SciDev.Net

This series of commentaries and research articles — published by The Lancet, the Peking University Health Sciences Centre and the China Medical Board — addresses China's major health challenges, strategies and future. It has been produced by a group of 63 scientists from 10 countries with Chinese scientists making up two-thirds of the authors.

The research papers give scientific evidence on key health issues including the emergence and control of both infectious and chronic non-infectious diseases in China as well as the performance of China's healthcare system.

Authors of the series' commentaries further discuss a range of topical issues affecting China's health system, including the state of biomedical science and technology (see 'Progress in Chinese biomedicine a massive challenge'), medical research ethics, the lessons learnt from China's schistosomiasis control programme and the challenges the country faces in controlling HIV/AIDS.

Cardiovascular disease accounts for 30% of deaths worldwide and 10% of all years of healthy life lost to disease, and the figures are nearly as high in developing countries — 27 per cent and 9 per cent respectively. This compares with 10% of lives lost worldwide from HIV/AIDS, TB and malaria put together (12% in developing countries). So why have donors not invested as heavily into tackling non-communicable chronic diseases as they have with infectious ones? The authors of this article suggest several reasons: infectious diseases are in some ways easier to solve by a vaccine or drugs so it might seem sensible to use precious funding this way; Western donors may want to see epidemics contained quickly to avoid global spread; pictures of small African children dying of AIDS are more heartrending than a middle-aged man with hypertension, even if that man is supporting a large family; there is a myth that chronic diseases are more costly to prevent than infectious ones. This last issue is one that should be tackled strongly to spread awareness that low-cost methods can have an enormous effect on chronic diseases.

Vaccination for infectious diseases is a vital method of prophylaxis, and has transformed modern medicine. By contrast, research into vaccines against chronic diseases has been less successful, in part because of the increased complexity involved.

In this opinion piece, the authors outline the prospects for the development of chronic disease vaccines. These might not need to rely on the traditional method of inducing the body to produce antibodies, but rather on introducing monoclonal antibodies against specific proteins — this has so far worked well against Crohn's disease and rheumatoid arthritis.

The authors outline key hurdles in developing a successful therapeutic vaccine. Safety and efficacy are two obvious ones, but there is a third that is unique to vaccines for chronic diseases. Because these vaccines would block bodily chemicals — such as cytokines or hormones — it would not be acceptable for a vaccine to induce a life-long block (unlike a malaria vaccine, for example, where a lifelong block would be ideal).

These might be particularly useful in developing countries, say the authors. Because prophylaxis with vaccines is already a familiar concept, there should be no problem with patients' compliance, and judicious partnerships between public and private organisations could mean the vaccines are produced cheaply.

The Millennium Development Goals (MDGs) practically define health efforts in the 21st century, but they virtually ignore non-communicable diseases such as mental health, say these authors. This is despite evidence that mental health disorders are among the most important cause of sickness and disability and even premature mortality. The authors argue that tackling mental health problems will be vital to achieving the MDGs, and three in particular — eradicating poverty, reducing child mortality, and improving maternal health.

Poverty and hunger are well-recognised risk factors for mental health, but mental health also makes it harder for people to escape the hunger trap. Mothers who are depressed during pregnancy and post natally, are more likely to have underweight babies; not only that, the illness means these mothers are more likely to stop breastfeeding and less likely to ensure their children are properly immunised than mothers without depression.

The authors advocate that strengthening basic health-care systems should be holistic. For example, developing countries need more and better-trained health workers but they should not only know how to deliver babies but also how to counsel new mothers. HIV/AIDS programmes, as another example, should ensure that individuals not only have good access to antiretrovirals but also to treatment for depression if they need it.

Schizophrenia is relatively rare — affecting 1% of the world's population — but is arguably one of the most severe mental illnesses. Diagnosing and treating it can be hard enough in developed countries; the challenges are magnified in developing nations with inadequate health systems; few trained staff; and pervasive social stigma. So how best to treat it? In this debate, three psychiatrists offer their different viewpoints.

