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WELCOME to the fourth quarter global health 

E-Brief, designed to inform readers about key 

global health activities at the CDC (Centers for 

Disease Control and Prevention). Our final issue 

for 2007 spotlights global chronic diseases and 

health conditions—the greatest drivers of rising 

health care costs around the world. Currently, 

they are the major cause of death among adults in 

almost all countries, and by 2020 are expected to 

account for 73% of all deaths. CDC and its partners 

are committed to addressing this growing burden 

by building a global workforce capacity in health 

promotion, chronic disease prevention and control, 

and sustainable public health infrastructures.

Chronic Disease in Jordan 

The Field Epidemiology Training Program (FETP) is one of 

CDC’s most widely disseminated global health capacity 

building programs. Established in 1980, and modeled 

after CDC’s world renowned Epidemic Intelligence Service, 

the FETP helps foreign countries develop and implement 

dynamic, public health strategies to improve and 

strengthen their public health systems and infrastructures, 

predominantly through the training of epidemiologists. 

To date, the FETP has primarily focused on infectious 

disease surveillance, epidemiology, and control, but the 

program is designed to be flexible and to respond to 

changing public health priorities. As a result, a number of 

countries are beginning to address the burden of chronic 

disease, a rising problem in the developing world, through 

their FETPs. 

 Taking the critical first step in better understanding 

the causes of – and finding ways to prevent and control 

– these diseases, the Ministry of Health in Jordan and 

the FETP worked with subject matter experts from CDC 

to develop the first Behavioral Risk Factor Surveillance 

System (BRFSS) in the Middle East. The survey, which has 

been in operation since 2002, now 

covers topics on hypertension, 

diabetes, cholesterol, obesity, 

smoking, physical activity, diet, 

healthy behaviors, oral health, 

injuries, nutrition, women’s health, 

use of medical services, and 

hospitalization. 

 FETP in-country residents, 

or trainees, play major roles in 

planning and conducting the 

survey and analyzing the data. 

Using the results of these surveys 

from over a period of 5 years, in 

combination with mortality statistics, hospital discharge 

surveys, and other periodic surveys - the MOH, with 

input from CDC, intends to develop effective control and 

promotion strategies for chronic diseases. 

Survey data confirmed the need for chronic disease 

prevention and control programs, and as a result, 

Jordan increased its funding commitment for chronic 

disease, creating a line item in its budget to conduct 

the BRFSS survey on a biannual basis, and allocating 

2.5 million dollars for the design and implementation 

of non-communicable disease prevention programs.

Other countries in the Middle East, such as Egypt and 

Lebanon, used the tools developed in Jordan, such as the 

questionnaire, to conduct similar surveys. 

Fourth Quarter 2007

CDC Global Health 

E-Brief

IN THIS ISSUE

Chronic Disease in Jordan

Zambia’s Cervical Cancer Screening Program 

Physical Activity and Quality of Life in Bogotá, 

Colombia 

Tobacco Control—A Global Health Priority 

The Americas Silicosis Initiative

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Confronting Chronic Diseases & 

Conditions Globally

Jordan’s FETP targets its chronic disease burden
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Zambia’s Cervical Cancer 

Screening Program

One of the key lessons learned from the United 

States’ efforts to improve global health is that many 

of the countries we assist provide opportunities 

for innovative approaches to the growing problem 

of chronic disease in less economically developed 

settings. 

CDC’s ability to offer innovative public health 

solutions in challenging global settings was utilized 

recently in Zambia, where life expectancy has 

dropped from 50 years of age in 1970 to 38 years of 

age in 2007, and two thirds of the population lives 

on less than $1 per day. In May, a team from CDC’s 

National Center for Chronic Disease Prevention 

and Health Promotion visited Zambia’s Center 

for Infectious Disease Research’s (CIDRZ) Cervical 

Cancer See and Treat program in Lusaka. 

CDC has begun to work hand in hand with this 

program, which is partially funded by CDC through the 

President’s Emergency Plan for AIDS Relief (PEPFAR). CDC 

plans to further See and Treat’s impact through technical 

and financial support to reduce the high incidence and 

mortality rates of cervical cancer in Zambia. 

