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Lopez et al. BMC Medicine 2014, 12:200 Medicine for Global Health
Remembering the forgotten non-communicablediseases Alan D Lopez1*, Thomas N Williams2,3, Adeera Levin4, Marcello Tonelli5, Jasvinder A Singh6,7,8, Peter GJ Burney9,Jürgen Rehm10,11,12,13,14, Nora D Volkow15, George Koob16 and Cleusa P Ferri17,18 The forthcoming post-Millennium Development Goals era will bring about new challenges in global health.
Low- and middle-income countries will have to contend with a dual burden of infectious and non-communicablediseases (NCDs). Some of these NCDs, such as neoplasms, COPD, cardiovascular diseases and diabetes, cause muchhealth loss worldwide and are already widely recognised as doing so. However, 55% of the global NCD burdenarises from other NCDs, which tend to be ignored in terms of premature mortality and quality of life reduction.
Here, experts in some of these ‘forgotten NCDs' review the clinical impact of these diseases along with theconsequences of their ignoring their medical importance, and discuss ways in which they can be given higherglobal health priority in order to decrease the growing burden of disease and disability.
Keywords: Global health, Non-communicable diseases, Sickle cell disease, Chronic kidney disease, Asthma,Dementia, Gout, Substance abuse, Alcohol, Liver cirrhosis government strategies more broadly to cope with what Alan D. Lopez (Figure are already the leading causes of health loss, namely In an era of considerable interest in global health, in non-communicable diseases (NCDs)? Are we doing part motivated by the Millennium Development Goals, enough to reduce the significant, but largely ignored, toll but also inspired by demonstrable success with disease that injuries cause throughout the developing world? control strategies for child survival, donors, countries Large global descriptive studies of the leading causes and the broader global development community are in- of health loss in populations, such as the ongoing Global creasingly asking: what's next? Certainly, the unfinished Burden of Disease Study provide comparable assess- agenda of substantially reducing the six million child ments, albeit with substantial and unacceptable uncer- deaths that still occur each year must remain a focus of tainty, of the epidemiological transition that is occurring global health and development efforts. However, there is virtually everywhere in the developing world. They are now increasing recognition of the imperative not only to also able to track the very modest progress that is being keep babies alive until adolescence, but of keeping ado- made in reducing premature death and disability from lescents alive, and healthy, into old age. Seeing global injuries, including suicide, homicide and collective vio- health priorities as an ‘either/or' dichotomy is becoming lence. Indeed, over 10% of health loss worldwide cur- increasingly irrelevant, and uncommon. There is much rently arises from injuries, no different to what it was reference made to the ‘double burden' or, more cor- two decades ago. Meanwhile, the fraction of the global rectly, the ‘triple burden' (including injuries) that low- burden of disease and injury due to NCDs, including and middle-income countries are facing. But are we, the mental and behavioural disorders, increased from 57% global health community, adapting our knowledge base, to 65%. In other words, two out of every three years of preventive practices, health care reform and whole-of- healthy life lost on the planet are attributable to NCDs.
This is not the future; it is the reality of global healthtoday, and it is likely to gather pace.
* Correspondence: 1School of Population and Global Health, The University of Melbourne, While demographic factors have contributed substan- Building 379, 207 Bouverie St, Carlton, Melbourne, VIC 3053, Australia tially to this growth, disease risk has not fallen as rapidly Full list of author information is available at the end of the article 2014 Lopez et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver applies to the data made available in this article,unless otherwise stated.

Lopez et al. BMC Medicine 2014, 12:200 engender a similar global response, and is it warranted?The evidence would suggest it is. While neoplasms,COPD, cardiovascular diseases and diabetes cause muchhealth loss worldwide, more of the global NCD burden(55%) arises from other NCDs. These include a diverseset of causes and conditions, but among the more im-portant are musculoskeletal disorders, especially lowback and neck pain, depression, substance use disorders,cirrhosis of the liver, chronic kidney disease, asthma,various digestive diseases including peptic ulcer, anxietydisorders, congenital anomalies and haemoglobinopa-thies. Unlike the ‘big four' NCDs, many of these condi-tions cause more health loss through chronic disabilityrather than premature death; arguably, preventingchronic disability ought to be an important goal of anyhealth system (Figure The collection of comments in this Medicine for Glo- bal Health forum article is a timely reminder that im-proving population health requires a focus not only onwhat is important and well-studied, but on what is im- Figure 1 Alan Lopez is a Melbourne Laureate Professor and the portant and hitherto largely overlooked. Levin and Rowden-White Chair of Global Health and Burden of Disease Tonelli point to the urgent need to improve the integra- Measurement at The University of Melbourne. He is also Director tion of research across the biomedical and clinical sci- of the Global Burden of Disease Group in the Melbourne School of ences with health systems and population-based studies Population and Global Health.
to enhance policy and patient outcomes for chronic kid-ney disease. Peter Burney reminds us that the disease as for leading communicable diseases. There is a very burden from asthma is not declining very much at all, real prospect of rates from major vascular diseases, and that health services, particularly in poor countries, chronic obstructive pulmonary disease (COPD) and can- are ill-equipped to manage the case load, compounded cers rising in men throughout the developing world dur- by a poor supply of affordable medicines. Liver cirrhosis, ing our lifetime as the full effects of their massive uptake long neglected as a global health priority, is another con- of smoking some decades ago begin to be seen This dition where the etiology is well understood, but as may well be compounded by the large increases in over- Jürgen Rehm points out, policy responses have been dis- weight and obesity that have occurred since the early appointing, particularly in reducing alcohol consump- 1980s, firstly in developed countries, and more recently tion, a leading risk factor for the disease. More broadly, in many developing populations, leading to substantial alcohol and drug use disorders are causing an increasing increases in disease burden from diabetes Under- share of health loss in many populations, quite apart standably, much research and many resources worldwide from the social pathologies associated with their use. As have been invested in understanding the epidemiology of Volkow and Koob argue in their article, a more effective these conditions in order to guide treatment and pre- response will require a serious rethink of how health ventive programs. But, just like the policy focus of the care services are provided, with greater emphasis on past few decades on child survival, with comparatively screening and improved case management.
little attention to health loss and premature death One of the principal consequences of population among adults, one might also ask whether too little at- aging, namely an increase in dementia, is often at the tention has been given in global health debates to other forefront of policy discussions about the key implications NCDs that, for one reason or another, might justifiably of social, economic and health trends, but there is con- siderable uncertainty about appropriate policy responses, So what are these ‘forgotten NCDs' and why do they in part because the condition is not well understood. As matter? Just as the creation of the concept (and termin- Ferri argues, that is changing, with recent evidence em- ology) of ‘neglected tropical diseases (NTDs)' has led to phasizing the importance of primary prevention to re- much greater recognition, research support and pro- duce this growing disease burden. The lack of visibility grammatic response, including from institutions such as for sickle cell disease, as Williams points out, is in part the Gates Foundation and the World Health Organisa- due to poor data, in part due to the fact it is concen- tion, might a more strategic focus on neglected NCDs trated in the world's poor, yet the condition accounts for Lopez et al. BMC Medicine 2014, 12:200 Figure 2 (See legend on next page.)

