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The Rise of Noncommunicable Diseases in Low- and Middle-Income Countries

Speaker: Thomas R. Frieden, Director, U.S. Centers for Disease Control and Prevention
September 9, 2012, New York
Council on Foreign Relations

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MS. : (In progress) -- (inaudible). Welcome, everyone, to this meeting of the Council on Foreign Relations with Dr. Thomas Frieden. And the theme today is noncommunicable diseases and new global health. And we have a lot of healthy food, I notice, which is a good thing.

So I have a few instructions. If everybody would please turn off their communication devices. That does interfere with the sound system. I'd also like to remind members that this meeting is on the record and that there -- we are being broadcast nationally and around the world to CFR members who are participating and have a password-protected site. So we'll be getting some questions from them during the course of our conversation. And immediately following this meeting, there will be another panel called "Scalable Strategies to Address NCDs in Developing Countries," which we hope we'll lay the groundwork for, that will start at 2:15. So we urge you to stay for that.

Just by way of a few words of introduction, according to the World Economic Forum's 2010 Global Economic Development Report, and I'm quoting, "Noncommunicable diseases pose a greater threat to global economic development than fiscal crises, natural disasters, corruption or infectious disease." In a recent Institute of Medicine report published earlier this year, it was noted that 63 percent of the roughly 57 million deaths that occurred in 2008 worldwide were from noncommunicable diseases, and nearly half of these were from the big four killers of cardiovascular disease, cancer, chronic respiratory disease and diabetes. And these diseases all share the common risk factors of tobacco, exercise, diet and alcohol use.

And while we in the United States and other high-income countries are increasingly focused on NCDs in U.S. health policy, especially relating to diabetes and its epidemic -- there was a recent editorial in The New York Times on Sunday about hypertension management in this -- in the U.S. -- the World Health Organization notes that in fact, 80 percent of the deaths from NCDs are now occurring in low- and middle-income countries, and by 2030 NCDs will be the leading cause of death and disability in every region of the world.

And this threat led to a high-level meeting on NCDs at the United Nations this past September, and it was only the second time that heads of state have been convened around a health issue, the last time being in the 1980s on HIV/AIDS. So it gives you a sense of the sense of urgency.

Dr. Thomas Frieden is here to help us understand this problem and identify some priorities for how to tackle it. As you all know, he is the director of the Centers for Disease Control and Prevention and the administrator for the Agency for Toxic Substances and Disease Registry. He's been in that role since 2009. Immediately prior to this appointment to what is arguably the most important public health position in the world, he served as commissioner of New York City's Department of Health and Mental Health, which I'm sure we all think is at least the second most important public health position in the world. And he really laid the foundation for New York City's pioneering work as a national model for cities in tackling a variety of risk factors for chronic diseases through his work on tobacco control, calorie postings, elimination of trans fats from restaurants and rigorous monitoring of diabetes. And with his personal and professional experience, work on tuberculosis control both internationally and in the United States, I don't think we could have a better person to introduce us to this topic and help us chart a way forward.

So Tom.

DR. THOMAS FRIEDEN: Great. Thank you very much. Thanks to the council. Thanks, Jo (sp), for your leadership and introduction.

Really, let me say one thing about the problem and one thing about the solution. Noncommunicable diseases are sometimes mischaracterized as diseases of affluence because we have the concept that as people get richer, they do more unhealthy things, and these diseases follow. But actually, I think these are fundamentally diseases of poverty. They're diseases of poverty because in most countries, not only do they disproportionately affect the poor, but they perpetuate poverty in individuals, in families, in communities and, perhaps most importantly, in countries.

Noncommunicable diseases are an enormous drag on economic development, on health care systems, on workplace productivity. And so they have enormous economic implications for individuals, families, communities, work sites and countries.

The global burden of disease has really shifted. For the first time in human history, we have more people living in cities than in rural areas. We have more people who are overweight than underweight. We have more deaths among adults than among children. And we also have more people dying from noncommunicable diseases in poor countries than in rich countries, with higher rates of noncommunicable diseases in poor countries than rich countries.

In fact, in poor countries, half of all deaths from noncommunicable diseases occur before the age of 70. In rich countries, it's about a quarter of all deaths from noncommunicable disease before the age of 70. So these are huge differences, and now non-communicable diseases kill more people than communicable diseases, about two-thirds of all of the world's deaths, and that burden is not only high, but it is increasing and on a trajectory to increase even further.

So I talked about the big four, and we think about four diseases and four risk factors. The four greatest diseases, or non-communicable diseases, are heart disease, stroke, cancer and diabetes. Those big four account for an enormous proportion of the suffering from non-communicable diseases and the cost and the economic losses that follow.

For the four risk factors, it's tobacco use, it's poor nutrition, it's physical inactivity and unhealthy alcohol use. Those four risk factors are driving those four diseases to a very great extent, and one thing that is very important to understand is that noncommunicable diseases are not inevitable.

Now, interestingly, communicable diseases were once seen as a force of nature about which we could do very little. In fact, when I first went to India to work on tuberculosis control in the mid-1990s, most tuberculosis experts in India still thought of tuberculosis as a disease that you could describe, maybe predict, but never control. And I think that's often the way we think about noncommunicable diseases, and yet it's very much within our power to change both the prevention and the treatment of noncommunicable diseases.

Just to give you a sense of the economic harms, the cumulative lost output just in low-and middle-income countries over the coming 15-year period for noncommunicable diseases is estimated at more than $7 trillion.

