prof k srinath reddy president public health foundation of india professor of cardiology, all india...
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Prof K Srinath ReddyPresidentPublic 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
NEEDED: A GLOBAL THRUST TO COUNTER A GLOBAL THREAT
Non- Communicable Diseases
NEEDED: A GLOBAL THRUST TO COUNTER A GLOBAL THREAT
Non- Communicable Diseases
Urgency + Anxiety About MDG Goals
Continuing Concerns on Infectious Diseases (ATM)
Momentum For Global Action on Chronic (Non Communicable) Diseases: MDG+
Advocacy For Inclusion of Mental Health and Injuries: NCD+
Movement For Universal Health Coverage
Resurgence of Primary Health Care
‘Health System’ Image Moves From Black Box To Switch Board
Urgency + Anxiety About MDG Goals
Continuing Concerns on Infectious Diseases (ATM)
Momentum For Global Action on Chronic (Non Communicable) Diseases: MDG+
Advocacy For Inclusion of Mental Health and Injuries: NCD+
Movement For Universal Health Coverage
Resurgence of Primary Health Care
‘Health System’ Image Moves From Black Box To Switch Board
GROWING EXPECTATIONS IN GLOBAL HEALTH
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)
0102030405060708090
Morogoro rural Hai Dar es Salaam(urban)
England andWales
Women MenDe
ath
s p
er 1
00,
00
0 p
op
ula
tio
n
R. Walker et al, The Lancet, 2000.
(poor rural) (well off)
Projected global numbers of deaths by cause for high-, middle- and low
Income countries (WHO, 2008)
2
67
9.510.5
22.5
4.1 4.5
123456789
1011
1960 1970 1980 1990 2000
Urban Rural
Increasing CHD in India
Prevalence (%)
Gupta R. CSI Cardiology Update. Ed. Manjuran RJ. 2003
0.0
2.0
4.0
6.0
1990 2020Num
ber o
f dea
ths
(mill
ions
)
Cardiovascular diseases
CVD Deaths
Trend of CVD mortality (1990-2000): China
Trend of CVD mortality (1990-2000): China
Wang YJ, International Journal of Stroke; 2007
• Demographic Shifts (Aging)
• Urbanization
• Industrialisation
• Globalization (Marketing)• Education• Culture
• Poverty (Access to Health)
• Built Environment (Barrier/Enabler)
Vectors : Tobacco; Unhealthy Food
DETERMINANTS
(Living Habits)
(Beliefs)
Risk factors: tobacco use on the rise in developing countries
Risk factors: tobacco use on the rise in developing countries
Developing Countries are in the Big LeagueDeveloping Countries are in the Big League
Imports of French fries (frozen) into the Central American countries from the United States
Imports of French fries (frozen) into the Central American countries from the United States
Source: FAO 2007Source: FAO 2007
Snack imports from the United States into Central America, 1989-2006
Snack imports from the United States into Central America, 1989-2006
Source: FAO 2007Source: FAO 2007
The Nutrition Transition in Developing Countries
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
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: MexicoTrends in Obesity & Overweight: Mexico
14.3 18.1 21.6 23.336.1 36.95.9
8.7 6.99.2
24.932.4
0
10
20
30
40
50
60
70
80
1999 2006 1999 2006 1999 2006
%
Obesity
Overweight
33%
14%
14%
20.226.8
28.532.5
61.0
69.3
6.6%0.94 pp/yr
4%0.57 pp/yr
8.3%1.2 pp/yr
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
-2
0
2
4
6
8
10
12
14
16
18
20
15 17 19 21 23 25 27 29 31 33 35 37
Body Mass Index
Per
cen
t
1989 cross-section (n=3948)
1997 cross-section (n=3015)
Source: Bell et al, 2000
The Nutrition Transition
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED 20 YEARS)
NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION
(AGED 20 YEARS)
0
50
100
150
200
250
300
350
Developed Developing World
Mil
lion
s
20002025
Source : Global Burden of Diabetes, 1995-2025; King H. et.al, Diabetes Care,1998
Mean Plasma Cholesterol Values in ChinaMean Plasma Cholesterol Values in China
0
50
100
150
200
250
mg/
dl
1958 1981 1997 2003