Lopez et al. BMC Medicine 2014, 12:200 (See figure on previous page.)Figure 2 Comparison of global disease burden (in DALYs) with a focus on neglected non-communicable diseases. Pyramid: Neoplasms,COPD, cardiovascular diseases and diabetes (the ‘big four') lead to the highest proportion of disease burden among all NCDs. However, manyother NCDs lead to a comparable proportion of disease burden, yet do not receive as much attention as the ‘big four'. We have discussed sevenof these neglected NCDs (alcohol and substance abuse, liver cirrhosis, asthma, chronic kidney disease, Alzheimer's and other dementias, sickle celldisease and gout) and reviewed their disease burden. Pie chart: NCDs account for 54% of total proportion of global DALYs. Although the ‘bigfour' comprise just under half of this burden (45% of the burden of NCDs; 24.4% of the total global DALY burden) all other NCDs (i.e. theneglected NCDs) account for 55% of the burden of NCDs; 29.6% of the total global DALY burden. Data for this infographic derived from Thefigure has been prepared by BioMed Central.
over one-third of the disease burden from haemoglobi- Competing interests nopathies. Even gout, though a relatively minor cause of The author declares he has no competing interests.
disease burden, is an example of a severely disablingcondition that ought, with current knowledge, be better Sickle cell disease: a neglected non-communicable managed and more readily preventable, as detailed in disease of growing global importance the article by Singh.
Thomas N Williams (Figure Collectively, this reminds us that, unlike the acute, and largely treatable nature of communicable diseases, NCDsare complex, diverse, and manifest their impact onpopulation health in different ways. Mitigating their im-pact will require a more strategic, comprehensive andbalanced approach to NCD research, treatment and pre-vention, beyond what has been the practice for the pasthalf century or so, giving greater emphasis to those con-ditions that are major causes of health loss, and whichhitherto have been largely ignored as global health prior-ities. So, what might public health research focus on toaccelerate the recognition of neglected NCDs as a globalhealth priority? In my view, four pillars of research andknowledge translation are critical to that endeavour: i). rapidly reduce ignorance and uncertainty about the true disease burden from these conditions by cost-effectively and strategically improving cause of deathand disability data collection systems; ii). improve knowledge about the most cost-effective strategies to reduce disease burden in different pop-ulations, and about the most appropriate and afford-able approaches to financing treatment andprevention; iii). improve knowledge and understanding of established interventions for controlling the impact of the moreimportant forgotten NCDs in health care debates, andpromote targeted research on promising interventionoptions where this is lacking; and iv). raise the profile of major forgotten NCDs in national Figure 3 Tom Williams is Professor of Haemoglobinopathy and global health fora by developing policy relevant Research at Imperial College London. As a clinical academic he forecasts of likely health, economic and social costs has been studying the epidemiology of haemoglobin disorders formore than 20 years, both in terms of the malaria protective effects of continuing to ignore them.
of carrier forms and the global burden and consequences ofhomozygosity, particularly in relation to sickle cell disease. Based in We should not continue to ignore or forget these NCDs.
Kenya for the last 15 years, he has recognised the growing importance The examples reported here suggest the need for an orga- of sickle cell disease as the country has entered its epidemiological nized, committed and urgent response by the global health transition. He co-chairs the Infectious Diseases Working Group of theGlobal Sickle Cell Disease Network.
community to reducing their disease burden everywhere.

Lopez et al. BMC Medicine 2014, 12:200 Few NCDs could be more neglected than sickle cell Disease (GBD) Survey a touchstone for policy- disease (SCD) despite the fact that, with early detec- makers worldwide, in which causes of death were esti- tion and an inexpensive package of basic care, the ma- mated from vital registration, verbal autopsy (VA), jority of those born with the condition can expect to mortality surveillance, censuses, surveys, hospitals, and po- lead a good quality of life into late adulthood, most pa- lice and mortuary records. Few reliable data regarding the tients with SCD are born in resource-limited settings contribution of SCD to the mortality burden can be de- (RLS) where the vast majority continue to die undiag- rived from any of these sources, exemplified by the fact nosed in early childhood SCD is a haemoglobin- that before 2012, no specific questions nor any specific opathy, which results from the pathological effects of diagnostic codes for SCD were included in the standard Haemoglobin S (HbS), an abnormal form of adult WHO VA tools As a result the study grossly under- haemoglobin (HbA) that results from a mutation (βs) in estimated global SCD-related deaths for 2010 at 28,600 the HBB gene Most subjects with SCD are βs homo- (16,800–40,900) a figure that should almost certainly zygotes (sickle cell anaemia; SCA), but the condition can be 4–6 times higher also result from the co-inheritance of the βs mutation Because official statistics are so poor, even basic pa- with a range of other HBB mutations, of which the most rameters such as the global number of affected births common are those that result in HbC and the β- and SCD-specific morbidity and mortality can only be thalassaemias [Despite recent promising develop- measured using indirect approaches. For example, we re- ments, including its recognition by both the UN and cently used a geostatistical model that combined data on the WHO as a disease of major and growing import- HbAS frequencies, overall birth rates and population ance, for the most part SCD remains virtually invisible densities to estimate birth rates for SCA (which accounts on the global health agenda. In common with many for approximately 70% of SCD) by country, concluding neglected NCDs, to a large extent this can be attributed that globally 312,000 (294,000 − 330,000) children were to three interrelated issues: the fact that its greatest bur- born with SCA in 2010, half being born in just three den falls on the world's poorest communities, the lack of countries: Nigeria, the Democratic Republic of Congo reliable data and inadequate political will.