Vikram Patel, at the London School of Hygiene and Tropical Medicine, says the shortage of mental health specialists means that the most effective way of spreading the expertise around might be for non-specialist health workers or community representatives to be trained to bear the brunt of providing first-line mental health services. Saeed Farooq, at Pakistan's Lady Reading Hospital, argues that the principles of the WHO's DOTS TB programme, in which patients are given an uninterrupted supply of medication taken under close supervision, could be used to treat schizophrenia. The rationale is that missing medication for schizophrenia, which can be common given the cognitive impairment associated with the illness, has serious consequences and can lead to much higher risks of relapse. R. Thara, director of the Schizophrenia Research Foundation, Chennai, India, advocates tackling stigma by offering proper treatment. In India at least, he says, the mystification of mental illness is intensified by a lack of awareness about schizophrenia and also by "magico-religious" beliefs. Effective treatment that shows the symptoms to be an illness rather than a religious curse is the best antidote to stigma, he says.

In 2005, the World Health Assembly called on WHO member states to tackle their growing rates of cancer by developing rigorous cancer control programmes. To help guide the process, the WHO developed a series of six modules that provide practical advice for programme managers and policy-makers on how to advocate, plan and implement effective cancer control programmes, particularly in developing countries.

Individual modules focus on planning; prevention; early detection; diagnosis and treatment; palliative care; and policy and advocacy. As of May 2008, all but the one on policy and advocacy have been published.

Worldwide, cancer kills more people than HIV/AIDS, malaria and TB put together. In developing countries where chronic diseases are now growing alongside infectious diseases, new strategies need to be developed.

This article outlines how to develop an effective cancer strategy in African countries on the basis of discussions at the recent African Cancer Reform convention. A cancer control plan clearly needs to take into account African countries' financial constraints and the authors outline six key essentials that would offer most health gain for money invested. These are: setting up cancer intelligence units to collect data on cancer incidence; controlling tobacco use; early diagnosis and prevention; offering treatment wherever possible; palliative care when treatment is no longer useful; and training and educating future generations of African oncologists.

Developed countries can offer crucial expertise and experience and collaborate on cancer information networks. Educating local communities about a disease that is relatively new but growing quickly will also be essential to stop it spiralling when many cancers are preventable or treatable when detected early enough.

In 2003, the Gates foundation infused new vigour into global health efforts by declaring that the 21st century's "grand challenges" included developing new vaccines and overcoming drug resistance. This new grand challenges initiative, launched by a collaboration of top global chronic disease experts, identifies priorities in tackling diseases like diabetes and cardiovascular disease, and explains in detail how research should be directed to meet each challenge (a challenge was defined as a critical barrier that if removed would help solve an important health problem).

To distill the range of opinions and priorities, the coordinators sought input from 155 stakeholders from different countries and disciplines. The initiative requires the participation of agencies like the WHO, individual governments, and non-governmental organisations as well as civil society and business if it is to succeed. The authors point out that the Gates initiative was linked to large funding, whereas this project will rely on multiple funding agencies to coordinate on these priorities.

Global health experts have watched with increasing alarm as the waistlines of people in developing countries have started to widen with the adoption of a "Western" lifestyle. Obesity is of such concern because of its heightened risks for other diseases, such as heart disease, cancer, and diabetes.

In developing countries, the number of people with diabetes is set to rise to 228 million by 2030 from 84 million estimated in 2000. The link between obesity and diabetes is so strong because obesity renders individuals unable to properly process glucose — about 90% of type 2 diabetes is due to being overweight. Obesity and diabetes also raise the risk for cardiovascular disease and kidney disease. Diabetic nephropathy was the most common cause of end-stage renal disease in 9 out of 10 Asian countries, say the authors, which could be deadly for countries unable to cope with the health repercussions.

This report is the WHO's official record of data produced by its technical programmes and regional offices in close consultation with countries and in collaboration with researchers and development agencies. The WHO produces the statistics to provide an evidence base for strategies to improve global public health.

The report clearly shows that the global burden of disease is shifting from infectious diseases to non-communicable diseases, with chronic conditions such as heart disease and stroke now being the chief causes of death globally. The shifting trends indicate that leading infectious diseases — diarrhoea, HIV, tuberculosis, neonatal infections and malaria — will become less important causes of death globally over the next 20 years.

