CARICOM Heads of Government Summit on Chronic Diseases

Presentation of Prime Minister Denzil Douglas

Overview of Presentation

• Global situation with Chronic NCDs • Caribbean situation and costs • Caribbean Response • Exploding common myths • Review of effective interventions • The Way Forward – Addressing the risk factors • Globalisation and health

Globalisation and Health THE MALADIES OF AFFLUENCE

The Economist, August 11th 2007

The poor world is getting the rich world’s diseases “Europeans have been exporting their maladies throughout history. They seem to be doing it again, but in a new way. In the past the problem was infection. Now illnesses associated with Western living standards are the fastest growing killers in poor and middle-income countries. Chronic disease has become the poor world’s greatest health problem”.

The Economist, August 11, 2007

Chronic Diseases and their Causes

Chronic Diseases

Heart Disease, Stroke, Cancer, Diabetes, Chronic Respiratory Disease

↑ Biological Risk Factors

Modifiable: overweight, high cholesterol, high blood sugar, high blood pressure Non-modifiable: Age, Sex, and Genetics

↑ Behavioral Risk Factors

Tobacco use, physical inactivity, unhealthy diet, alcohol abuse

↑ Social and Environmental Determinants

Social, economic and political conditions such as income, living and working conditions, physical infrastructure, environment, education, agriculture, and access to health services

↑ Global Influences

Globalization of food supply, urbanization, technology, migration

Distribution of Deaths by Major Cause in the World

Distribution of Deaths from Infectious and Chronic Disease by Income Category, 2005

Crude Mortality Rates (per 100,000 population ) for Select Diseases: (2000-2004) CARICOM Member States

40 20 80 60 140 120 100 0 2000 2001 2002

Year

Source: CAREC, based on mortality reports from countries 2003 2004

Heart Disease Cancers Diabetes Stroke Injuries Hypertensive Diseases HIV/AIDS

Leading Causes of Death in CARICOM Countries by Sex, 2004 (MINUS Jamaica) MALES 1. Heart Disease 2. Cancers 3. Injuries and violence 4. Stroke 5. Diabetes 6. HIV/AIDS 7. Hypertension 8. Influenza/pneumonia FEMALES 1. Heart Disease 2. Cancers 3. Diabetes 4. Stroke 5. Hypertension 6. HIV/AIDS 7. Influenza/pneumonia 8. Injuries and violence Source: CAREC, based on country mortality reports

Potential Years of Life Lost <65 years by main causes, 2000

& 2004, CARICOM countries (minus Jamaica)

and 2004, CARICOM countries

Injuries

(minus Jamaica)

HIV/AIDS Y2004 Y2000 Chronic Disease 0 10000 20000 30000 40000 50000 60000 70000 Source: CAREC, based on country mortality reports Note: Chronic Disease includes heart disease, stroke, cancer, diabetes, hypertension, chronic respiratory disease.

Injuries includes traffic fatalities, homicide, suicide, drowning, falls, poisoning

Disability Adjusted Life Years 2002

Disability Adjusted Life Years (000) 2002 300 250 200 150 100 50 0 Com Dis NCDs JAM TRT BAH BAR

M ortality Attributable to Select Risk Factors (Latin America & Caribbean), from DCP2

High BP Obesity Alcohol Tobacco High cholesterol Low fruits & veg Physical inactivity Unsafe sex 0 100 200 300

Attributable Deaths (thousands)

400 500

20 10 0

Trends in Adult Overweight/Obesity in the

in the Caribbean 60

Caribbean

50 40 30 Male Female 1970s 1980s

YEARS

1990s

Prevalence (%) of diabetes among adults in the Americas

16.4

Barbados Trinidad/Tobago Jam aica Belize Cuba Mexico USA Nicaragua Surinam e Bolivia Guatem ala Colom bia Costa Rica Argentina Brazil Haiti Paraguay Urban Peru Chile Honduras 8.4

8.2

7.9

7.6

7.6

7.3

7.2

7.2

6.3

6.1

12.7

12.6

12.4

11.8

9 9.3

10.7

8.7

8.6

Source:

Pan Am J Public Health

10(5), 2001; unpublished (CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)

Caribbean trends in Diabetes mortality 40 30 20 80 70 60 50 1985 1990 1995 2000 Male Female

A consequence of Diabetes

Amputations at the QEH 2002-2006

Male Female Total Diabetic 308 379 995 Non diabetic 116 120 236

Source A. Hennis, 2007

Age adjusted death rates/100,000 population from Diabetes (2000)

120 100 80 60 40 20 0 BAH BAR GUY JAM SUR TRT CAN USA

From community surveys, the prevalence of hypertension in adults 25-64 years of age was: Barbados 27.2 % Jamaica 24.0 % St. Lucia 25.9 % The Bahamas 37.5% Belize 37.3% Trinidad TBD Control of blood pressure would reduce the death rates from Cardiovascular Disease by about 15 20%.

Principal Clinic Visits, Saint Vincent & the Grenadines, 2000 vs 2003 20,000 15,000 10,000 5,000 0 HTN or HTN/DM DM or DM/HTN Arthritis/Muscu 2000 2003

Age adjusted death rates/100,000 population from Hypertension (2000)

50 45 40 35 30 25 20 15 10 5 0 BAH BAR GUY JAM SUR TRT CAN USA

Projected National Income Lost from NCDs 2005 -2015, $USBN 600 500 400 300 200 100 0 Bra Can Chi Ind Nig Pak Rus UK Tan

Diabetes Possible economic burden ($US Million, 2001) BAH BAR JAM TRT 27.3

37.8

208.8

494.4

Hypertension 46.4

72.7

Total 76.7

110.5

251.6

460.4

259.5

753.9

Total cost of DM and H/T as percent of GDP 8 7 6 5 4 3 2 1 0 BAH BAR JAM TRT

Exploding the Myths

•

Myth: Chronic diseases are a problem of the rich countries Fact: Non-communicable disease account for more than half the burden of disease and 80% of the deaths in the poorer countries which carry a double burden of disease.

