Transcript Slide 1

NEEDED: A GLOBAL THRUST TO
COUNTER A GLOBAL THREAT
Non- Communicable Diseases
Prof K Srinath Reddy
President
Public Health Foundation of India
Professor of Cardiology, All India Institute of
Medical Sciences
Bernard Lown Professor of Global Cardiovascular
Health, Harvard School of Public Health
GROWING EXPECTATIONS IN GLOBAL HEALTH
l
Urgency + Anxiety About MDG Goals
l
Continuing Concerns on Infectious Diseases (ATM)
l
Momentum For Global Action on Chronic
(Non Communicable) Diseases: MDG+
l
Advocacy For Inclusion of Mental Health and
Injuries: NCD+
l
Movement For Universal Health Coverage
l
Resurgence of Primary Health Care
l
‘Health System’ Image Moves From
Black Box To Switch Board
Cause of Death in Countries
(by World Bank income group) 2008
STROKE DEATH RATES AMONG 15-64
YEARS OLDS IN THREE AREAS OF
TANZANIA (1992-1995)
90
80
70
60
50
40
30
20
10
0
Morogoro rural
(poor rural)
Hai
(well off)
Women
Dar es Salaam
(urban)
England and
Wales
Men
R. Walker et al, The Lancet, 2000.
Projected global numbers of deaths by cause for high-, middle- and low
Income countries (WHO, 2008)
Increasing CHD in India
Prevalence (%)
10.5
9.5
7
6
4.1
2
2
1960
1970
4.5
2.5
1980
1990
2000
Urban Rural
Gupta R. CSI Cardiology Update. Ed. Manjuran RJ. 2003
Number of deaths (millions)
11
10
9
8
7
6
5
4
3
2
1
CVD Deaths
6.0
Cardiovascular diseases
4.0
2.0
0.0
1990
2020
Trend of CVD mortality (1990-2000):
China
Wang YJ, International Journal of Stroke; 2007
DETERMINANTS
• Demographic Shifts (Aging)
• Urbanization
• Industrialisation
(Living Habits)
• Globalization
• Education
• Culture
(Beliefs)
• Poverty
(Access to Health)
(Marketing)
• Built Environment (Barrier/Enabler)
Vectors : Tobacco; Unhealthy Food
Risk factors: tobacco use on the rise in
developing countries
Developing Countries are in the Big League
Imports of French fries (frozen) into the Central
American countries from the United States
Source: FAO 2007
Snack imports from the United States
into Central America, 1989-2006
Source: FAO 2007
The Nutrition Transition in
Developing Countries

