Advancing an Agenda on Risk and Chronic Disease
SCOTT C.RATZAN
Today, chronic diseases account for 60% of deaths globally. In 2000,
this would translate into more than 33 million deaths from cardiovascular
disease (CVD), especially coronary heart disease (CHD) and stroke (16
million deaths); cancer (7 million deaths); chronic respiratory disease
(3.5 million deaths); and diabetes (almost 1 million deaths). Mental
health problems further contribute to the burden of disease in many
countries. Despite much of the media focus on communicable diseases,
only in Africa are such diseases more frequent as causes of death than
chronic diseases.
It is clear that chronic diseases are important contributors to health
inequalities within and between countries. They also are heightening
disparities among poor populations. This is largely because of inequalities
in the distribution of major chronic disease risk factors — principally
diet, exercise, environmental risks, and tobacco use. This global pattern
of death and disability will continue to get worse as chronic diseases
(namely CHD and stroke)are expected to be the leading causes of death
and of disability adjusted life years lost (DALYs) by the year 2020.
We are now facing a challenging time in how people — from policymakers
to the public — perceive risk and advance health policy. Faced
with the need to develop strategies to combat chronic disease, government
agencies and private organizations encounter a host of challenges: Who
is at risk, what are the options for risk management, who can and does
control the risk, what is the nature of the process to determine the
risk mitigation, and other related areas. For example, a risk judged
more certain (e. g. , the risk from a known disease)may be viewed as
less risky than an equivalent or smaller risk that is perceived as more
ambiguous (e.g., the risk from a new, unfamiliar vaccine, or exposure
to flesh eating bacteria). Hence, overestimating rare causes of death
(e.g., bioterrorism) can garner public health resources while underestimating
the burden of common ones. At all levels of society, it is a challenge
to convey meaningful technical information to inform decisions.
Oftentimes, public concerns of minimal risk get limited resources This
is most obvious in how people avoid preventive measures for cancer —
a perceived long-term risk factors and distal consequences, versus judgment
of risk acceptability related to treatment of cancer. Yet, the threshold
on the probability of an adverse outcome and its magnitude or severity
for certain treatments is under intense scrutiny by regulators of medicines
— notably the U.S. Food and Drug Administration and the European
Medicines Agency. This in many cases demands better medicine and certainty
from drugs that provide incremental scientific progress as limited innovation
in a challenging area such as cancer. For example, should a treatment
be approved for patient use if it only offers 5%–25% efficacy?
Or should it be allowed in terminal cases if it has a side effect in
10%of the population? Should pain or palliative medicines have a different
threshold than curative interventions? Would an HIV vaccine with 25%
efficacy offer value and be approved for use?
Such questions are being decided on the grounds of science and the
protection of the public, while offering limited opportunity for ethical
deliberation and input from those who most likely will benefit from
future innovation. Additional new hurdles of the ‘‘value ’’or
cost effectiveness of prolonging life through different measures also
are clouding science and the rights of the individual to be offered
the best available treatment options to choose from.
One such challenge on the horizon is the approval and uptake of a vaccine
to prevent cervical cancer. Cervical cancer is still the leading cause
of cancer deaths worldwide, the second most common form of cancer in
all women (after breast cancer), and the most common in younger women.
As the human papilloma virus (HPV) has been identified as the most important
risk factor with more than 80 types of viruses (30 strains that can
be passed sexually) a vaccine has been developed for use in women of
reproductive age to protect against cervical cancer. Currently, cervical
cancer is detected well with annual Pap smear tests; if detected early,
effective treatment is nearly 100%successful. Further preventive measures
such as condoms do fully prevent transmission of HPV.
The Papanicolaou smear, commonly termed the Pap test, is arguably the
most effective cancer-screening test of any kind. Because of the Pap
test, deaths from cervical cancer declined 74% between 1955 and 1992,
and the death rate continues to decline at a rate of about 2% a year.
Even though there is progress, women still die from cervical cancer.
Even with detection and effective treatment, about 3, 710 women will
die from cervical cancer in the United States during 2005. Recently,
a vaccine has been developed for HPV that will require ethical deliberation
and societal choices. For example, should adolescent girls, parents,
and the public submit an extra protective measure for a preventable
and treatable cancer that is related to a sexually transmitted disease?This
development will present important dialogue to help set the course for
the health of the next generation.
Those in public health, public policy, and communication who wish to
advance the health of the public can offer important support by educating
the public with trustworthy information so that people can better understand
risk factors and mitigation as well as some basic epidemiology with
relevance to their lives. Further ethical opportunities should be promulgated
to give the public enough information to enable them to make decisions
according to their own values, and in some cases in partnership with
family members and health professionals. Such cross-fertilization between
fields could assist in the future as we will face challenges that will
not be solved by science alone and will require development of healthier
policies to protect rather than erode public health.
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Scott C. Ratzan MD, MPA, MA is Editor-in-Chief of the Journal
of Health Communication: International Perspectives. He also is
Vice President, Government Affairs, Europe for Johnson & Johnson
with academic appointments at George Washington University School of
Public Health, Tufts University School of Medicine, Yale University
School of Medicine, The College of Europe, and University of Cambridge.
