AFRO-NETS> World Health Report: Years of Healthy Life can be Increased 5-10 Years

[Claudio Schuftan <aviva@netnam.vn>]

World Health Report: Years of Healthy Life can be Increased 5-10 Years
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Worldwide, healthy life expectancy can be increased by 5-10 years if 
governments and individuals make combined efforts against the major 
health risks in each region, the World Health Organization (WHO) says 
in its new yearly report. 

The World Health Report 2002 -- Preventing Risks, Promoting Healthy 
Life -- breaks new ground by identifying some major principal global 
risks to disease, disability and death in the world today, quantify-
ing their actual impact from region to region, and then providing ex-
amples of cost-effective ways to reduce those risks, applicable even 
in poor countries. 

"This report provides a road map for how societies can tackle a wide 
range of preventable conditions that are killing millions of people 
prematurely and robbing tens of millions of healthy life," says WHO 
Director-General Gro Harlem Brundtland, MD. "WHO will take this re-
port and focus on the interventions that would work best in each re-
gion and on getting the information out to Member States." 

 From more than 25 major preventable risks selected for in-depth 
study, the report finds that the top 10 globally are: childhood and 
maternal underweight; unsafe sex; high blood pressure; tobacco; alco-
hol; unsafe water, sanitation and hygiene; high cholesterol; indoor 
smoke from solid fuels; iron deficiency and overweight/obesity. To-
gether, they account for about 40 per cent of the 56 million deaths 
that occur worldwide annually and one-third of global loss of healthy 
life years. These leading risks are comparatively much more important 
than widely believed. 

WHO calls the contrast between rich and poor people "hocking." The 
burden from many of the risks is borne almost exclusively by the de-
veloping world, while other risks have already become global. Some 
170 million children in poor countries are underweight, mainly from 
lack of food, while more than one billion adults worldwide - in mid-
dle income and high income countries alike are overweight or obese. 
About half a million people in North America and Western Europe die 
from overweight/obesity-related diseases every year. 

WHO warns that the "cost of inaction is serious." The report predicts 
that unless action is taken, by the year 2020 there will be nine mil-
lion deaths caused by tobacco, compared to almost five million a year 
now; five million deaths attributable to overweight and obesity, com-
pared to three million now; that the number of healthy life years 
lost by underweight children will be 110 million, which, although 
lower than 130 million now, is still unacceptably high. If all of 
these preventable risks could be addressed as WHO recommends (which 
WHO acknowledges is a highly ambitious goal), healthy life spans 
could increase as much as 16 plus years in parts of Africa, where 
healthy life expectancy now falls as low as just 37 years (in Ma-
lawi). 

Even in the richer developing countries, such as Europe, the United 
States, Australia, New Zealand and Japan, healthy life spans would 
increase by about five years. "Globally, we need to achieve a much 
better balance between preventing disease and merely treating its 
consequences," says Christopher Murray, M.D., Ph.D., Executive Direc-
tor of WHO's Global Programme on Evidence for Health Policy and over-
all director of World Health Report 2002. "This can only come about 
with concerted action to identify and reduce major risks to health." 

WHO has developed a unique framework for using a wide body of scien-
tific evidence to comparably assess the impact of different risks in 
a 'common currency' of lost healthy life years, called the DALY (dis-
ability-adjusted life year). This takes into account the impact of 
the different risks on mortality and on morbidity. A DALY is equal to 
the loss of one healthy year of life. Risks that result in death re-
duce life expectancy. Risks that result in short or long term morbid-
ity mean that people stay alive, but not in full health. Healthy life 
expectancy (HALE) is, therefore, lower than life expectancy. 

For example, overall life expectancy in Japan is 84.7 years for women 
and 77.5 for men, versus a healthy life expectancy of 73.6 years for 
men and women. The report divides the world into 14 different regions 
on the basis of geography and health development [see Annex (WHRre-
lease Oct 24 annex.doc)], then analyzes the risks most important in 
each area and the gains in healthy life span that can be achieved. 
The top risks vary widely, from being underweight and unsafe sex in 
most of Africa to tobacco use and high blood pressure in North Amer-
ica, Western Europe and developed countries in the Western Pacific 
such as Japan. The major risks reviewed in the report are responsible 
for a substantial loss in healthy life expectancy - on average about 
five years in developed countries and 10 years in developing coun-
tries. 

