Richard Smith: Non-communicable disease in the Eastern Mediterranean Region

Richard SmithThe Eastern Mediterranean Region (EMR) of WHO has some of the highest rates of non-communicable disease (NCD) in the world. Six of the countries with the highest rates of diabetes are in the region, half of the women are overweight or obese, and physical activity rates are the lowest in the world. Yet the region also has advantages, including the former director of NCD at the WHO Headquarters, Ala Alwan, now being the director of the region, and the presence of some very rich countries. A conference in Riyadh last week began the process of preparing an action plan to counter NCD in the region.
Alwan, a former minister of health in Iraq, seems to relish taking over what must be the most complex region in the world. Stretching from Morocco in the West, to Pakistan in the East, and Somalia in the South, the region includes not only the countries going through the Arab Spring, but also many of the world’s hotspots—Syria, Afghanistan, Palestine (but not Israel), and Somalia. It has two of the three countries in the world where polio has not been eradicated—Pakistan and Afghanistan—but the biggest threat to health in the region is NCD.

Despite its problems the region has done very well in improving its health in the past decade, said Chris Murray, director of the Institute for Health Metrics and Evaluation and the leader of the global burden of disease study. Using data from the new global burden of disease study, which should be published by the end of the year, he showed how the age structure of the region is very young, rates of cardiovascular disease diabetes are higher than in most regions, and cancer rates lower. Half of the years of life lost in the region are because of NCD, and NCD plus depression accounts for most disability.

Obesity and physical inactivity are two of the most important risk factors for NCD in the region, said Majid Ezzati from Imperial College London, and the rise in body mass index in the past decade has been one of the largest in the world. Smoking rates are high in some countries, but generally low among women. Blood pressure and cholesterol levels are steady, but this is not such good news as it sounds as both are falling in high income countries. The cities in the region are some of the most polluted in the world, the result of dense traffic and dust.

The causes of the very low rates of physical activity, particularly among women, were much debated at the conference, but some of them are obvious. The extreme heat is one cause, but this isn’t true across the whole region and is, of course, nothing new. Probably more important is the creation of cities where it’s extremely difficult to walk. Pavements are narrow or non-existent, and crossing the road can seem impossible. It’s never easy to find the stairs in the hotels, but these design features probably reflect a culture that doesn’t value walking. The clothes of the women don’t make for exercise, although they are on the verge of allowing girls and women to play football—but with all of them covered except their faces. Then the Saudis themselves have servants to do housework for them, and, as one young woman said, the children will have a maid bring them a drink while they sit in front of a screen.

(The 9m foreigners in Saudi Arabia tend to be forgotten, although one Saudi man spoke passionately about how they lack health insurance and need to be cared for in some way.)

The region has made some response to NCD, but there are many gaps, said Alwan. Data are scarce. Surveillance is weak. Some countries have mounted some responses, but they are not institutionalised. Most countries have done very little. Staff are not trained, and the region is weak on what the “best buys” are for intervening. Sectors other than health have generally not been engaged, and the region is “not doing well” on implementing the Framework Convention on Tobacco Control.

The central question, said Alwan, is not what to do but how to get it done. In broad terms, he said, the region needs surveillance, better evidence, guidelines, implementation of “best buys,” multisectoral action, resources, and the development of capacity, particularly trained staff.

With only 20% of women and children in the region reaching recommended levels of physical activity, action on this should be a priority. Fiona Bull from the University of Western Australia and a tireless advocate for physical activity said that public education on the importance of physical activity is the “best buy” but is not sufficient on its own. It’s important, she said, for the region to build its own evidence base, but we know that programmes in schools, workplaces, and primary care can lead to improvements. Developing public transport and designing cities to encourage walking is fundamental but clearly takes time.

Some NCD advocates are skeptical about physical activity—not its importance as a risk factor but because of thin evidence of being able to make a big difference. Bull says that evidence on physical activity does lag behind that on tobacco, but it is likely that as with tobacco it will be important to have a constant series of actions on many fronts. In this way Canada, said Bull, has managed to raise levels of physical activity by 20% over 20 years.

