 Welcome to CSIS. My name is Catherine Bliss and I'm a senior fellow and deputy director with the Global Health Policy Center here. As most of you know, next week leaders from around the world will meet in New York at the United Nations to, among many other things, meet in a high level meeting to chart a path for greater global cooperation on chronic diseases. Now the decision to organize a high level session around chronic diseases was made some time ago in light of information that revealed that chronic diseases are creating significant social, economic, and political challenges even in regions around the world. But while the chronic disease issue is often called an emerging one, it was nearly 10 years ago in 2002 that health ministers in the Americas recognized that chronic diseases had become the number one cause of death in the region. They also recognized that chronic diseases were creating a daunting socioeconomic burden and called on the Pan-American Health Organization, or PAHO, the regional arm of the World Health Organization, to develop a strategy for enhancing regional action and coordination on the issues. Now, five years later, leaders from around the world will meet at the United Nations in New York on September 19th to 20th to chart a path for greater cooperation. As might be expected, lessons from the experience of the Americas in developing coordinated efforts aimed at preventing and controlling chronic diseases will inform discussion and debate during the high level meeting. Here to tell us about the experience of the Americas in developing a strategy to address chronic diseases and to suggest some future directions for integrated action and effort is Dr. John Andrus, Deputy Director of the Pan-American Health Organization. Dr. Andrus assumed his current duties at PAHO in 2009. Previously, he served as lead technical advisor for PAHO's Immunization Program and has held faculty appointments at George Washington University, the Johns Hopkins Bloomberg School of Public Health, and the University of California in San Francisco, a former Peace Corps volunteer in Malawi, and medical epidemiologist with the CDC in Atlanta, but I think serving all around the world or certainly in the Americas and Southeast Asia. Dr. Andrus has focused his more than 25 years of work within the health field on issues related to vaccines, immunization, and primary care in developing countries. So before I turn the phone over to Dr. Andrus, let me briefly mention two upcoming events that may also be of interest to you. The first one is going to be on Thursday, September 14th, so just two days from now. This is a one day or kind of half day conference called Sharing the Responsibility, Non-Communicable Diseases. It's hosted by the Washington Post and will take place, I believe, from about nine until two in the afternoon. And I believe you can attend in person or online. Steve Morrison, who's the Director of the Global Health Policy Center here at CSIS, will be speaking along with Sir George Aleen, Director Emeritus of the Pan-American Health Organization, and Julio Frank, former Health Minister of Mexico, among other speakers from the Americas and around the world. The second is a session on outcomes from the high level meeting that CSIS will host at the Kaiser Family Foundation Building at Metro Center. This will take place on Thursday, September 29th, from 12.30 to 2.00 p.m. And at that meeting, we expect to feature perspectives from U.S. officials, as well as representatives from some of the key countries involved in the negotiations. And you can look for more information about that on our website at www.smartglobalhealth.org and by invitation. And it's now my pleasure to invite Dr. Anders to speak to us. He will describe some of the early recognition of the chronic disease challenge in the region, give us a preview of PAHO's role in the high level meeting next week, and tell us about opportunities for regionally coordinated action beyond next week's meetings, including the forthcoming launch of a forum. And I won't reveal any more details than that. So, Dr. Anders, please. Thank you, Catherine. And thank you, CSIS, the organizers of this event. I'm delighted and honored to be here to discuss this important issue. In December 2009, PAHO launched the Partners Forum for Action on Chronic Disease in the Americas. In collaboration with several partners, including the International Business Leaders Forum, the World Economic Forum, PAHEF, the Public Health Agency of Canada, and in consultation with the Carmen Network, which is a network of centers of excellence dealing with chronic disease in the Americas, the World Health Organization, WHO Collaborating Centers, international NGOs, all working on chronic disease, including heart disease, diabetes and cancer, and also from civil societies such as Consumers International. That forum was welcomed by virtually all the stakeholders. But in going forward, in 2010, we recognized the need to alter the terms of reference. An internal assessment was conducted by PAHO. We consulted with our partners, engaged a consultant to help us with better stewardship of the forum, to take advantage and prioritize those actions that would have the most rapid impact on the disease burden of chronic disease. So what I intend to do is give you an update of where we are with the forum and also discuss in detail what I feel are tremendous opportunities going forward. Do I do page up, page down? Page down. OK. So as Katherine mentioned, the bulk of my talk will be covering chronic disease opportunities. But I wanted to share with you a little bit of background to set the stage and then also cover some of the hard work conducted by actually colleagues in this room, including those at PAHO like James Olspi-Dallas, James Hill and others, but other colleagues and partners that have been working hard behind the scenes in preparation for the high level meeting. So 63% nearly 2 thirds of the global burden of mortality is due to chronic disease. The situation is even worse in our region where we estimate three quarters of the causes of mortality due to chronic disease. And you see here in this graphic, certainly the role the big four have, cardiovascular disease, cancer, diabetes, and chronic respiratory disease. We estimate that some 3.9, probably over 