Responding To The Global Challenge of NCDs

Transcription

1 Responding To The Global Challenge of NCDs Prof K Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health

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3 Projected global numbers of deaths by cause for high, middle and low income countries (WHO, 2008)

4 NCDs & ECONOMIC DEVELOPMENT (HIC vs LMIC) Proportional Mortality Is Higher in HIC Absolute Mortality Is Higher in LMIC BUT Age Standardised Mortality Rates Are Also Higher In LMIC!

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6 Cardiovascular disease (Age-standardized death rate per , males) No Data Yach D., 2009

7 Global Health Indicators and their relationship to CVD WHO Region Life Expect. (2007) Male Female CVD age-std. mortality rates by cause (per million), 2004 African Region The Americas SEAR European region Eastern Med Region West Pac. Region

8 The TOP 10

9 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!)

10 NCDs: Economic Impact NCDs accounted for five of the six top causes of economic loss in 2008 Heart disease : $752bn Stroke: $298bn Diabetes: $204bn 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 NCDs will lead to a loss of 30 Trillion Dollars globally up to 2030 representing 48% of global GDP in 2010 Harvard + WEF Study 2011

11 Age-adj death rates for total CVD, diseases of the heart, CHD, and Stroke: USA

12 Deaths per 100,000 population Males Bennett SA et al. Med J Aust 1994;161: Females All cardiovascular diseases All cardiovascular diseases Coronary heart disease Coronary heart disease

13 Trend of CVD mortality ( ): China Wang YJ, International Journal of Stroke;

14 RAPID EPIDEMIOLOGIC TRANSITION FROM INFECTIOUS AND NON-COMMUNICABLE CAUSES, MEXICO, Massive total deaths Large absolute and proportionate in NCDs Large absolute infectious diseases Infectious &parasitic NCDs

15 GLOBAL VARIATION IN STROKE AND CHD Stroke mortality ranged from 12.7% higher to 27.2% lower than CHD mortality Stroke burden disproportionately higher in China, Africa and South America CHD mortality higher in Middle East, North America, Australia and much of Europe Lower national income was associated with higher relative mortality and burden of disease from stroke. Diabetes mellitus and mean serum cholesterol associated with higher relative burden of CHD, even after adjustment for national income Kim AS, Johnston C. Circulation, 2011

16 Why are different countries showing different patterns of CVD? Rise/Fall of Mortality Rates CHD/Stroke As Dominant CVD

17 Stages of Health Transition Stage I Age of Pestilence and Famine Stage II Age of Receding Pandemics Stage III Age of Man Made Degenerative Diseases Stage IV Age of Delayed Degenerative Diseases Stage V Age of Social Upheaval and Health Regression Stage VI Era of Environmental Degradation Sub Saharan Africa Rural India Urban India Russia Omran (1971) Latin America Olshansky and Ault (1986) Eastern Europe Yusuf and Reddy (2001) Thakker and Reddy (2008)

18 STAGE I Life Expectancy : ~ 35 years Dominant Diseases : Infections; Nutritional Deficiencies CVD : RHD, Cardiomyopathies

19 STAGE II Life Expectancy : ~ 50 years Dominant Diseases : Mixed Pattern Stage I Diseases Prominent But Chronic Diseases Emerge CVD : RHD; High BP & Hemorrhagic Stroke

20 HEMORRAGIC STROKE HIGH BLOOD PRESSURE HYPERTENSIVE HEART FAILURE THROMBOTIC STROKE CORONARY HEART DISEASE OTHER RISK FACTORS ( Lipids; Smoking; Diabetes)

21 STAGE III Life Expectancy : ~ 60 years Dominant Diseases : Chronic Diseases CVD : CHD; Both Forms of Stroke

22 STAGE IV Life Expectancy : > 70 years Dominant Diseases : Chronic Diseases CVD* : CHD; Both Forms of Stroke (Mainly Thrombotic) * CHD and Stroke are still dominant but kill much later in life

23 VALUE? Health Transition Model Provides An Evolving Perspective Instead Of A Limited Cross-Sectional View It Helps To Anticipate The Epidemic And Provide A Proactive Preventive Response BUT It Is Dominated By Proportional Mortality And Ignores Age Standardised Mortality Rates It Is Not Likely To Be A Simple Linear Model. Complex Systems Are Non-Linear

24 Demographic Shifts (Aging) Urbanization Industrialisation DETERMINANTS (Living Habits) Globalization (Marketing) Education Culture (Beliefs) Poverty (Access to Health) Built Environment (Barrier/Enabler) Vectors : Tobacco; Unhealthy Food; Alcohol

