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SLMA president address 2009

The document discusses the regional health situation in Sri Lanka and outlines several key challenges: strengthening the health system; promoting healthy lifestyles; addressing environmental health issues; preventing and controlling communicable and non-communicable diseases. It notes the increasing burden of non-communicable diseases like diabetes, hypertension, and cardiovascular disease. Statistics on the prevalence of these conditions in Sri Lanka are provided over time, demonstrating the growing epidemic. The roles of risk factors, lifestyle changes, and the health system in addressing this transition are examined.

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SLMA Presidential Address 2009
Regional Health Situation 2007 - The challenges • Strengthening Health System Public Health Funding Equity Human Resource Development Heath Informatics • Promoting a healthy life course MDG Malnutrition STD Immunization • Addressing challenges in healthy environments Water supply coverage Sanitation Climate change Global Warming Occupational Health Food Hygiene Disaster preparedness • Tackling risk factors and preventing NCD CVD Tobacco Mental Illness Trauma • Preventing controlling eliminating & eradicating communicable disease TB HIV Respiratory Infections Diarrhoeas Dengu Chikungunya Strengthening Health System Public Health Funding Equity Human Resource Development Heath Informatics Promoting A Healthy Life Course MDG Malnutrition STD Immunization Healthy Environments Water supply coverage Sanitation Climate change Global Warming Occupational Health Food Hygiene Disaster preparedness Tackling risk factors and preventing NCD CVD Tobacco Mental Illness Trauma Diabetes Preventing controlling eliminating & eradicating communicable disease TB HIV Respiratory Infections Diarrheas Dengue Chikungunya
Communicable diseases Group A 1.Cholera 2.Plague 3.Yellow Fever Group B 1.Acute Anterior Poliomyelitis 2.Dengue Fever/Dengue Hemorrhagic Fever 3.Diphtheria 4.Dysentery 5.Encephalitis 6.Enteric Fever 7.Food Poisoning 8.Human Rabies 9.Leptospirosis 10.Malaria 11.Measles 12.Rubella (German Measles) 13.Simple Continued fever of 7 days + 14.Tetanus 15.Typhus Fever 16.Viral Hepatitis 17.Whooping Cough 18.Tuberculosis
WHO List of non-communicable diseases • Cardiovascular diseases • Stroke • Cancer • Diabetes • Chronic obstructive pulmonary disorders (COPD) or chronic respiratory diseases, • Mental illness and • Trauma
Epidemic Chronic Disease • “Epidemic” • Traditionally used in connection with infectious diseases….they occurred in large no in a short space of time and referred to as pandemics when they occurred across continents. • The non communicable diseases are even larger in numbers but more “chronic”. Hence the WHO recognises the term “Epidemic Chronic Disease”
9. NEOPLASM 12. DIABETES 15. MENTAL HEALTH 20. HYPERTENSIVE DISEASE 20. ISCHAEMIC HEART DISEASE 23. STROKE 44. TRAUMATIC INJURIES 46. PESTICIDES Indoor Morbidity Statistics 2006 by Broad Disease Groups
Cardiovascular Cancer COPD Trauma HT / Stroke Leading Cause of Hospital Deaths 2006
Differences between communicable & non communicable diseases (NCD) Communicable • Single causative agent • Sudden onset of symptoms • Responds to short courses of treatment Non communicable • Multifactorial • Gradual onset with long course • Requires prolonged care & treatment • Affects quality of life • Linked to common risk factors (tobacco, alcohol, unhealthy diet, physical inactivity & environmental carcinogen) The World Health Report of 1999 shows that in 1998 NCD accounted for 77% of global mortality and 85% of the global burden of disease was from low and middle income countries. The situation worsens in 2008…
Chronic diseases include heart disease, stroke, cancer, chronic respiratory diseases and diabetes. Visual impairment and blindness, hearing impairment and deafness, oral diseases and genetic disorders are other chronic conditions that account for a substantial portion of the global burden of disease. From a projected total of 58 million deaths from all causes in 2005, it is estimated that chronic diseases will account for 35 million, which is double the number of deaths from all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies combined.
Changes in the last 50 years of relevance to Societal Health • Demographic transition • Epidemiological transition • Other factors Industrialization, urbanization, westernisation, dietary habits, sedentary life styles, stress, infant & child survival, diagnosis & treatment, life expectancy, socio-political changes, health seeking behaviour, cost of health care, expectations of outcome, access to information litigation, easy communication
Factors reducing mortality • Income growth leads to better … • Improved medical technology – • Public Health Programmes – • Knowledge about health – Drugs Vaccine Diagnostic Potable water Sanitation Food regulation Schools Health Education Food Housing Access to healthcare
Factors influencing changes Doctor – Patient interaction • Dependence on history, examination, experience • Paternalistic care • More humane personal care • Belief & trust → Dependence on investigation →Partnership with doctor →More ”commercialised" delivery →More suspicion & litigation
Demographic transition in Sri Lanka Population pyramids 1981 and 2001 WHO Country Cooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]
Epidemiological transition WHO Country Cooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]
Epidemiological transition WHO Country Cooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]
Symptomatic Disease Deaths Mild or No S/S Non specific S/S Difficult to diagnose EARLY DISEASE RISK FACTORS
Let us look at some of the key illnesses which are increasing in epidemic proportions globally, regionally and locally causing chronic ill health 1.Diabetes 2.Hypertension 3.Obesity 4.Metabolic Syndrome 5.Cardiovascular Disease 6.Cancer 7.Chronic Kidney Disease
1. Diabetes – Definitions Stage of hyperglycaemia Venous plasma glucose mmol/l (mg/dl) Diabetes mellitus • Fasting • 2h post glucose load or random blood sugar >7.0 (126) > 11.1 (200) Impaired glucose tolerance (IGT) • 2h post glucose load 7.8-11 (140-199) Impaired fasting glucose (IFG) • Fasting 5.6-6.9 (100-125) Normal • Fasting • 2h post glucose load <5.6 (100) <7.8 (140)
Diabetes Global Situation 246 million worldwide Diabetes atlas 2006, International Diabetes Federation TYPE II DIABETES According to the recent estimates of the International Diabetes Federation (IDF), the global prevalence of diabetes among those between 20 to 79 years of age was 6.6% amounting to 246 million people. This figure is expected to increase to 7.3% (380 million) in 2025.
