Prof K Srinath ReddyPresidentPublic Health Foundation of India Professor of Cardiology, All India Institute of Medical Sciences Bernard Lown Professor of Global Cardiovascular Health, Harvard School of Public Health

NEEDED: A GLOBAL THRUST TO COUNTER A GLOBAL THREAT

Non- Communicable Diseases

NEEDED: A GLOBAL THRUST TO COUNTER A GLOBAL THREAT

Non- Communicable Diseases

Urgency + Anxiety About MDG Goals

Continuing Concerns on Infectious Diseases (ATM)

Momentum For Global Action on Chronic (Non Communicable) Diseases: MDG+

Advocacy For Inclusion of Mental Health and Injuries: NCD+

Movement For Universal Health Coverage

Resurgence of Primary Health Care

‘Health System’ Image Moves From Black Box To Switch Board

Urgency + Anxiety About MDG Goals

Continuing Concerns on Infectious Diseases (ATM)

Momentum For Global Action on Chronic (Non Communicable) Diseases: MDG+

Advocacy For Inclusion of Mental Health and Injuries: NCD+

Movement For Universal Health Coverage

Resurgence of Primary Health Care

‘Health System’ Image Moves From Black Box To Switch Board

GROWING EXPECTATIONS IN GLOBAL HEALTH

Cause of Death in Countries (by World Bank income group) 2008

STROKE DEATH RATES AMONG 15-64 YEARS OLDS IN THREE AREAS OF

TANZANIA (1992-1995)

0102030405060708090

Morogoro rural Hai Dar es Salaam(urban)

England andWales

Women MenDe

ath

s p

er 1

00,

00

0 p

op

ula

tio

n

R. Walker et al, The Lancet, 2000.

(poor rural) (well off)

Projected global numbers of deaths by cause for high-, middle- and low

Income countries (WHO, 2008)

2

67

9.510.5

22.5

4.1 4.5

123456789

1011

1960 1970 1980 1990 2000

Urban Rural

Increasing CHD in India

Prevalence (%)

Gupta R. CSI Cardiology Update. Ed. Manjuran RJ. 2003

0.0

2.0

4.0

6.0

1990 2020Num

ber o

f dea

ths

(mill

ions

)

Cardiovascular diseases

CVD Deaths

Trend of CVD mortality (1990-2000): China

Trend of CVD mortality (1990-2000): China

Wang YJ, International Journal of Stroke; 2007

• Demographic Shifts (Aging)

• Urbanization

• Industrialisation

• Globalization (Marketing)• Education• Culture

• Poverty (Access to Health)

• Built Environment (Barrier/Enabler)

Vectors : Tobacco; Unhealthy Food

DETERMINANTS

(Living Habits)

(Beliefs)

Risk factors: tobacco use on the rise in developing countries

Risk factors: tobacco use on the rise in developing countries

Developing Countries are in the Big LeagueDeveloping Countries are in the Big League

Imports of French fries (frozen) into the Central American countries from the United States

Imports of French fries (frozen) into the Central American countries from the United States

Source: FAO 2007Source: FAO 2007

Snack imports from the United States into Central America, 1989-2006

Snack imports from the United States into Central America, 1989-2006

Source: FAO 2007Source: FAO 2007

The Nutrition Transition in Developing Countries

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

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

Trends in Obesity & Overweight: MexicoTrends in Obesity & Overweight: Mexico

14.3 18.1 21.6 23.336.1 36.95.9

8.7 6.99.2

24.932.4

0

10

20

30

40

50

60

70

80

1999 2006 1999 2006 1999 2006

%

Obesity

Overweight

33%

14%

14%

20.226.8

28.532.5

61.0

69.3

6.6%0.94 pp/yr

4%0.57 pp/yr

8.3%1.2 pp/yr

Fernald et al., 2007

8-year Change in the BMI Distribution for a Cross-section of Chinese Adults 20-45--tripling of Male and Doubling of

Female Obesity

-2

0

2

4

6

8

10

12

14

16

18

20

15 17 19 21 23 25 27 29 31 33 35 37

Body Mass Index

Per

cen

t

1989 cross-section (n=3948)