Shift in diet structure – towards a high
fat and refined sugar Western Diet

Accelerating rate of change in diet


Shift in activity patterns
Link between diet and activity
changes and increases in obesity
Popkin, 2001
Trends in Obesity & Overweight: Mexico
80
70
8.3%
1.2 pp/yr
Obesity
Overweight
61.0
60
%
50
40
26.8
20.2
10
4%
0.57 pp/yr
6.6%
0.94 pp/yr
30
20
69.3
24.9
32.5
28.5
14%
9.2
8.7
6.9
14.3
18.1
21.6
23.3
1999
2006
1999
2006
14%
5.9
33%
32.4
36.1
36.9
1999
2006
0
Fernald et al., 2007
8-year Change in the BMI Distribution for a Cross-section of
Chinese Adults 20-45--tripling of Male and Doubling of
Female Obesity
20
18
1989 cross-section (n=3948)
16
1997 cross-section (n=3015)
14
Percent
12
10
8
6
4
2
0
-2
15
17
19
21
23
25
27
29
31
33
35
37
Body Mass Index
The Nutrition Transition
Source: Bell et al, 2000
NUMBER OF PEOPLE WITH DIABETES
IN THE ADULT POPULATION
(AGED  20 YEARS)
350
300
Millions
250
200
2000
2025
150
100
50
0
Developed
Developing
World
Source : Global Burden of Diabetes, 1995-2025; King H. et.al, Diabetes Care,1998
Mean Plasma Cholesterol Values in China
250
200
mg/dl
150
100
50
0
1958
1981
1997
2003
Major risk for chronic diseases in Middle East
Hypertension in the EMR Based on STEPwise Surveillance
Overweight & Obesity based on STEPwise
Surveillance (BMI>=25)
Percent
80
81.2
66.9
76.4
67.4
56.3
60
%
100
53.9
40
20
0
Iraq
Jordan
Syria
Kuwait
Egypt
45
40
35
30
25
20
15
10
5
0
40.4
33.4
Iraq
Sudan
25.5
26
Jordan
Saudi
Arabia
DM in the EMR (STEPwise Surveillance)
24.6
Syria
Kuwait
23.6
Egypt
100
20
16
17.9
19.9
19.2
16.7
Sudan
Low Physical Activity
25
15
%
10
28.8
80
16.5
%
10.4
60
56.7
55.4
40
5
86.8
79
33.8
32.9
Saudi
Arabia
Syria
50.4
20
0
0
Iraq
Jordan
Saudi
Arabia
Syria
Kuwait
Egypt
Sudan
Iraq
Jordan
Kuwait
Egypt
Sudan
THE WORLD AS ONE POPULATION
If we plot the distributions of:
• BP
• Cholesterol
• Exposure to Tobacco Smoke (Active/Passive)
• Physical Inactivity
• Dysglycemia
• Overweight & Obesity
AT THE GLOBAL LEVEL
WE WILL FIND A RIGHTWARD SHIFT
In Each Of Their Distributions, Compared To 20-30 Yrs. Ago
Q. IS CVD A THREAT TO DEVELOPMENT ?
A. Yes, because of
- Loss of productivity (Premature Deaths; Prolonged
Disability)
- High Health Care Costs
(All Affairs of The Heart Are Expensive!)
% (not numbers) of CVD deaths by age
group, 2000-2030, assuming stable risks
70
60
50
<45
45-64
65-74
75 +
40
30
20
10
0
U.S.
Russia
S. Africa
Brazil
Note how deaths from CVD in the U.S.
occur principally at ages >75+
while in developing economies
they occur at younger ages.
Years Of Life Lost Due To CVD In Populations
Aged 35-64 Years
17.9
India
9.2
10.5
China
6.7
3.2
3.3
Russia
PPYLL IN 2030
PPYLL IN 2000
2
1.6
USA
S. Africa
0.4
0.3
Portugual
0.05
0.04
0
2
4
6
8
10
12
14
16
18
20
NUMBER IN MILLIONS
PPYLL= Potentially Productive Years of Life Lost
600
400
200
Pa
ki
st
an
K
U
ra
zi
l
B
ia
In
d
us
si
a
R
hi
na
0
C
International $ (billions)
Lost National Income due to IHD, Stroke
and Diabetes (2005-2015)
Preventing chronic diseases : a vital investment : WHO global report
NCDs Hurt Economic Growth
• Each 10% rise in NCDs
= 0.5% lower rate of
annual economic growth
• 50% rise in NCDs in Latin = 2.5% loss in
America by 2030
economic growth rates
– Stuckler D, Milibank Quarterly, 2008
• NCDs cost developing countries between 0.02% to
6.77% of GDP
This economic burden is more than that caused by
Malaria (1960’s) or AIDS (1990’s)
- IOM Report 2010
FALSE PERCEPTIONS
(MYTHS)
• Problem only of HIC
In LMIC
• Only rich are affected
• Only urban elites are affected
• Only elderly are affected
• Mainly men are affected
NCDs: THE SOCIAL GRADIENT
As socio-economic and health transitions
advance within each country……
The Social gradient for NCD risk factors and
for NCD events progressively reverses till
THE POOR BECOME MOST VULNERABALE
(Reddy KS et al, PNAS, 2007)
SES GRADIENT:ORDER OF REVERSAL
FOR CVD RISK FACTORS
Tobacco
Blood Pressure
Plasma Cholesterol
↓ Physical Activity
Obesity
Health Transition
Tanzania: Smoking & HT ↑ in low SES; BMI ↑ in High SES Group
(Bovet P, 2002)
China: Smoking, HT, Obesity inversely correlated with years of
education in Chinese women
(Zhije Yu, 2000)
India: Higher risk of MI in urban residents with low level of
education and income
(Rastogi T, 2004)
In Industrial employees and families, all CVD risk factors
are inversely correlated with education
(Reddy KS, 2007)
Brazil: Obesity rates declining in High SES; Rising in Low SES
(Bell, 2000)
STROKE: CHINA QUEST STUDY (2009)
4739 Survivors of stroke
71% Patients Experienced Catastrophic OOPE
•
OOPE from Stroke pushed 37% of
patients and their families below
the poverty line; 62% without
insurance went into poverty
- Heeley E et al,
Stroke, 2009; 40:2149-5
CVD: IMPACT ON HOUSEHOLDS
(KERALA, INDIA)
• Catastrophic health expenditures (72.9%)
Distress Financing Common (50%)
• 40% of CVD patients lost sources of income
• 82% did not have health insurance
• 13% could not continue medication due to
cost factors
(Harikrishnan, 2010)
The World Bank on NCDs (2007)
“To what extent do NCDs affect the poor? The
answer depends to some extent on the country
and the indicator of the NCD burden that is
considered. However, in all countries and by any
metric, NCDs account for a large enough share of
the disease burden of the poor to merit a serious
policy response.”
NOW ……..
• A momentum appears established
• ECOSOC meeting (2009)
• UN Secretary General’s Meeting (2009)
• World Health Assembly Resolution (2010)
• UN General Assembly Special Session
(UNGASS 2011)
THE HEALTH OF
PERSONS PEOPLE
POPULATIONS
CALLS FOR DIFFERENT LEVELS OF ACTION
POLICY APPROACHES
WIDER SOCIETY
Social
Determinants
Biological
Risk
INDIVIDUAL
Health
Inequities
FAMILY
Behavioral
Risk
NEIGHBORHOOD, COMMUNITY
Education
Enhancement of Knowledge, Motivation, and
Skills of Individuals
Cultural and
Social Norms
Media
Community Interventions
Settings Based
HEALTH COMMUNICATION
HEALTH CARE DELIVERY
Environment To Enable Individuals To
Make and Maintain Healthy Choices
Demographic
Globalization
Change
Drugs &
Technologies
Trade
Quality of
Care
Regulatory
Access
to Care
Legal
Systems
Infrastructure
Financial
Preventive, Diagnostic,
Therapeutic,
Rehabilitative Services
DETERMINANTS
Globalization
Health
Workforce
(Global; National; Local)
Estimated Costs of five priority interventions for
non-communicable diseases (NCDs)
in three countries
RESEARCH ON NCDS
(POLICY)
Objective
To identify enablers and barriers for
development of coherent, convergent and
coordinated MULTISECTORAL POLICY
INITIATIVES,
at national, regional and global levels, for
POPULATION-WIDE IMPACT
on the major determinants of NCDs
RESEARCH ON NCDs
(POLICY)
Pathways
- Financial (such as Taxes and Subsidies)
- Regulatory (such as Ad-Bans and Health Warnings)
- Infrastructure (Urban Design & Transport)
- Agro-Industrial (Production; Processing; Pricing)
- Trade (WTO Regulations; Trade Agreements)
RESEARCH ON NCDs
(PRACTICE)
Objective
To effectively integrate evidence based practices into
PRIMARY HEALTH CARE
for preventing and reducing the risk of NCDs in
INDIVIDUALS
through programmes that are delivered
by an efficient and adequately resourced
HEALTH SYSTEM
OPERATIONAL RESEARCH
RESEARCH ON NCDs
(PRACTICE)
Pathways
- Health Promotion Focusing on DATA
(Diet; Activity; Tobacco; Alcohol)
- Identification of High Risk Individuals (HRIs)
(Opportunistic & Targeted Screening Strategies)
-
Risk Reduction Interventions
(Primary & Secondary Prevention)
-
Early Management of Acute Events
Development of Chronic Care Systems in
Health Services
GPS FOR GLOBAL HEALTH