The amount of lost healthy life years due to these leading risks var-
ies by region In Canada, the United States and Cuba (highest ranked 
group in the Western Hemisphere), healthy life expectancy can in-
crease by 6.5 years, from their current healthy life expectancy of 
Canada, 69.9 years; Cuba, 66.6 years, U.S., 67.6 years. In the 
wealthiest countries of Europe, including Germany, France, Italy, 
Spain and the United Kingdom, healthy life expectancy can grow by 5.4 
years; in most of Latin America, including Argentina, Brazil and Mex-
ico, 6.9 years; in an Asian group including China, 6 years; in an-
other Asian group including India, 8.9 years. (WHO estimates apply to 
each region as a whole and may not apply to any given country.) A 
considerable part of this burden could be reduced by that of cost-
effective interventions identified in the report. 

WHO has developed a first-ever system of identifying and reporting 
cost-effective health interventions consistently across different re-
gions that it calls CHOICE (CHOosing Interventions that are Cost-
Effective). Various CHOICE options are contained in a new statistical 
database that is also a part of the World Health Report 2002, one of 
the largest research projects ever undertaken by the World Health Or-
ganization. These interventions can be implemented on an à la carte 
basis, depending on each country's individual circumstances. "Al-
though the report carries some ominous warnings, it also opens the 
door to a healthier future for all countries - if they're prepared to 
act boldly now," says Dr. Murray. "In order to know which interven-
tions and strategies to use, governments must first be able to assess 
and compare the magnitude of risks accurately. Our report gives as-
sessments for each of the major risks." 

Selected Major Risk Factors and What to Do About Them

The report shows that a relatively small number of risks cause a huge 
number of premature deaths and account for a very large share of the 
global burden of disease. For example, at least 30 per cent of all 
disease burden occurring in the highest mortality developing coun-
tries, such as those in sub-Saharan Africa and south-east Asia, re-
sults from underweight and deficiencies in micronutrients like iron 
and zinc, unsafe sex, unsafe water, sanitation, and hygiene and in-
door smoke from solid fuels, the leading risks examined in those 
countries.

"Every country has major risks to health that are known, definite and 
increasing, sometimes unchecked," says Anthony Rodgers, M.D., Ph.D., 
of the University of Auckland, New Zealand, and a WHO consultant who 
is one of the report's main writers. "For each of these risks, we 
have established effective, but often underused, interventions." The 
report also breaks new ground by assessing avoidable death and dis-
ability at a global scale. By incorporating current knowledge in risk 
factor, demographic and mortality trends, an intriguing picture 
emerges - an increasingly ageing world facing some major risks glob-
ally (such as tobacco), as well as remaining very high mortality re-
gions, particularly sub-Saharan Africa.

"This report brings out for the first time that 40 per cent of global 
deaths are due to just the10 biggest risk factors, while the next 10 
risk factors add less than 10 per cent," says Alan Lopez, Ph.D., WHO 
Senior Science Advisor and co-director of the Report. "This means we 
need to concentrate on the major risks if we are to improve healthy 
life expectancy by about 10 years, and life expectancy by even more." 
Given the risks measured in this Report and other known major risks, 
current scientific knowledge has clearly identified causes for most 
death and disability globally. For example, more than three-quarters 
of major diseases such as ischaemic heart disease, stroke, HIV/AIDS 
and diarrhoea were due to the combined effects of risks assessed in 
the Report. WHO emphasizes that each risk is also a prevention oppor-
tunity, and the potential for prevention from tackling major known 
risks is clearly substantial, and much greater than commonly thought. 
"Since many of these risks are continuous, without a threshold, the 
most cost-effective interventions are often those that move the en-
tire population to a lower risk zone," says Dr. Rodgers. "A good ex-
ample would be government- and industry-led reductions of salt in 
processed foods, which would have major population-wide benefits."

Underweight/under-nutrition -- Childhood and maternal underweight was 
estimated to cause 3.4 million deaths in 2000, about 1.8 million in 
Africa. This accounted for about one in 14 deaths globally. Under-
nutrition was a contributing factor in more than half of all child 
deaths in developing countries. Since deaths from under-nutrition all 
occur among young children, the loss of healthy life years is even 
more substantial: about 138 million DALYs, 9.5 per cent of the global 
total.