Diabetic epidemic in Sri Lanka 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 1990 1994 2000 2004 2005 2006 Illangasekera, U. et al CMJ, 1993, Illangasekera, U. et al J R Soc Health, 2004, Fernando, D.J. et al Postgrad Med J, 1994, Mendis, S. Et al Int J Cardiol, 1994, Malavige, G.N., et al., Diabetes Res Clin Pract, 2002, Wijewardene, K., et al., CMJ 2005, Katulanda, P., et al, Diab Med 2006
Implications of diabetes in young adults • Among Sri Lankans between 20 – 30 and 30 - 40 years 1.3% and 6.4% have diabetes mellitus • Conservatively >200,000 patients with diabetes between 20 – 40 years • Implications of diabetes related morbidity among the young adult diabetic subjects are considerable Katulanda P, PGIM oration 2008
2. Hypertension…SLHS GUIDELINES 2005 BLOOD PRESSURE (mmHg) Other Risk Factors & Disease History Level I. no other risk factors II. 1-2 risk factors III. 3 or more risk factors or TOD or diabetes or ACC Grade1 SBP140-159 or DBP 90-99 LOW RISK Life style modifications 3-6 months MED RISK Life style modifications 1-3 months HIGH RISK Life style modifications Immediate drug therapy Grade 2 SBP 160-179 or DBP 100-109 MED RISK Life style modifications 1-3 months MED RISK Life style modifications 1-3 months HIGH RISK Life style modifications Immediate drug therapy Grade 3 SBP 180 or DBP 110 HIGH RISK Life style modifications Immediate drug therapy HIGH RISK Life style modifications Immediate drug therapy HIGH RISK Life style modifications Immediate drug therapy
• 90% of whose BP was normal (<140/90) at 55 years ultimately developed hypertension in their life time. • Risk of CVS disease increased progressively from 115/75 with doubling of the incidence of both coronary heart disease and stroke for every 20mmHg systolic / 10mmHg diastolic increment of blood pressure JNC7 introduced Pre Hypertension This entity is of public health importance as it adds to the burden of hypertensive population ; Therefore Annual & 6 monthly screening of BP is advised
Hypertension – magnitude of the problem • Hypertension is the commonest risk factor for the commonest death in adults. • In 1990 5.8% • In 2000 7.2% …increasing worldwide • By 2020 Hypertension will be the most common risk factor for death and disability globally • National Prevalence Survey – WB / MOH 2000 studied WP/NCP/SP/Uva Age Group 30 – 65 Years. Height , Weight, Waist, BP Wijewardene, Mohideen et al 2005 in 4 provinces on 6047 individuals Showed a prevalence of Males 19.4% Females 20.6%
1990 5.8% Worldwide deaths due to hypertension Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL. Selected major risk factors and global and regional burden of disease. Lancet 2002:360; 1347-60 2000 7.2%
0 1000 2000 3000 4000 5000 6000 7000 8000 Indoor air pollution Alcohol use Physical inactivity Overweight & Obesity Low fruit & veg intake Unsafe sex Child underweight for age High cholesterol Smoking High blood pressure Attributable deaths (000s) Mortality due to leading risk factors, 2001 Alan D Lopez, Colin D Mathers, Majid Ezzati, Dean T Jamison and Christopher JL Murray. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. The Lancet, Volume 367, Issue 9524, 27 May 2006-2 June 2006, Pages 1747-1757
Measure n (95% CI) Total number worldwide in 2000 972 million Total number in economically developed countries in 2000 333 million Total number in economically developing countries in 2000 639 million Total number worldwide in 2025 1.56 billion Kearney PM et al. Lancet 2005; 365:217-223 Estimated total number of adults with hypertension
0 100 200 300 400 500 600 700 800 900 1000 1980 1985 1990 1995 2000 2005 2006 2007 2008 2009 2010 rateper100,000population Diabetes Hypertension IHD Projected increase of Hospitalisation due to Diabetes, Hypertension and IHD Premaratne R et al. Hospitalisation trends due to selected non-communicable diseases in Sri Lanka, 2005- 2010. Ceylon Medical Journal. 2005 June; 50( 2):51-4.
Trends in mortality from Hypertension and Cerebrovascular disease 1980-1995 – Sri Lanka 0 5 10 15 20 25 1980 1985 1987 1989 1991 1992 1995 Agespecificdeathratesper100,000 pop Hyp-Males Hyp-Females Cerebrovascular-Males Cerebrovascular-Females Source: http://www.who.int/healthinfo/morttables/en/index.html
USA 27.4 Canada 16.0 Australia 7.0 Finland 20.5Scotland 17.5 Germany 22.5 Spain 15.5 France 27.0 England 6.0 India 9.0Zaire 2.5 Italy 23.4
Adequacy of blood pressure control – Sri Lankan study Systolic control 24% 3065 males and females, mean age 59 years, 3 centres in Sri Lanka Diastolic control 51% Both systolic & diastolic 22%
Males 19.4% Females 20.6% Prevalence of hypertension
Year Age group Criteria Location Number Prev Males Prev Females Total 1985 30 & over 160/95 *Baddegama (rural) 357 Not available Not available 10% 1991 35-59 160/95 #Central Province 975 17% (urban) 8% (rural) 14.90% 1992 30-80 160/95 **Bope- Poddala (semi-urban) 619 22.30% 32% 26.60% 1986 25 & over 160/90 §Galle-Fort (urban) 203 38.80% 32.80% 35.50% 1991 Not available Not available ***Rural (Indigenous) Not available 5.70% 1.90% Not available * Mohideen MR, Hettiarachchi J. Utilization of family health workers in screening for hypertension in a rural community in Sri Lanka. Ceylon Medical Journal 1985; 30: 97-101 # Mendis S, Ekanayake EM. Prevalence of coronary heart disease and cardiovascular risk factors in middle aged males in a defined population in central Sri Lanka International Journal of Cardiology 1994, 46:135-142P **Mohideen MR., Amerasinghe M.,.Abeykoon B,.Abeyratne DM, Anurakumara LHI.. Epidemiology of hypertension in Galle. Abstracts of the 105th Anniversary Academic Sessions of SLMA, March 1992. §Hettiarachchi J, Mohideen MR Hypertension in an urban community in Sri Lanka. Abstracts of the 99th anniversary academic sessions of SLMA. Colombo, March 1986. ***Mendis S. Coronary heart disease and coronary risk profile in a primitive population. Tropical Geography Mediicne. 1991 ;43(1-2):199-202. Prevalence of hypertension in previous studies
Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study) Prevalence of hypertension N = 4532
Prevalence of prehypertension Systolic blood pressure - 120 to 139 mm Hg and Diastolic blood pressure - 80 and 89 mm Hg 0 5 10 15 20 25 30 35 30-35 36-40 41-45 46-50 51-55 56-60 61-65 Males Females Male prevalence 25.2% ;Female prevalence: 19.8%
Drinkers Non drinker p Hypertension 26.8% (90) 16.6% (446) <0.001 Mean SBP (mmHg) 124.6 118.9 <0.001 Mean DBP (mmHg) 77.6 73.4 <0.001 Blood pressure and drinking status
Males Females Diabetes 14.9% 13.9 % Impaired fasting glucose 14.1% 14.1% Obesity 20.3% 36.5% Prevalence of other risk factors National Prevalence Survey Wijewardena K, Mohideen MR, Mendis S, Fernando DS et al. Prevalence of hypertension, diabetes and obesity: baseline findings of a population based survey in four provinces in Sri Lanka. Ceylon Medical Journal 2005; :62-70
Males Females Cigarettes 46.2% Beedi 14.5% Cigars 3.2% Prevalence of smoking National Prevalence Survey Overall prevalence – 51% Only 7 smokers
Hypertensive (%) Prehypertensive (%) Normotensive (%) Males Obese 310 (57.8) 489 (64.1) 1324 (76.6) Normal 226 (42.2) 274 (35.9) 404 (23.4) Females Obese 458 (63.6) 385 (52.2) 986 (43.2) Normal 262 (36.4) 352 (47.8) 1297 (56.8) Prevalence of hypertension in relation to obesity
3. Obesity WHO GLOBAL RECOMMENDATION PROPOSED CUT-OFF LEVELS FOR ASIANS BMI CATEGORY BMI CATEGORY < 16 KG/M2 SEVERE UNDERWEIGHT 16.0 – 16.9 KG/M2 UNDERWEIGHT 17.0 – 18.49 KG/M2 MILD UNDERWEIGHT < 18.5 KG/M2 UNDERWEIGHT 18.5 – 24.9 KG/M2 NORMAL RANGE 18.5 – 22.9 KG/M2 NORMAL RANGE 25.0 – 29.9 KG/M2 PRE OBESE ≥ 23 - 27.4 KG/M2 PRE OBESE 30.0 – 34.9 KG/M2 OBESE CLASS I ≥ 27.5 KG/M2 OBESE 35.0 – 39.9 KG/M2 OBESE CLASS II ≥ 40 KG/M2 OBESE CLASS III WHO (2000) World Health Organ Tech Rep Ser, 894, i-xii, 1-253. WHO (2004) Lancet, 363, 157-63.
Prevalence of generalised obesity P <0.0001 Male vs. Female 25.0 22.4 23.6 44.9 37.1 40.8 22.9 28.6 25.9 7.2 12.0 9.7 0% 20% 40% 60% 80% 100% Male Female All Prevalence ≥27.7 23-27.4 18.5-22.9 <18.5 Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)
Prevalence of central adiposity 30.1 56.0 43.4 14.1 36.1 25.6 17.4 40.1 29.2 0 10 20 30 40 50 60 Male Female All Male Female All Male Female All Urban Rural All Prevalence Central obesity – male ≥90cm; female ≥80cm Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)
4. Metabolic syndrome • Clustering of risk factors of CVD together more commonly than would have occurred by chance • These factors are central obesity, dysglycaemia, low HDL-C, elevated triglycerides (TG) and high blood pressure and some markers of low grade inflammation • Different names given to this phenomenon (Syndrome X, dysmetabolic syndrome & metabolic syndrome) • The International Diabetes Federation (IDF) has promoted a worldwide consensus on the terminology and definition (also supported by many other organisations) Alberti, K. G.et al Diabet Med, 23, 469-80.
Metabolic Syndrome - real or not? • One school of thought believes Metabolic Syndrome is real and exists. It is a useful concept in understanding the interaction of multiple risk factors for CVD and hence in fine tuning management in an individual. • Another school believes that there is no single entity called Met Syndrome and attention needs to be directed at individual risk factors. • I support the former as it is useful in Public Health interventions and population strategies in addition.
IDF criteria for Metabolic SyndromeCentral obesity Waist circumference – ethnic specific (male >90 and female>80) Plus any two of the following Raised triglycerides ≥1.7mmol/l (150mg/dl) Specific therapy Reduced HDL-Cholesterol <1.03 mmol/l (40mg/dl) males <1.29 mmol/l (50mg/dl) females Raised blood pressure Systolic ≥130mmHg or diastolic ≥ 85mmHg Or treatment of previously diagnosed hpt Raised plasma glucose Fasting plasma glucose ≥5.6 mmol/l †(100mg/dl) or previously diagnosed T2DM Alberti, K. G.et al Diabet Med, 23, 469-80.
Prevalence of Metabolic Syndrome 11.10 % 2 3 .6 0 % 18 .70 % 0% 4% 8% 12% 16% 20% 24% M a le F e m a le O v e ra ll P <0.001 (Male vs Female) Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)-n=4532
2 8 .70 % 17.10 % 5.9 0 % 18 .70 % 0% 4% 8% 12% 16% 20% 24% 28% 32% Urba n R ura l P la nta tio n O v e ra ll Metabolic Syndrome according to the sector of residence Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)
DM PREDIABETES METABOLIC SYNDROME Central Obesity Insulin Resistance (IR) Hypertension Hyperlipidaemia CAD, DM type 2 WHO 1998, IDF 2005
5. Cancer • 6 million deaths from Cancer each year. • 50% due to CA lung, stomach, colon, rectum, liver, breast. • Tobacco causes 3 million deaths and smoking accounts for 1 in 7 cancer deaths. • Avoid carcinogens • Early detection – Screening Treatment. • Emerging evidence that some cancers are associated with lifestyle eg Smoking (Lung Upper GI), Obesity(Colon Breast),Sedentary lifestyle (Breast).