and India (Figure Similarly, by analyzing popula- Because the carrier state for SCD (sickle cell trait; tion data on the age-specific prevalence of SCA, an in- HbAS) is associated with a strong survival advantage in direct measure of the loss through death of subjects malaria-endemic areas, the global burden of SCD is also with this condition, we recently concluded that current aligned to that of malaria As a consequence, the vast under-5 mortality among children born with SCA in majority of children with SCD are born in resource- Africa lies between 50% and 90% As for mortality, limited settings (RLS) (particularly sub-Saharan Africa) the importance of SCD as a cause of global morbidity where routine data are least reliable (Figure With few has been consistently under-estimated through lack of exceptions, diagnostic facilities are poor, early life data. Nevertheless, despite this caveat the numbers re- screening is non-existent and official statistics on health- main impressive, with estimates from the most recent facility usage and cause of death are sketchy within the GBD Survey of 5,641,000 (4,244,000–7,246,000) disabil- RLS in which the prevalence of SCD is highest. The net ity adjusted life years lost and 2,954,000 (1,957,000– result is illustrated by the most recent Global Burden of 4,240,000) years lived with disability .
Figure 4 Cartogram showing the estimated number of newborns with SCA by country. Cartogram showing the estimated total number ofbabies that will be born globally, by country, between 2010 and 2050. Figure adapted from Figure within reference drawn and contributedby Dr FB Piel.

Lopez et al. BMC Medicine 2014, 12:200 These global figures for morbidity and mortality should be considered in the context of data from the North, wherein recent years, many countries have adopted universalscreening for SCD and where most now provide compre-hensive care for affected individuals. As a result, mortalityis now rare among children born with SCD in Europe, theUSA and the Caribbean where the majority of affectedchildren can expect to live a relatively normal life into their40s and 50s Providing such services is within reachin many RLS: successful pilot studies of newborn screeninghave been conducted in several African countries [and,in comparison to diseases of higher priority (such as HIV,TB and malaria), the provision of basic care in specialistclinics is not expensive If widely implemented, suchapproaches could save the lives of almost ten million chil-dren worldwide between now and 2050 So how can SCD be brought ‘out of the shadows' of its current status as a virtually invisible NCD? Perhapsmost importantly, we need better data, without which itwill remain difficult to persuade ministries of health,policy makers, funders and the pharmaceutical industryto devote appropriate resources to the condition. Oneessential component is better data on the birth frequen-cies and survival of children with SCD at the micro-epidemiological level, potentially through investigationsusing large-scale sample sets collected for other reasons,such as national surveys of micronutrient status, HIV ormalaria prevalence. Similarly, the implementation ofearly-life screening would be made considerably simpler Figure 5 Adeera Levin is Professor of Medicine and Head of theDivision of Nephrology, University of British Columbia, in with the development of rapid tests that would circum- Vancouver Canada. She is the Executive Director of the BC vent the lack of quality-assured diagnostic laboratories Provincial Renal Agency, and President Elect of the International and the logistics of returning results to patients. Better Society of Nephrology.
data will lead to better advocacy for SCD at every level:from education in schools and colleges, through togroups of affected patients, the media, celebrities, politi- for CKD such as low birth-weight, obesity and hyperten- cians, funders and health agencies internationally.
sion is increasing, and when superimposed on environ-mental and genetic influences may serve to amplify the Competing interests rising incidence of CKD over time. In addition, there are The author declares he has no competing interests.
specific conditions (such as pregnancy, pre-eclampsia,and acute kidney injury); and specific environments (such as tropical regions, areas of poor sanitation) that TNW is funded by a Senior Fellowship from the Wellcome may promote or attenuate the progression of CKD Trust (091758). TNW thanks Dr Frederic B Piel for The Lancet publication of the Global Burden of contributing Figure Disease Study 2010 (GBD 2010) serves as importantmilestone in understanding of population health and Chronic kidney disease as a global health burden: the disease in this century The publication highlights need to integrate research and health policy the value and power of data to improve our understand- Adeera Levin (Figure and Marcello Tonelli (Figure ing of health, its determinants, and the impact of strat- Chronic kidney disease (CKD) is increasingly acknowl- egies aimed at addressing specific health issues. Global edged as a global public health problem, affecting 1 in changes in the incidence and prevalence of key NCDs 10 adults in most jurisdictions CKD serves as a will continue to impact the incidence of CKD. Further, multiplier of risk in all populations and has a complex CKD may influence global metrics of health such as years interface with other conditions (such as diabetes and lived with disability (YLD), given the burden faced by both cardiovascular disease). The prevalence of risk factors non-dialysis and dialysis CKD populations [In the Lopez et al. BMC Medicine 2014, 12:200 Estimates of the economic burden of CKD vary de- pending on whether dialysis and transplant therapies areincluded or excluded. Regardless, it is clear that CKD isa key driver of the high costs associated with NCDs.
One report, using provincial data in a Canadian prov-ince, described that of a cohort of patients with diabetes,cardiovascular disease and CKD, in various combina-tions: 18% of hospital costs were attributable to thosewith CKD either in isolation or combined with eitherDM or CVD. Thus of this high risk group comprising7.5% of the total cluster, an annual $ 189M was spent.
This study excluded those on dialysis or with trans-plants, and so is an underestimate of the entire burdenOthers have estimated that while the end stagerenal disease population (those on dialysis or transplant-ation) make up less than 1% of the total adult popula-tion, they consume up to 5% of national health carebudgets The study and practice of nephrology has changed substantially over the last 50 years. Initially nephrologywas a specialty characterized by detailed study of kidneyphysiology, but has evolved in parallel with availability ofdialysis and kidney transplantation – which are no lon-ger experimental treatments, but life-saving therapiesthat benefit hundreds of thousands of people worldwide.
Advances in diagnostics, research and more integratedapproaches to care have established CKD as a prevent- Figure 6 Marcello Tonelli is Professor of Medicine and able and treatable chronic disease, with multiple co- Associate Vice President (Health Research) at the University of morbidities that are directly and indirectly related to Calgary in Calgary, Canada. He is Past President of the Canadian CKD. CKD has a dramatic impact on patients and their Society of Nephrology and Chair of the Research and Prevention families - who must live with uncertainty, depression, and Committee, and council member of the International Societyof Nephrology.
the symptoms of kidney disease. Since CKD is a globalproblem, different health systems, political environmentsand infrastructure have led to varied strategies and prior- GBD 2010 report, deaths due to diabetes increased by ities around the world. As an international nephrology 20%, and due to chronic kidney disease by 15% between community, we recognize that sharing key discoveries, 1990 and 2010, so that both rose in the ‘league tables' best practices and methodologies is the way forward.
of causes of death (15 to 9, and 27 to 18 respectively).
