Noncommunicable diseases in the Americas: a review of the Pan American Health Organization’s 25-year program of work

**Background:** Noncommunicable diseases (NCDs) — including cardiovascular disease, diabetes, cancer, and chronic respiratory diseases — remain the leading causes of ill health, disability, and death in the Americas. The Pan American Health Organization (PAHO) began its NCD program in 1997 following the World Health Report that highlighted NCDs as the cause of half of all global deaths. Over 25 years, PAHO has developed regional strategies and plans of action on specific diseases and risk factors, as well as comprehensive NCD approaches. Political commitments evolved from a 1998 World Health Assembly resolution through the WHO Framework Convention on Tobacco Control (2003), the 2011 United Nations High-Level Meeting on NCDs, and the inclusion of NCD target 3.4 in the Sustainable Development Goals (SDGs), which calls for a one-third reduction in premature NCD mortality by 2030.

**Methods:** This is a narrative review describing PAHO's technical cooperation with ministries of health across 35 Member States in the Americas. Data sources include PAHO's ENLACE data portal, national civil registration and vital statistics systems, population-based surveys, and WHO country capacity surveys conducted since 2000. Mortality data cover all NCDs and the four main NCDs (cardiovascular diseases, cancer, diabetes, chronic respiratory diseases). Risk factor prevalence data come from national surveys. Policy implementation is tracked through the WHO country capacity survey and the Global NCD monitoring framework.

**Key Results:** NCDs were responsible for 5.8 million deaths in 2019, representing 81% of the 7.2 million total deaths in the Americas. The age-standardized NCD mortality rate was 411.5 per 100,000 population in 2019, higher in men (482.6/100,000) than women (351.7/100,000). NCD mortality varied substantially across the region: Haiti had 838.7/100,000 compared to Canada's 301.5/100,000. All-cause NCD mortality declined by 17.2% from 2000 (497.2/100,000) to 2019 (411.5/100,000), with a greater decline in men (−18.8%) than women (−16.5%). Premature mortality (deaths from the four main NCDs in ages 30–70 years) accounted for 1.5 million of 4.3 million NCD deaths (34.9%) in 2019. The unconditional probability of dying from these four NCDs between ages 30–70 was 14.0% overall (16.4% in men, 11.8% in women). Haiti had the highest premature NCD mortality at 31.3%. The annual percentage decline in premature NCD mortality slowed from −1.7% (2000–2011) to −0.8% (2011–2019), far below the −2.2% needed to meet the SDG target. Only Chile and Trinidad and Tobago are projected to achieve the target by 2030. Tobacco use prevalence decreased from 28.0% in 2000 to 16.3% in 2020, making the Americas the WHO region with the second lowest tobacco consumption. However, overweight and obesity prevalence reached 62.5% in 2016 (64.0% in men, 61.0% in women), the highest of all WHO regions, representing a 70.8% increase from 36.6% in 1975. Among children and adolescents, overweight and obesity rose from 12.4% to 31.7% between 1975 and 2016. Policy progress includes: 31 of 35 countries having an NCD unit (up from 17 in 2001); 19 countries with a national operational NCD plan in 2021; 13 countries with an operational multisectoral NCD commission; and 20 countries with evidence-based NCD guidelines. However, only 11 of 35 countries conducted NCD risk factor surveys as recommended. Investment cases showed returns of JA$ 2.1 per Jamaican dollar invested over 15 years and 3.0 Peruvian soles per sole invested.

**Clinical Implications:** The COVID-19 pandemic has disrupted NCD services, and about 240 million people in the Americas live with at least one NCD. The paper recommends: (1) integrating NCD services as a core pillar of primary care, using evidence-based protocols such as the HEARTS package (implemented in 1,380 primary health care centers across 22 countries) and the PEN package; (2) utilizing health taxes on tobacco, alcohol, and sugar-sweetened beverages as cost-effective interventions that also generate government revenue; (3) scaling up population-based policies using technical packages including MPOWER (tobacco), SAFER (alcohol), SHAKE and REPLACE (healthy diet), and ACTIVE (physical activity); and (4) strengthening NCD surveillance by integrating core indicators into national health information systems and conducting periodic surveys. Without accelerated action, the region will not achieve the SDG target of reducing premature NCD mortality by one-third by 2030.