Non-communicable disease and the future of development

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  • The majority of deaths worldwide for all ages are due to chronic diseases. Cardiovascular diseases (mainly heart disease and stroke) are responsible for 30% of all deaths. Cancer, chronic respiratory diseases, and diabetes are also major causes of mortality. The contribution of diabetes is underestimated because although people may live for years with diabetes, their deaths are usually recorded as being caused by heart disease or kidney failure.
  • 5.3 million deaths in 2000
  • VA data from Matlab HDSS clearly demonstrates that a major change among categories in causes of death taking place in rural areas of Bangladesh.
  • FIGURE 6 Increase and Decline in Heart Disease Rates through the Epidemiological Transition in the United States (1900 to 1996)   In the 1930s and ’40s, smoking and fat consumption continued to rise, as did the prevalence of heart disease. The U.S. had entered the third phase of the epidemiologic transition, the Age of Degenerative and Man-Made Diseases. By 1955, 55 percent of adult men were smoking, and fat consumption represented about 40 percent of total calories. Americans were also becoming more sedentary as a result of continued mechanization and urbanization and the rise of the suburbs after World War II, where more people were driving instead of walking and bicycling. Another important development affecting the health of Americans post WWII was the growth of the healthcare industry. By the late 1950s, more than 2/3 of the working population had some form of private insurance (7). As the 1960s progressed, age-adjusted CVD mortality rates began to decline, marking the beginning of the fourth phase of the transition, the Age of Delayed Degenerative Diseases. Since then, there have been substantial reductions in rates of mortality from both stroke and CHD. This decline can be attributed primarily to two main factors, therapeutic advances and prevention measures targeted at people with CVD as well as those potentially at risk for it. (8-10) Interestingly, healthier lifestyles may have actually had an even greater impact on the decline in age-adjusted rates of death. For example, improvements in diet due to access to fresh fruits and vegetables year round in developed countries may have contributed to declining cholesterol mean levels before effective drug therapy was widely available.     (1)    Starr, P: The Social Transformation of American Medicine . New York: Basic Books; 1982.   (2)    Goldman L, Cook EF: The decline in ischemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle. Ann Intern Med 1984, 101:825.   (3)    Hunink MG, Goldman L, Toteson, AN, et al: The recent decline in mortality from coronary heart disease, 1980-1990. The effect of secular trends in risk factors and treatment. JAMA 1997, 277:535.   (10) Cooper R, Cutler J, Desvigne-Nickens P, et al: Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation 2000, 102:3137.

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  • 1. Non-Communicable Disease and the future of development Richard Smith Director, UnitedHealth Chronic Disease Initiative
  • 2. Ban Ki-moon on NCDs • “Non-communicable diseases are a threat to development. NCDs hit the poor and vulnerable particularly hard, and drive them deeper into poverty.” • Ban Ki-moon
  • 3. Ban Ki-moon on NCDs • More than a quarter of all people who die from NCDs succumb in the prime of their lives. The vast majority live in developing countries. Millions of families are pushed into poverty each year when one of their members have become too weak to work. Or when the costs of medicines and treatments overwhelm the family budget. Or when the main breadwinner has to stay home to care for someone else who is sick.
  • 4. Agenda• Definitions• Scale of the problem• Causes• The UN meeting• How best to respond ?
