieve this, the transition from a 'health sustaining' pre-modern lifestyle through an 'unhealthy' modern lifestyle to a 'health promoting' neo-modern lifestyle must be telescoped. Some of the sane and salubrious components of the first will be integrated into the last, by choice and not by default. The complementary forces of global espousal and local empowerment described above could be harnessed to make such telescoping possible. Thereby, the epidemics of non-communicable diseases could be abbreviated even if not averted and a substantial burden of disease, disability and death could be avoided.

Is it naive to envision such a future within the next century? The hope lies in the demonstrated strength of collective human consciousness which has made sustainable environment an article of common faith on the global political agenda within the span of the past two decades. Sustainable health too would emerge as a priority item on this agenda if the collective consciousness of the global community ably articulates its concerns. Never before in the history of human civilization have we been so imperiled by common threats, imbued with a common identity and inspired by common purpose. The chimes of the new millennium must ring in a new accord on sustainable health for the global community.

REFERENCES:

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• Murray CJL, Lopez AD. Global comparative assessments in the health sector. Geneva World Health Organization, 1994.
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• Barker DJP, Fetal origins of coronary heart disease. BMJ 1995;31 1:171-174
• Drewnowski A, Popkin BM. The nutrition transition : New trends in the global diet. Nutrition Reviews, 1 997;55 :31-34
• Lang T. The public health impact of globalisation of food trade. In Shetty PS, McPherson K (eds.) Diet, Nutrition and Chronic Disease.
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