Under-nutrition is mainly a consequence of inadequate diet and fre-
quent infection, leading to deficiencies in calories, protein, vita-
mins and minerals. Underweight remains a pervasive problem in devel-
oping countries, where poverty is a strong underlying cause, contrib-
uting to household food insecurity, poor childcare, maternal under-
nutrition, unhealthy environments, and poor health care.

Interventions -- The most cost effective strategy to reduce under-
nutrition and its consequences combines a mix of preventive and cura-
tive interventions. Micronutrient supplementation and fortification - 
Vitamin A, zinc and iron - is very cost-effective. It should be com-
bined with maternal counselling to continue breast feeding, and tar-
geted provision of complimentary food as necessary. In addition, rou-
tine treatment of diarrhoea and pneumonia, major consequences of un-
der-nutrition, should be part of any health improvement strategy for 
children.

Unsafe sex -- HIV/AIDS caused 2.9 million deaths in 2000, or 5.2 per 
cent of total. It also causes the loss of 92 million DALYs (6.3 per 
cent of all) annually. Life expectancy at birth in sub-Saharan Africa 
is currently estimated at 47 years; without AIDS it is estimated that 
it would be around 62 years. Current estimates suggest that 95 per 
cent of the HIV infections prevalent in Africa in 2001 are attribut-
able to unsafe sex. In the rest of the world the estimated percentage 
of HIV infections prevalent in 2001 that are attributable to unsafe 
sex ranges from 25 per cent in Eastern Europe to 90 per cent or more 
in parts of South America and the developed countries of Western Pa-
cific. Interventions -- Most people infected with HIV do not know 
they are infected, making prevention and control more difficult. 
Various sexual practices contribute to the risk of sexually transmit-
ted infections. High-risk sex practices include multiple partners, 
together with lack of condom use and the type of sex acts involved. 
Treatments include:

* Population-wide mass media health promotion using the combination 
  of television, radio and printed media. 
* Voluntary counselling and testing. 
* School-based AIDS education targeted at youths aged 10-18 years. 
* Peer counselling for sex workers. 
* Peer outreach for men who have sex with men. 
* Treatment of sexually transmitted infections as a way of reducing 
  transmission of HIV infections. 
* Treatment of mothers with HIV infection to prevent maternal to 
  child transmission. 
* Anti-retroviral therapy has also been evaluated. 
* Intervention combinations: WHO says that the best way to address 
  the problem is to apply a combination of the above interventions at a 
  population-wide level. 

High blood pressure and cholesterol -- Worldwide, high blood pressure 
is estimated to cause 7.1 million deaths, about 13 per cent of the 
global fatality total. Across WHO regions, research indicates that 
about 62 per cent of strokes and 49 per cent of heart attacks are 
caused by high blood pressure. High cholesterol is estimated to cause 
about 4.4 million deaths (7.9 per cent of total) and a loss of 40.4 
million DALYs (2.8 per cent of total), although its effects often 
overlap with high blood pressure. This amounts to 18 per cent of 
strokes and 56 per cent of global ischemic heart disease. Blood pres-
sure is a measure of the force that the circulating blood exerts on 
artery walls. High blood pressure levels damage the arteries that 
supply blood to the brain, heart, kidneys and elsewhere. Cholesterol 
is a fat-like substance found in the bloodstream that is a key compo-
nent in the development of atherosclerosis, the accumulation of fatty 
deposits on the inner lining of arteries of the heart and brain.

Interventions -- The World Health Report 2002 urges countries to 
adopt policies and programs to promote population-wide interventions 
like reducing salt in processed foods, cutting dietary fat, encourag-
ing exercise and higher consumption of fruits and vegetables and low-
ering smoking. These are the most cost-effective interventions iden-
tified to reduce cardiovascular disease. This reflects recent evi-
dence that such therapy benefits all groups at elevated risk, even 
those with average or below average blood pressure or cholesterol.

When added to this base, a combination of drugs -- statins (choles-
terol lowering), low-dose blood pressure lowering medications and 
low-dose aspirin (blood-thinning) -- given daily to people at ele-
vated risk of heart attack and stroke, would achieve very substantial 
additional benefits. This highly effective drug combination is likely 
to more than halve stroke and heart disease incidence and could be 
widely used in the developed world, and is increasingly affordable in 
the developing world.