Interventions such as certain drugs, exercise, com- This change in the relative burden of communicable bined specialty clinics and engagement of primary care and non-communicable diseases as drivers of mortality and patients, have been studied and shown to improve in most countries parallels the profound increase in the patient outcomes. Administrative databases are used ‘lifestyle' driven risk factors CKD now ranks 39 glo- to understand the impact of CKD on health care systems bally as a cause of YLD, while diabetes and ischemic and generate population-based estimates of disease burden.
heart disease rank 9 and 21 respectively. All of the condi- An increasing number of investigator-initiated randomized tions display regional variability, but note the YLDs due trials have begun to address fundamental questions about to CKD have increased by 20% since the 1990 report.
how best to care for CKD patients - how to prevent or As infant mortality and mortality from communicable delay kidney failure, when to commence dialysis treatment, diseases are reduced in the developing world, the disabil- how best to treat glomerulonephritis and to prevent rejec- ity from NCDs will increase. Some of that disability will tion of transplanted kidneys. As in other medical re- be driven by CKD and all of its consequences. Identify- searchers, kidney scientists are increasingly interested in ing and implementing proven strategies to address risk new translational approaches to drug development, which factors such as hypertension, obesity, and high salt in- may lead to the discovery of novel compounds.
take will help to reduce the burden of CKD - as demon- A comprehensive investigative framework that includes strated in some parts of the world such as Asia .
four pillars of research (biomedical sciences, clinical

Lopez et al. BMC Medicine 2014, 12:200 research, health systems studies and population research) improve our ability to continue progress and sustain is the key to improving the outcomes for patients with focus on improving patient outcomes - across the con- CKD. The nephrology community has built on this frame- tinuum of kidney disease and its major risk factors.
work to integrate clinical care and health policy with theCKD research agenda. There are multiple examples of Competing interests teams where clinicians, investigators and administrators The authors declare they have no competing interests.
work together to improve understanding of the burden indifferent environments. As an example, there are provin- Gout: an Old disease with New windows of opportunities cial, national and international specific initiatives whereby Jasvinder A. Singh (Figure researchers, administrators and clinicians collaboratively Gout, a common inflammatory arthritis in adults used data to inform decision making and track outcomes caused by elevated levels of uric acid in the blood that (for example, [. The CKD PC (Chronic Kidney lead to joint inflammation and other manifestations Disease Prognosis Consortium) has established a rich such as kidney stones, is a major public health burden resource, comprising over one million people with CKD in worldwide Recognized in 2640 B.C., and later de- various stages . The data is collated from interven- scribed by Hippocrates as ‘the unwalkable disease', tional trials, large cohort studies and administrative data gout is one of the oldest known diseases. It is also a sets, and as such covers the spectrum of CKD from high forgotten disease. However, in terms of its impact on risk populations to established CKD populations. Through patients, high prevalence, well-known pathophysiology robust analysis of data, this international group of re- and biochemical abnormality, and availability of cheap, searchers has established estimates for the prognosis ofmajor events, such cardiovascular disease, hospitalizations,infections, mortality and progression to end stage kidneydisease; and recently provided evidence to support a newend point in clinical trials The latter will facilitatetesting of interventions.
Awareness of CKD in the global health arena will depend on continued efforts of the clinical and researchcommunities. The research agenda for nephrology remainsmultifaceted: the support for basic science discoveries is es-sential to uncover novel targets and mechanisms to fosterdrug or therapeutic developments. Scaling up existing ad-ministrative, research and clinical databases (some of whichhave large bio-banking platforms) will optimize the designof clinical trials, and allow clinicians to target the highestrisk individuals. New methods for setting research prior-ities, including the perspectives of administrators, healthpolicy makers, patients and their families, along with prac-ticing clinicians, remains critical. We need new studies thatinform evidence-based public policy and assess how best toallocate scarce resources to optimize health outcomes. Fi-nally, there is an increasing emphasis on evaluating the bestmethods for translation of research findings into practice,so that the science reliably benefits the patients.
CKD will continue to be a major public health prob- lem for the foreseeable future, and the most rapid Figure 7 Jasvinder Singh is an Associate Professor of Medicine growth in disease burden will be in developing countries.
at the University of Alabama at Birmingham and a staff To achieve a meaningful reduction in death and disabil- physician at the Birmingham Veterans Affairs medical center.
ity due to CKD, the global kidney research agenda must He is an epidemiologist and a clinician with 14 years of experiencein treating rheumatic conditions. His research focus is health services encompass and integrate basic, clinical, health outcome, and outcomes research in patients with arthritis with a focus on and population health perspectives. The international gout, osteoarthritis and arthroplasty. Another area of interest is nephrology community is committed to this engagement systematic reviews and meta-analyses, with a focus on Network of patients, healthcare administrators and policymakers Meta-analyses. He is the Director of the UAB Cochrane Musculoskeletal in the research agenda. The recognition of CKD as Group Satellite Center and serves on several national andInternational organizations.
important in the global health and NCD agendas will Lopez et al. BMC Medicine 2014, 12:200 affordable treatments, it's clearly a missed opportunity The rates of joint fluid aspirate-proven diagnosis of gout in medicine.
are low. Given the common involvement of great toe In the course of several diseases such as diabetes, can- and other lower extremity joints in two other common cer, rheumatoid arthritis and others, there is a single conditions, osteoarthritis and pseudogout, a presumptive window of opportunity, where interventions in early dis- diagnosis of gout based on a history of big toe pain and ease can prevent future complications. In comparison, a borderline high or higher than normal range serum gout has several windows of opportunities throughout urate level is problematic (Figure Documentation of the disease course and amongst various aspects of additional clinical features of acute synovitis, radio- the disease. The incidence and prevalence of gout seems graphic signs of overhanging margin and punched-out to be increasing according to several epidemiological erosions typical of gout, and close attention to looking studies. The Rochester Epidemiology project (REP) for features of other differential diagnoses (osteoarthritis, showed a similar increase in the incidence of gout from pseudogout and rheumatoid arthritis), will often help 0.045% in 1977–1978 to 0.061% in 1995–1996 . A in a correct diagnosis of gout. The 1977 American study in a health maintenance organization showed an Rheumatism Association (ARA) preliminary criteria for almost doubling of prevalence of gout and/or hyperuri- classification of acute gouty arthritis are also commonly cemia from 2% in 1990 to 4% in 1999 A study based used for a clinical diagnosis of gout, but are inadequate on National Health and Nutrition Survey (NHANES) also for in-office diagnosis in about 21% of cases . At- found that the prevalence of self-reported physician- tempts should always be made to aspirate joint/bursa/ diagnosis of gout increased from 2.7% in 1988–1994 to tophus and confirm the diagnosis, since documentation of 3.9% in 2007–08 ]. Many of these opportunities may be urate crystals in synovial fluid confirms gout as a single test missed, leading to an increased burden of gout in the face and the treatment for gout is often life-long.
of neglected prospects for diagnosis and treatment.
