Also In This Issue

Health Worker Migration: Disease or Symptom?

Greater than the Sum

In-Country Supply Chains

Leadership and Management

Health System’s Levers

The Road Not Taken

The Making of Anatomy of a Pandemic: A PBS Documentary

North American Diseases Go South of the Border

James Hospedales

Rates of chronic disease have risen sharply in Latin America and the Caribbean over the past 15 years, as the population has aged and the effects of lifestyle changes have taken hold.

Patricia Pizarro thought she was a good mother, so she was upset when the pediatrician told her she needed to change how she was raising her son Fernando. She had taken the 12-year-old in for a rash, but the doctor gave her an unexpected diagnosis: the boy was obese and had high blood pressure, and if things didn’t change, he could become diabetic or even worse.

Fernando’s lifestyle, it seems, was the problem. After eating a sandwich each morning for breakfast, he’d snack on sweets at recess and eat just about anything but vegetables at lunch. At home, he spent most of his time watching TV and playing or chatting on the computer, all the while snacking on cookies, potato chips, candy, more sandwiches and sodas. When his parents got home, he’d eat one more time before going to bed.

A daily routine like this is not unusual for a child in Santiago, Chile, or in any other Latin American city today. “Modern” lifestyles are on the rise throughout the hemisphere, and with them chronic non-comunicable diseases (CNCDs). Heart attacks, strokes, diabetes and cancer now cause two out of every three deaths in the Americas and consume by far the largest share of health-care spending. And as is true in other regions of the world, chronic diseases take their greatest toll on the poor, who have less access to health care and fewer resources to cope with loss of income or disability. The good news is that most of it is preventable.

It is tempting to blame the rise of chronic diseases on only junk food and TV, but the root causes are more complex. Most CNCDs are strongly related to a handful of risk factors, chief among them, unhealthy diet, physical inactivity, and tobacco use. All of these have increased as a result of urbanization, changes in work, transportation and leisure, as well as modernization and globalization of agriculture and new marketing and retail trends.

For example, trade liberalization in Central America has been shown to be a factor in the “nutrition transition” and rising rates of obesity and CNCDs. Data from the World Health Organization/Pan American Health Organization (WHO/PAHO) show that fewer than half the region’s residents get the recommended 30 minutes of physical activity per day. Now an alarming 50-70 percent of adults in Latin America and the Caribbean are overweight or obese, along with 7-12 percent of children under 5 years.

The growing epidemic of CNCDs is forcing public health advocates in the region to broaden their focus beyond infectious diseases, maternal and child mortality, and malnutrition. It also demands a different approach. Unlike infectious diseases, which are linked to germs and can be targeted with vaccines or other drugs, chronic diseases result from a combination of causes that are difficult – but necessary – to address at the same time.

Fighting Back

In the past five years, countries in Latin America and the Caribbean have begun to respond in earnest to the CNCD epidemic. In 2006, ministers of health of the Americas approved a regional strategy for the prevention and control of chronic diseases, including diet and physical activity. In 2007, at a special summit on CNCDs in Trinidad and Tobago, Caribbean heads of state put chronic diseases at the top of their health agenda in a 14-point declaration, “Uniting to Stop the Epidemic of Chronic Diseases.” In 2009, Central American health ministers also issued a resolution calling for action on CNCDs.

These and related initiatives have spurred actions such as the “five-a-day” campaigns, encouraging people to eat fruits and vegetables to wider interventions to make “the healthy choice the easier choice.”  WHO’s recent publication Interventions on Diet and Physical Activity: What Works cites several of the region’s recent efforts as models of effective action. These include Brazil’s national school meals program, which promotes healthy eating based on locally produced foods, and the Ciclovias movement, which closes off city streets to create safe spaces to promote physical activity.