 CIDRZ initiated a cervical cancer prevention 

intervention that targets both HIV-positive and non-HIVinfected female patients. Though HIV positive women live 

longer thanks to improved access to care and treatment 

programs targeting HIV/AIDS, they continue to develop 

and die from serious chronic diseases - such as cervical 

cancer. Cervical Cancer rates have declined during the 

past decades for most of the developed world, but are 

increasing or unchanged, for women in Eastern Africa, 

Zambia and Swaziland. In these countries, the incidence of 

cervical cancer is up to ten times higher than in other parts 

of the developing world. 

 The See and Treat Program is an outstanding 

example of CDC’s commitment to comprehensive, crosscutting global health issues and strategies, particularly 

the rising incidence of non-communicable disease in 

less economically developed countries. Based at the 

anti-retroviral clinics in Lusaka, Zambia, and spearheaded by Dr. Groesbeck Parham from the University 

of Alabama-Birmingham School of Medicine, and Dr. 

Mulindi Mwanahamuntu from the University Teaching 

Hospital in Zambia, the See and Treat program is a lowcost, innovative approach to detecting cervical cancer. 

The protocol begins with visual inspections by trained 

nurses. If abnormal cells are found, the nurse provides 

basic treatment and digital images, or makes a referral 

for further histologic evaluation by Drs. Parham or 

Mwanahamuntu. 

The See and Treat program, is the first free, public 

health-based cervical cancer prevention program in 

Zambia. Since its beginning in November 2005, more than 

10,000 women have been screened, 13 nurse-midwives 

and 3 gynecologists have been trained, nine cervical 

cancer prevention clinics have been developed, and one 

cervical cancer peer educator for each clinic has been 

trained and hired. 

 CDC’s collaboration with CIDRZ will enhance the 

See and Treat clinical program in Zambia through the 

development of a Management Information System to 

track the disease burden; human papillomavirus (HPV) 

vaccine research; digital pathology/consultation; and 

HPV laboratory capacity and evaluation. Plans are also 

underway to develop and implement an arrangement 

to sustain this activity in Zambia through a student and 

professional exchange program with U.S. medical and 

graduate schools, a Health Promotion/Health Education 

program, cervical cancer nurse certification, peer educator 

training, and a micro-credit lending program.

 Through its careful approach to addressing one 

chronic disease-cervical cancer- the See and Treat 

screening program is a model for other countries. It creates 

needed community infrastructure for chronic disease 

prevention and enhances opportunities for on-going 

professional development. This program leverages 

CDC’s technical and scientific assets and shows that 

partnership is essential to solving global public health 

disease problems, particularly the rising burden of 

chronic disease in developing countries. 

The CDC Global Health E-Brief is produced quarterly by the Centers for Disease 

Control and Prevention’s (CDC) Coordinating Office for Global Health (COGH). To 

find out more about CDC and COGH, go to www.cdc.gov and www.cdc.gov/cogh. 

If you have questions or comments relating to the E-Brief, please contact Dana 

Pitts at GQO1@CDC.GOV.
Physical Activity and Quality of 

Life in Bogotá, Colombia

In Bogotá, the largest and most populous city in Colombia, 

chronic diseases and conditions such as heart attacks, 

stroke, high blood pressure and obesity are the leading 

causes of death. According to a recent study, 20% 

of deaths due to chronic diseases in the city may be 

attributable to physical inactivity. In spite of the widely 

recognized health benefits of physical activity, the majority 

(55.3%) of adults in Bogotá are inactive, and only 8.6% 

engage regularly in physical activity during leisure time.

 During the past 15 years, influential politicians and 

civic leaders in Bogotá have worked to implement policies 

that support community access to, and participation in, 

healthy activities. These policies include limiting some 

public roads to pedestrians and cyclists on Sundays, 

providing rapid transit, and making recreational activities 

available in public parks. The Centers for Disease Control 

and Prevention’s WHO Collaborating Center on Physical 

Activity and Health recently invited two young scientists 

to help study whether these policy and environmental 

changes are also associated with changes in physical 

activity and quality of life. One scientist, an Emory/Georgia 

Tech joint degree graduate student, collected data on 

the relationship between park design, maintenance and 

use. The other scientist, a native Colombian, analyzed 

qualitative data on how and why important policy and 

environmental changes were made. She also worked 

to strengthen CDC’s collaborative relationships with 

recreation and public health institutions in Bogotá. 

