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NON-COMMUNICABLE DISEASES: THE COMING PLAGUE
Where we are and where we are
going
Shah EbrahimLondon School of Hygiene & Tropical
Medicine&
South Asia Network for Chronic DiseasesPublic Health Foundation of India
Where we are -• Strong evidence of NCD burden• Remarkable success in MCH• An ageing population = increases
in NCDs• Technical solutions but limited
action• Vested interests
Global Burden of Disease, 1990
Murray C, Lopez A, Jamison D. Bull World Health Organization, 1994;72: 495-509
EME: established market
economies
FSE: former socialist
economies
CHN: China
LAC: Latin America/
Caribbean
OAI: Other Asia & Islands
MEC: Middle East
IND: India
SSA: Sub-Saharan Africa
Global burden of disease: DALYs
Lopez et al, Lancet 2006:367:1747
Low & middle income countries High income countries
UN Inter-agency group on child mortality estimation. Levels and trends in child mortality, 2011
Dramatic declines in child mortality - globally
Per
cent
pop
ulat
ion
80+
yea
rs
1960
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1970
Per
cent
pop
ulat
ion
80+
yea
rs
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1980
Per
cent
pop
ulat
ion
80+
yea
rs
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1990
Per
cent
pop
ulat
ion
80+
yea
rs
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
Per
cent
pop
ulat
ion
80+
yea
rs
2000
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2010
Per
cent
pop
ulat
ion
80+
yea
rs
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2020
Per
cent
pop
ulat
ion
80+
yea
rs
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
Per
cent
pop
ulat
ion
80+
yea
rs
2030
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
Per
cent
pop
ulat
ion
80+
yea
rs
2040
Africa
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
HelpAge International; www.un.org/esa/population/ageing/ageing2009chart.xls
Successful maternal child health programmes result in reductions in fertility and increased life expectancy – an ageing population
Lancet October 5th, 2005
World Health Organization & World Bank have emphasised need for chronic diseases in low and middle income countries to be taken seriously
Many Calls to Action on NCDs...
but so has everything else
- Adapted from Ebrahim, Int J Epidemiol 2008
THE LANCET
“No serious conversation about global health can now take place without at least citing chronic diseases as a critical part of international health strategies”
8-14 December 2007
Chronic diseases
“36 million deaths from chronic diseases could be postponed by public health and primary care in the next 10 years at a cost of US$1.50 per person per year”
Beaglehole, Ebrahim, Reddy et al, Lancet 2007
December 8th 2007
WHO’s 2007 strategy for low and middle income countries
• Population wide: tobacco control, salt restriction (awareness, voluntary code)
• High risk strategy: all those with CVD + those at high risk (1.5% annual risk of death) defined by risk factor profiles (age, sex, smoking, BP, BMI) treated with “multi-drug regimen”
Tobacco: consumption and tax association in China
Wang et al Lancet 2005;366: 1821-4
Salt control: voluntary code for food industry, advice to reduce salt in the home
A pill to prevent 80% of heart attacks
28 June 2003
Polypill would contain a statin, three antihypertensives, folic acid and aspirin
BMJ
Potential impact of interventions on death rates over 10 years
13.2 million deaths not avoidable
16.5 million deaths
prevented
18 million deaths
prevented
Population High risk Not avoided
Asaria et al, Lancet 2007;370:2044-2053
The UN High Level meeting on NCDsUnited States, Europe, and key Western allies, blocked consensus on action on NCDs
Food companies lobbying for increased LMIC markets (by Obama’s former Comms. Executive)
Philip Morris – Project Sunrise – subversive operations against anti-tobacco lobby Civil society NGOs receive funding from food, alcohol and pharmaceutical industries
Bill & Melinda Gates Foundation – own 10% of global Coca Cola stock
Stuckler, Basu, McKee. Commentary: UN high level meeting on non-communicable diseases: an opportunity for whom?
BMJ 2011; 343 doi: 10.1136/bmj.d5336
Where we are going
• UN High Level meeting• Alliances: not disease specific silos• Global Health not NCDs• Getting political
United Health* & NHLBI collaborating centres of excellence
* “We're in the business of helping people live healthier lives”
Global Alliance for Chronic Disease
National Health Medical Research Council, AustraliaCanadian Insititutes of Health ResearchChinese Academy of Medical SciencesMedical Research Council UKNIH – NHLBI & FogartyIndian Medical Research Council
- 80% of public health research funding
35
VHS: ChennaiSANGATH
Goa
SNEHA: Mumbai
ARAVIND: Pondicherry
CCDC factory sites
Lucknow
SANCD, CCDC, PHFIAGA KHAN:
Karachi
ICDDR,B: Dhaka
Wellcome Strategic Award for building research capacity for chronic diseases (£4.5 million), 2009-2013
Inst Research & Development, Sri Lanka
CCMB, NIN, Hyderabad
mHealth: diabetes, hypertension, depression
Population-based research National Family
Household Survey, NSSO analyses
Andhra Pradesh Children & Parents Study
Genetics: COPD, DBT Policy: insurance, DfID
South Asia Network for Chronic Disease, Public Health Foundation of India
Talking about global health
Joe the Plumber says:-HIV-Hunger-Poverty
- Siegel and Stuckler 2010 in preparation
What do we need to do?
Geneau et al Lancet 2010;376:1689-98
Political Process Model
-Reframing the Debate
-Create Political Opportunities
-Mobilise Resources
Reframing the Debate: Social Causes
- Diseases of choice: victim-blaming
- Diseases of affluence
- ‘Us’ and ‘them’
“Isn’t obesity a sign of progress?”Personal Communication, author of World Bank World Development Report 2003
Social & Economic
Determinants
Common risk factors
Common chronic diseases
Health care costs +economic productivity
Failure to meet MDGs
The causal chain goes from the political to the pathological
The causal chain goes from the political to the pathological
Political choice: palm oil not
soya oil
Blood cholesterol
levels
Coronary heart disease
increases
Health care costs +economic productivity
Failure to meet MDGs
Political opportunities
• UN High Level meeting level• Older people vote• Social inequalities + civil unrest• Understanding the opposition
Not a headline grabber...
Compared with a decade ago...
Buenos Aires, protest against UN High Level Meeting on NCDS ignoring older people
http://www.helpage.org/newsroom/latest-news/un-meeting-on-ncds-ageing-and-dementias-
now-included/
• Life expectancy
• Infant mortality
• Income
• Employment
• Gender
• Education
• Ethnicity
• Health care
• Social support
Commission on Social Determinants of Health
• “India’s 12th Plan will be a health plan” Manmohan Singh, PM
• Public & private sector providers
• Funding 1.2% GDP up to 3%
• But no role for health insurance
- Advocate Global Health- Co-benefits & common cause
- MDGs, climate change, early life health system
- Pathways to Prevention- (eg Lazarus Effect)
Mobilising Resources
- Clear message- “3FOUR50”?- “Roll back Malaria”- “No health without mental health”
Framework convention on tobacco control: ratified but not implemented
India banned smoking in public places before England
But multi-national corporates move fast...
Corporate agendas for health and happiness? Who benefited here?
The debate is not about priorities for child survival or cataract surgery for old men. Both young and old require a functioning primary health care service – adequate, accessible, affordable
Summary
• Chronic diseases are THE major cause of death and disability in most developing countries
• Demographic and epidemiologic transitions are due to remarkable success stories in development
• We have effective means of controlling population risk factor levels – we need to implement them
• A new political process is required to achieve action focused on development for health