4 million deaths currently occurring every year, about one quarter of our hemisphere's population, with an estimated population of about 940 million people, have some chronic disease. We estimate that 145 million smoke, 139 million are overweight, and this burden of disease disproportionately affects those that are marginalized, poor women in particular, and so we really have a challenge. I believe that the task at hand really is a public health moral imperative. We are going to be confronted with an economic burden. Imagine today X number of dialysis patients in Paraguay receiving treatment and with the growing trends, the epidemic that we're facing. Imagine what that burden will be in 10 years and the cost implications. And as I alluded to, these are diseases of poverty, there's no question, and there's a disproportionate impact on women. It's estimated that two thirds of the $2 trillion health costs in the United States, estimated by CDC, is due to chronic disease. Now, I believe it was, I'm missing a slide, but I would believe it was Winston Churchill who said that pessimists think of the difficulties in every opportunity, and optimists think of the opportunities in every difficulty. And so given the burden that I just described, there are tremendous opportunities. If you, the slide I wanted to show you that it depicts the following, if you reduce the prevalence of smoking by 20% and reduce salt intake by 15% and provide essential basic medicines like hydrochlorothiazide to a hypertensive patient to 60% of those patients that have chronic disease, in the next 10 years we can save 3.4 million lives, 3.4 million lives. Think of it. And those are relatively simple interventions that will have a major impact in those communities of poverty and women that I refer to. That was the slide I wanted to show you that, unfortunately, I don't have it in this presentation. But fortunately, we do have cost-effective interventions that are being implemented listed on this slide. I'm not going to go through all of them, but think about Cicloviris, where in Spanish that means bicycle free days. Number of cities in the region, most recently Bogota, close the streets like we do on Rock Creek Drive on the weekends to provide opportunities for physical activity. But also I want to highlight the last bullet where Jamaica, Trinidad, Tobago, and Brazil are providing access to these basic medications for free. So there are opportunities to definitely make a difference in the poorest of the poor. But what we have been focusing, particularly in our approach to health, is limited to health. And we will require a all-of-society approach that will include education, transportation, parks, urban planning, environment, all those that contribute to the chronic disease burden. I often cite the example of the child living in a underserved community where the school lunch is not a particularly nutritious lunch, where the nearest grocery store may be a small corner market, where the refrigerator is full of soft drinks loaded with sugar or the counters are stacked with processed foods. There's no fruit. There's lots of candy and other items that are not healthy. So despite the opportunity to make the proper choice, there's no access to those choices that would be healthy. So for that reason, requires a all-of-society, multi-sectoral approach. And countries are implementing these cost-effective interventions, but much, much more needs to be done. And that's why in 2007, the heads of states of the Caribbean, the CARICOM summit, provided an opportunity for Caribbean to take the lead supported by PAHO and other partners to address this important problem. And at CARICOM, they came out with a multi-pronged approach. One was that led to the current global mobilization of commitment of heads of state to tackle chronic diseases. And the fruits of that labor are now paying off with the high-level meeting next week. Internally at PAHO, we have a task force chaired by our director that's supporting all the activities over the last few years going into next week's meeting. And you can see that well after the meeting, we need to avoid the dilemma or problem of just having a one-off event. And I'll get back to that issue. But we're taking advantage of all our country offices, our partners, and involved with preparation of documents and other materials. Next week on Tuesday, we'll be having an America's event where this paper will be launched, as well as the new partners form for action that I'll be discussing in more detail. Some of the other events, I don't want to go into each event leading to next week, but I would like to highlight a couple of them. One in particular, the Latin partnership for healthy lifestyles emerged. And that is going forward, similar to what was launched in the Caribbean a few years ago. We've also been involved with the Mexico City meeting that brought together civil society. And you can see events leading to next week. Again, this is not a one-off activity. This is something that we hope will benefit global health as much as the first UN summit did for AIDS. I referred to the CARICOM meeting in 2007. These are the heads of state that put forward that call to action with several action points, contributing, we believe, to the current situation and level of support going into this. But there have been challenges to developing the consensus required. I won't go into each of these. I'd like to select that third challenge, that as someone that's worked in immunization, eradicating polio measles, most recently rubella, in the region, the need to have targets and the need to have indicators. Because we can all talk, but walking the talk and demonstrating that we have made progress with accountability and reporting is going to be critically important. Now, having said that as a challenge, we recognize the need to put more emphasis on that. It is agreed upon by all that over the next year, this issue really has to be addressed. So next year, when someone is talking about this issue, certainly there'll be targets. At PAHO, we have a regional plan of action with targets and indicators. So from a regional perspective, we have a plan of action that we provide technical cooperation to countries. More focused in the health sector, the forum provides an opportunity for the all of society