Vision in a World of NCDs

Prof K Srinath ReddyPresident, Public Health Foundation of IndiaBernard Lown Professor of Cardiovascular Health, Harvard School of Public Health

Sir John Wilson Lecture

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 21st Century?

• How should Eye Health position itself in the broader ‘Health System’ framework and ‘Rights’ discourse?

Global Challenge of NCDs

APATHY (2000)

ATTENTION (2011)

ACTION ?

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 2011POL June 13 2011

Cardiovascular disease(Age-standardized death rate per 100 000,

males)

Yach D., 2009

723-1030

347-390391-426

391-426427-464

542-722723-1030

138-205206-281282-346347-390391-426427-464465-541542-722723-1030No Data

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

Is NCD a development issue? YES!(and the case for investment is strong)

NCDs are a cause and consequence of poverty

NCDs entrench poverty-cycle of debt Costs of loss of productivity and care will

increase as the burden rises Inaction will pose problems on fragile health

systems And… action on NCDs will contribute to

progress for other global priorities, e.g. MDGs

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 up 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

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

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.

25 By 25

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?

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

Risk Factors• Tobacco• Unhealthy Diet• Physical Inactivity• Harmful Use of Alcohol

Others Mentioned:- Indoor Smoke

- Breast Feeding - Infections

1% 4% 4%5%

5%

9%

12%47%

13% Onchocerciasis trachomachildhood blindnessdiabetic retinopathycomeal opacitiesAMDglaucomacataratOthers

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

How will vision fare in the 21st century?

Ageing NCDs Injuries Climate Change

SILVER TSUNAMI GLOBAL GRAYING

VERY ELDERLYELDERLY

DEMOGRAPHIC TRANSITION

AGEING

Global Ageing Trends (2012)

 

 

 

 

 

0 to 910 to 19

30 or over25 to 2920 to 24

Per centage 60 or over

Global Ageing Trends (2050)

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

Cataract

Age Related Macular Degeneration

Vitreous Degeneration

Glaucoma

Age Related Eye Problems

Risk Factors: Tobacco Use on the Rise in

Developing Countries

Smoked Tobacco And The Eye

Cataract 3 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

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

Country Prevalence in 2010 (%)China 9.7India 7.1Japan 7.3Republic of Korea 9.0Malaysia 10.9Singapore 12.7Thailand 7.7Vietnam 2.9United States 12.3

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

Rising Prevalence of Diabetes in Urban India

Mohan et al, Diabetologia, 2006; 49: 1175Ramachandran 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 CURES1971 1989 1995 2000 2004 2008

0

5

10

15

20

2.3

8.3

11.613.5 14.3

18.6

Prev

alen

ce[%

]

The “TOP 10”

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)

Blood Pressure and Eye

• Hypertensive Retinopathy

• Interaction Between HBP And Diabetes

• Interaction Between HBP And Tobacco

 

A. CVD WITH OCULAR EFFECTS

Stroke/ TIA Arrhythmias Vasculitis Drug Effects

B. COMORBIDITIES

Assessment of surgical risk

CVD and Eye

 

Tumours Primary Metastatic

Treatment

Steroids Radiotherapy

Cancer and Eye

HEALTH SYSTEM

PEOPLE

SOCIAL DETERMINANT

S (OF HEALTH & NUTRITION)

Societal Personal- Water - Income- Sanitation - Education- Food

System- Occupatio

n- Environmen

t- Social

Status- Social

Stability- Gender

- Development

- Networks

- Workforce

- Infrastructure

- Drugs, Vaccines & Technologies

- Financing- Information Systems

- Governance

 Clinical Changing Spectrum Increased Caseload

Public Health Services Continuity of Care Workforce Awareness

Policy Integration Financing

Implications for the Health System

Should Eye Health…..

• Remain a Vertical Programme

• Be part of a Horizontal Integration of many Programmes?

• Seek a Diagonal Approach?

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

Health Workforce

Universal Health Coverage

Sustainable Development

Health System

Equity Rights

Social Determinants

Human ResourcesEconomy

21st Century

The Global Path to Universal Health Coverage

Bismarck Model 1883Beveridge Model,

1942

Japan, 1938New Zealand, 1938

UK, 1948 (NHS)

Scandinavia: Norway, 1912; Sweden, 1955;

Denmark, 1973;

NHIF, Kenya, 1966Canada, 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

UNIVERSALITY

COVERAGE

EQUITY BRIDGING GAPS

HORIZONTAL VERTICAL

BREADTH

DEPTH

“Universal Health Coverage Based On

People Centric Primary Care’’

- Margaret Chan, DG of WHO (2012)

20th 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

21st 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)

HOW DO WE THEN GATHER MORE

STRENGTH

In our advocacy for adoption andadvancement of policies for eye health?

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)

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)

 Vision Impairment is the 6th 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

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

HEALTH EQUITY: PHILOSOPHICAL CONSTRUCT

• Capability Right

• Utilitarian Justice

Bentham

RawlsSen“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)

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

Eye Health is a Part of Health But….

• Isn’t It Also Related to EDUCATION?• Isn’t It Also Related to EMPLOYMENT?• Isn’t It Also Related to FOOD SECURITY?• Isn’t It Also Related to GENDER EQUITY?• Isn’t It Also Related to ENVIRONMENT?• Isn’t It Also Related to URBAN DESIGN?

YES IT IS !!!

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

“If you travel alone, you will go faster

If you travel together, you will go farther ”

- Old Proverb

“The Universal is the Local Minus the Walls”

- M.Torga

Differentiate Universal from Uniform and Common

“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)

The World is a Family