Third is the challenge of optimal control of serum First, physicians and patients need to update their urate. Urate-lowering therapy (ULT), including allopur- knowledge regarding the dietary and lifestyle risk factors inol and uricosurics are generic, affordable and the most for gout in order to take advantage of these windows of commonly used drugs; febuxostat, a new ULT, is also opportunities. New information from well-designed epi- available but is more expensive. ULT helps to lower demiological studies is available, which update our serum urate levels, a central biochemical abnormality in knowledge of the disease (based on clinical anecdotes) gout. Current guidelines recommend achieving target and confirm or refute previous prevalent beliefs about serum urate of <6 mg/dl which is achieved by at gout. Higher intake of meats, seafood, alcohol (in par- most 33% of patients This is a meaningful dis- ticular beer) and sugar-sweetened soft drinks (including ease target since it is associated with improved clinical fruit juices and sodas) increase the risk of gout, while outcomes such as reduction in gout flares, regression of low fat dairy products, Vitamin C supplements and cof- tophi and lower health care costs (Figure fee decrease the risk of gout (Figure Importantly, Achievement of this serum urate target frequently re- purine-rich vegetables and nuts do not increase the risk quires titration of allopurinol dose, sometimes up to 900 of incident gout A higher intake of purine-rich mg/day rather than a monotonic 300 mg/day dose foods from animal sources (meats etc.) and alcohol in- Physicians aiming to help gout patients avoid flares creases the risk of gout flares Since environmen- and improve function to reap the full benefits of treat- tal factors play a big role in the risk of gout as well as ment need to monitor serum urate after starting ULT risk of gout flares, they should be one of the main and follow a treat-to-target approach. We believe that it foci of gout management. Our recent work with pa- is possible to achieve disease remission in many gout pa- tients shows that they are interested in discussing tients with this approach. This is a paradigm shift in these options with their providers as part of their gout gout treatment that is likely to improve patient out- management Physicians can counsel patients comes. A patient-physician collaborative approach is es- during their regular follow-up regarding strategies to sential for this to succeed.
prevent gout and in those with gout, ways to decrease We have summarized briefly a few opportunities for the risk and suffering from gout flares. Therefore, this improving care and outcomes of gout, for which there is one key area of opportunity for both physicians and are several additional opportunities for interventions not mentioned here. We are at the brink of new treatment Second is the challenge of correctly diagnosing gout.
options for gout, a better understanding of its impact on Gout manifests as intermittent monarticular acute arth- cardiovascular and renal disease, and better management ritis in the early years/phase of the disease and as with existing pharmacological and non-pharmacological chronic polyarthritis with intermittent flares in the later treatment approaches. This is an exciting era in which years. Tophi and renal stones may accompany arthritis.
we know ever more about this ancient disease.

Lopez et al. BMC Medicine 2014, 12:200 Figure 8 Epidemiology, diagnosis and optimal management of gout.
Competing interestsJAS has received research grants from Takeda and Savientand consultant fees from Savient, Takeda, Regeneron andAllergan. JAS is a member of the executive of OMERACT,an organization that develops outcome measures inrheumatology and receives arms-length funding from 36companies; a member of the American College of Rheu-matology's Guidelines Subcommittee of the Quality ofCare Committee; and a member of the Veterans AffairsRheumatology Field Advisory Committee.
AcknowledgementsJAS is supported by grants from the Agency for HealthQuality and Research Center for Education and Researchon Therapeutics (AHRQ CERTs) U19 HS021110, NationalInstitute of Arthritis, Musculoskeletal and Skin Diseases(NIAMS) P50 AR060772 and U34 AR062891, NationalInstitute of Aging (NIA) U01 AG018947, National CancerInstitute (NCI) U10 CA149950, and research contract CE-1304-6631 from the Patient Centered Outcomes ResearchInstitute (PCORI). JAS is also supported by the re-sources and the use of facilities at the VA MedicalCenter at Birmingham, Alabama, USA. The fundingsources (National Institutes of Health and others) had norole in study conception, protocol development, data ana- Figure 9 Peter Burney is Professor of Respiratory Epidemiologyand Public Health at the National Heart and Lung Institute, lyses, manuscript preparation or decision to submit.
Imperial College London. Until 2006 he was Chair of Public Health andPrimary Care at King's College London. In the late 1980s he started the Asthma: a challenge for health care providers European Community Respiratory Health Survey to study asthma and Peter G. J. Burney (Figure allergies in adults, mostly in Western Europe. Currently he co-ordinates Asthma is generally defined as a reversible obstruction the Burden of Obstructive Lung Disease Study, a study of chronicobstructive lung disease mostly in low and middle income countries.
of the airway and is one of the most common chronic Lopez et al. BMC Medicine 2014, 12:200 conditions. Since the 1980s the term has come increas- marked decline in lung function This will lead to ingly to signify any wheezy illness that responds to bron- an increasing problem for an ageing population what- chodilators. Compared with other chronic lung diseases ever changes in prevalence occur. The burden associated it starts much younger and because the mortality is rela- with asthma is therefore likely to increase both because tively low and the disease tends to persist, it maintains a of continuing urbanisation in the poorer countries and high prevalence in the population.
because of the ageing of the population everywhere.