6. Cardio - Vascular Disease • Coronary Heart Disease – leading COD in Sri Lankan Hospitals – can be • Modifiable Risk factors - » Smoking » High Blood Pressure » Diabetes » High serum cholesterol » High LDL levels » Obesity » Diet - high saturated fat intake » ? Stress controlled avoided treated genetic / environmental component
7. CKD in Asia (defined as GFR <60mls/min/1.7m2 ) • CKD – increasing worldwide .Recognised as a public health problem. • ESRD and CVD when occurring together leads to adverse outcomes • Asia has high incidence of CKD • Diabetes major causative factor for CKD • High prevalence amongst family members Malaysia 57.5% India 42% Taiwan 39.5% Thailand 31.5% Japan 20% Singapore 17.7%
ACUTE ILLNESS • RENAL COLIC • ACUTE PYELNEPHRITIS • ACUTE RENAL FAILURE • ACUTE NEPHRITIS • SURGICAL TRAUMA • ACUTE TUBULAR NECROSIS • SNAKE BITES • POST PARTUM • PROSTATE • TRAUMA • DRUG INDUCED CHRONIC ILLNESS • DIABETIC NEPHROPATHY • HYPERTENSIVE NEPHROSCLEROSIS • OBSTRUCTIVE NEPHROPATHY • INTESTITIAL NEPHRITIS • INFECTIVE / RENAL TB • DRUG INDUCED • CONGENITAL – POLYCYSTIC KIDNEYS • CANCER OF THE KIDNEYS
CKDu epidemic in Sri Lanka • NWP, NCP, Uva • Increasing number of deaths • Physicians noticed the main cause of death has changed from IHD to ESRD deaths • Ministry setup many clinics • Some areas more prevalent • Public, Press, Politicians – are vocal • Over & above CKD due to hypertension, Diabetes, & Urological disease • Public Health Problem • Environment toxin likely • Various theories floated Fluoride, Cadmium, Water contamination (heavy metals, Organophosphates) NEEDS PLANNED STUDY
National Research Programme for CKDu • An internationally agreed case definition • Systematic Survey to identify low and high risk CKDu areas / GIS mapping • Hospital based CKD registry. • Histology • Comprehensive screening / analysis Soil, Water, Rice, Fish Blood, Multi element studies • Sociology / Diet studies • Vegetation, Animal studies • Other studies • Provided funds permit / Prioritized -Post mortem -Review of historical slides -Renal biopsy studies
CKDu Case Definition … NKDOQI modified 1. No P/H or current treatment for 2. Normal HbA1c <6.5% 3. BP <160/100 untreated or <140/90 on up to 2 antihypertensives -DM -Chronic or Severe HPT -Snake bite -Urological disease -Glomerulonephritis CKD 1 ACR ≥ 30mg/g + eGFR >90 CKD 2 Persistent albuminuria eGFR 60-89 CKD 3 eGFR 30 – 59 CKD 4 eGFR <30 CKD 5 eGFR <15
?How do we reduce the chronic disease burden
PREVENTION AIM TARGET Primordial Underlying conditions leading to exposure to causative factor Total population or selected groups Primary Limit incidence by controlling causes & risk factor Total population High risk individually Secondary Cure and reduce serious complication Early detection and treatment Tertiary Reduce progress of complications Therapeutic & Rehabilitative
• Primordial prevention Aim : reduce - leading causes of disease/ contribute to elevated risk - Avoid diet with high saturated animal fat - Discourage smoking - Promotion of regular physical activity - Promotion of healthy eating • Primary prevention Aim : limit incidence – control causes & risk factors) - Lowering cholesterol - Reducing urban air pollution - Stopping smoking / passive smoking - Wearing seatbelts • Screen for cancer of cervix • Use of condoms
• Secondary prevention Aim : cure, detect early & treat • Detect and treat hypertension • Detect and treat diabetes • Tertiary prevention Aim : reduce disability & minimise suffering) • Laser therapy to prevent/treat blindness • Stroke Rehabilitation
Prevention of chronic disease a) Population based approaches - Legislation (Tobacco, Food Labeling) - Policy (Healthy eating - Canteen policy in Schools) - City Planning (Walking & Exercise areas for the community) - Education (School curricula, Teacher training) - Social Marketing / Health promotion b) Individual based approaches - High risk - Smoking - Exercise - Alcohol - Stress - Diet + Saturated Fats - Drugs BP DM
Epidemiological AssessmentEpidemiological Assessment Awareness generation & high-level advocacyAwareness generation & high-level advocacy Development of policy & strategic planDevelopment of policy & strategic plan Capacity strengthening, resource mobilization and infrastructure development Capacity strengthening, resource mobilization and infrastructure development Multisectoral & multilevel action to modify environment Multisectoral & multilevel action to modify environment Health sector interventionsHealth sector interventions Population decrease in NCD risk factor level and Reduced adverse health events Population decrease in NCD risk factor level and Reduced adverse health events Reduced health & economic burden of NCDReduced health & economic burden of NCDReduced health & economic burden of NCD MOH/ Epidemiology Department SLMA / MOH / Specialist Societies MOH / WHO MOH MOH / PROFESSIONAL BODIES / CLINICIANS Service Delivery Points / Primary Care Giver / Private Sector
?How can SLMA help as an apex medical professional organisation
SLMA COMMITTEES •Communicable Diseases •Drugs •Ethics Review Committee •Ethics •Food & Nutraceuticals •Getting Research into Practice (GRIPs) •Health Care Waste Management •Health Management •Media Social Activities •Medical Education •Membership •Mental Health •National Health Policy •Non Communicable Diseases •Prevention of Motor Traffic Accidents •Central Continuing Professional Development Committee •Snake Bite •Tobacco, Alcohol and Illicit Drugs •Women's Health
Health Equity • Commission on Social Determinants of Health in 2005 - Setup by WHO - To promote equity in health Conclusion : Much of the Global burden of disease is avoidable & unacceptable • 1968 WHO Alma – Ata declaration ‘Health for all by year 2000’ Millennium Development Goals Expression of need for social justice Some low income states like Costa Rica, Kerala, Sri Lanka have achieved a level of good Health & equitable Health without high national wealth Poor social policies Unfair economic arrangements Bad politics Unequal distribution Power Income Goods Services ‘Toxic’ Combination
Health Equity – Clinicians have a key role to play • Chronic disease management with an additional focus on empowering the patient and use him or her for prevention in the community. • Individually and as professional organizations we can act as advocates and agents of social change • SLMA doctors over 120 years have done yeoman service to achieve what we have. There is more work to be done
Acknowledgements • All my house officers, registrars, senior registrars, departmental colleagues. • For preparation of this talk Dr Prasad Katulanda, Professor Chandrika Wijeratne, Professor Rifdy Mohideen,Prof Ravindra Fernando, Dr Eranga, Dr Sanjaya, Epidemiology Unit (MOH), Professor Shanthi Mendis • Special Thanks to the energetic Dr Ruvaiz Haniffa • To Mr Rajasingham & Staff of the SLMA and PGIM • My Son Dr Rikaz Sheriff for his IT input. • My wife Ameena and family. • To Allah for this opportunity. • To all others who have helped me in various ways…
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SLMA president address 2009

  • 1.
  • 2.
