Intended for healthcare professionals


Lessons in tackling chronic disease

BMJ 2006; 333 doi: (Published 19 October 2006) Cite this as: BMJ 2006;333:820
  1. Sania Nishtar (sania{at}, founder and president
  1. Heartfile, One Park Road, Chak Shahzad, Islamabad 44000, Pakistan

    Pioneering examples of partnerships in other regions are a useful source

    Chronic diseases account for about 47% of the total burden of disease in the 22 countries of the Eastern Mediterranean Region. By 2020 this figure is expected to be 60%.1 Cardiovascular disease, diabetes, cancer, and chronic lung disease account for two thirds of deaths in countries with relatively low overall mortality rates, such as Iran and Jordan, and more than 40% of deaths in those with the highest rates, such as Somalia and Sudan.2

    These chronic conditions are linked by common risk factors. Some are lifestyle related—for example, low fruit and vegetable intake, lack of physical activity, and smoking—others are related to biological factors such as obesity, dyslipidaemia, and hypertension. Close to two thirds of the adult population in the region have risk factors for chronic disease; in the oil rich Arab countries this is attributed to rising life expectancy coupled with rapid socioeconomic development.2 About 64% of men and 70% of women in Saudi Arabia are obese; 79% of women in Bahrain are obese.3 Diabetes is common; it affects around 18% of adults in Oman and close to 24% in Saudi Arabia.3

    The burden and cost of treating chronic disease in the Eastern Mediterranean Region is considerable, but policy makers show few signs of acknowledging this, perhaps because robust data on incidence and mortality are lacking. Also most countries have only limited experience with integrated approaches to dealing with chronic diseases. Public health systems are better at providing acute care than promoting healthy lifestyles. Fewer than half of the 22 countries in the region have national policies on chronic disease, and only a minority have implemented legislation to control the use of tobacco.4

    Concerted action is needed to reorientate health systems and policies to provide long term preventive care. Essential medicines to treat chronic disease should be included in national essential drug lists so that they are available at the primary care level. Simple devices such as tape measures, validated blood pressure instruments, and urine dipsticks for diabetes also need to be available in primary care. Health professionals need continuous education on prevention of chronic diseases.

    The current focus on nutrition needs to shift from concern about undernutrition to preventing obesity. More open spaces are needed to encourage people to exercise, and dependence on tax revenues generated from growing and advertising tobacco should be reduced. Agricultural and fiscal policies should concentrate on making healthy food more accessible.

    Countries planning to introduce policy change to tackle chronic disease have some pioneering regional examples to learn from. The Pakistan National Action Plan on Non-Communicable Diseases launched in 2003 has integrated surveillance and intervention for chronic diseases,5 6 and it is introducing chronic disease into the work plan of 70 000 healthcare providers at grass roots level.7 Jordan's Gateway to the Future has established a programme aimed at promoting behaviour change in three key domains—chronic disease, reproductive health, and child health.8 In Iran, the Isfahan's Healthy Heart Programme launched in 1999 has established community based interventions to increase physical activity, improve diet, and help people stop smoking. Although outcome data from these initiatives are not yet available, they are steps in the right direction.9

    Although plans to tackle chronic disease in individual countries are in their infancy there are encouraging signs of independent action on health advocacy. These capitalise on the region being mostly Muslim. For example, the hajj (Muslim pilgrimage) was made tobacco free in 2002. Religious teaching suggests that tobacco is “undesirable,” and this point has been picked up by key regional publications.10 Similarly, it might become more acceptable for women in Muslim cultures to take more exercise if awareness about the issue is raised.

    Regional research priorities should be defined. In the case of cancer this should include investigation of the observed association between levels of depleted uranium (in the wake of the Gulf wars of 1991 and 2003) and increased incidence of cancer.11

    If the seven countries of the rich Gulf Cooperation Council promoted research into the management of chronic disease, this might initiate the development of a regional and possibly global partnership on chronic disease. Infectious disease partnerships have improved a range of health outcomes,12 and such partnerships could do the same for chronic disease.


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