In the article by Lopez and Cáceres [1], the authors describe the Central America Field Epidemiology Training Program (CA FETP) and its role as an applied epidemiology training programme designed to help Ministries of Health develop, set up, and implement dynamic, public health strategies to improve and strengthen their public health systems and infrastructure. The authors note that CA FETP, which according to the Centers for Disease Control and Prevention (CDC) website [2] includes Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (left off the list of countries in the article),  “…was designed to address the health issues present in the region…” [1]. The authors further note that CA FETP trainees have played an important role in responding to multiple public health emergencies including earthquakes, hurricanes, and outbreaks of dengue, cholera, vaccine-derived poliovirus, pertussis, and pesticide poisoning. However, the authors fail to describe what the CA FETP is doing to address one of the leading problems of the countries which it serves – chronic, noncommunicable diseases (NCDs).

During the next 20-30 years NCDs will govern the health care needs of populations in most low- and middle-income countries as a result of epidemiological transitions owing to 1) declines in communicable diseases and in conditions related to childbirth and nutrition, 2) population aging, and 3) changes in lifestyle factors such as diet, alcohol consumption, exercise and smoking [3-5]. During 2005, an estimated 35 million people died from NCDs; 80% of these deaths occurred among low- and middle-income countries [6]. NCDs accounted for 43% of total mortality in low-income countries (Table 1). Worldwide, the total number of people dying from NCDs is twice that of all infectious diseases (including HIV / AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies combined [7]; cardiovascular disease is the number one cause of death in the developing world with the exception of sub-Saharan Africa [8]. In fact, three times as many cardiovascular disease deaths occur in developing countries as compared with developed countries [9]. Furthermore, NCDs are projected to account for >50% of all deaths and nearly half of the burden of disease in low-income countries by 2030 (Table 1).

Consider the burden of NCDs in the countries covered by the CDC supported CA FETP (Table 2). With the exception of Honduras for which the level of evidence is suboptimal, the burden of NCDs and injuries greatly exceeds that of communicable diseases. Unfortunately, NCD training in many of the CDC-supported FETP programs is disproportionate to the burden of disease in the countries they serve. This is not to say that we should remove or redirect attention away from communicable diseases. No doubt this would be counterproductive. But given the increasing global burden of NCDs described above, further attention to NCDs including incorporation and expansion of NCD epidemiology, NCD prevention and health promotion into FETP programs seems warranted.

The epidemiologic transition in many of the countries served by FETP programs appears to call for organizational transitions including applied epidemiology training programs that can respond to the rapidly changing public health priorities that are emerging. More broadly, opportunities exist to ask the question, how can we build on the success and infrastructures put into place during the past 10-20 years to prepare for the health challenges that will emerge as the process of “epidemiologic transition” continues globally and is likely to accelerate in the near future? Are we prepared to apply the lessons learned in developed countries over the past several decades to move swiftly to reduce the incidence of NCDs and promote quality of life and healthy aging in developing countries? Together with its partners, the FETP training programs have an opportunity to make a real difference in the health and well-being of populations in developing countries as they move through and emerge from epidemiologic transitions during the coming decades.

In summary, there have been enormous and increasingly successful efforts to address the global burden of infectious diseases, maternal and child health, and nutritional deficiencies in developing countries [10,11]. The successes within global health in developing countries also heralds new and surprising challenges for those devoting resources to improving global health and well-being. Reducing the global NCD burden necessitates action on many fronts including applied epidemiology training programs. The CA FETP and CDC’s other FETP programmes provide an opportunity to build on the momentum and experience gained in addressing infectious diseases and malnutrition with forward looking application of the methods used to reduce the risk of NCDs in developed countries. It is no longer acceptable to respond by noting absent or suboptimal funding streams for NCDs in global health. If current evidence and projections are correct, then failure to address the rapidly emerging challenges of preventing and treating NCDs by quickly building upon the momentum created by programmes that are successfully addressing infectious diseases, child and maternal health and malnutrition may have disastrous consequences for the people of developing countries. Against the backdrop of momentum and success achieved during the past several decades, we must continue to look forward and anticipate emerging health needs of those in developing countries in order to ensure they will live healthier and longer lives.

David W. Brown

Rotterdam, The Netherlands

References

1. López A, Cáceres VM: Central America Field Epidemiology Training Program (CA FETP): a pathway to sustainable public health capacity development. Hum Resour Health 2008, 6:27.

2. Division of Global Public Health Capacity Development Overview of Field Epidemiology Training Program (FETP) and the Field Epidemiology and Laboratory Training Program (FELTP) [http: // www.cdc.gov / cogh / dgphcd / fetp]

3. Adeyi O, Smith O, Robles S: Public Policy and the Challenge of Chronic Noncommunicable Diseases. Washington, DC: The International Bank for Reconstruction and Development / The World Bank; 2007.

4. Mathers CD, Loncar D: Projections of global mortality and burden of disease from 2002 to 2030. PLos Medicine 2005, 3:e442.

5. Murray CJ, Lopez AD: Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997, 349:1498-1504.

6. Strong K, Mathers C, Leeder S, Beaglehole R: Preventing chronic diseases: how many lives can we save? Lancet 2005, 366:1578-82.

7. World Health Organization: World Health Statistics 2007. Geneva: WHO Press; 2007.

8. Gaziano TA: Reducing the growing burden of cardiovascular disease in the developing world. Health Affairs 2007, 26:13-24.

9. World Health Organization: World Health Report 2003: Shaping the Future. Geneva: WHO Press; 2003.

10. Levine R: Case Studies in Global Health: Millions Saved. Boston: Jones and Bartlett Publishers; 2007.

11. Levine R: Millions Saved: Proven Successes in Global Health. Boston: Jones and Bartlett Publishers; 2004.