Now what are we going to do about those problems? First and foremost, we need to understand them better, what we call in public health surveillance or, in more lay terms, monitoring. If you think about the fiscal crisis in this country and in other countries, wherever you come down politically on what should happen or should have happened or should be happening, I think everyone would agree that lack of effective, prompt, accurate information on what was happening made our response much less effective. And the same is true for health issues.

Senator Moynihan used to like to say that you're entitled to your own opinion, but you're not entitled to your data. In public health, all too often, we don't stand on a common ground of data, so we don't know really what's happening; we can't defend programs that are working or fix programs that are broken.

The definition of an epidemiologist. Now, the formal definition is someone who studies the pattern and the distribution of disease in society. But my definition of an epidemiologist is someone who loses sleep over denominators -- (laughter) -- because fundamentally, that's what we think about in public health. Not, do we have a nice little program that's helping a few people, but are we making a difference in society as a whole.

Now, that is a challenge not only for community prevention -- things that public health classically does -- safe water, safe food, safe air -- but also in clinical prevention. What's happening -- and you mentioned yesterday's editorial in The New York Times -- but what's happening with high blood pressure treatment?

Well, in the U.S., 54 percent of people with high blood pressure don't have it under control -- 54 percent. So this is quite important because, of course, what gets measured can get monitored, evaluated and improved. It's also important because, fundamentally, what gets measured is a measure of what we care about, and our lack of measuring something is an implicit statement of how important we think that is. And that's why I kind of start when I think of the lack of monitoring with our very problematic position with respect to vital registration.

In Southeast Asia, in Africa, most of the people will be born and die without an accurate record of their existence. We don't know who's dying, of what, where, at what ages. And without that, it's pretty hard to fix things. A great British public health figure of the 1800s said, the death rate is a fact, everything else is an inference. And we can't even get the death rates right. So a lot more is needed in this area, but we're making some real progress.

One of the areas is in tobacco control. So the Bloomberg Foundation, along with the CDC Foundation and CDC, have established a Global Adult Tobacco Surveillance System, part of a family of global tobacco surveys, and for the first time ever, there are standard definitions for what tobacco use is, for what a smoker is, for what quitting is. And there is a multi-country effort which has been very successful to document exactly what's happening -- who's smoking, who's not, when did they quit, what's happening.

And there have been some very surprising findings, some countries doing much worse than they thought they were -- I won't mention them; some countries doing much better than we realized they were -- Brazil, for example. So there's real value to surveillance, and examples of how it can be done and done well.

There are simple phone surveys. There are Web surveys. There are -- information available through health care systems. And increasingly, there are registry information through clinical systems that can be critically important, not to report to a central system but to empower clinical providers to do a better job of caring for their patients. That's what clinical epidemiology does, to have this challenge of thinking like an epidemiologist, of losing sleep over your denominator: how many patients are in my practice, how many of them have this disease under control.

The importance of surveillance data can't be overstated. I want to give you two quick examples. In New York City when I became commissioner, we did not have surveillance on the leading risk factors for death in this city. Within three months, we had up and running a community health survey that provided us annually information on every one of the 42 neighborhoods that you can break New York City into, and we rapidly used it to cut programs that weren't working, to expand ones that were needed.

We also, as you may recall, increased the tax on tobacco and made all restaurants and bars in New York City smoke free, and we saw big declines in smoking. The next hear we thought we were done. We thought everything would be fine. Smoking actually increased slightly. And we would not have known that if we hadn't had the surveillance system in place. We then implemented hard-hitting anti-tobacco ads and we saw a tremendous decline in smoking, especially in the communities where we ran the ads the hardest. So we knew that worked.

I'll give you a second example from communicable diseases, because for noncommunicable diseases we need to learn from the communicable disease work that's been effective. Mexico implemented a rotovirus vaccine. It's a fantastic vaccine, can save hundreds of thousands of lives a year. It has a rare complication that can be serious or even fatal for children, and they documented some fatal illnesses among children, which is terrible and we're working on ways to avoid that. But because we had surveillance information, we could say definitively that at least a thousand children were having their lives saved for any one who had a serious adverse event. So Mexico continued the vaccination program, and tens of thousands of kids are alive today because we had that information and the vaccination program didn't stop.

Now, in addition to surveillance, I think a second key component of effective action is what I like to call a technical packet. You know, sometimes people get to together and they talk about let's do something. Sometimes they say let's do everything. But what really works is figuring out what is going to be effective. You used a word earlier that will be one of the subsequent sessions, about scalability. Scalability is a really important concept. Let me use an example from HIV prevention.

We know that if you have 10 in-depth group discussion sessions with high-risk people, you can reduce their risk of contracting HIV. We also know that cost to do that in the united States at the level of scale would be more than $20 billion a year, and we don't have the staff to do it. So it's a great intervention, but it's not going to be scaled.

In the same way, we need to think about what's scalable in noncommunicable diseases. For tobacco, that's the MPOWER package of interventions: Monitoring; Protection from tobacco smoke through smoke-free laws; Offering help to people who want to quit; Warning about the dangers of tobacco; Enforcing advertising promotion and marketing bans; and Raising taxes on tobacco. It's a clear package; and where it's been implemented, it's effective. And the Bloomberg Foundation has been terrific with Kelly (sp) and Matt Myers and others at getting this implemented all around the world. Sorry -- Sandy Mullin here as well.