approach, but we do have targets and indicators that we monitor carefully and that we are held accountable for by our member states. Next week, there'll be some greater than 35 side events. In red, you see one event in particular, the America's event that I alluded to, that would help us launch this document as well as the partners forum for action. You see other activities there. Many of you will probably be going. Our director will be involved with several of the events as well as our team that's here today. What is the partners forum? It's really a platform to bring various key partners together. Raise awareness, help create new partnerships, strengthening existing partnerships, scale up successful practices, while all at the same time promoting the established regional plan of action that we have at PAHO in supporting member states. But it provides an opportunity to, again, be inclusive and bring in other key sectors. The mission I stated here is to achieve better health, but the goals more strategically will be to attempt to avoid this economic loss by disease prevention. That example that I started with at the beginning, that 20% reduction of tobacco prevalence, 15% reduction of salt intake, and provision of basic medicines for 60% of those with existing chronic diseases will, we estimate, save about 3.4 million lives. This comes from a methodology that was published in a Lancet paper that used, it was a global study that but used data from Mexico, Brazil, I believe Argentina and a few other countries. So it's a methodology that we have replicated and scaled up in the region to get an estimate on what we can do with best practices, interventions that we know work. It will require a multi-sectoral approach. And the functions you see there, PAHO will be an honest broker, have a catalytic role. We will seek support for our own plan of action, but we will help catalyze new partnerships that we may not be involved with, but will promote new opportunities for all sectors of society, particularly private. I mentioned it will be building on existing initiatives. The process is depicted here graphically, attempting to be open and exclusive as possible with the various key areas of key partners. Carmen, as I mentioned, is an existing network of centers of excellence dealing with chronic diseases in Latin America and the Caribbean. And through that process of dialogue, there'll be some planning and hammering out of specific activities and projects, some of which might go to PAHO, some of which would go directly to ministries of health or other new partnerships. But we believe we can help catalyze these new opportunities as well as be an honest broker. Another way to depict the process and the action going forward, I wanted to use this slide to remind you, we do have a timeline. We have a plan of action with products that we will deliver. And going forward, I can report on the next time I'm invited. So the key project areas of work are examples here of dietary, healthy workplaces, public awareness. I think the theme that weaves its way through all areas of work is using the best practices. And that's a role that PAHO can do in promoting best practices from one country that might or may not in some cases help other countries as situations are different. But tobacco is a problem in every country and more adolescent girls are smoking. So there are commonalities and interventions that we can use to make, as Tom Frieden says, save more lives more quickly with low hanging fruit and the opportunities to tackle them. I wanted to mention a little bit about cervical cancer. This is a strategic area of work that PAHO has been engaged with. We have new screening technologies that will provide opportunities to screen and treat on the same day. You can imagine the challenges to providing services, and particularly in the poorest of the countries, with access being what it is, but quality of care, and so on. The complexities are enormous. So when we have these new technologies, such as an antigen test that can provide an answer and then an opportunity to treat in the same visit will be excellent, that will be cost-effective. And we also have a vaccine that we've been working with countries to analyze the evidence, to make an evidence-based decision on this new opportunity for saving lives. But we know that it'll take 20 years to see the impact. So in the meantime, it behooves us to strengthen screening services. As an example, where PAHO is focused on providing technical cooperation for the biggest cancer killer among women. The rules of engagement, I mentioned being inclusive, dialoguing, being inclusive with the exceptions noted, and being committed to shared values that provide services to those in greatest need where the biggest disease burden occurs. We have some projects that, products of which will come out in the next couple of years. We have at least four regional projects under way. These are communication campaigns. We have also other opportunities for multi-stakeholder forums. And we are working on establishing a more robust project pipeline mechanism. We will need support within the PAHO to expand our secretariat. But we are, I think with the small team we have accomplishing a lot. But this is now a priority for the first time in history. More deaths are occurring due to chronic disease. We've been traditionally an organization focused on infectious disease. And I think that this is now emerging as our top priority. I mentioned our plan of action, the plan of technical cooperation we provide. It does focus on interventions that will provide the biggest impact. And it's focused on prevention, screening, and early detection as I mentioned using the example of cervical cancer. We will revise this plan of action based on some of the outcomes of next week, but certainly over the next year as targets and indicators are hammered out and consensus is achieved. But we do have our own at the moment. I just to quote our director. It took us, all of us governments, people and companies decades to get into this mess. And it will take all of us working together many years to get out of it. The slide that, I guess I moved it to the end. I meant to repeat it, copy it. But here's that illustration. And this is the opportunity. This is the strategic opportunity that, in one example, and