"Our new research finds that many established approaches to cutting 
CV disease risk factors are very inexpensive, so that even countries 
with limited health budgets can implement them and cut their CV dis-
ease rate by 50 per cent," says Derek Yach, M.D., Executive Director 
of the Cluster on Non-communicable Diseases and Mental Health. "In 
addition, drug treatments are increasingly affordable in middle and 
low-income countries, as effective drugs come off patent." Tobacco 
Use -- WHO estimates that tobacco caused about 4.9 million deaths 
worldwide in 2000, or 8.8 per cent of the total, and was responsible 
for 4.1 per cent of lost DALYs (59.1 million). In 1990, it was esti-
mated that tobacco caused just 3.9 million deaths, demonstrating the 
rapid evolution of the tobacco epidemic and new evidence of the size 
of its hazard, with most of the increase in developing countries.

Interventions -- Countries that have adopted comprehensive tobacco 
control programs involving a mix of interventions including a ban on 
tobacco advertising, strong warnings on packages, controls on the use 
of tobacco in indoor locations, high taxes on tobacco products and 
health education and smoking cessation programs have had considerable 
success. WHO found that for every 10 per cent real rise in price due 
to tobacco taxes, tobacco consumption generally falls by between 2 
per cent and 10 per cent. In addition to national programs, an effec-
tive Framework Convention on Tobacco Control will address transna-
tional aspects of the issues.

Nicotine replacement therapy (NRT) targeting at all current smokers 
was less cost-effective than the other strategies, but affordable in 
higher income countries. NRT includes nicotine patches, nicotine 
chewing gum, nicotine nasal sprays, lozenges, aerosol inhalers and 
some classes of anti-depressants. Unsafe Water and Sanitation -- Ap-
proximately 3.1 per cent of deaths (1.7 million) and 3.7 per cent of 
DALYs (54.2 million) worldwide are attributable to unsafe water, 
sanitation and hygiene. Of this burden, about one-third occurred in 
Africa and one-third in south-east Asia. Overall, 99.8 per cent of 
deaths associated with these risk factors are in developing coun-
tries, and 90 per cent are deaths of children. Various forms of in-
fectious diarrhoea make up the main burden of disease associated with 
unsafe water, sanitation and hygiene.

Interventions -- The United Nations has adopted a goal of halving the 
number of people with no access to safe water and sanitation by 2015. 
Improved water supply and basic sanitation, if extended globally, 
could prevent 1.8 billion cases of diarrhoea (a 17 per cent reduction 
of the current number of cases) annually. If universal piped and 
regulated water supply were achieved, 7.6 billion cases of diarrhoea 
(69.5 per cent reduction) would be prevented annually. Universal 
piped water is the ideal, but is high cost. In the short term, the 
most cost-effective strategy evaluated was disinfection of unsafe wa-
ter at the point of use. This is a simple technology, is of very low 
cost, and would achieve substantial health benefits. 

Iron deficiency -- Iron deficiency is one of the most prevalent nu-
trient deficiencies in the world, affecting an estimated two billion 
people with consequences for maternal and perinatal health and child 
development. In total, 800,000 (1.5 per cent) of deaths worldwide are 
attributable to iron deficiency, 1.3 per cent of all male deaths and 
1.8 per cent of all female deaths. Attributable DALYs are even 
greater, amounting to the loss of about 25.9 million healthy life 
years (2.5 per cent of global DALYs) because of the non-fatal out-
comes like cognitive impairment. 

Interventions -- Iron fortification is very cost-effective in areas 
of iron deficiency. It involves the addition of iron usually combined 
with folic acid, to the appropriate food vehicle made available to 
the population as a whole. Cereal flours are the most common food ve-
hicle, but there is also some experience with introducing iron to 
other vehicles such as noodles, rice, and various sauces. "We sur-
prised even ourselves in how far-reaching the health benefits can be 
if governments and health systems adopt our recommendations," says 
Dr. Murray. "WHO believes that the wide distribution of this report 
should become a prime goal of all Member States."

--
Claudio Schuftan
Hanoie, Vietnam
mailto:aviva@netnam.vn 

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