Non- communicable disease and mental health in low and middle income countries

Richard Smith

Director, UnitedHealth Chronic Disease Initiative

Agenda

• Definitions

• The UN meeting

• Scale of the problem

• Causes

• How best to respond (concentrating on NCDs)?

• What must be done?

Source: World Health Organization, 2005

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

In September 2011 the UN held a high level meeting on NCDs (did not include mental health)

• Only the second high level meeting of the UN on health

• The first in 2001 led to the Global Fund for AIDS, TB, and malaria

• Led to a flurry of activity and a raising of consciousness (although not among ordinary people)

• 130 countries spoke; 200 civil society representatives attended; 40 side meetings

• Russia committed $60m and Australia $3.9m

Future commitments with target dates

• 2012: work with WHO and all stakeholders to set targets

• 2013: review of the MDGs; integrate NCDs

• 2014: UN review of progress

What was achieved?

• On global agenda

• Meeting was a step change

• Understanding that a response must go well beyond health sector

• “Whole of society, whole of government”

• Development issue

• Civil society movement important

• Beginning not the end

What didn't happen

• Nothing on mental health. Should there be another high level meeting?

• No new funding apart from Russia and Australia, didn't expect it

• WHO costing report and WEF report came too late, some best buys got lost

• NCD Alliance has issues with best buys—major omissions

• Alcohol weak

• No champion countries—Australia, Norway

• China and India not very visible; too few G8 champions

• Not many LMIC stepping forward

• Yet to engage the public—must do by 2014

Burden of disease

Chronic diseases:

Heart disease30.2%

Cancer15.7%

Diabetes1.9%

Other chronic diseases15.7%

Infectious diseases:

HIV/AIDS 4.9%

Tuberculosis 2.4%

Malaria 1.5%

OtherInfectiousDiseases20.9%

Injuries 9.3%

Total:58.0M

Global Causes of Death (2006)

The total number of people dying from chronic diseases is double that of all infectious diseases including HIV/AIDS, tuberculosis and malaria (Nature, 2007).

10

Leading Causes of Mortality and Burden of Diseaseworld, 2004

%

1. Ischaemic heart disease 12.2

2. Cerebrovascular disease 9.7

3. Lower respiratory infections 7.1

4. COPD 5.1

5. Diarrhoeal diseases 3.7

6. HIV/AIDS 3.5

7. Tuberculosis 2.5

8. Trachea, bronchus, lung cancers 2.3

9. Road traffic accidents 2.2

10. Prematurity, low birth weight 2.0

%

1. Lower respiratory infections 6.2

2. Diarrhoeal diseases 4.8

3. Depression 4.3

4. Ischaemic heart disease 4.1

5. HIV/AIDS 3.8

6. Cerebrovascular disease 3.1

7. Prematurity, low birth weight 2.9

8. Birth asphyxia, birth trauma 2.7

9. Road traffic accidents 2.7

10. Neonatal infections and other 2.7

Mortality DALYs

11

Burden of disease by broad cause group and region, 2004

12

Age-standardized DALYs for noncommunicable diseases by major cause group, sex and country

income group, 2004

Deaths from chronic disease are displacing deaths from infectious disease even in rural Bangladesh

Upper-middle

Low

Lower-middle

High

0 20 40 60 80 100 0 5 10 15 20 25-5-10

Deaths, % of Total, 2005 Forecast Deaths, 2006-2015, % ChangeTotal

Deaths, M

0.57.1

0.52.7

2.513.2

13.712.3

Chronic diseasesInfectious diseases

Shifting Patterns of Global Health

16

Ten leading causes of burden of disease, world, 2004 and 2030

Causes of NCDs

18

Leading causes of attributable global mortality and burden of disease, 2004

%

1. High blood pressure 12.8

2. Tobacco use 8.7

3. High blood glucose 5.8

4. Physical inactivity 5.5

5. Overweight and obesity 4.8

6. High cholesterol 4.5

7. Unsafe sex 4.0

8. Alcohol use 3.8

9. Childhood underweight 3.8

10. Indoor smoke from solid fuels 3.3

59 million total global deaths in 2004

%

1. Childhood underweight 5.9

2. Unsafe sex 4.6

3. Alcohol use 4.5

4. Unsafe water, sanitation, hygiene 4.2

5. High blood pressure 3.7

6. Tobacco use 3.7

7. Suboptimal breastfeeding 2.9

8. High blood glucose 2.7

9. Indoor smoke from solid fuels 2.7

10. Overweight and obesity 2.3

1.5 billion total global DALYs in 2004

Attributable Mortality Attributable DALYs

19

Deaths attributed to 19 leading factors,by country income level, 2004

We can make a difference: death rates in the US, 1900-1996

Decline

Yet only 3% of global health aid ($21 billion)

goes to NCDs and mental health.

