The strategy seeks to reduce preventable mortality This emph
The 25×25 strategy seeks to reduce preventable mortality. This emphasis leads to the selection of the four disorders specified in the strategy (cardiovascular disease, diabetes, cancer, and chronic respiratory disease), which account for 87% of all deaths from NCDs (). However, when the burden of disease is measured as disability-adjusted life-years (DALYs), which incorporates information on both mortality and morbidity, a rather different picture appears. The big four NCDs now account for only 54% of NCD DALYs. The so-called missing NCDs include neurological disease, mental health disorders, musculoskeletal disease, and hearing and vision loss (). Other NCDs are also included in the 25×25 strategy (eg, Madecassoside cost is included under respiratory disease), but receive little emphasis because they are rarely fatal, even though they account for a non-trivial proportion of DALYs. For some of these missing NCDs (eg, neurological disease, asthma), the major causes are unknown, so ongoing research is needed, alongside global action on known causes of NCDs. Mental-health issues have been included in the WHO Global NCD Action Plan 2013–2020, but the other missing NCDs have not. Most cases of these missing NCDs are not caused by the risk factors targeted by the 25×25 strategy (ie, tobacco, diet, physical activity, and alcohol). The missing causes include infections, occupational exposures, and environmental exposures. Consideration of the structural (distal) determinants—ie, causes of the causes—is also essential. Key environmental causes of the causes include urban design; poverty and development; and air pollution, lifestyle, and climate change. More than 6 million people die each year because of air pollution (about half from ambient and half from household air pollution). Programmes that promote physical activity tend to focus on leisure-time physical activity, but they show a failure to understand that most poor people do not have leisure time. In recent decades, energy expenditure has decreased markedly because of changes in the urban environment, including urban design, safety concerns, the rise of the car, and the near demise of public transport. What is required is environmental change so that physical exercise becomes part of daily life again, rather than being a lifestyle choice. Furthermore, individualised interventions need to be undertaken, and paid for, in each generation. Upstream interventions are also potentially longer lasting than is individual behavioural change and have effects across the entire life-course. Finally, we need to supplement the 25×25 strategy by strengthening existing health systems in LMICs, particularly in primary care. Some LMICs—such as India, China, Brazil, Laos, Indonesia, and the Philippines—are substantially increasing health expenditures. There is therefore a major opportunity to guide this massive investment, but the 25×25 strategy risks missing it because of its neglect of health care for NCDs. Atun and colleagues note how the successful HIV/AIDS response has shown the need for broad-based governance mechanisms that include civil society, affected communities, and the public and private health sectors. Crucially, the experience with HIV/AIDS has shown the importance of the positive interplay of health care and prevention. We can see why, for policy makers, the simplified 25×25 approach, with just a few bullet points, might be preferable, particularly for international agencies such as WHO. However, the desire to keep it simple is counterproductive when it leads to complexity denial. Prevention activities gain more traction if they are embedded in health services and in society—ie, health must be involved in all policies. Prevention strategies also need to adapt as the food, tobacco, alcohol, and drug industry tactics evolve; otherwise, even the small goals of 25×25 will be difficult to attain. Health promotion focused on individuals will be insufficient, particularly in LMICs, without structural changes at the societal level—for example, the ban of trans fatty acids in New York, together with a policy aiming to prevent obesity, has been more effective than individualised health promotion. Active travel—ie, walking and cycling—has major benefits both for individual health and for the health services. The core elements of an antismoking strategy are now recognised as bans on smoking in public places, restrictions on marketing, and increased taxes, with individualised approaches such as nicotine replacement playing a subsidiary role.