there are other examples. But, and it doesn't cost, certainly providing basic essential supplies does cost. But changing tobacco policy and laws, that's something that doesn't cost much. So there's some immediate action that we can take now as we mobilize more resources. And it will require, for reasons I mentioned, the all of society multi-sectoral approach that you see is very inclusive as highlighted by this slide that includes business, private sector, the civil society and local government agencies and people or partners involved at the point of service. It involves not only introducing new interventions, but looking at the quality of services of old interventions like cervical cancer screening that's been grossly a failure in our country. So quality will be an issue. Mexico is one country using a promotora approach to following monitoring and trying to strengthen quality of services. So in conclusion, we have an unprecedented opportunity to save more lives more quickly with known interventions that work and focus on prevention. And the alternative is just unacceptable. I'd like to thank the organizers for inviting us. Thank you very much. We have some time for questions and discussion. Would you like to take a seat? I think while, well, those of you who are in the audience, take a few minutes to formulate some questions in your mind. I just had a couple here that I wanted to start out with. There's a lot going on in the region and it seems like a set of very complex issues but also some very straightforward messages as well. But one thing I wanted to ask, you talked about the roles that the government and civil society and the private sector can all play particularly as you look toward this Pan-American forum getting going. And I just wanted to ask about the role of social movements with respect to chronic diseases. We've seen particularly with respect to HIV-AIDS and some of the other infectious or communicable diseases, some real achievement and advocacy around very, very specific kinds of diseases. But I wanted to ask what your sense is in the region about the organization of not just NGOs or civil society groups but real social movements around some of these issues. What is the status of mobilization around some of this? It's a great question. I can respond generically having worked in other WHO regions of the world, Southeast Asia and Africa. There is a culture of prevention and I felt that strongly with the use of vaccines in the region. We're the only region in the world that have eradicated polio, measles and rubella. So there's this acceptance of preventive measures in my former experience seeing it with vaccines. But I think we're beginning to see it with chronic disease as well. The Caribbean, it turns out that many of the initiatives that PAHO embarks upon or supports countries with, sometimes usually start in the Caribbean actually, that's where basically rubella and measles started. And in 2007 when the heads of state all got together, that was a nodal point in history. Your question about civil society, partnerships, movements, I'm less aware of, but I know they're there. I can't name names, but they, I believe my feeling is that there's this acceptance and there's a culture of prevention. We now, I hate to cite immunization all the time, but that's my primary expertise. We now have 16 countries that have introduced rotavirus vaccine, a number of countries that have introduced HPV vaccine and these are preventive measures that I think where policymakers see the benefit over and above curative measures. This prevention is something we wanna take advantage of because there is an exact, the sophistication there of understanding the power of prevention. Thank you, let me just pose kind of coming from a very different perspective. You talked quite a bit about the role or at the beginning about the role of not just the health sector, but also the education sector and the importance of particular thinking about the built environment. I think one of your examples was about the child who can't get outside to play because there's a highway right there or something. And just thinking about some of the broader challenges that are facing many of the countries in the region, I mean violence is something that comes up quite a bit and I wanted to know to what extent the security agencies are able to be integrated into any of those to help create safe conditions for people to spend time. It's a great question. I think looking through the lens of PAHO, I think we've been very fortunate to have a response, particularly in emergencies of all sectors, including defense sector. I think of the response to Haiti, the earthquake, the cholera, where the US government, for example, provided the USS comfort. There were other interventions that helped with a health response. We probably need to do a much better job on the day-to-day activities and work that goes into the prevention and control of chronic disease to take, not just for security, but for all aspects. Security being a critical issue. When health, I see the economic burden that's going to emerge contributing to instability unless we tackle it now. I know in the interview I had before this, I cited the example of childhood obesity and there, if we don't reverse that trend, we know by 2030 we'll lose all the gains in life expectancy that have been achieved through safe water, sanitation, and immunization. That also will contribute to instability unless we tackle it. So it's a two-way street in many ways. For those of you who heard of the interview, we recorded a podcast interview prior to this session, so you can look for that on our website probably by tomorrow sometime. Just a preview of what will happen next week at the high-level meeting. We have time for questions and comments from the audience and we do have some microphones in the back of the room. So for those of you who have questions, I would invite you just to put your hand up and when the microphone comes to you, just say your name and affiliation and pose your question please. And I believe we have a question up here in the front. Thank you. Wendy Baldwin, Population Reference Bureau. I want to applaud the focus on the four main chronic diseases and four main risk factors. I know that must have taken an enormous amount of negotiation