25 RISK CASCADE OF NCDs GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL Development (stage and speed) Distribution (equity) Perceptions (cultural) Priorities (socio-economic) Beliefs Behaviours Biology Demand- Supply (trade) Pathways (availability, access)

26 World Deaths in 2000 attributable to selected leading risk factors WHR 2002

27 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 Popkin, 2001

28 Mean Plasma Cholesterol Values in China mg/dl

29 Trends in Obesity & Overweight: Mexico 8.3% 1.2 pp/yr % 0.94 pp/yr % 0.57 pp/yr % % 33% Fernald et al., 2007

30 Low birth weight and its consequences Rebound Adiposity Hypertension Coronary heart disease Atherosclero sis, Stroke Type II Diabetes, Insulin resistance? Cancer Adult lung function

31 Risk factors: tobacco use on the rise in developing countries

32 NCDs: 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)

33 SES Gradient: Order of Reversal for CVD Risk Factors Tobacco Blood Pressure Plasma Cholesterol Physical Activity Obesity Health Transition

34 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) Brazil: Obesity rates declining in High SES; Rising in Low SES (Bell, 2000) 34

35 VARIATIONS IN HEALTH TRANSITION : ETHNIC DIVERSITY What is ethnicity? Differences due to genes or environment or both? Lessons from Migrant studies. (Ni-Hon-Son; Chinese; Indians; Kenyan nomads) Multi-ethnic comparisons. (London; Canada; INTERHEART; Seven Countries)

36 While ethnic comparison studies do suggest that some ethnic groups are at a higher risk of manifesting CHD (e.g; South Asians) or Stroke (East Asians; Africans), MIGRANT STUDIES SUGGEST THAT ENVIRONMENT IS THE DOMINANT FACTOR IN THE EXPRESSION OF RISK

37 THE TASK BEFORE US Stage I Stage II Stage III Stage IV? Avoid /Abbreviate the Stage of Mid-Life Death and Disability

38 RESPONSE TO HEALTH TRANSITION POPULATIONS Demographic and Social Determinants Low Risk High Risk Public Health Interventions Low Risk INDIVIDUALS Biology + Beliefs + Behaviors Clinical + Behavioral Interventions High Risk

39 PRINCIPLES OF RISK Risk operates in a continuous manner- and not across arbitrary threshholds (BP; Cholesterol; Body weight; Smoking; Blood Sugar) Most adverse events arise in a population in people in the midrange of a risk factor distribution When multiple risk factors co-exist, the overall risk is additive In all populations, majority of the CVD events arise in persons with modest elevation of many risk factors rather than in individuals with high level of a single risk factor.

40 PRINCIPLES OF PREVENTION Small reductions in risk factor levels, when achieved across the whole population, result in a large reduction of CVD events Non-drug measures prevent risk across the whole population and reduce it in persons who have already acquired a high risk profile Drug therapy to reduce risk is most cost-effective in persons who are a high risk of adverse events in the next 10 years. Best results are achieved through a combination of population based prevention and high risk individual management approaches.

41 THE HEALTH OF PERSONS PEOPLE POPULATIONS CALLS FOR DIFFERENT LEVELS OF ACTION

42 CVD PREVENTION POPULATION INDIVIDUAL POLICY EDUCATION DRUGS + NON-DRUG SINGLE MULTIPLE

43 PUBLIC HEALTH INTERVENTIONS Policy Interventions Educational Interventions Enabling Environment Health Beliefs and Behaviours (Financial, Social, Physical) (Community; Individual) Desired Change

44 PRINCIPLES OF HEALTH PROMOTION Supportive Services Knowledge I know Help is Available Perform Personally Motivation I want I Act Reach & Teach (Involve Others) Skills I can It is possible Enabling Environment

45 POWER OF POLICY FOR CHRONIC DISEASE PREVENTION TOBACCO Evidence is available from many countries (including LMIC) that - Taxation - Ad Bans - Smoke Free Policies - Health Warnings ARE EFFECTIVE 48.1% of mortality averted in UK ( ) is attributable to reduced smoking (Unal B et al. Circulation 2004)

46 POWER OF POLICY FOR CHRONIC DISEASE PREVENTION DIET Evidence of preventive potential of policy interventions available from Mauritius (Price of Edible Oils) Poland (Import of F-V and Healthy Fats) Finland (Farming; Marketing; Community Education) New Initiatives Food Labeling Reduced Salt in Processed Foods Ban on Trans-Fats Advertising Restrictions