  • 5. Non-communicable disease • WHO defines non-communicable disease (NCD) as cardiovascular disease, diabetes, chronic respiratory disease, and certain cancers. • All of these have in common that they are caused predominantly by tobacco use, poor diet, physical inactivity, and the harmful use of alcohol. • Doesnt include mental health and many other chronic conditionsSource: World Health Organization, 2005
  • 6. Burden of disease
  • 7. Leading Causes of Mortality and Burden of Disease world, 2004 Mortality DALYs % %• Ischaemic heart disease 12.2 • Lower respiratory infections 6.2• Cerebrovascular disease 9.7 • Diarrhoeal diseases 4.8• Lower respiratory infections 7.1 • Depression 4.3• COPD 5.1 • Ischaemic heart disease 4.1• Diarrhoeal diseases 3.7 • HIV/AIDS 3.8• HIV/AIDS 3.5 • Cerebrovascular disease 3.1• Tuberculosis 2.5 8. Prematurity, low birth weight 2.99. Trachea, bronchus, lung cancers 2.3 • Birth asphyxia, birth trauma 2.7• Road traffic accidents 2.2 • Road traffic accidents 2.711. Prematurity, low birth weight 2.0 • Neonatal infections and other 2.7 8
  • 8. Deaths from chronic disease are displacing deaths frominfectious disease even in rural Bangladesh
  • 9. NCDs are commonest among the poorest inrural Bangladesh
  • 10. Ten leading causes of burden of disease, world, 2004 and 2030 11
  • 11. We can make a difference: death rates in the US, 1900-1996Decline
  • 12. Yet only 3% of global health aid ($21 billion)goes to NCDs and mental health.
  • 13. Causes of NCDs
  • 14. In September 2011 the UN held a high level meeting onNCDs• Only the second high level meeting of the UN on health• The first in 2001 led to the Global Fund for AIDS, TB, and malaria• Led to a flurry of activity and a raising of consciousness (although not among ordinary people)• 130 countries spoke; 200 civil society representatives attended; 40 side meetings
  • 15. Future commitments with target dates• 2012: work with WHO and all stakeholders to set targets – Currently arguments over targets – Can targets be sensibly set? – Will they set some countries up to fail?• 2013: review of the MDGs; integrate NCDs• 2014: UN review of progress
  • 16. What was achieved?• On global agenda: meeting was a step change• Understanding that a response must go well beyond health sector: “Whole of society, whole of government”• Development issue• Civil society movement important: NCD Alliance
  • 17. What didnt happen• Nothing on mental health. Should there be another high level meeting?• No new funding apart from Russia and Australia• NCD Alliance had issues with best buys—major omissions• Alcohol weak• Little on children• No champion countries – China and India not very visible; too few G8 champions – Not many LMIC stepping forward• Yet to engage the public—must do by 2014
  • 18. How best to respond?
  • 19. Priorities of the UN Secretary General• Complete government wide action on risk factors• Sustained primary health care with prioritised packages plus palliative and long term caregivers• Surveillance and monitoring• Learning from and integration with AIDS, TB, and malaria programmes• Governments, private sector, civil society, and international organisations must all work together
  • 20. How best to respond? • “We need a whole of government and a whole of society response” • Margaret Chan, director general, WHO
  • 21. Which is the best level at which to intervene?
  • 22. WHO calculations of cost effectiveness of priorities forpreventing and controlling NCDs• Depends on geography and disease patterns in each country/region• Looked at 500 single or combined interventions• Costs: resources needed multiplied by unit price (varies widely), in $Int, which takes account of purchasing power• Benefits: DALYs averted• “Highly cost effective” if cost per DALY below GDP per person
  • 23. Interventions that cost less than GDP per head:SubSaharan Africa• Cardiovascular disease, diabetes and tobacco: 8 – Preventive multidrug treatment at 35% risk of CVD event – Increased taxation on tobacco – Retinopathy screening, 80% coverage• Cancer: 6 – Cervical cancer, pap smear at age 40, lesion removal plus cancer treatment, 50% coverage – Colorectal cancer: surgery/chemotherapy/radiotherapy• Respiratory disorders: None• Sensory disorders: 8• Mental disorder: 8• Injuries (road traffic): 3
  • 24. Cost effectiveness of different interventions forpreventing and controlling NCDs in Mexico
  • 25. Interesting question What might an entirely new system for preventing and controlling NCDs in a low income country look like?
  • 26. Best system for responding to NCDs in LMIC• High level task force that is whole of government and whole of society• Emphasis on public health and prevention with an emphasis on structural changes• Patients TRULY in charge• Extensive use of community health workers• Extensive standardisation and use of protocols• Emphasis on primary care• Few hospitals and specialists—to avoid capture of resources