Pervasive myths that have prevented action

• Global economic development will improve all health conditions

• Chronic disease results from freely adopted risk

• Chronic diseases are diseases of the elderly

• Chronic diseases are diseases of the rich

• Benefits of countering chronic disease accrue only to the individual

• We can fix chronic disease as we are fixing infectious disease

• We should wait until we've controlled infectious disease

• Screening and treating patients is the the most cost effective way to go

How best to respond?

How best to respond?

• “We need a whole of government and a whole of society response”

• Margaret Chan, director general, WHO

Need for a broad strategy

Comprehensive and integrated action is the means to prevent and control chronic diseases

Difficult questions

• What is the best level at which to intervene? Social determinants? Behavioural risk factors? Biological risk factors? Treatment? Or rather how much to intervene at each level?

• What are the best buys?

• What should be the priorities?

• What MUST be done?

• What is the best system of governance?

• What to do if very few (even no) resources are available?

• What to do in this particular country?

• How to think about these difficult questions at the same time?

Some preliminary answers to some of the questions?

What is the best level at which to intervene? Or rather how much to intervene at each level?

• Social determinants? – Acting at this level may bring benefits beyond NCDs—for

example, on poverty, trade, agriculture, education– Some cannot be controlled—ageing of the population,

globalisation

• Behavioural risk factors? – We have strong evidence on how to act on some of these

—for example, raising taxes on tobacco and alcohol, banning smoking in public places

– Can be very cost effective– Interventions on diet and physical activity are more

complicated, but there are some relatively simple ones—like banning trans fats, reducing salt in food

What is the best level at which to intervene? Or rather how much to intervene at each level?

• Biological risk factors? – Later in the disease process than acting on behavioural risk

factors, less cost effective

– How much can the health system achieve alone?

– Strengthening the health system helps patients with other problems, counteracting to some extent the criticism aimed at “vertical systems”

– Strong evidence on the benefits of treating cardiovascular risk, but depends on some sort of health system and tends to work poorly even where there are well functioning health systems (rule of halves)

– Poor effectiveness on obesity

– Good evidence on prediabetes and prehypertension (doesn't depend on doctors and nurses)

• What is the best level at which to intervene? Or rather how much to intervene at each level?

• Treatment?

– The major cost of developed world systems (over 90%)

– Least cost effective

– Hard to change once you have it, huge vested interest

– Hard even to reshape existing systems—stronger primary care, less dependency on doctors, fewer hospitals, closer links with social services, more disease management, stronger palliative care, etc

– But people expect “the sick to be treated”

– Health systems are traditionally concerned with the sick not the “healthy” Could it be different?

Best buys for reducing the burden of NCDs (WHO): (none of them depend on health systems)

• 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

Interesting question

What might an entirely new system for preventing and controlling NCDs in a low

income country look like?

It’s a more complicated problem than countering infectious disease

acute childhood infections maternal deaths

Simple technologies

Rapid impact

Controlled by health services

Within the remit of the health campus and the health department

chronic, life long infectious and non-infectious diseases

Complex interventions

Decades before impacts

Main levers outside health service control

Takes a whole university and all government!

View from Scotland on best way to look after people with long term conditions

Best system for responding to NCDs in LMIC

• High level task force that is whole of government and whole of society

• Emphasis on public health and prevention with an emphasis on structural changes

• Patients TRULY in charge

• Extensive use of community health workers

• Extensive standardisation and use of protocols

• Emphasis on primary care

• Few hospitals and specialists—to avoid capture of resources

11 UnitedHealth and NHLBI Collaborating Centres of Excellence to counter chronic disease

Outcomes proposed by UnitedHealth NHLBI Centers of Excellence

• A strong commitment to action by the UN and member states with global and national plans for action

• Creation of a global partnership with all groups able to join, clear governance, and a global plan with with targets and regular reporting

• Energetic implementation of the Framework Convention on Tobacco Control

• Action on other risk factors

• Universal access to essential drugs and technology

• Strengthening of health systems (benefits all patients)

• Emphasis on research, particularly implementation research

What are the “must dos” in the many countries that are currently doing very

little?

What MUST be done?

• National plan

• “Infrastructure”--government apparatus

• Surveillance

• Advocacy

• Implement Framework Convention on Tobacco Control (not all countries have signed)

Conclusion

• NCDs present a major challenge to health, particularly in the developing world

• Problem will get rapidly worse without action

• So far very few resources devoted to NCDs

• There is now high level commitment, but public consciousness of the problem needs raising

• The response must be “all of government and all of society”

• It is possible to prevent most premature deaths from NCDs

• There are many cost effective interventions, most of them outside the health system

• We need a global plan (with targets) and national plans. They are coming.