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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