    Regional Health Situation2007 - The challenges • Strengthening Health System Public Health Funding Equity Human Resource Development Heath Informatics • Promoting a healthy life course MDG Malnutrition STD Immunization • Addressing challenges in healthy environments Water supply coverage Sanitation Climate change Global Warming Occupational Health Food Hygiene Disaster preparedness • Tackling risk factors and preventing NCD CVD Tobacco Mental Illness Trauma • Preventing controlling eliminating & eradicating communicable disease TB HIV Respiratory Infections Diarrhoeas Dengu Chikungunya Strengthening Health System Public Health Funding Equity Human Resource Development Heath Informatics Promoting A Healthy Life Course MDG Malnutrition STD Immunization Healthy Environments Water supply coverage Sanitation Climate change Global Warming Occupational Health Food Hygiene Disaster preparedness Tackling risk factors and preventing NCD CVD Tobacco Mental Illness Trauma Diabetes Preventing controlling eliminating & eradicating communicable disease TB HIV Respiratory Infections Diarrheas Dengue Chikungunya
  • 3.
    Communicable diseases Group A 1.Cholera 2.Plague 3.YellowFever Group B 1.Acute Anterior Poliomyelitis 2.Dengue Fever/Dengue Hemorrhagic Fever 3.Diphtheria 4.Dysentery 5.Encephalitis 6.Enteric Fever 7.Food Poisoning 8.Human Rabies 9.Leptospirosis 10.Malaria 11.Measles 12.Rubella (German Measles) 13.Simple Continued fever of 7 days + 14.Tetanus 15.Typhus Fever 16.Viral Hepatitis 17.Whooping Cough 18.Tuberculosis
  • 4.
    WHO List ofnon-communicable diseases • Cardiovascular diseases • Stroke • Cancer • Diabetes • Chronic obstructive pulmonary disorders (COPD) or chronic respiratory diseases, • Mental illness and • Trauma
  • 5.
    Epidemic Chronic Disease •“Epidemic” • Traditionally used in connection with infectious diseases….they occurred in large no in a short space of time and referred to as pandemics when they occurred across continents. • The non communicable diseases are even larger in numbers but more “chronic”. Hence the WHO recognises the term “Epidemic Chronic Disease”
  • 6.
    9. NEOPLASM 12. DIABETES 15.MENTAL HEALTH 20. HYPERTENSIVE DISEASE 20. ISCHAEMIC HEART DISEASE 23. STROKE 44. TRAUMATIC INJURIES 46. PESTICIDES Indoor Morbidity Statistics 2006 by Broad Disease Groups
  • 7.
  • 8.
    Differences between communicable &non communicable diseases (NCD) Communicable • Single causative agent • Sudden onset of symptoms • Responds to short courses of treatment Non communicable • Multifactorial • Gradual onset with long course • Requires prolonged care & treatment • Affects quality of life • Linked to common risk factors (tobacco, alcohol, unhealthy diet, physical inactivity & environmental carcinogen) The World Health Report of 1999 shows that in 1998 NCD accounted for 77% of global mortality and 85% of the global burden of disease was from low and middle income countries. The situation worsens in 2008…
  • 9.
    Chronic diseases includeheart disease, stroke, cancer, chronic respiratory diseases and diabetes. Visual impairment and blindness, hearing impairment and deafness, oral diseases and genetic disorders are other chronic conditions that account for a substantial portion of the global burden of disease. From a projected total of 58 million deaths from all causes in 2005, it is estimated that chronic diseases will account for 35 million, which is double the number of deaths from all infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies combined.
  • 11.
    Changes in thelast 50 years of relevance to Societal Health • Demographic transition • Epidemiological transition • Other factors Industrialization, urbanization, westernisation, dietary habits, sedentary life styles, stress, infant & child survival, diagnosis & treatment, life expectancy, socio-political changes, health seeking behaviour, cost of health care, expectations of outcome, access to information litigation, easy communication
  • 12.
    Factors reducing mortality •Income growth leads to better … • Improved medical technology – • Public Health Programmes – • Knowledge about health – Drugs Vaccine Diagnostic Potable water Sanitation Food regulation Schools Health Education Food Housing Access to healthcare
  • 13.
    Factors influencing changes Doctor– Patient interaction • Dependence on history, examination, experience • Paternalistic care • More humane personal care • Belief & trust → Dependence on investigation →Partnership with doctor →More ”commercialised" delivery →More suspicion & litigation
  • 14.
    Demographic transition in SriLanka Population pyramids 1981 and 2001 WHO Country Cooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]
  • 15.
    Epidemiological transition WHO CountryCooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]
  • 16.
    Epidemiological transition WHO CountryCooperation Strategy 2006 – 2011: Democratic Socialist Republic of Sri Lanka(WHO, 2006)]
  • 18.
    Symptomatic Disease Deaths Mild orNo S/S Non specific S/S Difficult to diagnose EARLY DISEASE RISK FACTORS
  • 19.
    Let us lookat some of the key illnesses which are increasing in epidemic proportions globally, regionally and locally causing chronic ill health 1.Diabetes 2.Hypertension 3.Obesity 4.Metabolic Syndrome 5.Cardiovascular Disease 6.Cancer 7.Chronic Kidney Disease
  • 20.
    1. Diabetes –Definitions Stage of hyperglycaemia Venous plasma glucose mmol/l (mg/dl) Diabetes mellitus • Fasting • 2h post glucose load or random blood sugar >7.0 (126) > 11.1 (200) Impaired glucose tolerance (IGT) • 2h post glucose load 7.8-11 (140-199) Impaired fasting glucose (IFG) • Fasting 5.6-6.9 (100-125) Normal • Fasting • 2h post glucose load <5.6 (100) <7.8 (140)
  • 21.
    Diabetes Global Situation 246million worldwide Diabetes atlas 2006, International Diabetes Federation TYPE II DIABETES According to the recent estimates of the International Diabetes Federation (IDF), the global prevalence of diabetes among those between 20 to 79 years of age was 6.6% amounting to 246 million people. This figure is expected to increase to 7.3% (380 million) in 2025.
  • 23.
    Diabetic epidemic inSri Lanka 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 1990 1994 2000 2004 2005 2006 Illangasekera, U. et al CMJ, 1993, Illangasekera, U. et al J R Soc Health, 2004, Fernando, D.J. et al Postgrad Med J, 1994, Mendis, S. Et al Int J Cardiol, 1994, Malavige, G.N., et al., Diabetes Res Clin Pract, 2002, Wijewardene, K., et al., CMJ 2005, Katulanda, P., et al, Diab Med 2006
  • 25.