 CDC and its partners in Bogotá measured the influence 

of community design and transportation infrastructure on 

levels of walking, cycling and quality of life. The study also 

included an analysis of rationales and methods community 

leaders used to change policy. The study concluded that 

The Iraqi Ministry of Health (MOH) 

appointed Dr. Ihsan Al-Khayat as 

the interim manager of their Field 

Epidemiology Training Program 

(FETP). As Director of Public Health 

and Primary Health Care, Dr. Al-Khayat 

is a key decision maker at the MOH, 

giving the FETP a high profile within 

Iraq’s public health infrastructure. 

A team at Iraq’s MOH, including the 

deputy minister of health, will visit 

Atlanta in January 2008. 

A surveillance workshop for the heads 

of surveillance units in Iraq took place 

in Amman, Jordan from October 28–

November 22. CDC worked with the 

WHO-Iraq office to plan the workshop 

and provided training materials, 

textbooks, and technical assistance 

in teaching. Several sessions were 

devoted to the recent cholera 

outbreak. The workshop is developing 

a cholera control and prevention plan 

that will be submitted to Iraq’s MOH. 

CDC’s Safe Water Team received the 

2007 Circle of Excellence Award in 

November for the Advancement of 

Military Medicine in the category 

of Prevention. This was the first 

time HHS/Public Health Service has 

received this distinction. The award 

recognized their initiative and vision 

in introducing, implementing and 

evaluating an innovative water 

treatment and hand washing 

intervention in a Kenyan maternal 

and child health clinic. The Safe 

Water program protects those most 

susceptible to diarrheal disease 

(children under 5) and has been 

expanded to other clinics in Nigeria, 

Uganda, Malawi and Indonesia. 

CDC was in attendance at the White 

House on December 5, to stand 

alongside Proctor & Gamble (P&G) 

as the company accepted the 2006-

2007 Ron Brown Award for Corporate 

Leadership for P&G’s Children’s Safe 

Drinking Water program. CDC helped 

P&G develop and field test PuRTM, the 

cornerstone product of the Children’s 

Safe Drinking Water Program. CDC’s 

work on PuRTM was recognized as 

a critically important contribution. 

Henrietta Fore, Director of U.S. 

Foreign Assistance highlighted this 

private public partnership as a model 

for the way forward. 

Project Horizon is an effort that 

brings together senior executives 

from across the US Government to 

conduct long-term, interagency 

strategic planning. On November 

9, Project Horizon’s Interagency 

Strategic Planning Group met 

at CDC’s Washington D.C. office 

to secure majority support and 

commitment to advance interagency 

engagement on global health. A plan 

for a “whole of government” approach 

to global health was one of Project 

Horizon’s top priorities. The following 

United States Government Agencies 

were represented at the meeting: 

Commerce, DHS (& USCG) DOD (Joint 

Staff and OSD), EPA, HHS/CDC, ODNI 

(& CIA) State, Treasury, USAID and 

USDA. The next E-Brief will feature 

this US Government global health 

initiative. 

CDC, along with WHO and other 

partners, is currently participating 

in the response to an Ebola 

outbreak in Uganda, involving a 

possible 5th strain of the virus. As of 

December 16th, 2007, the Ministry 

of Health reported 124 cases under 

investigation and 35 deaths, including 

5 health workers. The CDC team 

arrived on December 4th to assist in 

response efforts. 

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positive influences on physical activity and quality 

of life could be traced to these significant policy and 

environmental changes in the City of Bogotá. Further 

investigation into whether such policy changes and their 

resulting impact would be possible in other communities 

and other cultures is recommended. 

TOBACCO Control—A Global Health Priority

Each year, nearly 5 million people worldwide—14,000 

people every day—are killed by tobacco-related diseases. 

