Wall Street Journal - October 30, 2002
Ron Winslow, Staff Reporter of The Wall Street Journal

If individuals and governments take concerted steps along the lines of those recommended in the 248-page study, healthy life-expectancy could be extended by five to 10 years or more, depending on where people live, the authors say. If there is little action, then the number of world-wide deaths from tobacco use could soar 80% to nine million by 2020, for instance, and the toll from obesity could rise by two-thirds, to five million, the study says.

"We need to achieve a much better balance between preventing disease and merely treating its consequences," says Christopher Murray, executive director of WHO's Global Programme on Evidence for Health Policy, who headed up the study. While effective treatments for illness and injury are crucial ingredients for healthy lives, "if you go one step back in the chain and look at risks that influence disease, you have a host of opportunities to prevent it before it happens," he says.

The report comes amid daunting challenges to public health across all regions of the world and among all socio-economic groups -- though the burden is especially severe in areas marked by poverty. The AIDS epidemic that is ravaging populations in Africa and making inroads in such countries as China is just one example. It also follows several fresh studies documenting the growing toll of cardiovascular disease in developing nations as well as the emergence of obesity and its health consequences as a global problem -- even in nations where a significant portion of the population goes hungry.

"We believe this is a first step toward putting the magnitude of these risks on the health policy agenda and the strategies available to address them," says Dr. Murray. The hope is that individual countries will use the findings to stimulate debate and develop strategies tailored both to their most important risks and to the resources they have available to fight them.

The report, which took more than 150 researchers about four years to prepare, is likely the most exhaustive effort ever undertaken to quantify the major factors contributing to global disease.

HEALTH HAZARDS

Top 20 risks to a healthy life, world-wide, in order of their contribution to lost years:

1. Underweight

2. Unsafe sex

3. Blood pressure

4. Tobacco use

5. Alcohol consumption

6. Unsafe water, sanitation and hygiene practices

7. Cholesterol

8. Indoor air pollution from solid fuel

9. Iron deficiency

10. Overweight/obesity

11. Zinc deficiency

12. Low fruit and vegetable consumption

13. Vitamin A deficiency

14. Physical inactivity

15. Injury risks

16. Lead exposure

17. Illicit drugs

18. Unsafe health-care injections

19. Lack of contraception

20. Childhood sexual abuse

Source: World Health Organization Report 2002, Reducing Risks Promoting Healthy Life.

It is based in part on a systematic review of hundreds of scientific papers, government reports and other documents dealing with 26 different risk factors chosen because of their likelihood of making a measurable contribution to the burden of disease, because adequate data about them were available, and because they potentially can be changed through intervention. The study is being unveiled at a press conference Wednesday in London. A summary is also being published in the journal Lancet.

The two most significant global health risks, according to the study, are low child and maternal weight-reflecting poor nutrition, low birthweight and prevalence of such illnesses as diarrhea and pneumonia; and unsafe sex -- problems far more prevalent in developing societies where mortality rates are high. That finding wasn't surprising, Dr. Murray says, but many of the other risks that fill out the top 10 were. High blood pressure was No. 3, followed in order by tobacco use, alcohol use and, at No. 7, high cholesterol. Obesity was 10th.

"That these are global risks is really quite amazing," says Dr. Murray, who noted that aside perhaps from tobacco use, they have generally been viewed as associated with urbanization and more affluent societies. In a similar, though less ambitious, effort to catalog global risks a decade ago, blood pressure and cholesterol levels weren't among the top-tier factors.

Their rise reflects new analytical methods, the spread of urban living habits and new data showing that blood pressure and cholesterol levels are even more potent risk factors for death and debilitating lives than was previously thought.

Another surprising finding was the importance of indoor air pollution among developing nations. It results from fuels, including animal dung and wood, that people use to cook in their homes and is linked to severe respiratory problems in women and children, Dr. Murray says. Lack of necessary micronutrients was also a major issue, with iron, Vitamin A and zinc deficiencies all included in the top 20 risk factors.

The report details 170 different strategies that could be applied in various regions to make headway against health risks. The ideas were selected based on published studies demonstrating their cost effectiveness. For instance, to combat underweight and nutritional deficiencies, the report recommends that grains and sugars be better fortified with micronutrients in developing countries. It also urges aggressive counseling of mothers to promote breastfeeding.

It suggests a variety of population-based remedies to deal with unsafe sex practices, including mass media health promotion, school-based AIDS education and treatment of HIV-infected pregnant women to prevent transmission to their infants. It recommends high taxes on tobacco and bans on tobacco advertising to combat smoking and more use of inexpensive but effective drugs that treat blood pressure and cholesterol.

An editorial accompanying the study summary that appears in the Lancet calls into question some of the methodology used to rank the risk factors, but says the exact order of the list is less important than efforts to understand and address the hazards. "Public-health surveillance on this scale is a new, and immature, science," say John Powles and Nick Day of the Institute of Public Health, Cambridge, UK, who urge that the work toward describing such risks continue.

The report projects that aggressive efforts to reduce the most important risks could increase healthy life expectancy by 6.5 years in the U.S. and Canada, 5.4 years in wealthy European societies including the United Kingdom, France and Germany, and 6.9 years in Latin America. For India, the effort could add nearly nine years to a healthy life and as much as 16 years in southern Africa. "The potential to improve health is dramatic," Dr. Murray says.

Write to Ron Winslow at ron.winslow@wsj.com
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