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Vision in a World of NCDs Prof K Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health Sir John Wilson Lecture

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QUESTIONS THIS TALK WILL ADDRESS (Why) are NCDs (Finally) receiving policymaker attention at Global Level? Why is Eye Health not part of the UN/WHO NCD package? How will Ageing and NCDs impact on Eye Health in the 21 st Century? How should Eye Health position itself in the broader Health System framework and Rights discourse?

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Global Challenge of NCDs APATHY (2000) ATTENTION (2011) ACTION ?

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Is NCD a global crisis? YES! Source: Beaglehole R, Bonita R, Alleyne G, et al for the Lancet NCD Action group. UN HLM on NCDs: Addressing four questions. Lancet 2011 POL June 13 2011

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Cardiovascular disease (Age-standardized death rate per 100 000, males) Yach D., 2009 723-1030 3 47-390 391-426 427-464 542-722 723-1030 138-205 206-281 282-346 347-390 391-426 427-464 465-541 542-722 723- 1030 No Data

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

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Is NCD a development issue? YES! (and the case for investment is strong) l NCDs are a cause and consequence of poverty l NCDs entrench poverty-cycle of debt l Costs of loss of productivity and care will increase as the burden rises l Inaction will pose problems on fragile health systems l And action on NCDs will contribute to progress for other global priorities, e.g. MDGs l NCDs are a cause and consequence of poverty l NCDs entrench poverty-cycle of debt l Costs of loss of productivity and care will increase as the burden rises l Inaction will pose problems on fragile health systems l And action on NCDs will contribute to progress for other global priorities, e.g. MDGs

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NCDs: Economic Impact l NCDs accounted for five of the six top causes of economic loss in 2008 HHeart disease : $752bn HStroke: $298bn HDiabetes: $204bn l NCDs accounted for five of the six top causes of economic loss in 2008 HHeart disease : $752bn HStroke: $298bn HDiabetes: $204bn NCDs cost developing countries up to 6.77% of GDP; this economic burden is more than that caused by Malaria (1960s) or AIDS (1990s) - 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

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Are affordable cost-effective interventions available? YES! Source: Cecchini M, Sassi F, Lauer J et al. Tackling unhealthy diets, physical inactivity and obesity: health effects and cost-effectiveness. Lancet 2010

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UN ADOPTS NCDs! UNHLM September 2011 (New York) Political Resolution Adopted Global Target Set For 2025 25% Reduction in NCD Related Mortality Below 70 Yrs. UNHLM September 2011 (New York) Political Resolution Adopted Global Target Set For 2025 25% Reduction in NCD Related Mortality Below 70 Yrs. 25 By 25

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What are NCDs? Why Only Four? (CVD; DM; Cancer: COPD) Linked by Common Risk Factors What About: -Mental Health? -Oral Health? - Eye Health? -Renal Diseases? -Genetic Disorders? Where Do Injuries and Disabilities Fit In? Why Only Four? (CVD; DM; Cancer: COPD) Linked by Common Risk Factors What About: -Mental Health? -Oral Health? - Eye Health? -Renal Diseases? -Genetic Disorders? Where Do Injuries and Disabilities Fit In?

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UN Political Resolution 2011: Disease Burden & Determinants High and Rising Health Burden Advancing in LMIC Preventable Premature Deaths Common Risk Factors : Prevalence Social Determinants Recognized Economic Cost of Neglect : Huge High and Rising Health Burden Advancing in LMIC Preventable Premature Deaths Common Risk Factors : Prevalence Social Determinants Recognized Economic Cost of Neglect : Huge

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Risk Factors Tobacco Unhealthy Diet Physical Inactivity Harmful Use of Alcohol Others Mentioned: - Indoor Smoke - Breast Feeding - Infections Tobacco Unhealthy Diet Physical Inactivity Harmful Use of Alcohol Others Mentioned: - Indoor Smoke - Breast Feeding - Infections

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Global causes of blindness due to eye diseases, excluding refractive errors (2002) Source: Eggleston K and Tuljapurkar S. Aging Asia The Economic and Social Implication of Rapid Demographic Change in China, Japan and South Korea

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How will vision fare in the 21 st century? Ageing NCDs Injuries Climate Change Ageing NCDs Injuries Climate Change