    Implications of diabetesin young adults • Among Sri Lankans between 20 – 30 and 30 - 40 years 1.3% and 6.4% have diabetes mellitus • Conservatively >200,000 patients with diabetes between 20 – 40 years • Implications of diabetes related morbidity among the young adult diabetic subjects are considerable Katulanda P, PGIM oration 2008
  • 27.
    2. Hypertension…SLHS GUIDELINES2005 BLOOD PRESSURE (mmHg) Other Risk Factors & Disease History Level I. no other risk factors II. 1-2 risk factors III. 3 or more risk factors or TOD or diabetes or ACC Grade1 SBP140-159 or DBP 90-99 LOW RISK Life style modifications 3-6 months MED RISK Life style modifications 1-3 months HIGH RISK Life style modifications Immediate drug therapy Grade 2 SBP 160-179 or DBP 100-109 MED RISK Life style modifications 1-3 months MED RISK Life style modifications 1-3 months HIGH RISK Life style modifications Immediate drug therapy Grade 3 SBP 180 or DBP 110 HIGH RISK Life style modifications Immediate drug therapy HIGH RISK Life style modifications Immediate drug therapy HIGH RISK Life style modifications Immediate drug therapy
  • 28.
    • 90% ofwhose BP was normal (<140/90) at 55 years ultimately developed hypertension in their life time. • Risk of CVS disease increased progressively from 115/75 with doubling of the incidence of both coronary heart disease and stroke for every 20mmHg systolic / 10mmHg diastolic increment of blood pressure JNC7 introduced Pre Hypertension This entity is of public health importance as it adds to the burden of hypertensive population ; Therefore Annual & 6 monthly screening of BP is advised
  • 29.
    Hypertension – magnitudeof the problem • Hypertension is the commonest risk factor for the commonest death in adults. • In 1990 5.8% • In 2000 7.2% …increasing worldwide • By 2020 Hypertension will be the most common risk factor for death and disability globally • National Prevalence Survey – WB / MOH 2000 studied WP/NCP/SP/Uva Age Group 30 – 65 Years. Height , Weight, Waist, BP Wijewardene, Mohideen et al 2005 in 4 provinces on 6047 individuals Showed a prevalence of Males 19.4% Females 20.6%
  • 30.
    1990 5.8% Worldwide deaths dueto hypertension Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL. Selected major risk factors and global and regional burden of disease. Lancet 2002:360; 1347-60 2000 7.2%
  • 31.
    0 1000 20003000 4000 5000 6000 7000 8000 Indoor air pollution Alcohol use Physical inactivity Overweight & Obesity Low fruit & veg intake Unsafe sex Child underweight for age High cholesterol Smoking High blood pressure Attributable deaths (000s) Mortality due to leading risk factors, 2001 Alan D Lopez, Colin D Mathers, Majid Ezzati, Dean T Jamison and Christopher JL Murray. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. The Lancet, Volume 367, Issue 9524, 27 May 2006-2 June 2006, Pages 1747-1757
  • 32.
    Measure n (95%CI) Total number worldwide in 2000 972 million Total number in economically developed countries in 2000 333 million Total number in economically developing countries in 2000 639 million Total number worldwide in 2025 1.56 billion Kearney PM et al. Lancet 2005; 365:217-223 Estimated total number of adults with hypertension
  • 34.
    0 100 200 300 400 500 600 700 800 900 1000 1980 1985 19901995 2000 2005 2006 2007 2008 2009 2010 rateper100,000population Diabetes Hypertension IHD Projected increase of Hospitalisation due to Diabetes, Hypertension and IHD Premaratne R et al. Hospitalisation trends due to selected non-communicable diseases in Sri Lanka, 2005- 2010. Ceylon Medical Journal. 2005 June; 50( 2):51-4.
  • 35.
    Trends in mortalityfrom Hypertension and Cerebrovascular disease 1980-1995 – Sri Lanka 0 5 10 15 20 25 1980 1985 1987 1989 1991 1992 1995 Agespecificdeathratesper100,000 pop Hyp-Males Hyp-Females Cerebrovascular-Males Cerebrovascular-Females Source: http://www.who.int/healthinfo/morttables/en/index.html
  • 36.
  • 37.
    Adequacy of bloodpressure control – Sri Lankan study Systolic control 24% 3065 males and females, mean age 59 years, 3 centres in Sri Lanka Diastolic control 51% Both systolic & diastolic 22%
  • 38.
  • 39.
    Year Age group Criteria Location Number Prev Males Prev Females Total 1985 30& over 160/95 *Baddegama (rural) 357 Not available Not available 10% 1991 35-59 160/95 #Central Province 975 17% (urban) 8% (rural) 14.90% 1992 30-80 160/95 **Bope- Poddala (semi-urban) 619 22.30% 32% 26.60% 1986 25 & over 160/90 §Galle-Fort (urban) 203 38.80% 32.80% 35.50% 1991 Not available Not available ***Rural (Indigenous) Not available 5.70% 1.90% Not available * Mohideen MR, Hettiarachchi J. Utilization of family health workers in screening for hypertension in a rural community in Sri Lanka. Ceylon Medical Journal 1985; 30: 97-101 # Mendis S, Ekanayake EM. Prevalence of coronary heart disease and cardiovascular risk factors in middle aged males in a defined population in central Sri Lanka International Journal of Cardiology 1994, 46:135-142P **Mohideen MR., Amerasinghe M.,.Abeykoon B,.Abeyratne DM, Anurakumara LHI.. Epidemiology of hypertension in Galle. Abstracts of the 105th Anniversary Academic Sessions of SLMA, March 1992. §Hettiarachchi J, Mohideen MR Hypertension in an urban community in Sri Lanka. Abstracts of the 99th anniversary academic sessions of SLMA. Colombo, March 1986. ***Mendis S. Coronary heart disease and coronary risk profile in a primitive population. Tropical Geography Mediicne. 1991 ;43(1-2):199-202. Prevalence of hypertension in previous studies
  • 40.
    Katulanda et al.,Unpublished data (Sri Lanka Diabetes and CVD Study) Prevalence of hypertension N = 4532
  • 41.
    Prevalence of prehypertension Systolicblood pressure - 120 to 139 mm Hg and Diastolic blood pressure - 80 and 89 mm Hg 0 5 10 15 20 25 30 35 30-35 36-40 41-45 46-50 51-55 56-60 61-65 Males Females Male prevalence 25.2% ;Female prevalence: 19.8%
  • 42.
    Drinkers Non drinkerp Hypertension 26.8% (90) 16.6% (446) <0.001 Mean SBP (mmHg) 124.6 118.9 <0.001 Mean DBP (mmHg) 77.6 73.4 <0.001 Blood pressure and drinking status
  • 43.
