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 HealthTHE 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 CausesChronic Diseases

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

Biological Risk FactorsModifiable: overweight, high cholesterol, high blood sugar, high blood pressure

Non-modifiable: Age, Sex, and Genetics↑

Behavioral Risk FactorsTobacco 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 InfluencesGlobalization 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

0

20

40

60

80

100

120

140

2000 2001 2002 2003 2004

Year

Rat

es p

er 1

00,0

00 p

op

ula

tio

n

Heart Disease

Stroke

Diabetes

Injuries

Hypertensive Diseases

Cancers

HIV/AIDS

Source: CAREC, based on mortality reports from countries

Leading Causes of Death in CARICOM Countries by Sex, 2004 (MINUS Jamaica)

1. Heart Disease

2. Cancers

3. Injuries and violence

4. Stroke

5. Diabetes

6. HIV/AIDS

7. Hypertension

8. Influenza/pneumonia

1. Heart Disease

2. Cancers

3. Diabetes

4. Stroke

5. Hypertension

6. HIV/AIDS

7. Influenza/pneumonia

8. Injuries and violence

MALES FEMALES

Source: CAREC, based on country mortality reports

Potential Years of Life Lost <65years by main causes, 2000 & 2004, CARICOM countries (minus Jamaica)

0 10000 20000 30000 40000 50000 60000 70000

Chronic Disease

HIV/AIDS

Injuries

Y2004

Y2000

Note: Chronic Disease includes heart disease, stroke, cancer, diabetes, hypertension, chronic respiratory disease.Injuries includes traffic fatalities, homicide, suicide, drowning, falls, poisoning

Source: CAREC, based on country mortality reports

0

50

100

150

200

250

300

JAM TRT BAH BAR

Com Dis

NCDs

Disability Adjusted Life Years (000) 2002

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

0 100 200 300 400 500

Unsafe sex

Physical inactivity

Low fruits & veg

High cholesterol

Tobacco

Alcohol

Obesity

High BP

Attributable Deaths (thousands)

0

10

20

30

40

50

60

Pre

vale

nce

(%

)

1970s 1980s 1990s

YEARS

Trends in Adult Overweight/Obesityin the Caribbean

Male

Female

Prevalence (%) of diabetes among adults in the Americas

6.16.3

7.27.27.37.67.67.98.28.48.68.799.3

10.711.812.412.612.7

16.4

Honduras

Chile

Urban Peru

Paraguay

Haiti

Brazil

Argentina

Costa Rica

Colombia

Guatemala

Bolivia

Suriname

Nicaragua

USA

Mexico

Cuba

Belize

Jamaica

Trinidad/Tobago

Barbados

Source: Pan Am J Public Health 10(5), 2001; unpublished (CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)

Caribbean trends in Diabetes mortality

20

30

40

50

60

70

80

Ra

te/1

00

,00

0

1985 1990 1995 2000

Male

Female

A consequence of Diabetes

Amputations at the QEH 2002-2006

Diabetic Non diabetic

Male 308 116

Female 379 120

Total 995 236

Source A. Hennis, 2007

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

0

20

40

60

80

100

120

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

0

5,000

10,000

15,000

20,000

HTN or HTN/DM DM or DM/HTN Arthritis/Muscu

2000

2003

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

0

5

10

15

20

25

30

35

40

45

50

BAH BAR GUY JAM SUR TRT CAN USA

Projected national income lost from NCDs ( 2005-2015)Projected National Income Lost from NCDs

2005 -2015, $USBN

0

100

200

300

400

500

600

Bra Can Chi Ind Nig Pak Rus UK Tan

Possible economic burden($US Million, 2001)

BAH BAR JAM TRT

Diabetes 27.3 37.8 208.8 494.4

Hypertension 46.4 72.7 251.6 259.5

Total 76.7 110.5 460.4 753.9

Total cost of DM and H/T as percent of GDP

0

1

2

3

4

5

6

7

8

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%

10%

54%

non-communicable diseasescommunicable diseasesinjuries

87%

7%6%

Developing countries carry a double disease burden

Percentage of deaths by cause

Low- and Middle-income countries High-income countries

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

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 mortalityT&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 3rd phase: major thesis that Caribbean health can be improved through actions taken universally and collectively.

• 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 amputations or renal failure.

Caribbean Responses Summarised

Financial resources

Quality assurance of care

National standards and protocols for treatment

Demonstrative community-based programs

National system of Health reports, survey and surveillance

Implementation of DPAS

Implementation of FCTC

National Objectives

National law, legislation, decree

National focal point, Department or Unit

TRT

SUR

JAM

HAI

GUY

BAR

BAH

ANT

ANG

Financial resources

Quality assurance of care

National standards and protocols for treatment

Demonstrative community-based programs

National system of Health reports, survey and surveillance

Implementation of DPAS

Implementation of FCTC

National Objectives

National law, legislation, decree

National focal point, Department or Unit

TRT

SUR

JAM

HAI

GUY

BAR

BAH

ANT

ANG

Source: PAHO Survey of NCD National Response Capacity, 2005

Addressing the risk factorsTobacco 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