47 Societal policies and processes influencing the population prevalence of obesity INTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL /HOME INDIVIDUAL POPULATION Transport Public Transport Leisure Activity/ Facilities Globalization of markets Development Media programs & advertising Urbanization Health Social security Media & Culture Education Health Care Public Safety Sanitation Manufactured/ Imported Food Labour Infections Worksite Food & Activity Family & Home Energy Expenditure Food intake : Nutrient density % OBESE AND OVER-- WEIGHT Food & Nutrition Agriculture/ Gardens/ Local markets School Food & Activity National perspective Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipathies V. IOTF website 1999:

48 Estimated Costs of five priority interventions for non-communicable diseases (NCDs) in three countries

49 Health System Challenges Health Workforce Health Care Services Drugs & Technologies Health Financing Integration Among NCDs Integration with Other Health Programs Coordination with Other Sectors

50 Health system options for dealing with the NCD epidemic: possible complementary and parallel actions Reconfigure the health workforce Challenge 1: Multiple Disease Burden Divert personnel from redundant programmes Challenge 2: Can we multi-skill health workers? Train existing health workers Challenge 3: Overall shortage of health workers Challenge 4: Are existing health worker categories enough? Challenge 5: Is focusing on the health care alone sufficient? Expand the existing health system Create new cadres of health workers for NCD management Create a new cadre of public health professionals

51 NON PHYSICIAN HEALTH WORKERS FOR NCD MANAGEMENT: EVIDENCE OF EFFECTIVENESS Kwazulu Natal - Nurses were able to control: 68% patients with diabetes 82% patients with Hypertension 84% patients with asthma Treatment adherence increased from 79% to 87% Iran Behvarz (Rural Primary Health Care) Workers Each additional Behvarz worker was associated with 0.09 mmol/l ( ) lower FPG & 0.53 mm Hg ( ) lower SBP India & Pakistan NPHWs reliably and effectively apply WHO Cardiovascular Risk Management Package (80% a priori agreement with physicians) (Sources: Coleman et al. 1998; Farzadfar et al. 2012; Abegunde et al. 2006)

52 Health Services Agenda Diagnostic Facilities Treatment Facilities Drugs & Technologies Chronic Care Systems 1 o Care 2 o Care 3 o Care Diagnosis Treatment Guidelines Referral And Follow up Systems Emergency Services Cost Containment Mechanisms Quality Assurance Systems

53 PRIMARY PREVENTION OF NCD Risk Detection + Risk Reduction in Individuals EDUCATION People Professionals Self -Referral + Opportunistic Screening HBP, Overweight, Tobacco, Physical Inactivity, Diet, Age, Gender, Personal/Family History GUIDELINES (Diagnostic Algorithms) Risk stratification (Step I) Targeted Screening Diabetes, Dyslipidemia, Assessment for NCD GUIDELINES (Management Algorithms) Risk Stratification (Step II) Appropriate Therapy Lifestyle Measures + Drugs

54 Secondary Prevention: Moving From Efficacy To Effectiveness IMPROVING PRACTICE PATTERNS OF HEALTH CARE PROVIDERS Integrating effective secondary prevention into primary health care ENABLING UPTAKE & ADHERENCE BY PATIENTS Availability; affordability; knowledge; motivation; support systems; simplified regimens STRENGTHENING HEALTH SYSTEMS FOR CHRONIC CARE Referral & follow-up; vascular clinics; Involvement of non-physician health care providers; monitoring and evaluation

55 Policy Measures (Usually) Do Not Cost The Government Money - Tobacco Taxes - Ad Bans - Public Smoking Bans - Regulation of Processed Food (eg., Salt, Trans Fats) - Food Labeling

56 However, NCD Programs Will Cost! Cost can be contained by - Choosing Cost-Effective Interventions - Integrating Different NCD Programs - Integrating NCD Prevention & Control into Other Health & Development Programs

57 Objective RESEARCH ON NCDS (POLICY) 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

58 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)

59 Objective RESEARCH ON NCDs (PRACTICE) 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

60 Pathways RESEARCH ON NCDs (PRACTICE) - 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

61 POLICY APPROACHES (Global; National; Local) DETERMINANTS Globalization Demographic Globalization Change Social Determinants Health Inequities Education Cultural and Social Norms Biological Risk Behavioral Risk Financial Legal Regulatory Trade Environment To Enable Individuals To Make and Maintain Healthy Choices Media WIDER SOCIETY INDIVIDUAL FAMILY NEIGHBORHOOD, COMMUNITY Enhancement of Knowledge, Motivation, and Skills of Individuals Community Interventions Preventive, Diagnostic, Therapeutic, Rehabilitative Services Settings Based Health Workforce Drugs & Technologies Quality of Care Access to Care Systems Infrastructure HEALTH CARE DELIVERY HEALTH COMMUNICATION