Non- communicable disease and mentalhealth in low and middle income countries Richard Smith Director, UnitedHealth Chronic Disease Initiative
Agenda• Definitions• The UN meeting• Scale of the problem• Causes• How best to respond (concentrating on NCDs)?• What must be done?
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 smoking, poor diet, physical inactivity, and the harmful use of alcohol. • Doesnt include mental health and many other chronic conditionsSource: World Health Organization, 2005
In September 2011 the UN held a high level meeting onNCDs (did not include mental health)• 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• Russia committed $60m and Australia $3.9m
Future commitments with target dates• 2012: work with WHO and all stakeholders to set targets• 2013: review of the MDGs; integrate NCDs• 2014: UN review of progress
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• Beginning not the end
What didnt happen• Nothing on mental health. Should there be another high level meeting?• No new funding apart from Russia and Australia, didnt expect it• WHO costing report and WEF report came too late, some best buys got lost• NCD Alliance has issues with best buys—major omissions• Alcohol weak• No champion countries—Australia, Norway• China and India not very visible; too few G8 champions• Not many LMIC stepping forward• Yet to engage the public—must do by 2014
Global Causes of Death (2006)Chronic diseases: Infectious diseases: HIV/AIDS 4.9%Heart disease Tuberculosis 2.4%30.2% Malaria 1.5% Total: Other Infectious 58.0M Diseases 20.9%Cancer15.7% Injuries 9.3% The total number of peopleDiabetes dying from chronic diseases is1.9% double that of all infectiousOther chronic diseases diseases including HIV/AIDS, tuberculosis and malaria15.7% (Nature, 2007).
Leading causes of attributable global mortality and burden of disease, 2004 Attributable Mortality Attributable DALYs % %1. High blood pressure 12.8 1. Childhood underweight 5.92. Tobacco use 8.7 2. Unsafe sex 4.63. High blood glucose 5.8 3. Alcohol use 4.54. Physical inactivity 5.5 4. Unsafe water, sanitation, hygiene 4.25. Overweight and obesity 4.8 5. High blood pressure 3.76. High cholesterol 4.5 6. Tobacco use 3.77. Unsafe sex 4.0 7. Suboptimal breastfeeding 2.98. Alcohol use 3.8 8. High blood glucose 2.79. Childhood underweight 3.8 9. Indoor smoke from solid fuels 2.710. Indoor smoke from solid fuels 3.3 10. Overweight and obesity 2.359 million total global deaths in 2004 1.5 billion total global DALYs in 2004 18
Deaths attributed to 19 leading factors, by country income level, 2004 19
We can make a difference: death rates in the US, 1900-1996Decline
Yet only 3% of global health aid ($21 billion)goes to NCDs and mental health.
Pervasive myths that have prevented action• Global economic development will improve all health conditions• Chronic disease results from freely adopted risk• Chronic diseases are diseases of the elderly• Chronic diseases are diseases of the rich• Benefits of countering chronic disease accrue only to the individual• We can fix chronic disease as we are fixing infectious disease• We should wait until weve controlled infectious disease• Screening and treating patients is the the most cost effective way to go
How best to respond? • “We need a whole of government and a whole of society response” • Margaret Chan, director general, WHO
Need for a broad strategy Comprehensive and integrated action is the means to prevent and control chronic diseases
Difficult questions• What is the best level at which to intervene? Social determinants? Behavioural risk factors? Biological risk factors? Treatment? Or rather how much to intervene at each level?• What are the best buys?• What should be the priorities?• What MUST be done?• What is the best system of governance?• What to do if very few (even no) resources are available?• What to do in this particular country?• How to think about these difficult questions at the same time?
Some preliminary answers to some of the questions?
What is the best level at which to intervene? Or rather how muchto intervene at each level?• Social determinants? – Acting at this level may bring benefits beyond NCDs—for example, on poverty, trade, agriculture, education – Some cannot be controlled—ageing of the population, globalisation• Behavioural risk factors? – We have strong evidence on how to act on some of these—for example, raising taxes on tobacco and alcohol, banning smoking in public places – Can be very cost effective – Interventions on diet and physical activity are more complicated, but there are some relatively simple ones— like banning trans fats, reducing salt in food
What is the best level at which to intervene? Or rather how muchto intervene at each level?• Biological risk factors? – Later in the disease process than acting on behavioural risk factors, less cost effective – How much can the health system achieve alone? – Strengthening the health system helps patients with other problems, counteracting to some extent the criticism aimed at “vertical systems” – Strong evidence on the benefits of treating cardiovascular risk, but depends on some sort of health system and tends to work poorly even where there are well functioning health systems (rule of halves) – Poor effectiveness on obesity – Good evidence on prediabetes and prehypertension (doesnt depend on doctors and nurses)
•What is the best level at which to intervene? Or rather how muchto intervene at each level?• Treatment? – The major cost of developed world systems (over 90%) – Least cost effective – Hard to change once you have it, huge vested interest – Hard even to reshape existing systems—stronger primary care, less dependency on doctors, fewer hospitals, closer links with social services, more disease management, stronger palliative care, etc – But people expect “the sick to be treated” – Health systems are traditionally concerned with the sick not the “healthy” Could it be different?
Best buys for reducing the burden of NCDs (WHO):(none of them depend on health systems)• Protecting people from tobacco smoke and banning smoking in public places• Warning about the dangers of tobacco use• Enforcing bans on tobacco advertising, promotion and sponsorship• Raising taxes on tobacco• Restricting access to retailed alcohol• Enforcing bans on alcohol advertising• Raising taxes on alcohol• Reduce salt intake and salt content of food• Replacing transfat in food with polyunstaurated fat• Promoting public awareness about diet and physical activity, including through mass media
Interesting question What might an entirely new system for preventing and controlling NCDs in a low income country look like?
It’s a more complicated problem than counteringinfectious diseaseacute childhood infections maternal chronic, life long infectious and non- deaths infectious diseasesSimple technologies Complex interventionsRapid impact Decades before impactsControlled by health services Main levers outside health service controlWithin the remit of the health campus Takes a whole university and all and the health department government!
View from Scotland on best way to look after peoplewith long term conditions
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
11 UnitedHealth and NHLBI Collaborating Centres of Excellence tocounter chronic disease
Outcomes proposed by UnitedHealth NHLBI Centers ofExcellence• A strong commitment to action by the UN and member states with global and national plans for action• Creation of a global partnership with all groups able to join, clear governance, and a global plan with with targets and regular reporting• Energetic implementation of the Framework Convention on Tobacco Control• Action on other risk factors• Universal access to essential drugs and technology• Strengthening of health systems (benefits all patients)• Emphasis on research, particularly implementation research
What are the “must dos” in the manycountries that are currently doing very little?
What MUST be done?• National plan• “Infrastructure”--government apparatus• Surveillance• Advocacy• Implement Framework Convention on Tobacco Control (not all countries have signed)
Conclusion• NCDs present a major challenge to health, particularly in the developing world• Problem will get rapidly worse without action• So far very few resources devoted to NCDs• There is now high level commitment, but public consciousness of the problem needs raising• The response must be “all of government and all of society”• It is possible to prevent most premature deaths from NCDs• There are many cost effective interventions, most of them outside the health system• We need a global plan (with targets) and national plans. They are coming.