    Males Females Diabetes 14.9%13.9 % Impaired fasting glucose 14.1% 14.1% Obesity 20.3% 36.5% Prevalence of other risk factors National Prevalence Survey Wijewardena K, Mohideen MR, Mendis S, Fernando DS et al. Prevalence of hypertension, diabetes and obesity: baseline findings of a population based survey in four provinces in Sri Lanka. Ceylon Medical Journal 2005; :62-70
  • 44.
    Males Females Cigarettes 46.2% Beedi14.5% Cigars 3.2% Prevalence of smoking National Prevalence Survey Overall prevalence – 51% Only 7 smokers
  • 45.
    Hypertensive (%) Prehypertensive (%) Normotensive (%) Males Obese 310 (57.8)489 (64.1) 1324 (76.6) Normal 226 (42.2) 274 (35.9) 404 (23.4) Females Obese 458 (63.6) 385 (52.2) 986 (43.2) Normal 262 (36.4) 352 (47.8) 1297 (56.8) Prevalence of hypertension in relation to obesity
  • 46.
    3. Obesity WHO GLOBALRECOMMENDATION PROPOSED CUT-OFF LEVELS FOR ASIANS BMI CATEGORY BMI CATEGORY < 16 KG/M2 SEVERE UNDERWEIGHT 16.0 – 16.9 KG/M2 UNDERWEIGHT 17.0 – 18.49 KG/M2 MILD UNDERWEIGHT < 18.5 KG/M2 UNDERWEIGHT 18.5 – 24.9 KG/M2 NORMAL RANGE 18.5 – 22.9 KG/M2 NORMAL RANGE 25.0 – 29.9 KG/M2 PRE OBESE ≥ 23 - 27.4 KG/M2 PRE OBESE 30.0 – 34.9 KG/M2 OBESE CLASS I ≥ 27.5 KG/M2 OBESE 35.0 – 39.9 KG/M2 OBESE CLASS II ≥ 40 KG/M2 OBESE CLASS III WHO (2000) World Health Organ Tech Rep Ser, 894, i-xii, 1-253. WHO (2004) Lancet, 363, 157-63.
  • 47.
    Prevalence of generalisedobesity P <0.0001 Male vs. Female 25.0 22.4 23.6 44.9 37.1 40.8 22.9 28.6 25.9 7.2 12.0 9.7 0% 20% 40% 60% 80% 100% Male Female All Prevalence ≥27.7 23-27.4 18.5-22.9 <18.5 Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)
  • 48.
    Prevalence of centraladiposity 30.1 56.0 43.4 14.1 36.1 25.6 17.4 40.1 29.2 0 10 20 30 40 50 60 Male Female All Male Female All Male Female All Urban Rural All Prevalence Central obesity – male ≥90cm; female ≥80cm Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)
  • 50.
    4. Metabolic syndrome •Clustering of risk factors of CVD together more commonly than would have occurred by chance • These factors are central obesity, dysglycaemia, low HDL-C, elevated triglycerides (TG) and high blood pressure and some markers of low grade inflammation • Different names given to this phenomenon (Syndrome X, dysmetabolic syndrome & metabolic syndrome) • The International Diabetes Federation (IDF) has promoted a worldwide consensus on the terminology and definition (also supported by many other organisations) Alberti, K. G.et al Diabet Med, 23, 469-80.
  • 51.
    Metabolic Syndrome -real or not? • One school of thought believes Metabolic Syndrome is real and exists. It is a useful concept in understanding the interaction of multiple risk factors for CVD and hence in fine tuning management in an individual. • Another school believes that there is no single entity called Met Syndrome and attention needs to be directed at individual risk factors. • I support the former as it is useful in Public Health interventions and population strategies in addition.
  • 52.
    IDF criteria forMetabolic SyndromeCentral obesity Waist circumference – ethnic specific (male >90 and female>80) Plus any two of the following Raised triglycerides ≥1.7mmol/l (150mg/dl) Specific therapy Reduced HDL-Cholesterol <1.03 mmol/l (40mg/dl) males <1.29 mmol/l (50mg/dl) females Raised blood pressure Systolic ≥130mmHg or diastolic ≥ 85mmHg Or treatment of previously diagnosed hpt Raised plasma glucose Fasting plasma glucose ≥5.6 mmol/l †(100mg/dl) or previously diagnosed T2DM Alberti, K. G.et al Diabet Med, 23, 469-80.
  • 53.
    Prevalence of MetabolicSyndrome 11.10 % 2 3 .6 0 % 18 .70 % 0% 4% 8% 12% 16% 20% 24% M a le F e m a le O v e ra ll P <0.001 (Male vs Female) Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)-n=4532
  • 54.
    2 8 .70% 17.10 % 5.9 0 % 18 .70 % 0% 4% 8% 12% 16% 20% 24% 28% 32% Urba n R ura l P la nta tio n O v e ra ll Metabolic Syndrome according to the sector of residence Katulanda et al., Unpublished data (Sri Lanka Diabetes and CVD Study)
  • 55.
    DM PREDIABETES METABOLIC SYNDROME Central Obesity InsulinResistance (IR) Hypertension Hyperlipidaemia CAD, DM type 2 WHO 1998, IDF 2005
  • 56.
    5. Cancer • 6million deaths from Cancer each year. • 50% due to CA lung, stomach, colon, rectum, liver, breast. • Tobacco causes 3 million deaths and smoking accounts for 1 in 7 cancer deaths. • Avoid carcinogens • Early detection – Screening Treatment. • Emerging evidence that some cancers are associated with lifestyle eg Smoking (Lung Upper GI), Obesity(Colon Breast),Sedentary lifestyle (Breast).
  • 58.
    6. Cardio -Vascular Disease • Coronary Heart Disease – leading COD in Sri Lankan Hospitals – can be • Modifiable Risk factors - » Smoking » High Blood Pressure » Diabetes » High serum cholesterol » High LDL levels » Obesity » Diet - high saturated fat intake » ? Stress controlled avoided treated genetic / environmental component
  • 59.
    7. CKD inAsia (defined as GFR <60mls/min/1.7m2 ) • CKD – increasing worldwide .Recognised as a public health problem. • ESRD and CVD when occurring together leads to adverse outcomes • Asia has high incidence of CKD • Diabetes major causative factor for CKD • High prevalence amongst family members Malaysia 57.5% India 42% Taiwan 39.5% Thailand 31.5% Japan 20% Singapore 17.7%
  • 60.