because there's always 10 or 12 or 20 others that people want to see included and the focus on prevention. One aspect that seems to be getting far less attention that I think helps focus a great deal is the fact that smoking and alcohol use both commenced in adolescence and young adulthood. And if we have not managed to instill habits of good diet and physical activity in adolescence, the possibility of doing this when people are at 45 is probably vanishingly small. And it seems there is a way to kind of bring these four risk factors together around a focus on youth and building strong youth for the future, et cetera. And I would really just appreciate your reflections on that. I really see very little focus on youth, certainly if you scan any of the documents, any of the way data has been marshaled, I would just be interested in your reaction to that. That's a great comment and certainly speaks to a longer term vision that will produce and benefit many decades from now but is worth committing to. I was in El Paso, we have a border office in El Paso where chronic disease is a challenge along the border community that's typically marginalized, typically poor. I learn a lot about what's being done with what are called, I believe they're called echo clubs, whereby children, adolescents are brought together to address, in their way, environmental issues. So getting them involved, getting them active, developing leadership roles in their community that would set the stage for being a more responsible citizen in the future. So that initiative, I was very impressed with having seen it in El Paso and it's something that's happening as I learn more about it across the region. But I think, I mention it because there is an opportunity to address exactly what you're saying and put a focus on youth. We're seeing tobacco prevalence going up in certain countries because of the way marketing is being conducted and we're seeing that in adolescent girls. So it's something that we're gonna have to definitely tackle. Thank you for your question, that was excellent. From our webcast audience, which is what is being done to ensure that grassroots organizations and the voice of people living with chronic diseases are included and heard at the summit? Basically, I would restate what I mentioned in the presentation that this has to be a movement that's inclusive, that does a better job of what our traditional role has been, which is focused on health. This has to be an all society approach and that would include grassroots organizations. I haven't, well, let me ask Steve in the back, please. Have a question. Thank you, John, thank you so much for your presentation. We know that a decision's not been taken, really, to include in the outcome document clear indicators and targets in this next cycle that will be put off for another year, perhaps a little longer in WHO playing a leading role in this. Can you comment a little bit around the reluctance to take that step in the immediate term and what that means? I mean, does that then put a burden back upon individual countries or regional bodies to push ahead, to begin to institute these kind of indicators that are so important in being able to set goals and to measure against those goals? And the second question is around the business community. You made some exclusions that are the usual exclusions. On the other side is, of course, winning over the business community to becoming active partners in this because so much of this rests upon reformulation, upon different measures that industry can take in terms of making affordable access and the like. If you could just comment on those two, I appreciate that, thank you. Thank you. With regards to reluctance, it's work in progress. I think we need to do a better job at developing the consensus that would recognize the opportunity that I mentioned at the beginning that really to change a tobacco law is essentially can happen at relatively no cost. It does cost something, it costs people time and so on, but in terms of what we do in government, it's something that's worth doing and can be done very rapidly and lead to decreased prevalence and burden due to tobacco. So those are the short-term things that we can do and stay focused on, get more buy-in, it's work in progress, but then over the longer period of time, again using the example of providing the essential medicines, that will require an investment in the current, the timing right now with the economic crisis is unfortunate because certain donors, their knee-jerk reaction is to be more reluctant as you refer to. We hope that this can be circumvented because the risk of complacency, the risk of not supporting it 20, 30 years from now will be just overwhelming. So I think developing better communication messages and continuing work on consensus recognize that there's risk groups that we can help immediately. Businesses is an area we definitely need to engage. I think previously we talked about businesses who were accountable, who had good practices, who did not use marketing strategies that would provide a poor health impact. Accountability changes, and so it's been difficult to, and particularly for PAHO, we're not good at working particularly well with private sector. Our job is to work with the government sector, our member states, that's who we are accountable to, but we recognize there's a huge opportunity for businesses and working with PAHEF and others to mobilize those resources and within the culture of a business, establish better business practices that would provide products that are healthier, so the food industry being a key component of that. Without the business side of things, we won't be able to tackle this challenge. We will be looking at the reversal of the life expectancy gains, we vitally need them. So I, you have a great question. Yes, we have a question up here in the front, please. Thank you very much for an interesting presentation. My name is Eckhart Kleinal from Cameras International. Can you say a little bit more about the data collection side, what in terms of information systems needs to be improved because some of the data we have, the accuracy probably is somewhat questionable, and as even though we don't have agreed upon targets and indicators yet, but eventually hopefully we will get there, and what is