1997 cross-section (n=3015)

Source: Bell et al, 2000

The Nutrition Transition

NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION

(AGED 20 YEARS)

NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION

(AGED 20 YEARS)

0

50

100

150

200

250

300

350

Developed Developing World

Mil

lion

s

20002025

Source : Global Burden of Diabetes, 1995-2025; King H. et.al, Diabetes Care,1998

Mean Plasma Cholesterol Values in ChinaMean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg/

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle EastMajor risk for chronic diseases in Middle East

Overweight & Obesity based on STEPwise Surveillance (BMI>=25)

66.9 67.456.3

81.2 76.4

53.9

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Per

cen

t

Hypertension in the EMR Based on STEPwise Surveillance

25.5 2628.8

24.6

33.4

23.6

40.4

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

%DM in the EMR (STEPwise Surveillance)

10.4

1617.9

19.916.7 16.5

19.2

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

%

Low Physical Activity

56.7

79

33.8 32.9

55.4 50.4

86.8

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

%

THE WORLD AS ONE POPULATION

If we plot the distributions of:• BP

• Cholesterol

• Exposure to Tobacco Smoke (Active/Passive)

• Physical Inactivity

• Dysglycemia

• Overweight & ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions, Compared To 20-30 Yrs. Ago

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!)

% (not numbers) of CVD deaths by age group, 2000-2030, assuming stable risks

0

10

20

30

40

50

60

70

U.S. Russia S. Africa Brazil

<45

45-64

65-74

75 +

Note how deaths from CVD in the U.S. occur principally at ages >75+ while in developing economies

they occur at younger ages.

Years Of Life Lost Due To CVD In Populations Aged 35-64 Years

PPYLL= Potentially Productive Years of Life Lost

0.04

0.3

1.6

3.3

6.7

9.2

0.05

0.4

2

3.2

10.5

17.9

0 2 4 6 8 10 12 14 16 18 20

Portugual

S. Africa

USA

Russia

China

India

NUMBER IN MILLIONS

PPYLL IN 2030

PPYLL IN 2000

Lost National Income due to IHD, Stroke and Diabetes (2005-2015)

0

200

400

600

Inte

rnati

on

al $ (

billio

ns)

Preventing chronic diseases : a vital investment : WHO global report

NCDs Hurt Economic Growth• Each 10% rise in NCDs = 0.5% lower rate of

annual economic growth

• 50% rise in NCDs in Latin = 2.5% loss in America by 2030 economic growth rates

– Stuckler D, Milibank Quarterly, 2008

• 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

FALSE PERCEPTIONS (MYTHS)

• Problem only of HIC

In LMIC

• Only rich are affected

• Only urban elites are affected

• Only elderly are affected

• Mainly men are affected

NCDs: THE SOCIAL GRADIENTNCDs: 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)

SES GRADIENT:ORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

↓ Physical Activity

Obesity

Health Transition

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)

In Industrial employees and families, all CVD risk factors are inversely correlated with education (Reddy KS,

2007)

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

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)

In Industrial employees and families, all CVD risk factors are inversely correlated with education (Reddy KS,

2007)

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

STROKE: CHINA QUEST STUDY (2009)STROKE: CHINA QUEST STUDY (2009)

4739 Survivors of stroke

71% Patients Experienced Catastrophic OOPE

- Heeley E et al,

Stroke, 2009; 40:2149-5

• OOPE from Stroke pushed 37% of

patients and their families below

the poverty line; 62% without

insurance went into poverty

CVD: IMPACT ON HOUSEHOLDS (KERALA, INDIA)

(Harikrishnan, 2010)

• Catastrophic health expenditures (72.9%)

Distress Financing Common (50%)

• 40% of CVD patients lost sources of income

• 82% did not have health insurance

• 13% could not continue medication due to cost factors

The World Bank on NCDs (2007)The World Bank on NCDs (2007)

“To what extent do NCDs affect the poor? The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered. However, in all countries and by any

metric, NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy response.”