    ACUTE ILLNESS • RENALCOLIC • ACUTE PYELNEPHRITIS • ACUTE RENAL FAILURE • ACUTE NEPHRITIS • SURGICAL TRAUMA • ACUTE TUBULAR NECROSIS • SNAKE BITES • POST PARTUM • PROSTATE • TRAUMA • DRUG INDUCED CHRONIC ILLNESS • DIABETIC NEPHROPATHY • HYPERTENSIVE NEPHROSCLEROSIS • OBSTRUCTIVE NEPHROPATHY • INTESTITIAL NEPHRITIS • INFECTIVE / RENAL TB • DRUG INDUCED • CONGENITAL – POLYCYSTIC KIDNEYS • CANCER OF THE KIDNEYS
  • 61.
    CKDu epidemic inSri Lanka • NWP, NCP, Uva • Increasing number of deaths • Physicians noticed the main cause of death has changed from IHD to ESRD deaths • Ministry setup many clinics • Some areas more prevalent • Public, Press, Politicians – are vocal • Over & above CKD due to hypertension, Diabetes, & Urological disease • Public Health Problem • Environment toxin likely • Various theories floated Fluoride, Cadmium, Water contamination (heavy metals, Organophosphates) NEEDS PLANNED STUDY
  • 62.
    National Research Programmefor CKDu • An internationally agreed case definition • Systematic Survey to identify low and high risk CKDu areas / GIS mapping • Hospital based CKD registry. • Histology • Comprehensive screening / analysis Soil, Water, Rice, Fish Blood, Multi element studies • Sociology / Diet studies • Vegetation, Animal studies • Other studies • Provided funds permit / Prioritized -Post mortem -Review of historical slides -Renal biopsy studies
  • 64.
    CKDu Case Definition …NKDOQI modified 1. No P/H or current treatment for 2. Normal HbA1c <6.5% 3. BP <160/100 untreated or <140/90 on up to 2 antihypertensives -DM -Chronic or Severe HPT -Snake bite -Urological disease -Glomerulonephritis CKD 1 ACR ≥ 30mg/g + eGFR >90 CKD 2 Persistent albuminuria eGFR 60-89 CKD 3 eGFR 30 – 59 CKD 4 eGFR <30 CKD 5 eGFR <15
  • 65.
    ?How do wereduce the chronic disease burden
  • 66.
    PREVENTION AIM TARGET PrimordialUnderlying conditions leading to exposure to causative factor Total population or selected groups Primary Limit incidence by controlling causes & risk factor Total population High risk individually Secondary Cure and reduce serious complication Early detection and treatment Tertiary Reduce progress of complications Therapeutic & Rehabilitative
  • 67.
    • Primordial prevention Aim: reduce - leading causes of disease/ contribute to elevated risk - Avoid diet with high saturated animal fat - Discourage smoking - Promotion of regular physical activity - Promotion of healthy eating • Primary prevention Aim : limit incidence – control causes & risk factors) - Lowering cholesterol - Reducing urban air pollution - Stopping smoking / passive smoking - Wearing seatbelts • Screen for cancer of cervix • Use of condoms
  • 68.
    • Secondary prevention Aim: cure, detect early & treat • Detect and treat hypertension • Detect and treat diabetes • Tertiary prevention Aim : reduce disability & minimise suffering) • Laser therapy to prevent/treat blindness • Stroke Rehabilitation
  • 69.
    Prevention of chronicdisease a) Population based approaches - Legislation (Tobacco, Food Labeling) - Policy (Healthy eating - Canteen policy in Schools) - City Planning (Walking & Exercise areas for the community) - Education (School curricula, Teacher training) - Social Marketing / Health promotion b) Individual based approaches - High risk - Smoking - Exercise - Alcohol - Stress - Diet + Saturated Fats - Drugs BP DM
  • 70.
    Epidemiological AssessmentEpidemiological Assessment Awarenessgeneration & high-level advocacyAwareness generation & high-level advocacy Development of policy & strategic planDevelopment of policy & strategic plan Capacity strengthening, resource mobilization and infrastructure development Capacity strengthening, resource mobilization and infrastructure development Multisectoral & multilevel action to modify environment Multisectoral & multilevel action to modify environment Health sector interventionsHealth sector interventions Population decrease in NCD risk factor level and Reduced adverse health events Population decrease in NCD risk factor level and Reduced adverse health events Reduced health & economic burden of NCDReduced health & economic burden of NCDReduced health & economic burden of NCD MOH/ Epidemiology Department SLMA / MOH / Specialist Societies MOH / WHO MOH MOH / PROFESSIONAL BODIES / CLINICIANS Service Delivery Points / Primary Care Giver / Private Sector
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    ?How can SLMA helpas an apex medical professional organisation
  • 72.
    SLMA COMMITTEES •Communicable Diseases •Drugs •EthicsReview Committee •Ethics •Food & Nutraceuticals •Getting Research into Practice (GRIPs) •Health Care Waste Management •Health Management •Media Social Activities •Medical Education •Membership •Mental Health •National Health Policy •Non Communicable Diseases •Prevention of Motor Traffic Accidents •Central Continuing Professional Development Committee •Snake Bite •Tobacco, Alcohol and Illicit Drugs •Women's Health
  • 73.
    Health Equity • Commissionon Social Determinants of Health in 2005 - Setup by WHO - To promote equity in health Conclusion : Much of the Global burden of disease is avoidable & unacceptable • 1968 WHO Alma – Ata declaration ‘Health for all by year 2000’ Millennium Development Goals Expression of need for social justice Some low income states like Costa Rica, Kerala, Sri Lanka have achieved a level of good Health & equitable Health without high national wealth Poor social policies Unfair economic arrangements Bad politics Unequal distribution Power Income Goods Services ‘Toxic’ Combination
  • 74.
    Health Equity –Clinicians have a key role to play • Chronic disease management with an additional focus on empowering the patient and use him or her for prevention in the community. • Individually and as professional organizations we can act as advocates and agents of social change • SLMA doctors over 120 years have done yeoman service to achieve what we have. There is more work to be done
  • 75.
    Acknowledgements • All myhouse officers, registrars, senior registrars, departmental colleagues. • For preparation of this talk Dr Prasad Katulanda, Professor Chandrika Wijeratne, Professor Rifdy Mohideen,Prof Ravindra Fernando, Dr Eranga, Dr Sanjaya, Epidemiology Unit (MOH), Professor Shanthi Mendis • Special Thanks to the energetic Dr Ruvaiz Haniffa • To Mr Rajasingham & Staff of the SLMA and PGIM • My Son Dr Rikaz Sheriff for his IT input. • My wife Ameena and family. • To Allah for this opportunity. • To all others who have helped me in various ways…
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