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Countries urged to take tough action to prevent NCDs Uruguay is hosting the WHO Global Conference on Noncommunicable Diseases (NCDs) this month, from 18–20 October. Tabaré Vázquez, the President of Uruguay, tells the Bulletin of the World Health Organization about his country’s efforts to prevent and fight NCDs and why countries should step up the global response.

Q: Why did you study medicine and what drew you to oncology? Tabaré Vázquez, the president of Uruguay, has been A: As a child I always admired the leading major health reforms in his country over the family doctor who visited our family last two decades. Vázquez is a radiation oncologist when one of us was sick. He brought and, since 1987, has been a professor of oncology with him a magic solution – or so it at the University of the Republic and since 1981 he seemed – to our problems. From then has been chief of the radiotherapy service of the on, I wanted to become a doctor. Later I decided to specialize in oncology after National Institute of Oncology of the ministry of public both my parents and my sister died of health. Vázquez is a member of several national and Courtesy of Tabaré Vázquez Courtesy of Tabaré cancer in the 1960s. Tabaré Vázquez international scientific societies, including an honorary member of the Union for International Cancer Control. Q: How did you become interested in He was president of the Frente Amplio political party from 1996 to 2006, the public health? mayor of the Uruguayan capital Montevideo from 1990 to 1994. His first term A: In Uruguay, physicians train in as President of Uruguay was from 2005 to 2010 and his current term is from public hospitals and university hospitals. 2015 to 2020. Vázquez has received international accolades for his public health These institutions open their doors to policies, including the champions award of the Campaign for Tobacco Free Kids the poorest and most vulnerable people and special recognition from the John Hopkins Bloomberg School of Public in society and, as junior doctors, we Health as a “public health visionary”. Vázquez graduated in 1969 in medicine learn more about how poor people live. It was this experience that drew me to from the University of the Republic of Uruguay, where he also qualified in public health practice, and later, a public radiology and oncology in 1972. health policy that strives to improve the quality of health care and patients’ quality of life. Also, public health topics, basic health needs of the population, in towards primary health care, the pre- including social medicine and epide- addition to providing housing, trans- vention of noncommunicable diseases miology, are an important part of our portation and food. We decentralized (NCDs) – as these cause by far the great- medical training in Uruguay. health care by opening primary health est burden of disease and death in Uru- care centres on the outskirts of the city, guay – and health promotion activities. as these areas were poorly served, and we That’s why Uruguay was one of the first started providing child benefit. countries to sign up to the World Health The WHO Organization (WHO) Framework Con- Q: What were the most important Framework Convention vention on Tobacco Control in 2003. “ health policies during your first term as on Tobacco Control is president? Q: Your tough tobacco control measures the beacon that shows A: When I first came to office in have made headlines around the world us – all countries – the 2005, we introduced several social since then. Can you tell us about these way in the fight against reforms to reduce inequities. We imme- measures? NCDs. diately started moving towards universal A: Uruguay was the first country in health coverage (UHC), so that everyone Latin America to enact 100% smoke-free ” in our country could access essential national legislation in 2006 by banning health services regardless of their abil- smoking in all indoor public places. By ity to pay. We had just been through a 2010, we had significantly increased the Q: What were your main public health severe economic crisis, huge disparities price and taxes on tobacco products and initiatives as mayor of Montevideo? had developed between rich and poor. imposed an indoor smoking ban. We A: When I took over as mayor of The health-care sector was fragmented, became the first country in the world to Montevideo, our country was going with many private and public providers require that health warnings and strik- through a major economic crisis and of health care. In 2007, we launched ing images of the effects of tobacco are there were several priorities. Many the National Integrated Health System displayed on 80% of the principal surfaces people could no longer afford health care (Sistema Nacional Integrado de Salud) of cigarette packages. We have banned and several private health-care centres bringing together all the private and tobacco advertising and misleading mar- closed. High unemployment was also a public sub-systems under one umbrella, keting descriptions, such as “light” and serious problem. Our response was to to provide comprehensive and equitable “ultralight” cigarettes because all of these expand and strengthen primary care health coverage for all. Our strategy has products contain carcinogens and are polyclinics across the city to meet the also been to shift health-care delivery harmful to people’s health. We banned the

