What happens when the political and socio-economic climate within a nation delays the government’s response to solving some of the most critical health issues within a society? One outcome is that non-governmental stakeholders, including the private sector, look towards dev eloping alternative solutions. When businesses employ individuals from that same society, declines in health status start to impact business continuity. With a need for efficiency and quick results, the private sector is able to use its technical and financial assets to carry out successful workplace-based interventions within both communicable and non-communicable disease (NCD) programmes. As an example, many simultaneous factors, such as the integrated push from civil society, academia and international NGOs, led to the provision of anti-retroviral treatment (ART) by the South African government in each of the country’s 53 districts in March 2005 . However, the first organization to provide ARTs free of charge was not the government, but a private sector entity, the mining company Anglo American in South Africa. Anglo American estimated that at one point 21% of its workforce was HIV positive. As individuals became ill, productivity levels declined, absenteeism rose and healthcare costs increased. In the absence of a treatment programme, it was estimated that HIV-related acquired immune deficiency syndrome (AIDS) would have cost the company 5% of its payroll (range for individual operations 0.1–6.7%) . Thus, in 2002, Anglo American became the first major employer in the world to offer free ART to its employees. Through its ability to respond and avoid bureaucracy, it was able to do so 2 years before the South African government made treatment available to all in April 2004. In Indonesia in 2017, smoking rates among men had reached the highest level in the world at 65% and NCDs accounted for 73% of all deaths . Indonesia is one of nine countries that are neither signatories nor parties to the Framework Convention on Tobacco Control (FCTC). The FCTC is a United Nations supranational agreement that seeks to protect populations from tobacco harm by enacting a set of provisions that include rules that govern the production, sale, distribution, advertisement and taxation of tobacco. It is considered best practice when it comes to legally binding international health cooperation in NCD prevention. While an internal political battle continued in Indonesia between health advocates and tobacco investors, another mining company set a precedent and rolled out its own tobacco control programme within the workplace. PT Freeport Indonesia (PTFI), an affiliate of FreePort-McMoRan a global mining company, adopted five out of the six tobacco control measures identified by the World Health Organization (WHO), including banning tobacco sales among supermarket chains within the area where it operates. As of January 2017, tobacco use prevalence rates among employees have decreased significantly after a 5-year follow-up survey and longer duration of employment (10 years) with the company has predicted lower tobacco use (adjusted odds ratio = 0.81, P < 0.001)  although this decrease in tobacco prevalence has yet to be seen at the national level. Cardiovascular disease is a major cause of mortality in Indonesia, and the WHO has identified sodium reduction as a ‘Best Buy’ for NCD prevention. As part of the ongoing Cardiovascular Outcomes in a Papuan Population and Estimation of Risk (COPPER) Study [4–7], PTFI carried out a national sodium baseline study among a subsample of 283 employees recruited during annual medical check-up. Salt and potassium intake was determined by measuring sodium excretion in 24-h urine. Completeness of urine collections was verified using creatinine excretion in relation to weight. A 24-h urine baseline collection is regarded as the ‘gold standard’ method for assessing salt-level consumption within the population and a necessary first step. The study determined that mean salt (NaCl) intake was 9.2 ± 3.6 g/day (sodium 3.6 ± 1.4 g/day) with 86% of participants having an intake of more than the WHO recommended 5 g NaCl/day . Both case studies are examples of private sector initiatives to prevent ill-health either through targeting individuals or through a population-based approach. Population-based approaches focus largely on health promotion interventions and influence the environment (physical, social, economic and regulatory). Individual-based approaches focus on screening high-risk individuals within a given population and then matching an intervention to the needs of the individual (e.g. the Framingham risk score). Advocates for population-based approaches argue that shifting the risk distribution curve by a small amount in a population has a greater beneficial effect in preventing morbidity and mortality than concentrating on treating patients with high risk. For example, a 5 mmHg drop in