Asthma is generally divided into allergic and non- Currently there is wide variation in the relative impact allergic. The relation of asthma to allergic sensitisation is of asthma on mortality. Although asthma ranks as only complicated. Both sensitisation and atopic diseases such the 42nd most common cause of death globally, it is as asthma run in families, but they are not inherited in much more highly ranked in Oceania (13th), South East the same way In childhood, asthma associated Asia (25th), South Asia (26th) and North Africa and the with allergies is more persistent and tends to be more Middle East (30th) than in Southern and Andean (65th severe. In adulthood ‘non-allergic' asthma tends to be and 62nd) Latin America and Western Europe (60th).
more severe. In childhood allergies are less common in Because asthma often has an early onset and is persist- low income countries, as are the atopic conditions asso- ent throughout life, it is a relatively important cause of ciated with allergies, but non-allergic wheeze is equally disability adjusted life years lost (DALYs), ranking 28th common in countries at all economic levels The globally among the causes of DALYs but 8th in Oceania, prevalence of allergic sensitisation has been increasing 15th in Australasia and Tropical Latin America, 18th is over the long term though more recent changes in South East Asia and 19th in the Caribbean the prevalence of atopic conditions such as asthma have The chronic nature of asthma requires continuous been more variable among children care and reliable access to affordable medications. These The International Study of Asthma and Allergies in conditions have been set out by the Global Initiative for Childhood (ISAAC) Study was the largest global survey Asthma (GINA) together with the need to prevent of the prevalence of asthma, rhinitis and eczema involv- exacerbations with the use, in the first instance, of in- ing almost 2,000,000 children in 105 countries. This haled corticosteroids. However the costs and availability study has shown very wide variations in the prevalence of inhaled steroids are very variable and there is a ten- of wheezy illness, with very high rates in the English dency for these to cost more in low income countries speaking countries and Latin America and wide varia- This leads to poor management and reliance on tions even across single continents such as Europe, emergency rooms to provide care, a wasteful and less ef- where rates fall from high levels in the northwest to low fective method of managing the condition. In a survey of levels in the southeast The prevalence of more se- treatment failures seen in emergency rooms in 11 coun- vere disease has a different distribution, however, with a tries, patients with inadequate insurance and those with- far higher proportion of cases being recorded as severe out a consistent source of continuing medical care were in sub-Saharan Africa in particular less likely to be on the recommended dose of inhaled Information on adults is more sparse and comes from steroids. In addition, those without adequate steroid use the European Community Respiratory Health Survey were more likely to have lost work because of asthma in (ECRHS) and the World Health Survey Although the recent past demonstrating the high cost to pa- mean prevalence is least common in middle-income tients and their families of inappropriate care.
countries, the maximum prevalence recorded in the poor- Asthma is a common condition that causes considerable est countries is below the maximum prevalence in middle morbidity and with increasing age leads to a disease that is or high income countries. Sampling decisions need to in- more difficult to manage, along with increasing mortality.
form the interpretation of all these studies. For instance, Although it is mostly not difficult to manage, along with in low income countries there has been a consistent find- other chronic conditions it requires continuous care, ing that asthma is less common in rural areas ] and which traditional health services are not designed to pro- over sampling of urban populations may therefore inflate vide. Currently the problem of inadequate health services overall estimates in low income countries.
is compounded by a poor supply of over-priced medica- Asthma is not a common cause of death and age- tions. These problems are shared by other chronic condi- standardised death rates fell by 42% between 1990 and tions and have common solutions including the provision 2010 from 9.0 to 5.2 per 100,000. However, the global of continuous long-term care and reliable access to afford- number of deaths fell only 9% from 380,000 to 346,000 able, high-quality medication.
between 1990 and 2010 The slower rate of declinein total deaths represents the aging of the population.
Competing interests Mortality from asthma increases markedly with age PGJB has acted as a Consultant to Novartis through and with age some patients with asthma experience a Lopez et al. BMC Medicine 2014, 12:200 Liver cirrhosis – time for addressing a neglected Global death rates due to liver cirrhosis seem to have non-communicable chronic disease been quite stable over the years: the World Health Jürgen Rehm (Figure Organization (WHO) estimated and predicted 14.5 deaths Liver cirrhosis is an abnormal condition with irrevers- per 100,000 for the years 2000 and 2030, respectively, with ible scarring as a result of continuous and long-term almost no variation for years in between However, liver damage, which is primarily caused by excessive al- when standardized rates are considered, liver cirrhosis cohol consumption, hepatitis, and non-alcoholic steato- deaths are predicted to decrease.
hepatitis. It is among the top 15 causes of death globally There are several factors that may become important and, in 2012, was estimated to have caused more than to explain trends for liver cirrhosis. A downward trend 1,000,000 deaths and more than 36,000,000 years of lives in high income countries may be predicted to be linked lost to either premature death or disability.
to improved clinical practices leading to lower case fatal-ity rates although there is not much evidence onthis, and, to give just one example, historically, case fa-tality rates have not shown any improvement over thetime period between 1968 and 1999 in England Anupward trend may be linked to increases in alcohol con-sumption in low- and mid-income countries as they in-crease their economic wealth In terms of burden ofdisease, most DALYs were derived from years of life lostto mortality, that is, due to the high case fatality. However,as indicated above, this may constitute an underestimatefor high-income countries due to the lower case fatalityand thus higher duration of living with disability.
While the overall prevalence of liver cirrhosis mortal- ity and burden of disease seems stable, there are hugevariations by gender, age and regions [and they seemto be caused by preventable risk factors. Men have consid-erably higher rates of liver cirrhosis morality and burden ofdisease, globally more than twofold the rates of women,and highest in the men between 50 and 69 years of age.
The only exception for the higher prevalence of liver cir-rhosis mortality and burden is the Eastern Mediterraneanregion, where women have slightly higher rates; this regionalso has by far the lowest alcohol consumption whichis the main risk factor for liver cirrhosis.
Figure gives an overview of the burden of disease of liver cirrhosis for the year 2012 in DALYs by WHO region,and the role of alcohol in causing this disease (data basedon . As indicated above, alcohol consumption isglobally the most important risk factor for liver cirrhosis, Figure 10 Jürgen Rehm, Ph.D. has been appointed the responsible for about half of the global burden (50%; men: Inaugural Chair for Addiction Policy at the Dalla Lana School of 53%; women: 44%; ; other main global risk factors are Public Health of the University of Toronto. In addition he holds hepatitis B and C, and obesity ,]. Europe, especially positions at the Centre for Addiction and Mental Health (Toronto, the Eastern European region, has the highest rate of liver Canada) as Director of the Social and Epidemiological ResearchDepartment and Head of the PAHO WHO Collaborating Centre, and cirrhosis, with alcohol consumption a large factor (63%).
at the Institute for Clinical Psychology and Psychotherapy of the For low- and mid-income countries, hepatitis-induced Technical University Dresden (Germany). Dr. Rehm has published more liver cirrhosis is relatively more important, with the rela- than 600 peer-reviewed publications in addiction research, comprising tive impact differential between high income and other studies in epidemiology, economics and clinical research, the latter countries being largest for hepatitis B [.