36%

Developing countries carry a double disease burden

Percentage of deaths by cause Low- and Middle-income countries 10% High-income countries 6% 7% 54% 87% non-communicable diseases communicable diseases injuries

Exploding the Myths

Myth: NCDs are a problem only of the elderly Fact: Half of these diseases occur in adults less than 70 years of age and the problems often begin in the young e.g., obesity Myth: NCDs affect men more than women Fact: NCDs affect women and men almost equally and globally, heart disease is the largest cause of death in women.

Exploding the Myths

Myth: NCDs cannot be prevented Fact: If the known risk factors are controlled, at least 80% of heart disease, stroke and diabetes and 40 % of cancers are preventable, and in addition there are cost-effective interventions available for control.

Exploding the Myths

• •

Myth:

people with NCDs are at fault and to be blamed because of their unhealthy lifestyles

Fact:

individual responsibility, while important, only has full effect where people have equal access to healthy choices. Governments have a crucial role to play by altering the social environment

to help make the healthy choice the easy choice

.

Exploding the myths

• •

Myth:

“my grandfather smoked and lived to 90 years”, and “everyone has to die of something”

Fact:

While some people who smoke will live a normal lifespan, the majority

will

have shorter, poorer quality lives. And yes, everyone has to die, but death does not need to be slow, painful or premature, as is so often the case with NCDs

What works?

• A small shift in average population levels of several risk factors can lead to a large reduction in chronic diseases • • Population wide approaches form the central strategy for preventing and controlling chronic disease epidemics, but should be combined with interventions for individuals Many interventions are not only effective, but suitable for resource constrained settings

Finland: Dramatic Declines in NCD Mortality

Relation of fitness to mortality T&T, St. James Cardiovascular Study

•

1309 men had blood sugar, cholesterol, fitness measured at baseline and then followed up carefully for 7 years.

•

Unfit men compared with fit men were: - 3.6 times more likely to die - 2.5 times more likely to have a heart attack

Caribbean Responses

• Since the 1960s, history of collective action in health, formalized in 1986 as the Caribbean Cooperation in Health (CCH) initiative. • Countries, CAREC, CFNI and CHRC, CARICOM secretariat, PAHO/WHO and partners have had successes e.g.,, malnutrition and gastroenteritis, vaccine preventable diseases, HIV/AIDS (p (PANCAP). • CCH now entering 3 rd phase:

universally and collectively

amputations or renal failure. .

major thesis that Caribbean health can be improved through actions taken

• Current priorities for action under CCH include chronic diseases where the cited goals are to reduce deaths by 2% per year and to reduce serious, costly complications such as

Caribbean Responses Summarised

community-based programs

National standards and protocols for treatment Source: PAHO Survey of NCD National Response Capacity, 2005

Addressing the risk factors Tobacco and alcohol

• Increase taxes with proceeds to prevention and treatment • Ban smoking in public places • Ban smoking in all schools • Ban cigarette and tobacco advertising near to schools • Curtail promotion of alcohol products targeted to women and children • Establish target dates for passage of the legal provisions in the FCTC already ratified.

Addressing the risk factors Physical activity

• Have physical education compulsory in schools and provide the facilities • Provide healthy, secure exercise spaces • Provide wellness centers • Give tax relief for worksite exercise facilities

Addressing the risk factors

Improve dietary practices

• Promote a standard of meals in public eating places eg. eliminating trans fats • Provide healthy school meals • Establish community based networks for training in preparation of health foods • Mandate RNM to investigate the trade issues which impact negatively on healthy food imports • Promote elimination of trans fats from Caribbean diets

Addressing the risk factors

In the case of cancer

• Primary prevention Eg screening and vaccination to prevent cervical cancer Promote screening for breast cancer

Secondary prevention

• Screening programs for NCDs • Provide health services with resources to apply the established cost-effective interventions • Establish mechanisms to ensure availability of the medications necessary for the long term treatment of NCDs when they occur

Critical other recommendations

• Establish national level Commissions on NCDs • Mandate CAREC to establish a system of behavior and risk factor surveillance • Insist on the updating of the Caribbean Regional Plan of Action for NCDs • The Caribbean should name a “CARIBBEAN WELLNESS DAY”

Involve Partners

• PAHO/WHO • Financial institutions • Caribbean social partners – private sector and civil society

Monitoring and evaluation

• Designate CARICOM/PAHO as the joint Secretariat with responsibility for monitoring and reporting progress in the control of the NCDs.

The way forward First:

We

can

utilize the policy instruments at our disposal legislation taxation regulation

Second:

We

should

establish partnerships

Third:

We

must

take personal responsibility and lead by example

CONCLUSIONS

• The Caribbean has a very serious problem - getting worse • Economically and socially, it is not sustainable • There are cost-effective interventions that work; why not utilise them?

• We must put into effect National and Caribbean-wide (CCH) plans • It is CRITICAL to strengthen health services to for management and control of chronic diseases • Deepened partnership with public and private sector, and civil society absolutely needed