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Learning from low and middle income countries about responding to non-communicable disease
1. Learning from responses to
the pandemic of non-
communicable disease (NCD)
in low and middle income
countries
Richard Smith
Director, UnitedHealth Chronic Disease Initiative
2. Agenda
• What do we mean by NCD?
• Global pandemic of NCD
• Global response
• UnitedHealth Chronic Disease Initiative
• General learning from LMIC
• Community health workers
• Polypill
• M-health
• Community Interventions for Health
• Conclusions
3. Non-communicable disease
• WHO defines non-communicable disease (NCD) as
cardiovascular disease, diabetes, chronic respiratory
disease, and certain cancers.
• All of these have in common that they are caused
predominantly by smoking, poor diet, physical
inactivity, and the harmful use of alcohol.
• Doesn't include mental health and many other chronic
conditions
• NCD is the preferred term
4. Deaths from chronic disease are displacing deaths
from infectious disease even in rural Bangladesh
5. Shifting Patterns of Global Health
Deaths, % of Total, 2005 Forecast Deaths, 2006-2015,
Total % Change
Deaths, M
13.7
Low
12.3
2.5
Lower-middle
13.2
0.5
Upper-middle
2.7
0.5
High
7.1
0 20 40 60 80 100 -10 -5 0 5 10 15 20 25
Infectious diseases Chronic diseases
14. Proportion of DALYs due to ischaemic heart
disease from individual risk factors 2010
15. We can make a difference: death rates in the
US, 1900-1996
Decline
16. Yet only 3% of global
health aid ($21 billion)
goes to NCD
17.
18. Priorities of the UN Secretary General
• “Whole of government, whole of society response”
• Complete government wide action on risk factors
• Sustained primary health care with prioritised
packages plus palliative and long term caregivers
• Surveillance and monitoring
• Learning from and integration with AIDS, TB, and
malaria programmes
• Governments, private sector, civil society, and
international organisations must all work together
19. Future commitments with target dates
• 2012: work with WHO and all stakeholders to
set targets
– Currently arguments over targets
– Can targets be sensibly set?
– Will the targets set some countries up to
fail?
• 2013: review of the MDGs; integrate NCDs
• 2014: UN review of progress
• 2015: Sustainable Development Goals
20.
21. View from Scotland on best way to look
after people with long term conditions
22. Best buys for reducing the burden of NCDs (WHO)
• Protecting people from tobacco smoke and banning smoking in
public places
• Warning about the dangers of tobacco use
• Enforcing bans on tobacco advertising, promotion and sponsorship
• Raising taxes on tobacco
• Restricting access to retailed alcohol
• Enforcing bans on alcohol advertising
• Raising taxes on alcohol
• Reduce salt intake and salt content of food
• Replacing transfat in food with polyunstaurated fat
• Promoting public awareness about diet and physical activity,
including through mass media
23. Further “best buys” from WHO (health system
examples)
• Counselling and multidrug therapy, including
glycaemic control for diabetes for people over 30 with
a 10 year risk of 20% of a cardiovascular event
• Aspirin therapy for acute myocardial infection
• Screening for cervical cancer once at age 40 with
removal of any cancerous lesions
• Biennial mammography for women 50-70
• Early detection of colorectal and oral cancer
• Treatment of persistent asthma with inhaled
corticosteroids and beta-2 agonists
24. Cost effectiveness of different interventions for
preventing and controlling NCDs in Mexico
25. 11 UnitedHealth and NHLBI Collaborating Centres of
Excellence to counter chronic disease
26.
27. Work of the centres in relation to WHO priorities
• Surveillance (Bangladesh, Delhi, Tunisia, Kenya, Peru, Southern
Cone)
• Tobacco control (Tunisia)
• Reducing biofuels (Kenya, Peru)
• Better nutrition (Tunisia, Northern Mexico, Central America, China)
• Increase physical activity (Tunisia, Northern Mexico)
• Risk assessment (China, South Africa, Peru)
• Better Dx and Rx (China, Delhi, Bangalore, South Africa, Central
America)
• Strengthen primary care, more community health workers (China,
Delhi, Bangalore, South Africa, Northern Mexico, Central America)
• Social determinants (Bangladesh, Delhi, all centres in joint studies)
31. 10 ways in which developed countries benefit and
learn from partnerships with developing countries
• Rural health service delivery
• Skills substitution
• Decentralisation of management
• Creative problem-solving
• Education in communicable disease control
• Innovation in mobile phone use
• Low technology simulation training
• Local product manufacture
• Health financing
• Social entrepreneurship
32. Community health workers
• Most centres working with community health
workers
• In many places doctors and nurses simply not there;
and if there in short supply
• CHWs are not just supplemental; they usually speak
the same language and share the same culture as
local people
• Working on primary, secondary, and tertiary
prevention
• Evidence from a Cochrane review of their
effectiveness, particularly with communicable
disease, vaccination, and maternal and child health
35. Disease management
• RCT in India and Pakistan
• CHW plus decision support software
supporting physicians treating patients
with diabetes versus usual care
37. Polypill concept
• Combine antihypertensive drugs, a statin, and possibly
aspirin into one pill taken once a day
• Many polypills
• Antihypertensives (usually three and usually at half dose)
• “Agreement” on use in secondary prevention. FDA may
license in 2013
• Trial with clinical endpoints underway for primary
prevention
• Most radical idea—offer to everybody at 55
• Individual lifestyle modification—costly and
unsustainable
38.
