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Prof K Srinath Reddy President Public Health Foundation of India Professor of Cardiology, All India Institute of Medica

NEEDED: A GLOBAL THRUST TO COUNTER A GLOBAL THREAT Non- Communicable Diseases. Prof K Srinath Reddy President Public Health Foundation of India Professor of Cardiology, All India Institute of Medical Sciences

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Prof K Srinath Reddy President Public Health Foundation of India Professor of Cardiology, All India Institute of Medica

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  1. NEEDED: A GLOBAL THRUST TO COUNTER A GLOBAL THREAT Non- Communicable Diseases • Prof K Srinath Reddy • President • Public 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

  2. GROWING EXPECTATIONS IN GLOBAL HEALTH • 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

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

  4. STROKE DEATH RATES AMONG 15-64 YEARS OLDS IN THREE AREAS OF TANZANIA (1992-1995) Deaths per 100,000 population (poor rural) (well off) R. Walker et al, The Lancet, 2000.

  5. Projected global numbers of deaths by cause for high-, middle- and low Income countries (WHO, 2008)

  6. Increasing CHD in India Prevalence (%) CVD Deaths Gupta R. CSICardiology Update. Ed. Manjuran RJ. 2003

  7. Trend of CVD mortality (1990-2000): China Wang YJ, International Journal of Stroke; 2007

  8. DETERMINANTS • Demographic Shifts (Aging) • Urbanization • Industrialisation • Globalization (Marketing) • Education • Culture • Poverty (Access to Health) • Built Environment (Barrier/Enabler) (Living Habits) (Beliefs) Vectors : Tobacco; Unhealthy Food

  9. Risk factors: tobacco use on the rise in developing countries

  10. Developing Countries are in the Big League

  11. Imports of French fries (frozen) into the Central American countries from the United States Source: FAO 2007

  12. Snack imports from the United States into Central America, 1989-2006 Source: FAO 2007

  13. 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 Popkin, 2001

  14. 8.3% 1.2 pp/yr 69.3 61.0 4% 0.57 pp/yr 6.6% 0.94 pp/yr 32.5 28.5 14% 26.8 20.2 14% 33% Fernald et al., 2007 Trends in Obesity & Overweight: Mexico

  15. 8-year Change in the BMI Distribution for a Cross-section of Chinese Adults 20-45--tripling of Male and Doubling of Female Obesity The Nutrition Transition Source: Bell et al, 2000

  16. NUMBER OF PEOPLE WITH DIABETES IN THE ADULT POPULATION (AGED  20 YEARS) Source : Global Burden of Diabetes, 1995-2025; King H. et.al, Diabetes Care,1998

  17. Mean Plasma Cholesterol Values in China

  18. Major risk for chronic diseases in Middle East

  19. The WORLD as one population • If we plot the distributions of: • BP • Cholesterol • Exposure to Tobacco Smoke (Active/Passive) • Physical Inactivity • Dysglycemia • Overweight & Obesity • At the global level • We will Find A Rightward shift • In Each Of Their Distributions, Compared To 20-30 Yrs. Ago

  20. 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!)

  21. % (not numbers) of CVD deaths by age group, 2000-2030, assuming stable risks Note how deaths from CVD in the U.S. occur principally at ages >75+ while in developing economies they occur at younger ages.

  22. Years Of Life Lost Due To CVD In PopulationsAged 35-64 Years PPYLL= Potentially Productive Years of Life Lost

  23. Lost National Income due to IHD, Stroke and Diabetes (2005-2015) Preventing chronic diseases : a vital investment : WHO global report

  24. 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

  25. 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

  26. NCDs: 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)

  27. SES GRADIENT:ORDER OF REVERSAL FOR CVD RISK FACTORS Tobacco Blood Pressure Plasma Cholesterol ↓ Physical Activity Obesity Health Transition

  28. 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)

  29. STROKE: CHINA QUEST STUDY (2009) 4739 Survivors of stroke 71% Patients Experienced Catastrophic OOPE • OOPE from Stroke pushed 37% of patients and their families below the poverty line; 62% without insurance went into poverty - Heeley E et al, Stroke, 2009; 40:2149-5

  30. 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

  31. 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.”

  32. 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)

  33. THE HEALTH OF PEOPLE PERSONS POPULATIONS CALLS FOR DIFFERENT LEVELS OF ACTION

  34. POLICY APPROACHES (Global; National; Local) Globalization Trade Financial Legal Regulatory Health Workforce Environment To Enable Individuals To Make and Maintain Healthy Choices Demographic Change Globalization Drugs & Technologies WIDER SOCIETY Social Determinants Biological Risk Preventive, Diagnostic, Therapeutic, Rehabilitative Services INDIVIDUAL HEALTH CARE DELIVERY DETERMINANTS Health Inequities Quality of Care FAMILY Behavioral Risk NEIGHBORHOOD, COMMUNITY Access to Care Education Enhancement of Knowledge, Motivation, and Skills of Individuals Cultural and Social Norms Systems Infrastructure Media Community Interventions Settings Based HEALTH COMMUNICATION

  35. Estimated Costs of five priority interventions for non-communicable diseases (NCDs) in three countries

  36. RESEARCH ON NCDs (POLICY) Objective To identify enablers and barriersfor 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

  37. 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)

  38. 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

  39. 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

  40. GPS FOR GLOBAL HEALTH • 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 ksr@phfi.org

  41. 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’

  42. HIV-NCD LINKS EXAMPLES • 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 Diabetes Smoking

  43. 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

  44. 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)

  45. PARTNERSHIPS SYNCHRONY OF EFFORT SYNERGY OF EFFECT FOR PUBLIC HEALTH

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