Tobacco use accounts for more than 1 in 10 adult deaths 

and unless urgent action is taken, will kill 1 billion 

people in this century. One of the greatest challenges in 

determining the extent of the problem and in developing 

effective tobacco prevention and control programs, is the 

lack of data on global tobacco use behavior. 

 To bridge this data gap, beginning in 1999 the World 

Health Organization (WHO), CDC, and the Canadian Public 

Health Association partnered to create and implement 

the Global Tobacco Surveillance System (GTSS). CDC’s 

Office on Smoking and Health (OSH) provides leadership 

and technical assistance to countries by 

providing instruments by which countries 

can collect this critical data and translate 

it into public health action. To date, CDC 

has supported the completion of the 

Global Youth Tobacco Survey (GYTS) in 

140 countries, with repeat surveys in 60 

countries; the Global School Personnel 

Survey (GSPS) in 62 countries; and the 

Global Health Professional Students Survey 

(GHPSS) in 36 countries - resulting in the 

world’s largest body of comparable data for 

youth and adult tobacco use. 

 In January 2007 the Bloomberg Family 

Foundation contributed $125 million to 

launch the Bloomberg Global Initiative 

to Reduce Tobacco Use. A significant 

portion of these resources has been used 

to help fill the data gap for adult tobacco 

use building on and mirroring the now successful youth 

tobacco surveys and to optimize the reach and results 

of the ongoing GTSS. This initiative provides resources 

to the CDC Foundation to partner with CDC and other 

global partners to expand the existing GTSS through 

measurement of adult tobacco use in 15 low- and middleincome countries. These countries are home to more than 

half of the world’s smokers —Bangladesh, Brazil, China, 

Egypt, India, Indonesia, Mexico, Pakistan, Philippines, 

Poland, the Russian Federation, Thailand, Turkey, Ukraine, 

and Vietnam—and bear the highest burden of tobacco 

use. The initiative made possible the development of a 

standard Global Adult Tobacco Survey (GATS). A survey 

questionnaire was pilot tested in India and the Philippines 

and protocol manuals have been completed. 

 Other partners in The Bloomberg Global Initiative 

to Reduce Tobacco Use include the WHO, the Campaign 

for Tobacco-Free Kids, the Johns Hopkins Bloomberg 

School of Public Health, and the World Lung Foundation. 

These critical partners are developing and implementing 

data driven key interventions that focus on establishing 

smoke-free regulations, taxing tobacco to increase price 

and prevent smuggling, countering the marketing efforts 

of the tobacco industry, encouraging community efforts to 

change social norms regarding tobacco use, and helping 

smokers quit. 

 Using analyses derived from the compilation of these 

global tobacco surveys, the GTSS now provides the data 

needed for countries to effectively design, implement, and 

evaluate their own national comprehensive tobacco action 

plans, as well as to monitor the key articles of the WHO’s 

2003 Framework Convention on Tobacco Control (FCTC). In 

less than a decade, the GTSS has evolved into a leading 

public health surveillance system providing data on a 

variety of indicators important for tobacco control. The 

GTSS is the most comprehensive tobacco surveillance 

system ever developed and implemented on a global 

scale. 

Ciclovía / Recreovía: During all Sundays and Holidays, 128 kilometers of the city’s main streets 

are exclusively open to recreational and sports activities, from 7 a.m. to 2 p.m . In addition 

professionally led aerobics classes, are provided in 19 different points of the city
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The Americas Silicosis Initiative

When Chilean artisans worked in the past, they used 

hand tools to artfully shape and cut stone. Today, 

craftsman working in small open-air settings with two to 

four workers, use power tools for the same tasks. While 

efficient, these contemporary tools pose a major health 

risk by generating dust with high levels of airborne 

crystalline silica. When workers breathe in this dust, it can 

result in silicosis, a serious but preventable lung disease. 

Occupational exposure to crystalline silica inhaled in 

the lungs is also associated with lung cancer, pulmonary 

tuberculosis and airway diseases, and may be related to 

the development of autoimmune disorders, chronic renal 

disease, and other adverse health effects. 