PAHEF's recommendation to improve data collection in the future for the next three to five years? Thank you. I'll try to be brief with my answer, but we consider our area of expertise to be one that involves monitoring and evaluations, surveillance systems, the good public health practices that would allow for better data to evaluate progress. Now, you're right, the data is consistently poor and a huge challenge. If I cite cervical cancer registries, there's one example where we just have have to do a much better job, so we won't know what our impact will be in the leading cause of cancer deaths among women. So we need to improve that. Again, it's work in progress. I think Jamaica just recently did a pretty, a very nice study on HPV prevalence, and a link to that was a strategy to improve their registry information and have better data going forward with the introduction of new screening technologies in the vaccine I mentioned. Many of the, but then I would spin it as an opportunity where we could use the input of various partners who would be well positioned to do prevalent studies. If we want to monitor tobacco interventions, doing periodic studies, utilizing expertise and partnerships that we would benefit from tapping more. Certainly there's an opportunity going forward there to monitor impact of strategies. Good question, I wish I had a better answer, but it's something that's very high on our problem list. We have another question over here, again in the front row please. Hi, I'm Jock Whittlesey from the State Department. Could you talk a little bit more about the saving lives? Because to me it sounds, in many cases, what you're doing is extending lives. Somebody who's gonna die in their 50s or 60s would now be able to live into their 70s or 80s. Could you talk a little bit more about perhaps some of the demographics of what those life is, who's affected by those, and maybe touch on some of the economic aspects. And I'd also like to hear more about the differential impacts on women, please, thank you. You're right about extending lives, lifespan. In the example of cervical cancer, to the extent your prevention would lead to another cause of death, essentially. If you're gonna prevent cervical cancer, that woman's gonna die of something else. But it won't be a premature death, so that's where your point is well taken, extending lives. Of the 3.9 million deaths that occur annually, these are based on 2007 data, some 23, 20, nearly a quarter of them occur among people aged less than 70. Again, your point supported. Economics, I often think of as a family physician, if you have a patient on dialysis, and you have X number of patients on dialysis at this given point in time, as the trend continues to rise, what is that current impact on your health budget? It's something fairly substantial, disproportionate for that particular disease. And then as you go forward, fast forward, 10, 15 years from now, the economic implications. I don't have hard data. This is something that PAHO could work on to generate more data, because then that would lead to having better information to generate the consensus and commitment required. Women, so there we refer to, again, I don't have data, which makes me kind of hesitate, but I'm extending it from our experience of field work where particularly in communities of poverty, the mother has a role in the family, and if she, in many cases, is responsible for keeping the family together, having some economic income, that will adversely affect the economics of the situation. I wish I had better data to share with you. I was actually asking about the different... I don't, I can't cite data at the moment, yeah. Unless, is there someone from PAHO James, Dr. Hospitalis, do you wanna come in? Could I ask you to come in? Let's, there should be a mic coming your way, thanks. For those of you, Dr. Hospitalis is a technical, our technical expert on chronic disease working at PAHO. Thanks, John. Thanks, John. Well, where women are concerned, I mean, there's obviously the sort of biologically based one, cancer to the breast, cancer to the cervix. Cancer to the cervix is six to eight times commoner in Latin America in the Caribbean, both incidence and mortality, six to eight hundred percent more common. That's one that really we wanna put some emphasis on, and obesity, overweight and obesity is much common in women and increasing rapidly. Projections to 2015 showed that many, many more, and that's gonna drive up maternal mortality. It's gonna put up diabetes, heart, cancer, and so on. So those are some of the areas where there is a disproportionate impact. John mentioned smoking in Chile, in Argentina, in Brazil, in Costa Rica, more girls 13 to 15 years of age are smoking by a big margin than boys. That's almost unprecedented. And so you have cohorts coming through where the girls are smoking more than the boys. Our global school health survey data shows similar proportions of girls and boys aged 12 to 16 who have been drunk, binge drinking in the last month, and it's a high percentage. And when I first saw it, I was really surprised. I thought the girls were smarter than that. But those are some of the examples where there is a different impact. Thanks, James, for your help. I didn't quite understand your question, and I think that in addition to that, the premature cervical cancer mortality in particularly Central America and the Caribbean, those rates are some of the highest in the world. East Africa, West Africa probably lead the world, but we're not far behind in those subregions I mentioned as another example. Yes, please. But please wait for the mic, because we've got an online audience which is trying to listen as well. Just to that same point about the effect on women, if you want to step away from the exact, the immediate effect of illness on them, the fact as you've pointed out that in the low and middle income countries, NCDs have an impact at an earlier stage of life. That's when their individuals are still economically active. So you have a different kind of impact. Women are more likely to be caregivers, and so these are not deaths that happen overnight. These are deaths that happen with a long lead up of disability frequently for many of the diseases, and women are the caregivers there. If you look at alcohol consumption, which