672 Bull World Health Organ 2017;95:672–673 | doi: http://dx.doi.org/10.2471/BLT.17.031017 News

marketing of electronic cigarettes and we and can be used to share information specially selected unhealthy foods in offer smoking cessation therapy for those for the benefit of these patients. We have schools and colleges. The ministry of who want to quit smoking. In 2012, we done many public information cam- public health has published a guide to launched a public awareness campaign on paigns to tell people what they can do healthy eating for the general popula- the risks of smoking for women – espe- to prevent cancer and when they should tion. We plan to introduce tough re- cially during pregnancy. In 2014, we made come to the health clinic for check-ups. quirements for the labelling of highly the ban on tobacco advertising, promotion processed foods to guide the consumer and sponsorship comprehensive. This ban and for the catering sector to offer foods includes the display of tobacco products with low or zero salt content. We have at points of sale, digital and social media several tough alcohol control measures marketing and product placement in Between 65% and in place, including a zero tolerance law videos, film and television. All of these “70% of total mortality for people who drink alcohol and drive measures were taken for the simple reason is attributable to NCDs. and we plan to extend restrictions on the that smoking kills. In some parts of the sale of alcoholic beverages. Finally, we world the burden of promote physical activity for people of Q: What are the results of these mea- disease and death due all ages. For example, every school must sures so far? now have a physical education teacher, to NCDs is increasing. A: First, indoor air pollution has we have installed gym equipment in been reduced by 90%, according to a It’s a real pandemic public places and we have created a new study looking at the change since smoke- and one that needs post for a minister of sport. free legislation was enacted. According global solutions. to Yale University’s environmental per- Q: You are hosting the Global Conference formance index, Uruguay ranks first in ” on NCDs this month. What do you hope the world in terms of the best indoor the event can achieve? air quality. We reduced the prevalence A: Between 65% and 70% of total of smoking in adults: from 32% in 2006 Q: Uruguay is a small country with a mortality is attributable to NCDs. In to 22.2% in 2014 and in young people population of about 3.4 million. How some parts of the world the burden aged 13–15 years from 23.2% in 2007 have you managed to fight the influence of disease and death due to NCDs is to 12.8% in 2014. In addition, after we of the global tobacco business? increasing. It’s a real pandemic and one passed 100% smoke-free legislation, A: The main challenge is to make that needs global solutions. The WHO we saw a 22% reduction in hospital the general public more aware of why Framework Convention on Tobacco admissions for acute myocardial in- we need tough tobacco control mea- Control is the beacon that shows us farction, in studies done one and two sures and why we need to reduce the the way in the fight against NCDs. This years after that. At the same time, while risk factors for so many diseases. An- agreement is based on strong scientific fewer people are smoking and tobacco other challenge comes from outside evidence and proposes concrete and sales have fallen, thanks to increases our country. The tobacco industry has effective ways to reduce risk factors in tobacco tax rates, the state collected tried unsuccessfully to make us reverse to help people become healthier and, significantly more tobacco tax revenue: our tough tobacco control measures. In ultimately, to save lives. Countries need in 2004, US$ 84 million compared with 2010, tobacco multinational Philip Mor- to comply with the WHO Framework US$ 318 million in 2011. There’s still a ris International challenged Uruguay at Convention on Tobacco Control so lot to do, but we are making progress. the World Bank’s international centre for that they can make progress towards settlement of investment disputes for an attaining sustainable development goal Q: You mentioned strong preventive alleged breach of the investment protec- target 3.4 on NCDs by 2030. Uruguay policies to reduce one important risk tion agreement between Uruguay and has a tradition of fighting NCDs and, at factor, but what about the detection and Switzerland. Philip Morris International the conference this month we are keen treatment of cancer? challenged measures related to restric- to find common solutions with other A: In Uruguay, cancer has been tions on different presentations of the countries for our shared problems. We the second leading cause of death after same cigarette brand, the increase in the hope that the Montevideo roadmap, the cardiovascular diseases for decades, ac- size of mandatory health warnings on final outcome of the WHO conference counting for more than 8000 deaths a cigarette boxes from 50% to 80% and the on NCDs this month, will guide and year and about 25% of all deaths in our use of pictograms with striking images drive countries’ efforts to take action country. Our current national health of the health consequences of smoking. so together we protect the health of our plan includes several goals for cancer, The company lost the case in 2016. people and save more lives. ■ including primary prevention of cancer, and timely detection and treatment. We Q: How are you protecting your popula- gather patients’ clinical information re- tion’s health in spite of globalized food lated to cancer screening, diagnosis and and soft drinks companies and the treatment in the electronic cancer health global alcohol industry? record (historia clínica electrónica on- A: Our approach is to combine cológica). This serves as a repository of public education with tough regulatory patient information related to cancer action. We have prohibited the sale of

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