Currently, there are about -- nearly 4 million people in the world. More -- most of the world is covered by at least one of the five aspects of tobacco control from MPOWER. More than a billion people are covered by two or more. But only 330 million people -- only one out of 20 people in the world is covered by three or more of the five key measures. And you know, not a single person in the world is covered by all five.

How would we think about the world if we had -- we use 17 vaccines in this country; most countries use five, 10, 12 -- what would it be like if not a single child anywhere were fully vaccinated? And yet that's the situation we're in today on tobacco.

Now, there are many areas in clinical medicine and public health where we can do a lot more together. We talked briefly about hypertension. There's a lot that can happen. The public health system can be an honest broker for information; it can be a safe space for people to discuss and come up with standardized protocols and monitoring systems. Ultimately, we're going to have to figure out how to get more health value for our health dollars.

Right now in the U.S., again, less than half of people with high blood pressure have it under control. And yet if there were one thing -- just one thing you want to do right in clinical medicine, it would be to control blood pressure because that will save the largest number of lives. And it's not very expensive.

Community interventions are also going to be key. So we think of prevention in two broad buckets -- we -- prevention in the clinical setting and prevention in the community. So you can either get fluoride in the water or you can fill cavities. You can decide if you want to pay for more treatment or pay for healthier people. And ultimately you want to do both, because you're never going to prevent everything -- but if you only treat everything you're never going to treat everything, either.

So those two worlds have to intersect. And I don't have the answer for how they can do so most effectively, but I do know that there are some things that each can learn from the other and that that's going to be one of the leading challenges in the U.S. and around the world in the years to come.

Now, a lot more can be done sometimes from the community level, helping people millions at a time, as the motto goes.

So if we take one of the most successful examples ever of a noncommunicable disease program -- the island of Mauritius used to use palm oil for their basic cooking. It's not a particularly healthy oil; it's very high in unhealthy fats. And they switched to polyunsaturated oils as a community, and they documented a 30 milligram-per-deciliter decline in cholesterol in their population. Now, you could give statins to everyone, or you could change the oil. And sometimes you've got to do some of both. But that kind of community impact can be huge, and we look for those sweet spots in public health.

Innovation is also going to be really important -- trying things out, figuring out if they work. Brazil is now spending $700 million dollars of its own money to help 4,000 communities throughout the country increase physical activity. That's going to teach us what works; it's going to show what works. They're going to build, essentially, adult jungle gyms and send personal trainers out. And we'll see, because no one's ever really done this on a societal basis. They are also providing free anti-hypertension medicines for their entire country. We'll see if it works, and how to do it and how to make it work effectively.

Addressing non-communicable diseases is the right thing to do -- not just because we'll be healthier and better off, not just because we need to build on the momentum from the U.N. High-Level Meeting, not just because it's important that we learn from others and they learn from us, because all of us are figuring out the right way forward for all of these -- it's also important fundamentally because the answer is going to be in joint responsibility.

It's not going to be a question of whether it's individual responsibility or collective responsibility. It's going to be what's the right balance. It's not going to be a question of whether the government should be doing anything, it's what should the government be doing, or whether industries should be doing anything, it's what industries should be doing.

Sometimes responsibility is spoken of as either/or. Either it's a personal responsibility or it's a community responsibility. Well, we have traffic lights, but that doesn't mean that you don't have a responsibility to drive carefully or to walk carefully. We don't take them down so that people will develop better reflexes. In the same way, we need to get the government's role right in making it so that if you go with the flow and do what's easiest, you will live the kind of long, healthy, productive life that you would like to live.

At the same time, individuals need to do a lot, not just in their own lives, but to help their communities structure in a way that's going to promote health for all in the community in a way that that -- the full value of healthy choices becomes easier.

Ultimately, we would like for every child to grow up and reach adulthood at a healthy weight and not addicted to nicotine. If we could just ensure those two birthrights for every human being, it would change the world, it would save literally trillions of dollars and hundreds of millions of lives. Thank you.

MS. : Great. OK, thanks. (Applause.)

Well, while everyone is thinking up their question, I'm going to start off with a couple of things. I'm going to go back up to the 30,000-foot level for a minute because a number of the examples you gave, like Mauritius or your own experience with Mayor Bloomberg in New York, are -- deal with the issue of governance, in a sense, and how political leadership, political will can be mobilized.

One of Secretary Clinton's obviously big initiatives in being -- is seeing global health as sort of at the center of a smart power initiative and really calling on the diplomatic corps to engage prime ministers, heads of state, ministers of finance on these issues. I'm sure you've been involved in some of these conversations. I wonder if you could just give people a sense of the responsiveness, the understanding, where the focus is on getting that political will mobilized.

FRIEDEN: I think there is remarkable consensus on the importance of global health as an issue, and commitment to address a whole host of global health challenges.

The PEPFAR program has been a shining success. This is a program that has come in ahead of schedule, under budget and has built systems at the same time. And what does that mean? It means that today, around the world, there are more than 4.5 million people on antiretroviral treatment who would be dead or dying otherwise. Last year alone more than 200,000 babies were born without HIV who would have been HIV-infected otherwise.

But not only has it met those targets, it's also built systems. We've helped train thousands of epidemiologists throughout Africa. We've helped accredit thousands of laboratories throughout the world and, for the first time, throughout Africa, so that you can get reliable results.