mean population systolic BP would result in 9% fewer deaths from coronary heart disease, 14% fewer deaths from stroke and 7% fewer deaths overall . Although 5 mmHg might not be significant at the individual level in a clinical setting, a single-digit shift in mortality within a large population could result in millions of deaths being avoided. Questions regarding the long-term sustainability of population-based approaches to NCD prevention have been answered following robust evidence generated from programmes such as the North Karelia project in Finland , soda tax in Mexico  or population-wide salt reduction programmes carried out in various countries . For large populations, this approach results in a more cost-effective means of saving lives. However, smaller populations such as those based in the workplace might benefit from targeted interventions geared towards individuals. Notwithstanding, educating people to make healthy choices when environments are not supportive is likely to produce weak and short-term effects. As the NCD epidemic continues, effective approaches to prevention are required to mitigate the increasing impact on societies and their workforces. Employers are gradually looking towards public health interventions to deal with an epidemic that will cost the developing world $21 trillion alone over the next two decades . As the complexity of NCD drivers such as globalization and rapid urbanization increases, fortunately so does our understanding of how to counteract them. The global health community is shifting away from a solely individual-based medical approach towards a wider societal and environmental approach to prevention. The evidence base suggests that tackling factors at macro-societal level focusing on the social determinants of health may prove more cost-effective than clinical prevention alone. While we wait for governments to scale up efforts and redirect resources towards where they are needed the most, private sector organizations can lead and provide best practice in the field of NCD prevention. References 1. Simelela NP , Venter WDF . A brief history of South Africa’s response to AIDS . S Afr Med J 2014 ; 104 ( 3 Suppl 1 ): 249 – 251 . Google Scholar CrossRef Search ADS PubMed 2. Van Zyl A , Muirhead D , Kumaranayake L , et al. Determinants of Labour Cost of HIV/AIDS in Southern African Firms . Presentation to the International Health Economics Association Conference . Copenhagen, Denmark , 2007 . 3. World Health Organization . WHO Report on the Global Tobacco Epidemic . Geneva : WHO , 2017 . 4. Rodriguez-Fernandez R , Farrand C , Cridland Raspail L , Viliani F , Amiya RM . Goliath versus Goliath: leveraging private mining industry resources for public health gains in tobacco control . Global Heart 2016 ; 11 ( Suppl ): e21 – e22 . Google Scholar CrossRef Search ADS 5. Rodriguez-Fernandez R , Rahajeng E , Viliani F , et al. Non-communicable disease risk factors in Indonesian miners: longitudinal findings from the Cardiovascular Outcomes in a Papuan Population and Estimation of Risk (COPPER) Study . Occup Environ Med 2015 : 1 – 8 . doi: 10.1136/oemed-2014–10266 6. Rodriguez-Fernandez R , Amiya RM , et al. The double burden of disease among mining workers in Papua, Indonesia: at the crossroads between Old and New health paradigms . BMC Public Health 2016 ; 16 : 951 Google Scholar CrossRef Search ADS PubMed 7. Rodriguez-Fernandez R , Farrand C , Kusuma P , Webster J . Estimation of salt intake by 24-hour urinary sodium excretion: findings from the Cardiovascular Outcomes in a Papuan Population and Estimation of Risk (Copper) Study . Global Heart 2016 ; 11 ( Supplement ): e19 Google Scholar CrossRef Search ADS 8. Havas S , Roccella EJ , Lenfant C . Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium . Am J Public Health 2004 ; 94 : 19 – 22 . Google Scholar CrossRef Search ADS PubMed 9. Jousilahti P , Laatikainen T , Salomaa V , Pietilä A , Vartiainen E , Puska P . 40-Year CHD mortality trends and the role of risk factors in mortality decline: the North Karelia project experience . Global Heart 2016 ; 11 : 207 – 212 . Google Scholar CrossRef Search ADS PubMed 10. Colchero MA , Popkin BM , Rivera JA , Ng SW . Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study . Br Med J 2016 ; 352 : h6704 . Google Scholar CrossRef Search ADS 11. Trieu K , Neal B , Hawkes C , et al. Salt reduction initiatives around the world – a systematic review of progress towards the global target . PLoS One 2015 ; 10 : e0130247 . Google Scholar CrossRef Search ADS PubMed 12. Bloom DE , Cafiero ET , Jané-Llopis E , et al. The Global Economic Burden of Non-communicable Diseases . Geneva : World Economic Forum , 2011 . © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: email@example.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Occupational Medicine – Oxford University Press
Published: May 17, 2018
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