especially in the area of treatment evaluation. He is listed among theISI/Thompson Reuters most highly cited in the fields of social research The role of alcohol consumption in causing and wors- and epidemiology and has been awarded the Jellinek Award, the most ening the course of liver cirrhosis has been evident on prestigious award in alcohol research. He has served as public health the individual level and on the aggregate level in consultant to many countries, and is currently member of the WHO comparisons between countries ], or in analyses over Expert Advisory Panel on Drug Dependence and Alcohol Problems.
time It is important to understand that alcohol

Lopez et al. BMC Medicine 2014, 12:200 Figure 11 Disability adjusted life years due to liver cirrhosis per 100,000 population in WHO regions in 2012. Afr: African region. Amr:Americas. Emr: Eastern Mediterranean region. Eur: Europe. Sear: South East Asian Region (including India). Wpr: Western Pacific Region.
consumption increases the risk of mortality for all kinds of liver cirrhosis, independent of the original aetiology I would like to thank Drs. Gretchen Stevens, Michael (3), and thus abstinence is the major goal in most guide- Livingstone and Robin Room, who provided important lines for treatment of liver cirrhosis.
information for this article.
Intervention studies show that a reduction of alcohol consumption via policy interventions resulted in a Substance use disorders: implications for global health marked reduction of liver cirrhosis (for example in Nora D Volkow (Figure and George Koob (Figure Russia Although liver cirrhosis is a chronic dis- Substance use disorders (SUD) associated with legal ease, interventions have immediate effects, as not only substances are two of the three leading contributing fac- shown by the Russian experiences cited above, but also tors for global burden of disease and injury (DALYs for for instance by the impact of the German seizures of al- tobacco: 6.3%; for alcohol: 5.5%) and those associated cohol on French mortality rates during World War II, or with illicit substances are within the top twenty factors the impact of prohibition in the US It may (DALYs 0.8%) ]. The past 20 years has seen an in- take up to 20 years, however, before all of the effects of crease in the contribution of SUD to the global burden interventions can be seen of disease, mostly from alcohol (32%) and illicit drugs A sizable portion of liver cirrhosis mortality could be (57%) . Moreover, the global burden of disease attribut- reduced in the first year after implementing effective in- able to SUD is likely to be underestimated particularly for terventions to reduce alcohol, such as higher taxation, illicit substances due to incomplete epidemiological data decreased availability, advertisement and marketing bans on estimates of impactful and preventable outcomes (i.e.
or brief interventions and treatment especially injuries, violence and mental health problems) []. Thus, among heavy drinkers ]. The effect is more pro- SUV prevention and treatment would have a major impact nounced for heavy drinkers because the risk curve for in improving public health globally.
mortality is exponential; that is, relatively more mortality The recent endorsement by the United Nations Office can be avoided for the same amount of reduction in on Drugs and Crime (UNODC) of addiction as a brain average drinking for heavy drinkers compared to light or disease and the recommendation that it should be moderate drinkers Such interventions would not treated as a medical and public health issue rather than only reduce liver cirrhosis rates but also other causes of a criminal justice and or moral issue highlights the role mortality such as other non-communicable diseases that the healthcare system can play in the prevention (cancers, hypertensive heart disease, stroke, pancreatitis) and treatment of SUD The conceptualization of ad- or injuries Given this situation, and given diction as a brain disease reflects in part findings from the fact that there are proven effective interventions to brain imaging studies and preclinical research that have reduce alcohol consumption, we see no reason why glo- identified the brain circuits that are disrupted by drugs bal liver cirrhosis rates should continue to be as high as (legal and illegal) and how their disruption impairs the they are now.
addicted individual's ability to control his/her behaviourMoreover, excessive drug and alcohol use in adoles- Competing interests cence impairs executive function and increases the vul- The author declares he has no competing interests.
nerability to SUDs in adulthood. Clinical studies have Lopez et al. BMC Medicine 2014, 12:200 Figure 12 Nora D Volkow is Director of the National Institute Figure 13 George F. Koob was recently appointed Director of on Drug Abuse; a position she had held since 2003. Her the National Institute on Alcohol Abuse and Alcoholism after research transformed the drug addiction field by providing the first 30 years at The Scripps Research Institute in La Jolla California.
evidence for specific molecular (loss of striatal D2 receptors) and His research has focused on the dysregulation of the brain arousal functional (impaired frontal control circuitry) changes in brains of and stress systems that drive compulsive drug and alcohol seeking.
addicted individuals that link to compulsivity and loss of control. She He has made significant contributions to our understanding of the has also made ground-breaking discoveries in the neurobiology of neurocircuitry of negative emotional states and their role ADHD and obesity.
in pathophysiology.
also shown that SUD can be prevented and treated, and mental illnesses, since they are frequently co-morbid with like other chronic diseases requires continuity of care SUD, and inappropriate management of either condition Because all countries have health care infrastruc- exacerbates the other. Similarly, integrated care is funda- ture, it is recommended that these healthcare systems mental for the treatment of infectious diseases such as integrate treatment of SUD within the system norms.
HIV and HCV for which substance abusers are at higher Drug associated health consequences are still some of risk and for which compliance with medical treatment of the main preventable causes of disability and the health- the infectious disease requires parallel treatment of the care system can play a crucial role in their prevention SUD. In addition, SUD is the main underlying cause of ve- and treatment. This recommendation provides a plat- hicle accidents. Therefore, integrated care will also facilitate form that is relevant and available to countries with dif- addressing this factor, for if untreated the alcoholic or drug ferent levels of economic development.
abuser will continue to contribute to repeated incidents.