And that is an example of something that people, I think, see as very successful. You can always say how it could be different or better, but it's shown the world what's possible when we focus and get things done. And I think often in public health it's so important to have those real successes.

When I -- again, when I first went to India, in 1995, '96, the polio campaign had had tremendous progress there right up to that point. They just vaccinated a hundred million kids in a single day. And for the first time, people were saying, you know, maybe we really can do something. And so the work that I was doing on tuberculosis control was greatly facilitated by the group -- work that the polio group had done in showing that it was possible. I think that's broadly true in global health, and people recognize that some issues may be hard in health or in development or in global policy, but in health, we can make real progress.

MS. : And you mentioned this issue of health systems, strengthening in health systems. It has been -- is now one of the leading agendas in the Global Health Initiative. And as AIDS has become, in a sense, more of a chronic disease, happily, because of prevention efforts and treatment efforts, some would argue that it may be a base for health systems responding more effectively to management of things like -- (inaudible). Could you just reflect on that a little bit?

FRIEDEN: Well, it has been, actually. If you look at the data, health systems that participate in the PEPFAR program and HIV treatment have higher immunization rates.

They're more likely to provide critical care to women who are in need of assistance with delivery. So they can be a platform, and Ambassador Goosby and I have discussed this extensively.

With the initial PEPFAR, the goal was really just do HIV. With the reauthorization of nearly five years ago, there was a real understanding that we're going to come in under budget and ahead of schedule, but we're also going to build systems. So with PEPFAR dollars, we again trained epidemiologists, established laboratories, strengthened clinical systems, and I think that does provide a critical platform for further development.

MS. : Mmn hmm. You mentioned countries like Brazil that are kind of moving from the sort of recipient country status like Brazil, India, China, others, South Africa, into more of a donor country or sort of expansive. Could you talk a little bit about the sort of south-south collaborations and the degrees to which -- some of those examples that you mentioned that have been so important in terms of U.S. policy are also beginning to emerge perhaps from some of these countries that we used to support with our own funding.

FRIEDEN: Well, we've seen terrific examples of south-south collaboration. For example, we're almost at the finish line with polio now. India has not had a case in more than 18 months, and they have superb surveillance. So we're confident that it's not circulating anywhere there. But Nigeria, Pakistan and Afghanistan still have polio and they have been exporting it to other countries, including Angola and Mozambique. And Brazil, sharing a common language, has been terrific in providing experts and assistance to Angola and Mozambique in addressing polio and other problems, as well as more broadly throughout Africa in addressing a variety of things.

We also are able to recognize the tremendous value of helping the BRICs be better at what they're doing. So just in the past month, for example, we had worked in both China and in Brazil to help strengthen a whole host of systems on influenza surveillance, for example, which strengthened those countries and they keep us safer in this country.

So China we assisted to become one of only five global reference centers for influenza. What that means is that every week, they post on the web the DNA sequences of all of the new strains of influenza that they've identified in high quality laboratories that we helped them to establish. They're proud of it, and they should be. They're protecting their own population and they're protecting the world by doing that.

MS. : OK. I think we're at the point where I'm supposed to open the floor. And I want to invite members to engage with Dr. Frieden with their own questions. And if you would -- I think there are microphones that will be passed.

If you wait for the mic and speak into it, state your name before and your affiliation. And we want to ask you to please limit yourself to one question and not a -- not a particularly long talk if you have to make a comment to set up your question. And we will have national members that are online that are submitting activities by email. So we expect to get one of them.

Yes, sir.

QUESTIONER: (Off mic) -- Frieden, nice review. Can you comment on what you think the schools of public health are doing or should do in training a professional workforce to meet the 21st century as opposed to the 20th which they now focus on?

MS. : Tell us who you are.

QUESTIONER: Oh, I'm sorry. Henry Greenberg, Mailman School of Public Health.

MS. : All right.

FRIEDEN: I think CDC has been very effective because of what I would call the secret sauce of CDC is the linking of an epidemiologist who knows field epidemiology with what's called a public health adviser who knows how to get things done.

And if you look at what CDC did in smallpox eradication, it was to send a team, one epidemiologist and one disease control expert, to each country to get the job done. And they have very complementary skills.

Often the epidemiologist would have very impractical ideas or good ideas that couldn't be implemented. And the public health adviser type figured out how to get it done.

Those are two unique skillsets. The first involves being able to amass data from a variety of sources, analyze it accurately and present it clearly. The second is taking good ideas and changing them to reality.

I've often thought that the final exam for any public health degree should be that you have some period of time -- I used to say two hours and people criticized me so now I say four hours -- alone in a room but with complete access to the internet, and you're given a public health problem to deal with. And you've got to write a one-pager convincing a decision-maker of what to do. That means being able to absorb that epidemiologic information, absorb what's possible, what's scalable, what's effective, how to communicate it well and then to make that communication.

MS. : Yeah, let's go over here, and we'll go back and forth. (Chuckles.) Yes, please.

QUESTIONER: Judy Miller, from the Manhattan Institute and Fox News. I -- over the weekend we had a very long, extremely good article on MDR-TB -- (audio break) -- an area in which you've worked. I realize we're talking about noncommunicable diseases here, but since this is going to be or could be a challenge --

FRIEDEN: That's OK. I talk about tuberculosis in every talk I've give anyway. (Laughter.)