The report documents in detail "the levels of mortality in children and adults, patterns of morbidity and burden of disease, prevalence of risk factors such as smoking and alcohol consumption, use of health care, availability of health care workers, and health care financing."

This joint publication between the World Health Organization and the Global Forum for Health Research reveals mental health research capacity in 114 low-income and middle-income countries in Africa, Asia, and Latin America and the Caribbean. The extensive review identified over 10,000 articles, 4,633 mental health researchers and 3,829 other stakeholders. The authors argue that this is "the first systematic attempt to confirm the pressing needs of improving research capacity in mental health".

The publication provides useful details in table and charts, analysed by group of stakeholders and by region, on topics such as: researchers' profiles; priority-setting process; amount and type of research production; services and technical support available to them; courses and trainings offered; funding patterns; and dissemination of research findings. The appendix provides two extensive lists — by country — of policy and practice that resulted from research evidence, as well as research evidence that was never translated into policy and practice.

Nine recommendations indicate how the management of mental health research can be strengthened so that it meets the national needs of the countries as well as contributes to the global fund of knowledge. The authors say their report thus enables evidence-based decision-making in funding and priority setting in the area of mental health research in low-income and middle-income countries.

These consist of two reports: SuRF1(Surveillance of risk factors related to non-communicable diseases: current status of global data) and SuRF2 (Surveillance of chronic disease risk factors: country-level data and comparable estimates).

These reports are the result of a large WHO project to set up for the first time a global database of the prevalence of risk factors for non-communicable diseases collected from WHO member states. The first report is largely a collection of the country profiles; the second analyses the data to produce comparable estimates for risk factor prevalence in the countries. The WHO designed this as an advocacy tool to highlight where primary prevention and health promotion need to be directed.

The eight risk factors were chosen because they are easily measurable and theoretically can be changed through prevention efforts. They are: tobacco and alcohol use, patterns of physical inactivity, low fruit/vegetable intake, obesity (as measured by BMI), blood pressure, cholesterol and diabetes (measured by blood glucose).

The second report presents country-level estimates for overweight/obesity and systolic blood pressure. It also shows the attributable mortality and disease burden from all causes of death due to these overweight and high blood pressure for the 11 most populated countries. 

(See WHO Global InfoBase Online for electronically searchable data contained in the reports http://www.who.int/infobase/surf2/online.html.)

This series of five articles outlines new challenges and unsolved problems since the journal's last series in 2005. The first article ([189kB]) predicts the disease burden and economic losses that developing countries would face from chronic diseases such as cardiovascular disease, cancer, chronic respiratory disease, and diabetes. In the 23 countries that the authors incorporated into a model, chronic disease was responsible for 50% of the disease burden in 2005. If no action is taken, they say, about US$84 billion of economic production will be lost from heart disease, stroke, and diabetes alone in these 23 countries between 2006 and 2015. The second article ([105kB]) looks at how to scale-up strategies to fight chronic diseases in developing countries. The authors review evidence to identify which methods are cost-effective and financially feasible, and therefore ready to be scaled-up.

Tobacco control, salt reduction (both of which are detailed in the series' third paper ([177kB])), and a multidrug strategy to treat individuals with high-risk cardiovascular disease (see an in-depth look in paper four ([220kB])) are prime candidates for scaling-up. What effect improving health systems has on the level of chronic diseases should be properly evaluated, say the authors. For some health interventions, such as preventing or controlling diabetes, there is little cost-effectiveness data for low or middle-income countries, but their scientific effectiveness is so compelling that countries should consider how best to incorporate them. The final paper ([92kB]) is a call to action to incorporate existing interventions into healthcare programmes, which in 2005 was costed at US$5.8 billion.

1990 saw the first major effort to estimate the main causes of illness and the biggest killer diseases in different countries. The data are important for public-health officials to allocate their resources wisely but also for feeding into estimates to plan for the future. Importantly, these need to be regularly updated to ensure that health programmes are still going in the right direction. This paper updates the 1990 study and offer predictions up to 2030.

