Global cancer prevention: an important pathway to global health and development.

Cancer is a leading global cause of death and disability, responsible for approximately 7.6 million deaths each year. Around one-third of cancers are attributable to a small number of preventable risk factors - including smoking and the harmful consumption of alcohol - for which effective interventions exist at the population level. Despite this, progress in global cancer control has been slow and patchy, largely due to the weak and fragmented nature of both the global and national responses. This has been exacerbated by the economic crisis and the tendency for other challenges involving food, energy security and climate change to overshadow cancer on the global policy agenda. This paper reviews the global burden of cancer, and summarizes knowledge about effective interventions. Responding to the global challenge of cancer requires a comprehensive and integrated approach that includes legislation and regulation. A re-invigorated approach to global cancer prevention, within the broader context of non-communicable disease prevention, is an important pathway to global health and development.

Grading of evidence of the effectiveness of health promotion interventions.

AIMS: Grading of evidence of the effectiveness of health promotion interventions remains a priority to the practise of evidence-based health promotion. Several authors propose grading the strength of evidence based on a hierarchy: convincing, probable, possible and insufficient; or strong, moderate, limited and no evidence. Although these grading hierarchies provide simple and straightforward rankings, the terms that describe the categories in the hierarchies, however, do not explain, in an explicit manner, in what way the strength of the evidence in one category is more, or less, superior than that in another. METHODS: To enhance the explanatory power of the hierarchy, we propose that evidence be classified into three grades, each with a short explanatory note on the basis of three criteria: the degree of association between the intervention under study and the outcome factors, the consistency of the findings from different studies, and whether there is a known cause-effect mechanism for the intervention under study and the outcome factors. CONCLUSION: For more in-depth grading, a three-grade expanded hierarchy is also recommended. Examples are given to illustrate our proposed grading schemes.

Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults.

The growing global burden of non-communicable diseases in poor countries and poor populations has been neglected by policy makers, major multilateral and bilateral aid donors, and academics. Despite strong evidence for the magnitude of this burden, the preventability of its causes, and the threat it poses to already strained health care systems, national and global actions have been inadequate. Globalisation is an important determinant of non-communicable disease epidemics since it has direct effects on risks to populations and indirect effects on national economies and health systems. The globalisation of the production and marketing campaigns of the tobacco and alcohol industries exemplify the challenges to policy makers and public health practitioners. A full range of policy responses is required from government and non-governmental agencies; unfortunately the capacity and resources for this response are insufficient, and governments need to respond appropriately. The progress made in controlling the tobacco industry is a modest cause for optimism.

Globalization and health: a framework for analysis and action.

Globalization is a key challenge to public health, especially in developing countries, but the linkages between globalization and health are complex. Although a growing amount of literature has appeared on the subject, it is piecemeal, and suffers from a lack of an agreed framework for assessing the direct and indirect health effects of different aspects of globalization. This paper presents a conceptual framework for the linkages between economic globalization and health, with the intention that it will serve as a basis for synthesizing existing relevant literature, identifying gaps in knowledge, and ultimately developing national and international policies more favourable to health. The framework encompasses both the indirect effects on health, operating through the national economy, household economies and health-related sectors such as water, sanitation and education, as well as more direct effects on population-level and individual risk factors for health and on the health care system. Proposed also is a set of broad objectives for a programme of action to optimize the health effects of economic globalization. The paper concludes by identifying priorities for research corresponding with the five linkages identified as critical to the effects of globalization on health.

Reinvigorating public health.

PIP: In the Public Health Quintet published in The Lancet, it was pointed out that although the scope of modern public health is broad and inclusive, breadth is missing from much of the practice. It is faced with new and even more difficult challenges brought on by the increasing globalization of the determinants of health. In view of such, this article suggests an approach to address the issue of reinvigorating public health. It is noted that to achieve the goal of reinvigoration, an increase in commitments from the public health workforce to a broader view of public health and to values of equity and ecological sustainability is required. The public health practice needs to focus on overall improvement in population health through the reduction of the readily preventable burden of disease, whether communicable or noncommunicable, especially among disadvantaged groups. Social and economic deprivation should be reduced by focusing on its underlying structural determinants. Moreover, there should be strong political and professional leadership at the global level to increase the value of researches on priority issues, including poor health as a determinant of poverty. Overall, if the reinvigoration of public health gathers pace, the ultimate goal for public health practitioners will be achieved.^ieng

The changing global context of public health.

Future health prospects depend increasingly on globalisation processes and on the impact of global environmental change. Economic globalisation--entailng deregulated trade and investment--is a mixed blessing for health. Economic growth and the dissemination of technologies have widely enhanced life expectancy. However, aspects of globalisation are jeopardising health by eroding social and environmental conditions, exacerbating the rich-poor gap, and disseminating consumerism. Global environmental changes reflect the growth of populations and the intensity of economic activity. These changes include altered composition of the atmosphere, land degradation, depletion of terrestrial aquifers and ocean fisheries, and loss of biodiversity. This weakening of life-supporting systems poses health risks. Contemporary public health must therefore encompass the interrelated tasks of reducing social and health inequalities and achieving health-sustaining environments.

Explanation for the decline in coronary heart disease mortality rates in Auckland, New Zealand, between 1982 and 1993.

BACKGROUND: We sought to determine how much of the recent, substantial fall in coronary heart disease (CHD) mortality rates in New Zealand can be attributed to "evidence-based" medical and surgical treatments and how much can be attributed to cardiovascular risk factor reductions. METHODS AND RESULTS: A cell-based mortality model was developed and refined. This model combined (1) the published effectiveness of cardiological treatments and risk factor reductions with (2) data on all medical and surgical treatments administered to all CHD patients and (3) trends in population cardiovascular risk factors (principally smoking, cholesterol, and hypertension) from 1982 to 1993 in Auckland, New Zealand (population 996 000). Between 1982 and 1993, CHD mortality rates fell by 23.6%, with 671 fewer CHD deaths than expected from baseline mortality rates in 1982. Forty-six percent of this fall was attributed to treatments (acute myocardial infarction 12%, secondary prevention 12%, hypertension 7%, heart failure 6%, and angina 9%), and 54% was attributed to risk factor reductions (smoking 30%, cholesterol 12%, population blood pressure 8%, and other, unidentified factors 4%). These proportions remained relatively consistent after a robust sensitivity analysis. CONCLUSIONS: Approximately half the CHD mortality rate fall in Auckland, New Zealand, was attributed to medical therapies, and approximately half was attributed to reductions in major risk factors. These findings emphasize the importance of a comprehensive strategy that maximizes the population coverage of effective treatments and actively promotes a prevention program, particularly for smoking, diet, and blood pressure reduction.