QUESTIONER: OK. Could you talk about what the implications of what's going on in India for us and for our health system, and what the CDC is doing about it? Thank you.

FRIEDEN: Thank you. Well, actually, I do think tuberculosis is an interesting model for noncommunicable diseases because it really is the bridge between an acute infection and a chronic infection. George Comstock, who did much of the original research on tuberculosis, then turned to noncommunicable diseases and did the rest of his career on that and continued to do both up into his 90s. So there are important reflections.

Are you referring to The Wall Street Journal article?

QUESTIONER: Yeah.

FRIEDEN: OK.

So multidrug-resistant tuberculosis is a symptom of a poorly performing tuberculosis control program. It does not come out by a spontaneous generation; it comes out because -- but we're not ensuring that patients are getting the treatment that they need to get. And to confront it, you need a balanced portfolio, you need to make sure that you're doing three things.

One is not creating more of it, because a bad program can create multidrug-resistant TB faster than any program can treat it. So you've got to stop creating new cases of multidrug-resistant TB.

The second is, you've got to stop it from spreading. In New York City in the early '90s, when I was an Epidemic Intelligence Service officer, we were able to document that at least 6 percent of all tuberculosis cases in New York City were being picked up in hospitals. Now, that was just what we were able to document -- and I actually mean document; we can show that the people were in the same place at the same time when one was infectious and the other was not. And it was only a one-month snapshot. And I don't remember the proportion of the MDR cases that were picked up in hospitals, but it was significantly higher than that.

So we know that infection control needs to get a lot better. And it's not necessarily expensive to do that.

And third, we need to treat people and treat them in a way that's scalable. So that will be different in different parts of the world. I went on a series of visits to Russia, and Dr. Henning (sp) went as well -- a long back. Russia had 600 culture labs; of course they should be doing culture and susceptibility testing for drug-resistant TB and tailoring treatment based on the results. In some places in Africa, that may not be possible today, but maybe it's possible tomorrow, with the newer technologies for testing for drug resistance. So I think all of those are key.

But the lesson that I learned most from the work in tuberculosis is the lesson of accountability. I sat in a restaurant in Chinatown in 1991 -- or '92, actually -- and -- across from a man named Karel Styblo. Styblo, S-T-Y-B-L-O, created the DOTS strategy. He had spent his whole life treating and studying TB --

MS. : Can you tell us what the DOTS strategy was?

FRIEDEN: -- first in -- first in Europe and then in Africa. It's directly observed treatment, short-course, but it's a whole package of interventions. It's not just watching someone.

And he said, you know, tuberculosis control is really very simple. There's only one rule: no cheating. Every single person you start on treatment, you are accountable for their outcome. And when we think about noncommunicable diseases, we need to be in that kind of relationship with our patients and to our patient populations so that in the U.S., with 68 million people with high blood pressure and 37 million uncontrolled, we need to go to every provider and say, do you know what proportion of your patients are controlled, and are you working to improve it?

Because the doctors want to do a great job. Doctors want to do a better job than anyone else around them. That's how they got into medical school. And they're very competitive. So when you start looking at and reporting on outcomes, you see big improvement.

And the clinical systems that have looked at high blood pressure like that have gotten to 80, 85, 90, even 95 percent control rates for their patients. But if you don't, you end up around 40 (percent), 50 (percent), 60 (percent), and that's exactly what happened to TB. So making sure that we're accountable is important.

And to answer your question about what we're doing at CDC, we have staff seconded to the World Health Organization who work in India and elsewhere. We also are helping to strengthen a laboratory system so we can diagnose drug-resistant TB and strengthen infection control so we stop spreading it. And to their credit, the government of India has taken us very seriously. They have greatly increased their financial commitment to tuberculosis control, and in Mumbai, which is kind of the epicenter of uncontrolled multidrug resistance, they're putting in a whole system to try to get it under control.

MS. : Laurie?

QUESTIONER: Laurie Garrett from the council. Tom, you talk about -- you use the metaphor of PEPFAR as next portable model. We came up with a way to control HIV; we can export this as a program overseas. But how in the world are we in a position to say we have an exportable model for chronic disease management, prevention and control when we have absolutely the worst data, the worst outcomes, of any of the industrialized nations? We're at the bottom. We're -- you know, boom, boom, boom all the day down the list. We may have a high cure rate for tertiary treatment of cardiac arrest, but for prevention and on and on down the numbers, we're in rotten shape.

What's our exportable model? What are we saying to the world? Oh, be like America, fat. Be like America, have your kids drop dead of diabetes at the age of 16. (Laughter.)

FRIEDEN: (Chuckles.) Thank you, Laurie. (Laughter.) So I think there are a couple of things that we do have to share with the world. One is monitoring systems. We do have probably the best monitoring systems in the world, things like NHANES, as well as BRFSS and HIS. These are -- NHANES is the gold standard of an examination survey. So we examine 8(,000) to 10,000 people per year, every year, randomly selected in a very gold standard, standardized way, and that's how we know what's going on with obesity. That's how we know what's going on with smoking. That's how we know definitively what's happening.

So monitoring, we certainly have the information to share. In tobacco control, we know that there are successes all over the world. There are places like New York City, California, where you've seen tremendous progress against tobacco. They're not the best in the world, necessarily, but they're wonderful examples.