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SILVER TSUNAMIGLOBAL GRAYING VERY ELDERLY ELDERLY DEMOGRAPHIC TRANSITION AGEING

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Global Ageing Trends (2012) 0 to 9 10 to 19 30 or over 25 to 29 20 to 24 Per centage 60 or over

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Global Ageing Trends (2050)

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By 2050, 80% of older people will live in LMIC Chile, China and Iran will have a greater proportion of older people than USA. By 2050, 400 million persons over 80 years; 100 million in China alone Ageing in LMIC

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Cataract Age Related Macular Degeneration Vitreous Degeneration Glaucoma Age Related Eye Problems

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Risk Factors: Tobacco Use on the Rise in Developing Countries

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Smoked Tobacco And The Eye Cataract3 fold higher risk (nuclear cataract) Kelley et al 2005 AMD Glaucoma R.R. of 2.2 (95% CI, 1.4 3.5) for current smokers O.R. of 2.9 (95% CI, 1.3 6.6) Cheng et al 2000

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Smokeless Tobacco And The Eye Raju et al (2006) O.R. for Nuclear Cataract = 1.67 (9.5% CI, 1.16 2.39) Iyamu et al (2002) SLT Raises Intra Ocular Pressure

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CountryPrevalence in 2010 (%) China9.7 India7.1 Japan7.3 Republic of Korea9.0 Malaysia10.9 Singapore12.7 Thailand7.7 Vietnam2.9 United States12.3 Prevalence of Diabetes in Asia-Pacific Countries Source: For China, Yang et al. 2008. For all other countries, International Diabetes Federation Diabetes Atlas, www.diabetesatlas.org/content/regional-data

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Rising Prevalence of Diabetes in Urban India Mohan et al, Diabetologia, 2006; 49: 1175 Ramachandran et al, Diabetes Care, 2008; 31: 893 Over 14 years, DM prevalence increased by 72.3% Prevalence rate age standardized for Chennai Census 1991 NUDS CURES

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The TOP 10

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Diabetes And The Eye People with Diabetes Are 25 Times More Likely To Go Blind From Diabetic Retinopathy And Cataract Than Those Without Diabetes - Patel and Ireland (Sightsavers)

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Blood Pressure and Eye Hypertensive Retinopathy Interaction Between HBP And Diabetes Interaction Between HBP And Tobacco

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A.CVD WITH OCULAR EFFECTS Stroke/ TIA Arrhythmias Vasculitis Drug Effects B. COMORBIDITIES Assessment of surgical risk CVD and Eye

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Tumours Primary Metastatic Treatment Steroids Radiotherapy Cancer and Eye

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HEALTH SYSTEM PEOPLE SOCIAL DETERMINANTS (OF HEALTH & NUTRITION) SocietalPersonal -Water-Income -Sanitation-Education -Food System-Occupation -Environment-Social Status -Social Stability -Gender -Development-Networks -Workforce -Infrastructure -Drugs, Vaccines & Technologies -Financing -Information Systems -Governance

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Clinical Changing Spectrum Increased Caseload Public Health Services Continuity of Care Workforce Awareness Policy Integration Financing Implications for the Health System

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Should Eye Health.. Remain a Vertical Programme Be part of a Horizontal Integration of many Programmes? Seek a Diagonal Approach?

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Primary Care: Physicians Non Physician Health Care Providers Task Shifting Task Sharing Outreach Services (IT enabled) Secondary Care: Ophthalmologists + Allied Health Professionals Other Physicians Tertiary Care: Specialists Referral Services Supportive Supervision Health Workforce

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Universal Health Coverage Sustainable Development Health System Equity Rights Social Determinants Human ResourcesEconomy 21 st Century

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The Global Path to Universal Health Coverage Bismarck Model 1883 Beveridge Model, 1942 Japan, 1938 New Zealand, 1938 UK, 1948 (NHS) Scandinavia: Norway, 1912; Sweden, 1955; Denmark, 1973; NHIF, Kenya, 1966 Canada, 1966 Spain, 1986; Brazil, 1988; Columbia, 1993 South Korea; 1989 Rwanda, 2003; Ghana, 2004 South Africa, 2011/12 Philippines, 1995; Taiwan, 1995; Thailand,2002; Vietnam, 2009 INDIA, 2012 Chile, 1952 Australia, 1975, Italy 1978 Mexico, 2001 Germany, 1941 Sri Lanka, 1950