“To what extent do NCDs affect the poor? The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered. However, in all countries and by any

metric, NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy response.”

NOW ……..

• A momentum appears established

• ECOSOC meeting (2009)

• UN Secretary General’s Meeting (2009)

• World Health Assembly Resolution (2010)

• UN General Assembly Special Session

(UNGASS 2011)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global; National; Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUAL

FAMILY

NEIGHBORHOOD, COMMUNITY

Enhancement of Knowledge, Motivation, and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e, D

iagn

ostic

, T

hera

peut

ic,

Reh

abili

tativ

e S

ervi

ces

HE

ALT

H C

AR

E D

EL

IVE

RY

WIDER SOCIETY

DE

TE

RM

INA

NT

S

Globalization

Acc

ess

to

Ca

reS

yste

ms

Infr

ast

ruct

ure

He

alth

W

ork

forc

eQ

ua

lity

of

Ca

reD

rug

s &

Te

chn

olo

gie

s

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Estimated Costs of five priority interventions for non-communicable diseases (NCDs)

in three countries

Estimated Costs of five priority interventions for non-communicable diseases (NCDs)

in three countries

RESEARCH ON NCDS (POLICY)

RESEARCH ON NCDS (POLICY)

Objective

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

Objective

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

RESEARCH ON NCDs (POLICY)

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)

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)

RESEARCH ON NCDs (PRACTICE)

RESEARCH ON NCDs (PRACTICE)

Objective

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

Objective

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

RESEARCH ON NCDs (PRACTICE)

RESEARCH ON NCDs (PRACTICE)

Pathways

- 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

Pathways

- 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

The Spectrum of Research Must Stretch From MOLECULES To MARKETS

The Span of Policy Must Range From PERSONS To PEOPLE To POPULATIONS

The Arena of Advocacy And Action Must Extend From RISK FACTORS To RIGHTS

The Spectrum of Research Must Stretch From MOLECULES To MARKETS

The Span of Policy Must Range From PERSONS To PEOPLE To POPULATIONS

The Arena of Advocacy And Action Must Extend From RISK FACTORS To RIGHTS

GPS FOR GLOBAL HEALTH

ksr@phfi.org

WHAT CAN THE ‘NCD’ WORLD LEARN FROM THE ‘HIV’ WORLD?

• BUILDING A SOCIAL MOVEMENT

• RIGHTS BASED APPROACH TO HEALTH

• AFFORDABLE / AVAILABLE DRUGS

• REMOVAL OF STIGMA

• A VARIETY OF ‘PPP’s

‘Public-Private; Public-NGO;

Private-Private; Private-NGO’

HIV-NCD LINKS

• Disease Linked: Kaposi’s Sarcoma; Cardiomyopathy

• Treatment Linked: Accelerated Atherosclerosis

• Co-Morbidities: In HIV Survivors (Age Related)

• Risk Enhancement:

(For Infections)

• ‘Other’ NCDs: Mental Illness; Suicidal Deaths

HIV

Tuberculosis

Smoking Diabetes

EXAMPLES

BEYOND VERTICAL CONSTRUCTS

IN THE CONTEXT OF A ‘HEALTH SYSTEM’

WHAT UNITES HIV & NCDs IS

CHRONIC CARE

= Need For Long Follow up + Re-Visits + Referrals + Counseling

+ Social Support Systems + Multi-Sectoral Actions

WHAT CAN THE ‘HIV’ WORLD LEARN FROM THE ‘NCD’ WORLD?

• From Entreaty to Global Treaty (FCTC)

• Countering/Converting the industry

(Tobacco) (Food Industry)

• Bridging the Prevention –Treatment Divide

• Addressing Common Risk Factors (Responsible for a ‘Cluster’ of Diverse Diseases)

• Moving the Agenda From Diseases to Determinants (Biomedical To Social Determinants Approach)

PARTNERSHIPS

PUBLIC HEALTH

SYNERGY OF EFFECT SYNCHRONY OF EFFORT FOR