Major risk for chronic diseases in Middle EastMajor risk for chronic diseases in Middle East
Overweight & Obesity based on STEPwise Surveillance (BMI>=25)
66.9 67.456.3
81.2 76.4
53.9
0
20
40
60
80
100
Iraq Jordan Syria Kuwait Egypt Sudan
Per
cen
t
Hypertension in the EMR Based on STEPwise Surveillance
25.5 2628.8
24.6
33.4
23.6
40.4
05
1015202530354045
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
%DM in the EMR (STEPwise Surveillance)
10.4
1617.9
19.916.7 16.5
19.2
0
5
10
15
20
25
Iraq Jordan SaudiArabia
Syria Kuwait Egypt Sudan
%
Low Physical Activity
56.7
79
33.8 32.9
55.4 50.4
86.8
0
20
40
60
80
100
Iraq Jordan SaudiArabia
Syria 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 & ObesityAT 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
0
10
20
30
40
50
60
70
U.S. Russia S. Africa Brazil
<45
45-64
65-74
75 +
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
PPYLL= Potentially Productive Years of Life Lost
0.04
0.3
1.6
3.3
6.7
9.2
0.05
0.4
2
3.2
10.5
17.9
0 2 4 6 8 10 12 14 16 18 20
Portugual
S. Africa
USA
Russia
China
India
NUMBER IN MILLIONS
PPYLL IN 2030
PPYLL IN 2000
Lost National Income due to IHD, Stroke and Diabetes (2005-2015)
0
200
400
600
Inte
rnati
on
al $ (
billio
ns)
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 GRADIENTNCDs: 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)
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)STROKE: CHINA QUEST STUDY (2009)
4739 Survivors of stroke
71% Patients Experienced Catastrophic OOPE
- Heeley E et al,
Stroke, 2009; 40:2149-5
• OOPE from Stroke pushed 37% of
patients and their families below
the poverty line; 62% without
insurance went into poverty
CVD: IMPACT ON HOUSEHOLDS (KERALA, INDIA)
(Harikrishnan, 2010)
• 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
The World Bank on NCDs (2007)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.”
“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(Global; National; Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and Maintain Healthy Choices
INDIVIDUAL
FAMILY
NEIGHBORHOOD, COMMUNITY
Enhancement of Knowledge, Motivation, and Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATIONP
reve
ntiv
e, D
iagn
ostic
, T
hera
peut
ic,
Reh
abili
tativ
e S
ervi
ces
HE
ALT
H C
AR
E D
EL
IVE
RY
WIDER SOCIETY
DE
TE
RM
INA
NT
S
Globalization
Acc
ess
to
Ca
reS
yste
ms
Infr
ast
ruct
ure
He
alth
W
ork
forc
eQ
ua
lity
of
Ca
reD
rug
s &
Te
chn
olo
gie
s
Demographic Change
Globalization
Social Determinants
Health Inequities
Cultural and Social Norms
Education
Biological Risk
Behavioral Risk
Estimated Costs of five priority interventions for non-communicable diseases (NCDs)
in three countries
Estimated Costs of five priority interventions for non-communicable diseases (NCDs)
in three countries
RESEARCH ON NCDS (POLICY)
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
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)
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)
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)
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
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)
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
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
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
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
GPS FOR GLOBAL HEALTH
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
• Disease Linked: Kaposi’s Sarcoma; Cardiomyopathy
• Treatment Linked: Accelerated Atherosclerosis
• Co-Morbidities: In HIV Survivors (Age Related)
• Risk Enhancement:
(For Infections)
• ‘Other’ NCDs: Mental Illness; Suicidal Deaths
HIV
Tuberculosis
Smoking Diabetes
EXAMPLES
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
PUBLIC HEALTH
SYNERGY OF EFFECT SYNCHRONY OF EFFORT FOR