There are also examples elsewhere where it's -- Uruguay, which when WHO first looked at it, had the best tobacco control policies in the world. Who knew? Well, Uruguay's president, Tabare Vazquez, was an oncologist. And he decided he was going to do everything he could to control tobacco use. And so they had the best -- and probably still do have the best tobacco control program in the world.

For obesity, I think you'd have to say that we're early adopters of the obesity epidemic -- (laughter) -- and that no one has it figured out yet. We may be a warning to the world of what not to let happen. We know that kids who get into adulthood obese are going to have a hard time getting at a healthy way. We know that early childhood experiences are going to be really important. We see the obesity epidemic increasing in countries throughout the world, and we're trying things. We don't know definitively what will work.

What we've been able to do with support from the Public Health Prevention Fund of the Affordable Care Act is to fund communities all over the U.S. to try things and rigorously study them. And that, I think, is really important, because this -- you know, we didn't learn what worked in tobacco by thinking it out and saying, this is what works. We learned by trying things, different communities trying things and studying them. And the same is going to happen in obesity. We're beginning to see communities with decreases in childhood obesity. New York City had a 6 percent decrease in obesity, 10 percent in younger kids. In Massachusetts, we've seen some decreases; in other parts of the country we've seen some decreases.

It's far from over. You're talking about -- you doubled, and then you went down 5 (percent) or 10 (percent) or 15 (percent) or 20 percent, so it's nowhere near where it needs to be. But at least it's going in the right direction. I think what we can share most importantly is our commitment to doing things that work, figuring out whether things work and then adjusting our approach so that we have as effective approach as possible.

MS. : In the back? (Audio break.)

QUESTIONER: Adrienne Germain. The United Nations is currently reviewing its Millennium Development Goals, which are actually very useful in low- and middle-income countries, and the original set had almost all goals, in one way or another, directly affecting health.

Some of us are concerned now, with the new attention to NCDs, that the investments that have worked so well, as you've described -- in infant and child health, internal health and so on -- may fall by the wayside in this -- (audio break).

I was very struck by your last comment in your remarks, that if we could get every child to enter adulthood at the right weight, not tobacco-addicted, we'd change the world. Do you think that might be a way of framing a new millennium, or -- it won't be called millennium, but anyway a new development goal for health, an overarching goal that would lead the world in the right direction; in other words, a balance -- (audio break) -- and the noncommunicable -- (audio break)?

FRIEDEN: Well, I don't think it's either/or. I don't think attention to noncommunicable diseases will result in de-emphasizing the very important Millennium Development Goals. I do think there are some synergies and some differences. There is a big U.N. process going on now to come up with key indicators of noncommunicable disease control, and at the World Health Assembly in May, it was decided to at least start with death, because again, the death rate's a fact, everything else is an inference. So the -- decreasing the rate of death under age 70 from the noncommunicable diseases is a key thing that everyone can agree on.

The problem with only looking at kids is that then it's kind of do what I say, not what I do. And we know, for many years, that in tobacco control if you only do tobacco control for kids, you don't do much good at all. Interestingly, in New York City when I was commissioner, we did pretty much only tobacco control for adults, and rates in kids went down twice as fast as rates in adults. So I think that's because it's easier to never start than it is to quit. Or maybe because our kids smarter than we are. But in any case, that was what we found, and so I don't think you can only have those indicators.

Looking at the rate of tobacco use globally has to be an indicator, because we have over a billion people in the world who smoke. And we know that if we make modest decreases in that, we will save literally more than a hundred million lives. In the 20th century, a hundred million people were killed by tobacco. With current trends, a billion people will be killed by tobacco in a century. Every time I say that, I think I must have gotten the number wrong, let me go back and calculate it again. It's accurate. So it is a tremendous problem that we have to address.

And then high blood pressure is crucially important. A high blood pressure is the only underlying cause of death that kills more people than tobacco, about 8 million people around the world versus about 6 million from tobacco. And we can reduce it by reducing sodium, we can reduce it by improving weight, and, ultimately, we're going to reduce it by creating a lot of people. The systems in the country that have done good hypertension control have seen dramatic payoff in terms of lives saved and reduced health care costs.

MS. : You gave me an opening for a question that came in over the Internet, Joshua Busby (sp) from the University of Texas at Austin: What are your views on the challenges of drug access in NCDs, given the conflicts between India and branded pharmaceutical companies over patent rights, and the ongoing discussion on the Trans-Pacific Partnership, which may have major implications for developing countries' access to low-cost pharmaceuticals?

FRIEDEN: My impression of this is that it is going to be a tough issue. If you look at what happened with drugs for HIV, there was a broad recognition that there was no way that countries were going to be able to afford what is being paid here, and that, therefore, licensing of those drugs to be made at high quality in other countries was very important. With the non-communicable disease drugs, you have really a huge range. So for high blood pressure, you have drugs that will cost probably less than five dollars per year to manufacture, that will control 80, 90 percent of people's blood pressure. So very inexpensive, generic, off-patent drugs.

And, in general, we're not going to treat our way out of the noncommunicable disease epidemic. Now, that's in general. Hypertension is probably an exception, cholesterol maybe. Cancer, we're seeing lots of potential. And where that comes in are things like the human papillomavirus vaccine. This is a vaccine which potentially can be made for three or four dollars per dose. That's still pretty high for many developing countries. But we have -- between hepatitis B and HPV, human papillomavirus, we have vaccines against cancer that can prevent millions of cases around the world.