The most forceful change in disease trends is in developing countries, with the proportion of people affected by non-communicable diseases set to increase. Proportionally, the number of people with infectious diseases is set to fall, though not when it comes to HIV/AIDS.

Because the authors also rely on predicting socio-economic development trends, they created best-case and worst-case scenarios for economic growth. In the pessimistic scenario, by 2030, the three leading causes of illness will be HIV/AIDS, depression, and ischaemic heart disease; in the optimistic scenario, road-traffic accidents will replace heart disease as the third leading cause.

The WHO has provided its own estimates of how non-communicable diseases are set to rise in developing countries. These authors pool data from national registries and international databases to compare data on the differing burden from individual diseases. They outline the risk factors associated with the diseases.

The main three killers are cardiovascular disease, diabetes, and cancer. The paper ranks different types of cancer by how many people in developing countries they kill (lung and breast cancer are the deadliest) and also ranks diabetes prevalence by country (India, followed by China, has the highest prevalence).

To tackle these diseases, say the authors, people need to look closely at the risk factors in their life – eating healthily and exercising can do much to reduce the chances of getting one of these diseases.

Cardiovascular diseases are set to rise dramatically in developing countries, partly because of an increase in risk factors for the diseases, which include diet, physical activity, smoking. The authors looked at cardiovascular disease risks such as being overweight or obese, systolic blood pressure, and total cholesterol, and related them to national income, food purchase constraints, and urbanisation. Body mass index (BMI) and cholesterol increased as national income increased, then flattened, and eventually declined. BMI also rose with increasing urbanisation.

The authors suggest that cardiovascular disease risks will increasingly be concentrated in low-income and middle-income countries. Thus, preventing obesity should be considered a priority in these countries, along with measures to control blood pressure, cholesterol, and tobacco use.

Chronic diseases — heart and lung disease, cancer and diabetes — are having a negative economic impact on both the developed and developing world, says this report, which is why they should be properly addressed by domestic and international policy makers. Compared to the epidemiological evidence on the rise of non-communicable diseases in developing nations, there is little information on how this increase will affect their economies.

This report investigates the demographics of the problem and finds that contrary to popular belief, the disproportionate burden of disease on the elderly does have economic implications. The reason is that though the elderly may not be part of the workforce, they are still consumers and therefore a part of the economic equation.

Whether approaches to tackling chronic diseases are cost-effective or not is a vital issue for countries whose health budgets are already overstretched — the report outlines some of the interventions that offer most bang for buck. The authors point out that strategies that work well in developed countries are not so effective in developing countries, and call for more research to assess what will be appropriate.

This extensive report was one of the first to document the scale of the problem of chronic diseases in developing countries, and crucially, to offer guidance on feasible and practical methods of tackling them.

The document starts by laying out in detail the profiles of chronic diseases in different countries, projections for the future, and how chronic diseases are linked with poverty. It also examines in depth the economic costs of such diseases and the macroeconomic consequences of not tackling them quickly enough. The authors outline interventions — whether community, workplace, or school — that have robust evidence supporting them.

The report ends with a call for a unifying framework of global health experts and stakeholders, in which the government has a key role. It also specifies what policymakers need to do to ensure that measures to tackle chronic diseases are put into action.

This document presents the proceedings of a conference at the Royal Netherlands Academy of Arts and Sciences in December 2001. The conference papers deal with themes relating to the role of scientific research in the development of Northern countries and the need for North–South research cooperation. They document the experiences of research cooperation involving, among others, India, South Africa and a number of East African countries. Several papers deal with innovation and scientific cooperation, with case studies.

This paper presents a review of the challenges of international scholarly scientific collaboration. It looks at institutional constraints and points out that the challenges and problems multiply when collaborators come from different countries with differing conditions, resource endowments and institutional structures. It is easier to call for more and better forms of international collaboration than it is to design them. The report asserts that good design is helped by a better understanding of what collaboration is and how it has been carried out. It draws on social research insights to help reduce the transactional, financial, ethical and emotional costs of international linkages and exchange and provides a conceptual framework for thinking about international collaboration issues.