39.
40.
41.
42.
43. Polypill prevention trial
• 86 people over 50 no established disease took polypill
and placebo in cross over trial of 12 weeks each
• Polypill (amlodipine 2.5 mg, losartan 25 mg,
hydrochlorothiazide 12.5 mg and simvastatin 40 mg)
• All taking individual components before
• 84/86 completed both arms
• 98% of participants took more than 85% of their
allocated pills
• 24 reported one or more symptoms on the Polypill
compared with 11 on the placebo, but none considered
them troublesome enough to stop treatment.
53. Community interventions for health
• Work with schools, employers, health services, local
politicians, and media to create a healthier environment
• Make healthy choices the easy choices
• Emphasis on “structural changes”—healthier food in
schools, environmental changes to encourage walking
and cycling and discourage driving (Increased physical
activity is the closest we come to a panacea, halving the
chance of a heart attack)
• Being tested in Sousse, Tunisia against control areas
• Being implemented in New Haven
54. Conclusions
• There is a pandemic of NCD in low and middle
income countries
• The world is beginning now to take the problem
seriously
• Response must be “whole of government and whole
of society”
• United together with NHLBI has been leading the
way
• There should be learning for high income countries,
particularly around community health workers, the
polypill, m-health, and creating healthier
communities
Notes de l'éditeur
The majority of deaths worldwide for all ages are due to chronic diseases. Cardiovascular diseases (mainly heart disease and stroke) are responsible for 30% of all deaths. Cancer, chronic respiratory diseases, and diabetes are also major causes of mortality. The contribution of diabetes is underestimated because although people may live for years with diabetes, their deaths are usually recorded as being caused by heart disease or kidney failure.
VA data from Matlab HDSS clearly demonstrates that a major change among categories in causes of death taking place in rural areas of Bangladesh.
FIGURE 6 Increase and Decline in Heart Disease Rates through the Epidemiological Transition in the United States (1900 to 1996) In the 1930s and ’40s, smoking and fat consumption continued to rise, as did the prevalence of heart disease. The U.S. had entered the third phase of the epidemiologic transition, the Age of Degenerative and Man-Made Diseases. By 1955, 55 percent of adult men were smoking, and fat consumption represented about 40 percent of total calories. Americans were also becoming more sedentary as a result of continued mechanization and urbanization and the rise of the suburbs after World War II, where more people were driving instead of walking and bicycling. Another important development affecting the health of Americans post WWII was the growth of the healthcare industry. By the late 1950s, more than 2/3 of the working population had some form of private insurance (7). As the 1960s progressed, age-adjusted CVD mortality rates began to decline, marking the beginning of the fourth phase of the transition, the Age of Delayed Degenerative Diseases. Since then, there have been substantial reductions in rates of mortality from both stroke and CHD. This decline can be attributed primarily to two main factors, therapeutic advances and prevention measures targeted at people with CVD as well as those potentially at risk for it. (8-10) Interestingly, healthier lifestyles may have actually had an even greater impact on the decline in age-adjusted rates of death. For example, improvements in diet due to access to fresh fruits and vegetables year round in developed countries may have contributed to declining cholesterol mean levels before effective drug therapy was widely available. (1) Starr, P: The Social Transformation of American Medicine . New York: Basic Books; 1982. (2) Goldman L, Cook EF: The decline in ischemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle. Ann Intern Med 1984, 101:825. (3) Hunink MG, Goldman L, Toteson, AN, et al: The recent decline in mortality from coronary heart disease, 1980-1990. The effect of secular trends in risk factors and treatment. JAMA 1997, 277:535. (10) Cooper R, Cutler J, Desvigne-Nickens P, et al: Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation 2000, 102:3137.