And how we work that out, I think, is going to be very challenging. I don't know the right answer. You obviously have to balance. You have to balance respecting intellectual property and promoting innovation and research with the fact that people are dying today from conditions that might be treatable for a lot less money. I will tell you that at least one pharma representative has said to me, we will do it. We will sell at price to any country as long as we're sure they won't steal our property and sell it on the open market. We don't want to get rich off of this.

But I think one of the things that was encouraging about -- (inaudible) -- and what the Clinton Global Initiative did was they basically made a grand bargain, if you will, that we're going to preserve or increase your net profits by vastly expanding your market but bringing your margins down.

(Audio break.)

QUESTIONER: Mora McLean, the Africa-America Institute. Doctor Frieden, I want to pose the flip side of Lori Garrett's (sp) question. Are there areas that you've observed -- (audio break) -- (inaudible) -- that -- where there are advances in other countries, particularly in the so-called south, where we can learn how to do things better? And does our culture, policy environment and the bureaucracy of the CDC permit you to absorb and apply those lesson? (Audio break.)

FRIEDEN: Thank you. Very much so. There is so much we can learn, both in terms of what's happening and in terms of programs that work. So one of the most intriguing findings comes from a study called INTERSALT, where they measured sodium excretion from dozens of countries correlated with blood pressure, and there were four outlier communities. They were all preindustrial communities. And in those communities, the average sodium intake was about 500 milligrams a day. That's about one-seventh what we take in. People weren't salt-deprived.

And although there are many other factors, including physical activity and nutrition, in those communities there was no, no age-related increase in blood pressure. In this country, more than two-thirds of people over the age of 65 have high blood pressure. In these four communities, at age 14 it was 90 over 60; at age 30 it was 90 over 60; at age 60 it was 90 over 60. So that's very instructive. So there may be things that we can learn from the epidemiology or behaviors around the world.

There are also programs that we can learn from. The accountability of health systems is quite remarkable. There are systems that try to ensure that there is that kind of no-cheating approach that -- (inaudible) -- advocated for tuberculosis control for hypertension or access to other critical health services.

And third, there are community programs that we can learn from. I'm particularly interested in seeing how Brazil's Project GUIA turns out because -- or -- (audio break) -- because it's a remarkable program. It's a huge program: 4,000 communities, $700 million over four years. Can they do it? Can they increase physical activity on a population basis?

But of course in the noncommunicable diseases, we also need to look way beyond the health sector, way beyond health care, way beyond health, to agriculture, to transportation -- (audio break) -- environmental, to look at what are the things that we can do to bring down environmental contamination, to encourage people to walk or bike to work or for recreation. And those are things that I think we can learn a lot from various countries. And it's one of the benefits that we get through global collaboration.

Yes.

QUESTIONER: Tom Bollyky from the council. We are almost a year, almost to the date, from the U.N.'s high-level meeting on NCDs last year and the WHO processes that have gone on since. Tell me a bit about the -- what short-term success looks for you. What are three things you would like to see in the international effort around NCDs next year at this time, in the good fortune that you would be back with us? Or even more generally, what would you like to see?

FRIEDEN: Well, first, we've got to get the agreed-on indicators. You know, if you don't know what the speed limit is, if you don't know what the rules are, getting people to work together is going to be very, very difficult. So we have a U.N. General Assembly mandate to the World Health Organization. We have a World Health Organization commitment to doing it but we don't have them yet. So we need indicators that everyone can agree on first.

Second, we need to actually measure them, because once we have them, countries are going to have to strengthen their systems for tracking. And third, we need technical packages to achieve each of these indicators, because again, doing everything or doing nothing or committing to do something is not the way we're going to have progress in the NCDs; it's going to be by having a menu of things. And a country or community may say, we're not going to do that, we don't agree. That's fine. But at least we normatively, globally need to future out what works so that communities know what they can do to make a difference and how big a difference it's likely to make if they do it.

QUESTIONER: Jeff Laurenti with the Century Foundation. If I could ask you -- to take us back to that tobacco issue, a quarter century ago the Reagan administration made one of the top priorities for American trade policy breaking into Asian markets in particular, in trade negotiations, for American tobacco exports. Presumably there's been some change in consciousness from viewing tobacco as a big item to promote for exports, but -- and presumably there are other countries that have also had tobacco cultivation as a significant source of income earnings, and you have the complaints about the so-called nanny state.

But to what extent has U.S. policy in tobacco exports become visibly more restrictive? To what extent have other countries imposed sharper restrictions on imports, not just from the U.S., but anybody, of tobacco? And where are the countries that have been the most foot-dragging in their national policy on trying to reduce or constrain tobacco use?

MS. : That's three questions, but we'll let you -- (inaudible).

QUESTIONER: (Off mic.) (Laughter.)

FRIEDEN: U.S. trade policy has come a long, long way since there, and the U.S. is no longer promoting tobacco exports specifically. There are complex issues with WTO negotiations and trade agreements that I'm, frankly, not fully up to date on, so I can't comment.

I will say that the tobacco surveillance systems that Bloomberg funded and CDC helps to implement with WHO and others has shown striking differences among countries. And there are some which really have a long way to go. Now, in Russia you have Putin having said, by 2015 we're going to do a series of things, which is really encouraging because if they do that, it will be huge.

There are countries where the government owns the tobacco industry -- China, in particular. China produces about a third of the cigarettes in the world, and smokes nearly all it produces. So this is a huge problem.