Other promising initiatives in the region include:

• Agricultural policies that encourage increased production of, and lower prices on, healthy foods (Brazil and Chile);
• Urban development policies that promote public transportation as well as green and recreational spaces (Brasilia, Curitiba and Porto Alegre, Brazil; Santiago, Chile; Bogotá, Medellín and Pereira, Colombia; Quito, Ecuador; México City and Leon, Mexico);
• Voluntary or mandatory labeling of fat and salt content in processed foods (Argentina, Bolivia, Brazil, Chile, Paraguay and Uruguay);
• Restrictions on advertising of junk foods to children (Brazil and Mexico);
• Prohibiting the sale of soft drinks and junk food in schools (Chile and Argentina);
• Increased taxes and restrictions on advertising and sales of tobacco products (Trinidad and Tobago, Uruguay).

Countries in the region are also working, with PAHO support, to improve prevention and treatment of CNCDs by strengthening health systems with an emphasis on health promotion and primary health care. The efforts include changes in medical school curricula and health-worker training to confront the new challenges of CNCDs.

Meanwhile, advocates for chronic disease control will need to engage opinion leaders, lawmakers, the public, and private companies to take joint and sustained action against chronic diseases at all levels and on all fronts. The lives and the health of millions of residents of the Americas are at stake.

CNCDs in the Americas

Cardiovascular disease. Heart disease and stroke account for one in three deaths in Latin America and the Caribbean (LAC). Though CVD death rates have been declining in North America, in LAC they are expected to nearly triple over the next 20 years.

Cancer. Deaths from cancer increased 33 percent between 1990 and 2002 in LAC. Lung cancer is the leading cancer killer, thanks to smoking rates as high as 30–40 percent in some countries. Cervical cancer is a major cause of death for women in Central America, while breast cancer claims more lives in South America.

Hypertension. PAHO data show that some 140 million people in the Americas suffer from hypertension. The chief risk factors are smoking and especially dietary salt. People in LAC eat two to three times the maximum recommended levels of salt.

Diabetes. Some 35 million people in the Americas have diabetes (whose main risk factor is obesity) and the number is expected to double by 2025. Diabetes is now the leading cause of death in Mexico and claims some 340,000 lives annually throughout the region. PAHO estimates the cost of diabetes in the Americas at over US$65 million annually, as a result of premature death, worker absenteeism, disability, drugs, hospitalization and doctor visits.

What’s Being Done

The countries of Latin America and the Caribbean have individually and collectively undertaken a number of innovative initiatives to counter the growing epidemic of CNCDs. Among them are:

Brazil’s national school meals program is a comprehensive effort to improve and sustain the quality of food consumed by children in primary school. By law, 70 percent of the program’s budget for school meals – roughly $1 billion per year for 35 million children –must be spent on fresh vegetables and fruits and other minimally processed foods.

Ciclovias, also known as “Car-Free Sundays,” in which city streets are temporarily closed to motor vehicles, allows exclusive access to pedestrians, runners, skaters and cyclists. Ciclovias have spread to at least 38 cities in the hemisphere, including Bogotá, Guatemala City, Lima, Mexico City and Quito; and in North America, Chicago, El Paso, Portland, New York City and Ottawa.

Smoke-Free Americas was launched in 2001 by PAHO to support efforts to reduce exposure to second-hand tobacco smoke in the Americas. The initiative provides help and advice to governments and a wide range of resources to help advocates, parents, communities and the public create smoke-free environments.

Trans Fat Free Americas, another PAHO-led initiative, has brought nutrition experts together with representatives of the food industry to work toward eliminating trans fatty acids from industrially processed foods.

The CARMEN network, which links health professionals and health institutions in 30 member countries, shares knowledge and best practices in chronic disease policy development, implementation and evaluation. The network’s CARMEN School provides training in these areas through partnerships between schools of public health, public health agencies and ministries of health.

The Partners’ Forum for Action on Chronic Disease, which brings together members of the private sector, civil society and the public health community, exchanges ideas, mobilizes resources, and spurs action across sectors to prevent CNCDs. Launched in September 2009, the forum is being spearheaded by PAHO, the Pan American Health and Education Foundation (PAHEF), the World Economic Forum, and the International Business Leaders Forum. 

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Dr. James Hospedales is senior advisor for prevention and control of chronic diseases at the Pan American Health Organization (PAHO).