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UNIVERSALITY COVERAGE EQUITYBRIDGING GAPS HORIZONTAL VERTICAL BREADTH DEPTH

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Universal Health Coverage Based On People Centric Primary Care - Margaret Chan, DG of WHO (2012)

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20 th Century Health Care Clinician Centred Focus on Benefits of Treatment Increase Quality Patient as Passive Complier Good Care for Known Patients Hospital as Focus Operates Through Bureaucracy Driven by Finance High Carbon Usage Challenges met by Growth 21 st Century Health Care Patient-Centred Focus on Prevention of Disease and Harm Reduce Waste and Increase Value Patient as Co Producer Equitable Care for Populations Focus on systems Operates Through Networks Driven by Knowledge Low Carbon Usage Challenges met by Transformation -Sir Muir Gray (2007)

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HOW DO WE THEN GATHER MORE STRENGTH In our advocacy for adoption and advancement of policies for eye health?

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A Framework for Determinants of Issue Attention in Global Health (i)The collective strength of the actors mobilising around an issue; (ii)The ideas they use to portray and position the issue; (iii) The issue characteristics that pertain to inherent features of the issue; and (iv) The nature of the political context or features of the environment that individuals confront as they seek to advance attention of the issue, including other actors who do not work on the issue (Jeremy Shiffman, 2010)

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The Economic Argument Cause and Consequence of Poverty Productivity Losses Cost-Effective Treatments (Best Buys) Global cost of Visual Impairment and Blindness = USD 3 Trillion Patel and Ireland (Sightsavers)

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Vision Impairment is the 6 th largest cause of DALY loss (3%) - WHO How is Vision Loss weighted for estimation of Disability? - Perspective of Physicians - Perspective of Patients - Perspective of People Quality of Life is an important message to convey Value of Vision

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Why Do We Need A Rights Argument Economic arguments work BUT there are competing demands (within and beyond the Health Sector) Voice of Patients and Civil Society needed - e.g. HIV-AIDS, Tobacco Control

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HEALTH EQUITY: PHILOSOPHICAL CONSTRUCT Capability Right Utilitarian Justice Bentham Rawls Sen A well ordered society would ensure that all individuals have the capability to be healthy and at a level that is commensurate with human dignity in the modern world, which is their right - Sridhar Venkatapuram. Health Justice; Polity (2011)

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WHAT NEXT? Post 2015 UN Agenda: Sustainable Development Goals (SDH) Four Pillars - Inclusive Economic Development - Inclusive Social Development - Environmental Sustainability - Peace and Security Nine Thematic Working Groups Inter-Governmental Leadership Group (UK, Indonesia, Liberia) Position Eye Health Wherever Possible

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Eye Health is a Part of Health But. Isnt It Also Related to EDUCATION? Isnt It Also Related to EMPLOYMENT? Isnt It Also Related to FOOD SECURITY? Isnt It Also Related to GENDER EQUITY? Isnt It Also Related to ENVIRONMENT? Isnt It Also Related to URBAN DESIGN? YES IT IS !!!

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Coalitions: Looking Beyond The Profession How to Make Friends and Influence People? - Join Forces with Natural Allies (e.g. NCD Alliance) - Support THEIR cause - Show them how YOUR cause connects with their cause Position Eye Health in the Health Systems Discourse (Politics of Presence) - Health Systems and Policy Research - Global Health Workforce Alliance - Universal Health Coverage Movement

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If you travel alone, you will go faster If you travel together, you will go farther - Old Proverb

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The Universal is the Local Minus the Walls - M.Torga Differentiate Universal from Uniform and Common

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Ayam nijah parovetthi gananam laghu-chetasaam. Udaar charitanam tu vasudhaiva kutumbakam "Myself, this is mine, that is yours is a petty way of people in seeing reality; for those with noble consciousness, the whole world is a family. Maha Upanishad, Verse 71 (Upanishads: Ancient Indian Philosophical Treatises) (Upanishads: Ancient Indian Philosophical Treatises) The World is a Family