is one of the four big risk factors, that's also one of the big triggers for gender-based violence. So I think there are a number of ways, depending on how far you want to step away from just the diagnosis and morbidity and mortality, there are a number of ways to think about an adverse, a particular impact on women. Thank you. I'm sorry. No, I just wanted to thank you. That was excellent. And I believe we have a comment here in the back. Please. Hi, my name is Marika, and I work with John, and I am the coordinator for gender diversity and human rights at PAHO. And in addition to all the points that have been brought up, which I have so much to do with gender roles and cultural roles, and especially when we're talking about communicable diseases, there are diseases of social constructs. The biology plays a piece of that, but in a large extent, is the way we're behaved, we're treated, we live, the kind of environments we live in. And in addition to all the points that have been brought out by my colleague James, with whom we work very closely, is that there's also a very serious issue about women as caregivers, because increasingly we are going to be aging, and increasingly we are going to do so with non-communicable diseases and some kind of disabling conditions. And increasingly our health structures are not being able to hospitalize women and men to the extent that they could. And so increasingly that burden of care falls on the shoulders of women with huge consequences, economic as well as physical and emotional consequences, which is an issue that unfortunately is not considered as much as it should be. We know, I don't know all of you over 50 who read our AARP excellent publications show that this is really a very, very serious issue that AARP has put on their agenda. And obviously in PAHO this is also an issue that we should be paying a lot of attention to. And then I also wanna point out that in the list of all the wonderful things that we are doing to bring this to the attention of our region and our partners is we're also having a panel on gender and non-communicable diseases within the UN with partners, the NCD coalition and the mother and child coalition to bring this to the attention of we who are also interested in gender and women's rights issues. Thank you. Thank you. I believe I saw another question over here on this side, but that could have been mistaken. No, it was on this side, I'm sorry. Yeah, it's please. Good afternoon, Bill Martin from the National Institutes of Health. Early in your introduction you talked about disparities related both to women and to poverty. And so in the context of the Americas, environmental risks for those who are poor are quite different than from the developed community. So in the context of non-communicable disease is there any thing included focusing on indoor air pollution, the way women cook and are exposed lifelong to smoke that contributes to COPD, cardiovascular disease risk, acute pneumonia in children because that certainly is a gender specific issue and related to poverty. That's a great question. The short answer is yes and I'm familiar with Kirk Smith's work in Guatemala, I believe, where a lot of excellent data have shed the light on this problem and that there are doable, cost-effective interventions to correct it. So it's something that Dr. Galbao, who leads our environment group, who's highly focused and has a work plan to provide technical cooperation on that problem. I agree, indoor air pollution and the way it affects the primary cooker. The mother is gonna contribute to respiratory disease, which is one of the big four as you alluded to. So yes, there's a tremendous opportunity there and Dr. Galbao was, we've got involved, I think about a year ago, a year and a half ago, there was a global activity coordinated by Dr. Horton at Lancet that brought in the London School. We were involved, it was launched at the press club here in town and this, in fact, Kirk was on one of the panelists that I was on and that so I really admire his work in helping us prioritize this. Thank you for your question. Now I wanted to just get back to some of the questions of the organization, of the health systems themselves that you were talking about in your presentation and one of the things I wanted to ask you just to tell us a little bit more about is how human resource needs may change in the coming years as the chronic disease burden becomes more acute. Are medical schools and universities gearing up for training people for this coming challenge or this already existing challenge or is this something that, again, where attention and advocacy needs to be made? Another great question. My calendar is, sometimes I think like I'm a, it's a blur, but I can't remember if it was last week or the week before but I remember somebody saying that in medical school education, the amount of time spent on maternal child health issues, the traditional model of public health is weeks compared to a few hours on some of these issues that we're talking about prevention. Now certainly chronic disease, as a medical student, you spend a lot of time in the ICU and the CCU, Cardiac Care Unit, but in terms of prevention and what we could do as primary care physicians needs more emphasis. That's my short answer to your question. I'd like to cite Mexico again for the work that they're doing with the promadoras. When I was in El Paso, that was a border activity that our office was focused on in terms of quality of care and follow-up, yeah. Thank you. Do we have any more online questions that we can pose? Not at the moment, oh, okay. All right, are there any other questions here from the floor? Yes, please, sir, in the front. Thank you. My name is Andrew Benson, and vice president of International Relations for the International Food Information Council out of Washington, D.C. I want you to commend your focus in many initiatives on communications. And I know in Kalman and in your forum, you had stressed the significant importance of this particular element. I noted that three out of the six of your target areas involve childhood obesity, involve diet and physical activity. So that's about half of the program area. And these are areas which are tremendously difficult for communications. Obviously, diversity in the region, linguistic, cultural