One way to promote physical activity is to encourage people to play football, and when “football talks people listen,” said Jirí Dvorák, the chief doctor at FIFA. The World Cup has 30 billion viewers, and FIFA has 206 countries in membership, more than the United Nations. FIFA has developed a programme of 11 health and social messages for 11-12 years olds that it links to 11 aspects of football, each with its own globally known footballer. Lionel Messi, the world’s best footballer, promotes eating a balanced diet (“building a team” in football terms), and Cristiano Ronaldo urges people to avoid drugs and alcohol so that they can dribble well. The programme has two halves of 45 minutes, one for developing football skills and one for spreading the messages. FIFA insists that boys and girls play together, encouraging respect for girls, and some countries that prefer culturally to keep boys and girls apart allow them to play together because their love of football overcomes their cultural objection. (This seems unlikely in Saudi Arabia.)

Dvorák showed evidence of increased knowledge of the health messages among children in the programme, and he told me later that there is also evidence of improved behaviour. FIFA began its programme in Africa, and every child in Mauritius (which has one of the world’s highest rates of diabetes) has been through the programme. Some 46 000 children have been through the programme so far, but FIFA is aiming for 278 000 by 2013 and 2 million by 2015. (In fact the 2015 target was met during the meeting when the Mexican government told FIFA that it was going to put all 2 million Mexican children through the programme. They are crazy for football in Mexico, said Dvorák.)

Philip James from the London School of Hygiene and Tropical Medicine warned the conference that NCD is likely to have a much bigger impact in countries where in recent decades much of the population has been undernourished. He urged the necessity of improving the food supply and said that educating people wasn’t enough. If government funded institutions serve healthy food then they can change the country’s food supply. He warned as well about customs of serving many dishes and large portions. If you dine with the Queen in London, he said, you are given a small portion on a small plate. (I asked him later how often he dined with the Queen, and he said that the notion of mentioning the Queen came to him while giving his talk. He thought that it might make it more likely that his advice would be followed.)

The cheapest and most effective way to improve the food supply is to work with the food industry to steadily reduce the salt in food, said Graham MacGregor, a professor of cardiovascular medicine from London. In most countries almost all salt comes from processed food—bread, cheese, tinned soups, and most packaged foods. People do not notice if salt is reduced slowly, and though working with the food industry Britain has reduced daily salt intake from 9.5 g per person to 8.1g. This, said MacGregor, has saved 18 000 strokes and 9000 deaths, which has meant a financial saving of £1.5 billion at a cost of £5m. The aim is to get consumption down to 5 g by 2016. A similar strategy could work for sugar and fat, claimed MacGregor: taste buds can be reset fairly rapidly.

So far there has been almost no action on salt in food in EMR, and MacGregor urged countries to do so as one of the most cost effective ways of reducing deaths from NCD. He is frustrated that so few countries have pursued what seems to him an obvious strategy.

We heard from a series of countries in the region about their plans for countering NCD. Many have had plans in place for years, but they generally have not been comprehensive and have mostly focused on the health system—despite the recognition that a “whole of society and whole of government” approach is essential. Alwan told the conference how much work was underway—both regionally and globally—to draw in bodies from outside health. Kamel Ajlouni from Jordan urged using imams and mosques, pointing out that three quarters of the population of Jordan hear Friday prayers. Somewhat disturbingly he also described how Jordan had no funds for its programme  for NCD and so was grateful to the drug industry for funding it.

Sania Nishtar, a cardiologist and health activist from Pakistan, emphasised strongly the need to counter NCD through social change, the involvement of all of government, civil society, and the private sector, and transforming health services from providing episodic to continuous care. Universal coverage, she thinks, will be essential for providing adequate care for those with and at risk of NCD. Ironically in Pakistan she has seen adandoned the impressive national plan to counter NCD she helped develop.

She ended her talk by asking us to imagine two women in an African clinic (the region includes several African countries)—one infected with HIV and the other with gestational diabetes. The woman with HIV would receive coordinated, continuing, comprehensive care, whereas the woman with gestational diabetes would receive very little and possibly lose her baby and almost certainly later develop the serious complications of diabetes.

The main aim of the meeting was to urge action in the region and develop a regional action plan. Health ministers will meet later in the year, and, as Alwan said, moves are underway to involve other parts of government. Countries will be required in 2013 to report to the United Nations on their progress, and let’s hope that they have improvements to report. But this will be a long game with the pandemic of NCD rising steadily unless countries can manage comprehensive action.

Competing interest: RS had his fare paid to the meeting by the Saudi Ministry of Health and flew business class, for which he is very grateful. The flight will also give him points on his BA executive card, which with luck will keep him silver. He was also given about 150 dates.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.