 Concerned about these threats, the Chilean National 

Institute for Public Health (ISP) invited three industrial 

hygienists from CDC’s National Institute for Occupational 

Safety and Health (NIOSH) to examine high-risk work 

conditions among ornamental stone carvers in Pelequén, 

Chile. A NIOSH industrial hygienist said “the silica dust 

levels were some of the highest I’ve seen anywhere in the 

world – and there were no controls to prevent silicosis.” 

NIOSH plans to assist ISP in implementing interventions 

to introduce dust control measures in these small shops. 

NIOSH has expertise in all aspects of silica measurement, 

including control of exposure, diagnosis, treatment 

and medical surveillance of silica-related diseases. 

This expertise is sought by international and national 

organizations to address the problems in developed and 

developing countries, where occupational silicosis is 

believed to be widespread. 

 For many exposed workers, prevention measures are 

non-existent. China recorded more than 500,000 cases 

of silicosis from 1991- 1995. In Brazil, more than 4,500 

workers with silicosis have been cumulatively reported in 

the state of Minas Gerais. In India alone, millions of workers 

are at risk. In 1995, the World Health Organization (WHO) 

and the International Labour Organization (ILO) began a 

campaign to eliminate silicosis from the world by 2030. 

In 2005, WHO and its regional office, the Pan American 

Health Organization (PAHO), ILO, and the Chilean Health 

Ministry (MOH) requested that NIOSH provide technical 

assistance to build adequate capacity to eliminate silicosis 

in the Americas. In response to this request, NIOSH 

initiated a program called the “Americas Silicosis 

Initiative” in partnership with WHO, PAHO, and ILO. It is 

the first regional approach to silicosis and is based upon 

the sharing of expertise to benefit many countries. 

Substantial work was accomplished in Chile in 2006 and 

is underway in 2007 in Chile, Brazil, and Peru, including: 

 Training of physicians from Chile, Brazil, and Peru by 

US, Chilean and Brazilian experts 

 Development of a silica laboratory at the ISP 

in Santiago (including training for laboratory 

technicians from Chile, Brazil, Peru and Uruguay)

 Training of workshop participants from Chile, Peru, 

Brazil and Uruguay in methods of dust control

 Development of simple guidance for employers to put 

controls in place

 Provision of field visits to small quarries and stone 

crushing and stone craft worksites to develop 

customized guidance sheets 

The impact of NIOSH’s technical assistance was seen 

in July 2007, when Chilean Ministries of Health and Labor 

jointly hosted representatives of the Ministries of Brazil, 

Argentina, Uruguay, Mexico and Peru for a regional 

planning meeting that brought these countries into the 

Americas’ partnership. 

 The Americas Silicosis Initiative includes a costeffective, novel educational approach called “Control 

Banding” to control exposures to the hazardous crystalline 

silica dust. NIOSH’s technical assistance to partners in 

Brazil, Chile, and Peru enables these countries to develop 

their own capacity to implement National Plans to 

eliminate silicosis. This partnership is a model for other 

countries and is helping to meet the ILO/WHO goal to 

eliminate silicosis by 2030. 

 Global collaboration in silicosis benefits NIOSH in 

its effort to reach small business in the United States 

though experience and lessons learned in applying simple 

guidance to control silica exposures in small enterprises 

with partner countries in the Americas. At least 1.7 

million United States’ workers are potentially exposed to 

respirable crystalline silica in a variety of industries and 

occupations, including mining and construction, and many 

are exposed to concentrations that exceed limits defined 

by current regulations and standards. OSHA is currently 

working on new regulations and NIOSH is developing new 

forms of simple guidance for employers and workers. 

 In October, a NIOSH technical expert visited Chile 

to present the United States’ experience in controlling 

silicosis with the use of respirators in the workplace at 

the “Breath Safely” seminar. He met with the Chilean ISP 

on silica control topics related to respiratory protection, 

and proposed a joint project on developing respiratory 

protection programs for small and medium business 

enterprises. Prevention activities with the cooperation 

of government, labor, and industry are ongoing, and 

are the keys to silicosis elimination. 