differences. The mere fact that even in the USA, the vast majority of consumers do not understand what a calorie is. We have very little concept of the idea of energy balance. It's what you eat, how much energy you consume, how much physical activity you undertake. So it's a tremendous communications challenge. Very often, we get conflicting messages between stakeholders, industry, government agencies, policymakers, very well-intentioned advocacy groups. But when you hear six dissimilar messages from six different sources, the end result is confusion, lack of ability to change, and the situation gets worse, as we have seen year after year with the obesity epidemic throughout the Americas. You also mentioned the desire to enhance public-private cooperation, but the challenges in certain areas. And I think we all know those well, so I won't go into those in great detail. But it strikes me that the area of communications may be a common interest bridge between all these sectors that want their consumers and the public at large to benefit from increased public health and well-being. So you mentioned four existing programs already underway, and I'm wondering if there are opportunities for developing these aspects further after the NCD program in New York with communications being a common ground. Now, very briefly, this is a subject that's very central to my own organization, so I admit a bias in wanting to have effective communications. We are doing something about this, and we have organized a one-day program on September 20th, which the US Surgeon General will be the keynote speaker. We have representatives from EFSA and DGSANCO and the US Government Undersecretary for Food and Health. We'll be participating in this along with industry representatives, leading academics in the National Council Institute. So we really mean business in getting people together, working together, and yes, we'll have our differences to iron out, but I see it as an opportunity, as you said, rather than a challenge. Thoughts on that, how could we get engaged? Is it something worth pursuing after September 19th and 20th? Thank you. Excellent, thank you. That after statement rings loud and true, it can't be a one-off activity, and communication strategy will be critically important. Yes, we should talk, and I laud you on your event. I think that happens during our, did you say the 30th of September? No, the 20th. 20th, oh, okay. Yeah, yeah, okay. Excellent. So yes, let's talk, and it seems to me that someone like you and your group would benefit, or we would mutually benefit if you become more engaged with the Partners Forum over the next years to come. This is gonna be a high priority. With the communications message, we have so much more to do and to do it better. I used to love to be able to say, what minister of health would not want to be seen on TV vaccinating a child? Or what president would not want to be seen vaccinating a child? And that's the same kind of message. What company or what partner would not want to be seen providing good corporate practices, providing good products that are healthy? All right, thank you. We have another question over here to the right, please. Or my right, to the left of the room. I'm sorry, can you wait for the mic just because we are trying to capture this for our web audience. Okay, I just wanted to correct the date on that. My colleague from Europe advised me as September the 19th, okay, and it will begin at 10.30 a.m. at the Union League Club in New York on Parkham 37th Street, which is deliberately two to three blocks away from the UN. And there is a website on that at foodinside.org slash global summit. So just to put the record straight, I apologize. Thank you. And now we had another question over here, please. Hello, my name's Dan Fantosi. I'm an independent consultant. I used to be with the State Department. And you touched somewhat on finances and made the point about how a lot of the interventions are relatively cheap compared to others and there's a high payoff. But I wondered if you could talk more generally about where you see the financing for either the PAHO program or the global summit program coming from in the future. Do you see this as basically something that's going to have to be funded by national governments pretty much on their own? Or do you see the possibility of over time a development of kind of the international funding that we've seen going behind communicable diseases? Thank you. It's all the above in a way. I think in the American, in the best case scenario when governments pay for their own health budget, that's ownership and what better way to sustain a program or an effort. We certainly saw that in immunization over the years with the government purchasing their vaccines and relying less on external sources. We'd like to see that trend continue in other aspects of health and this is an opportunity to do that. You'll have a cross-section of variants in country capacity to do these things. And so in some countries, it will need external support and in others, it will need less. And as World Bank has stated, Latin America has the greatest disparities in the world. So we have a huge population of poverty that somehow needs to be supported in the best case scenario, government and those other scenarios, external support, particularly if it's catalytic, whereby government can take over in the next few years as we've often done with programs, then that helps and it's not something that's forever but it's catalytic and gets things moving and the momentum going so that there's enough time there where everybody starts to see the impact and it can take a hold. All right, well thank you very much. If there are no other questions, I'm going to call our session to a close. I wanna thank you all for joining us on a beautiful afternoon outside. You had a choice in coming to the park or coming here and we're glad that you came here to spend some time and learn about the chronic disease situation in the Americas and the many things that are happening both at the high level meeting next week and in the future with the Pan-American Forum and many different ways for government, civil society and the private sector to get involved. Please join me in thanking Dr. Andrews for speaking with us this afternoon. Thank you.