The Spectrum of Research Must Stretch
From MOLECULES To MARKETS

The Span of Policy Must Range From
PERSONS To PEOPLE To POPULATIONS

The Arena of Advocacy And Action Must
Extend From RISK FACTORS To RIGHTS
[email protected]
WHAT CAN THE ‘NCD’ WORLD
LEARN FROM THE ‘HIV’ WORLD?
• BUILDING A SOCIAL MOVEMENT
• RIGHTS BASED APPROACH TO HEALTH
• AFFORDABLE / AVAILABLE DRUGS
• REMOVAL OF STIGMA
• A VARIETY OF ‘PPP’s
‘Public-Private; Public-NGO;
Private-Private; Private-NGO’
HIV-NCD LINKS
EXAMPLES
• Disease Linked: Kaposi’s Sarcoma; Cardiomyopathy
• Treatment Linked: Accelerated Atherosclerosis
• Co-Morbidities: In HIV Survivors (Age Related)
• Risk Enhancement:
HIV
(For Infections)
Smoking
Diabetes
• ‘Other’ NCDs: Mental Illness; Suicidal Deaths
BEYOND VERTICAL CONSTRUCTS
IN THE CONTEXT OF A ‘HEALTH SYSTEM’
WHAT UNITES HIV & NCDs IS
CHRONIC CARE
= Need For Long Follow up + Re-Visits + Referrals + Counseling
+ Social Support Systems + Multi-Sectoral Actions
WHAT CAN THE ‘HIV’ WORLD LEARN
FROM THE ‘NCD’ WORLD?
• From Entreaty to Global Treaty (FCTC)
• Countering/Converting the industry
(Tobacco)
(Food Industry)
• Bridging the Prevention –Treatment Divide
• Addressing Common Risk Factors
(Responsible for a ‘Cluster’ of Diverse Diseases)
• Moving the Agenda From Diseases to Determinants
(Biomedical To Social Determinants Approach)
PARTNERSHIPS
SYNCHRONY OF EFFORT
FOR
SYNERGY OF EFFECT
PUBLIC HEALTH