China has more smokers, just about, than the U.S. has people. And at current rates, a hundred million people alive in China today will be killed by tobacco. They are living in this kind of a time -- you know, when you see a big increase in smoking, you begin to see the impact in asthma and heart attacks short term, but it may take 10, 20, 30, 40 years before you really harvest the cancer, the heart disease and the stroke that that brings. So China has the biggest tobacco problem in the world.

There are other countries where the industry has a great deal of influence on the government, and Indonesia might be an example of a country that has very high male smoking rates and has not yet signed the Framework Convention on Tobacco control. Of course, the U.S hasn't ratified it either, so -- in line with Laurie's comment earlier -- the Senate (is ?) a challenge there.

But every country can be assessed against what they're doing in terms of the MPOWER strategy, and that's a huge rate of progress, where we can say, all right, how are we doing? We have a standard. We have a global standard and we have a global way of measuring it for tobacco. We need that for all of the noncommunicables.

MS. : I have another one from one of our members online, Ellen Gustafson of the 30 Project from Coronado, California. I think it links to your notion that multiple sectors have to be involved here. So we're dealing with trade policy. Let's try U.S. agriculture policy. She has a question:

Since the obesity problem across the U.S. seems to be strongly linked to these policies and systems we developed in the last 30 to 50 years, what work are you doing or can you do at CDC to encourage alignment of agriculture policies with human health goals; and maybe ask you, in the interest of the topic at hand today, talking a little bit about low- and middle-income countries and other examples there as well.

FRIEDEN: We work very closely with the Agriculture Department. And I have to say in the last three years there has been a wonderful level of collaboration among federal agencies on a whole host of issues, whether it's with the FDA on tobacco and food safety or with Agriculture on nutrition. You see much better policies in the WIC program, for example, that have really changed that program and made the food much healthier. There's a lot of discussion with the farm bill, which did not get through Congress this year, on how can we promote fruit and vegetables; are there ways that we can, for example, provide crop guarantees the way there are for some of the commodity crops?

These aren't easy issues. And I think some of the analysis of them can be a little too facile because although there are, for example, subsidies, if you really work out what those subsidies mean at the cash register, it's very small. But maybe, you know, whatever you think of them, it's not likely to have a major impact on consumption. But the issue of promoting fruit and vegetables as crops and encouraging their production and consumption is clearly an area where a lot can be done.

MS. : And you mentioned palm oil earlier. I mean, are there any of those kind of basic activities going on? Some of the food industry folks are really looking at how you can have healthier core constituents, I guess, in some of their products. But that would be a big change, wouldn't it?

FRIEDEN: Well, the food industry definitely wants to be part of the solution here. And if you look at industrially produced trans fat, more than half has been eliminated from the food supply since 2006, when the FDA required it to be listed on the label. You can review that -- view that as, you know, artery half-full or artery half-clogged. (Laughter.) You know, but there may be more -- but a lot of the easier things to remove it from have been removed. So it's not going to be easy for the industry, and I think we have to respect and understand their challenges.

Same is true for sodium. In the U.K., they've been able to reduce sodium through voluntary measures by about 500 milligrams per day for the population on average. That's a lot. That's a -- you know, that's a half a gram of salt on average, through things that nobody noticed, you know, just because it was a gradual lowering of the sodium supply all through the system.

But we don't have a solution to the obesity epidemic. That's why we need to try things and study them.

MS. : Mmm hmm.

Question here.

QUESTIONER: Many years ago --

MS. : Could you please introduce yourself?

QUESTIONER: Pardon?

MS. : Introduce yourself.

QUESTIONER: Oh. Harry Evans of Reuters. Many years ago when I was a science reporter, and much younger, in fact, 1960, I had a big dispute with the minister of health, who said that tests for cervical cancer were a waste of time, and he was totally opposed to a national program. Now, things changed shortly after that. What I would like to know is globally now how significant is cervical cancer, how do the comparative rates work out between the developed and underdeveloped world, and which is better, an early screening, possibly a biopsy, or the vaccine we hear so much about?

FRIEDEN: All of the above. So first off, we have a shameful lack of information on the level of burden. We have estimates but not good data on either the rate of cervical cancer or the strains that are involved, which would affect very much which vaccines we produce.

Second, the vaccine can be tremendously effective, and we need to be providing it more broadly, but it's expensive to make, and we need to figure out how to address that.

And third, screening and curettage or other ways of removing cancerous cells before -- precancerous cells before they spread is something that can be done with relatively low level of investment, with low-tech, high-efficacy programs, but has not been scaled up.

So basically, it's a big problem. We haven't done nearly as much as we should on it. And there has been effort with the Pink Ribbon Red Ribbon Coalition to do more in this area, and I'm optimistic that in the coming years a lot more will get done.

MS. : I think we've hit the witching hour, and I know we need to stop on time. Do you have any kind of takeaway message for this group here?

FRIEDEN: Well, I would -- I would go back to the basic concept that noncommunicable diseases are a big problem, but they can be solved. There are things we can do to drastically reduce the burden, and when we do so, we'll have not only made our society healthier, we'll have not only have made our businesses more productive, we'll have not only made our health care costs go down, but we'll have a model for collective action that balances individual, corporate and governmental responsibilities in a way that gets us all moving, healthier, happier.

MS. : Thank you, Dr. Frieden. I -- we all thank you for coming. (Applause.) And we'll have a -- (audio break)

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