Health care systems can participate at all levels in the se- Moreover, in these times of increasing health care costs verity range of SUD, starting from its prevention to serving and burden, treating SUD's would translate into significant as a referral for specialized care for the most severe cases.
savings in the need to treat the secondary health costs Health care systems can also maximize the opportunity to integrate the care for the health problems associated The challenges in implementing healthcare involve- with SUD. Of particular importance is the management of ment in SUD management are complex and will vary Lopez et al. BMC Medicine 2014, 12:200 among countries on the basis of their economic re- of 65. Older people are likely to have multiple health sources, cultural norms, drug availability and policies to- conditions. Dementia however, has a disproportionate wards criminalization and legalization of drugs. This is impact on independent living, being a major cause of further compounded by rapid changes in the use of disability and dependence among older people.
drugs across the world, such as movements towards With the rapid ageing of the population worldwide, the legalization of marijuana, recent access to electronic number of people with dementia is predicted to rise. It drug delivery devices, rapid dissemination of new syn- is estimated that in 2010 there were 35.6 million people thetic drugs and the increased abuse of prescription with dementia, and predictions based on population age- medications. The opportunities that the healthcare sys- ing show that this figure is likely to double every 20 tem offers towards the control of SUD highlight the ur- years, reaching 115.4 million by 2050 Most people gent need for educating health care providers in the with dementia already live in low- and middle-income screening and management of SUD and the need to allo- countries (LMIC) and these same estimates predict that cate the resources necessary for its implementation.
by 2050 more than 70% of people with dementia will beliving in these countries Competing interests It has been estimated that the total worldwide cost of The authors declare they have no competing interests.
dementia was US$604 billion in 2010 ]. While mostof these costs are concentrated in high income coun- Placing dementia in the NCDs prevention strategies tries, where the costs are divided roughly equally be- Cleusa P. Ferri (Figure tween formal (hospital and social) and informal (family) Dementia is a syndrome that usually involves with loss care settings, in low- and middle-income countries, in- of memory, reasoning, and other cognitive functions formal care costs account for the vast majority of total progressively impairing an individual's everyday func- costs with the burden concentrated on families and tioning. The main risk factor for dementia is age, with informal carers. Formal costs are likely to increase in prevalence roughly doubling every 5 years over the age these countries, not only due to the increasing numbersof people with dementia in the future, but also becauseof a shift in the balance between informal and formalcare as the health care sectors develops in LMIC.
Future estimates are mostly based on population age- ing and include the assumption that age-specific preva-lence will be stable over time. However, some recentstudies have suggested that over the past 20 to 30 yearsthere has been a decline in the predicted burden of de-mentia in high-income countries [In the UK, forexample, a recent study indicates a reduction in de-mentia prevalence of around 20% over a 20-year period(from 1989–1994 to 2008–11). These reductions suggestthat predicted dementia cases were perhaps avoided ordelayed by changes in the risk factors for dementia atearlier ages, suggesting that these risks are modifiableand dementia, to some extent, can be prevented or, atleast, the risk reduced at particular ages.
Figure 14 Cleusa P. Ferri is an Affiliated Professor at the One possible explanation for the reduction in demen- Universidade Federal de Sao Paulo in the post-graduation tia is the change in cardiovascular diseases and risk fac- program of the Psychobiology Department, supported by tors. There is growing evidence supporting a strong Associação Fundo de Incentivo a Pesquisa (AFIP), and a SeniorEpidemiologist at the Institute of Education and Health Sciences and likely causal association between cardiovascular at the Hospital Alemao Oswaldo Cruz, Brazil. She worked as an disease (CVD) and its risk factors, and dementia international specialist on dementia for the Global Burden of Disease Therefore, the changes seen regarding the reduction in 2010 Project. In the same capacity, she was also involved with the dementia prevalence are likely partially due to improve- MHGap project with the WHO. For 10 years Dr Ferri worked at the ments in service provision and disease management of Institute of Psychiatry, King's College London. During this period,apart from her teaching and other research activities, she worked CVD, and also to changes in behaviour, with around with the 10/66 Dementia Research Group, studying the epidemiology half of the reduction in morbidity and mortality thought of dementia in low- and middle-income countries. She returned to to be accounted for by primary prevention. However, Brazil, her home country, in 2013 and is now focusing her work on the current models to estimate the impact of preventive strat- epidemiology of ageing and dementia in Brazil and Latin America.
egies on future vascular diseases do not consider the Lopez et al. BMC Medicine 2014, 12:200 impact on dementia. Some non-communicable diseases Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada. 6Medicine Service and (NCDs), such as cardiovascular diseases, are risk factors Center for Surgical Medical Acute care Research and Transitions, VA MedicalCenter, 510, 20th street South, Birmingham, AL FOT 805B, USA. 7Department for dementia and many risk and protective factors for de- of Medicine at School of Medicine, and Division of Epidemiology at School mentia are the same as those for other NCDs How- of Public Health, University of Alabama, 1720 Second Ave. South, ever, most countries' policies and prevention strategies for Birmingham, AL 35294-0022, USA. 8Department of Orthopedic Surgery, MayoClinic College of Medicine, 200 1st St SW, Rochester, MN 55905, USA.
NCDs do not include the prevention, or reduction of risk, 9National Heart and Lung Institute, Imperial College, London, UK. 10Centre for of dementia, despite some recent initiatives ].
Addiction and Mental Health, Toronto, Canada. 11Clinical Psychology and In low-, middle- and high-income countries, dementia Psychotherapy, Technical Universität Dresden, Dresden, Germany. 12AddictionPolicy, Dalla Lana School of Public Health, University of Toronto (UofT), can be seen as part of normal ageing. Although demen- Toronto, Canada. 13Department of Psychiatry, Faculty of Medicine, UofT, tia is indeed common in the oldest age groups, it is not Toronto, Canada. 14Institute of Medical Science, UofT, Toronto, Canada.
15 an inevitable consequence of long lifespans. Increasing National Institute on Drug Abuse, National Institutes of Health, Rockville, MD, USA. 16National Institute on Alcohol Abuse and Alcoholism, National awareness of dementia in society as whole, from patients Institutes of Health, Bethesda, MD 20892-9304, USA. 17Institute of Education to policy/decision makers, can contribute not only to de- and Health Sciences, Hospital Alemao Oswaldo Cruz, Rua João Julião, creasing stigma and increasing community solidarity, 245 – Bloco D CEP 01323-903, São Paulo, SP, Brazil. 18Department ofPsychobiology, Escola Paulista de Medicina, Universidade Federal de São Paulo, but also to improving the capacity of existing services Rua Botucatu, 862- 1o andar, São Paulo, CEP 04023-062, Brazil.
with evidence based approaches that can meet the needsof older people and those with dementia. It is important Received: 3 October 2014 Accepted: 3 October 2014 to note that awareness campaigns need to be carried outwith great care in order to avoid raising expectationsthat cannot be met, and avoid leading to unintended consequences, such as increased stigma and fear, through Murray CJ, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, Naghavi M,Salomon JA, Shibuya K, Vos T, Wikler D, Lopez AD: GBD 2010: design, use of dramatic imagery and language.
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