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.
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.
Learning from low and middle income countries about responding to non-communicable disease
Learning from responses to the pandemic of non-communicable disease (NCD) in low and middle income countries Richard Smith Director, UnitedHealth Chronic Disease Initiative
Agenda• What do we mean by NCD?• Global pandemic of NCD• Global response• UnitedHealth Chronic Disease Initiative• General learning from LMIC• Community health workers• Polypill• M-health• Community Interventions for Health• Conclusions
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 conditions• NCD is the preferred term
Deaths from chronic disease are displacing deathsfrom infectious disease even in rural Bangladesh
Shifting Patterns of Global HealthDeaths, % of Total, 2005 Forecast Deaths, 2006-2015, Total % Change Deaths, M 13.7Low 12.3 2.5Lower-middle 13.2 0.5Upper-middle 2.7 0.5High 7.1 0 20 40 60 80 100 -10 -5 0 5 10 15 20 25 Infectious diseases Chronic diseases
Multimorbidity in rural Bangladesh (among people over 60)
Changes in global risk factors for DALYs1990-2010
Proportion of DALYs due to ischaemic heart disease from individual risk factors 2010
We can make a difference: death rates in the US, 1900-1996Decline
Yet only 3% of globalhealth aid ($21 billion) goes to NCD
Priorities of the UN Secretary General• “Whole of government, whole of society response”• 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
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 the targets set some countries up to fail?• 2013: review of the MDGs; integrate NCDs• 2014: UN review of progress• 2015: Sustainable Development Goals
View from Scotland on best way to look after people with long term conditions
Best buys for reducing the burden of NCDs (WHO)• 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
Further “best buys” from WHO (health system examples)• Counselling and multidrug therapy, including glycaemic control for diabetes for people over 30 with a 10 year risk of 20% of a cardiovascular event• Aspirin therapy for acute myocardial infection• Screening for cervical cancer once at age 40 with removal of any cancerous lesions• Biennial mammography for women 50-70• Early detection of colorectal and oral cancer• Treatment of persistent asthma with inhaled corticosteroids and beta-2 agonists
Cost effectiveness of different interventions for preventing and controlling NCDs in Mexico
11 UnitedHealth and NHLBI Collaborating Centres of Excellence to counter chronic disease
Work of the centres in relation to WHO priorities• Surveillance (Bangladesh, Delhi, Tunisia, Kenya, Peru, Southern Cone)• Tobacco control (Tunisia)• Reducing biofuels (Kenya, Peru)• Better nutrition (Tunisia, Northern Mexico, Central America, China)• Increase physical activity (Tunisia, Northern Mexico)• Risk assessment (China, South Africa, Peru)• Better Dx and Rx (China, Delhi, Bangalore, South Africa, Central America)• Strengthen primary care, more community health workers (China, Delhi, Bangalore, South Africa, Northern Mexico, Central America)• Social determinants (Bangladesh, Delhi, all centres in joint studies)
10 ways in which developed countries benefit and learn from partnerships with developing countries• Rural health service delivery• Skills substitution• Decentralisation of management• Creative problem-solving• Education in communicable disease control• Innovation in mobile phone use• Low technology simulation training• Local product manufacture• Health financing• Social entrepreneurship
Community health workers• Most centres working with community health workers• In many places doctors and nurses simply not there; and if there in short supply• CHWs are not just supplemental; they usually speak the same language and share the same culture as local people• Working on primary, secondary, and tertiary prevention• Evidence from a Cochrane review of their effectiveness, particularly with communicable disease, vaccination, and maternal and child health
Polypill concept• Combine antihypertensive drugs, a statin, and possibly aspirin into one pill taken once a day• Many polypills• Antihypertensives (usually three and usually at half dose)• “Agreement” on use in secondary prevention. FDA may license in 2013• Trial with clinical endpoints underway for primary prevention• Most radical idea—offer to everybody at 55• Individual lifestyle modification—costly and unsustainable
Polypill prevention trial• 86 people over 50 no established disease took polypill and placebo in cross over trial of 12 weeks each• Polypill (amlodipine 2.5 mg, losartan 25 mg, hydrochlorothiazide 12.5 mg and simvastatin 40 mg)• All taking individual components before• 84/86 completed both arms• 98% of participants took more than 85% of their allocated pills• 24 reported one or more symptoms on the Polypill compared with 11 on the placebo, but none considered them troublesome enough to stop treatment.
Proportion of Medicaid patientsachieving 80% adherence 2011
Community interventions for health• Work with schools, employers, health services, local politicians, and media to create a healthier environment• Make healthy choices the easy choices• Emphasis on “structural changes”—healthier food in schools, environmental changes to encourage walking and cycling and discourage driving (Increased physical activity is the closest we come to a panacea, halving the chance of a heart attack)• Being tested in Sousse, Tunisia against control areas• Being implemented in New Haven
Conclusions• There is a pandemic of NCD in low and middle income countries• The world is beginning now to take the problem seriously• Response must be “whole of government and whole of society”• United together with NHLBI has been leading the way• There should be learning for high income countries, particularly around community health workers, the polypill, m-health, and creating healthier communities