CARICOMCARICOM

Regional Summit on Chronic Non-Communicable DiseasesTrinidad and Tobago,g ,

15 September, 2007

Presentation byPrime Minister of St Kitts & Nevis

Hon Dr Denzil Douglas

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• Global situation with Chronic NCDs• Caribbean situation and costs• Caribbean Response

Overview ofPresentation

p• Exploding common myths• Review of effective interventions• The Way Forward

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THE MALADIES OF AFFLUENCE

Globalisation andHealth

The Economist, August 11th 2007

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The poor world is getting the rich world’s diseases

“Europeans have been exporting their maladiesthroughout history. They seem to be doing it again,but in a new way. In the past the problem wasy p pinfection. Now illnesses associated with Western livingstandards are the fastest growing killers in poor andmiddle-income countries. Chronic disease hasbecome the poor world’s greatest health problem”.

The Economist, August 11, 2007

CARICOMChronic Diseases

Heart Disease, Stroke, Cancer, Diabetes, Chronic RespiratoryDisease↑

Biological Risk FactorsModifiable: overweight, high cholesterol, high blood sugar, high

blood pressureNon-modifiable: Age, Sex, and Genetics

Chronic Diseasesand their Causes

Non modifiable: Age, Sex, and Genetics↑

Behavioral Risk FactorsTobacco use, physical inactivity, unhealthy diet, alcohol abuse

↑Social and Environmental Determinants

Social, economic and political conditions such as income, livingand working conditions, physical infrastructure, environment,

education, agriculture, and access to health services↑

Global InfluencesGlobalization of food supply, urbanization, technology, migration

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Distribution ofDeaths by Major

Cause in the World

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Distribution of Deathsfrom Infectious andChronic Disease byIncome Category, 2005

Crude Mortality Rates (per 100,000 population)for Select Diseases: (2000-2004)

CARICOM Member States

80

100

120

140

0,00

0 po

pula

tion

HeartDisease

Diabetes

Cancers

Source: CAREC, based on mortality reports from countries

2000 2001 2002 2003 2004Year

0

20

40

60

Rat

es p

er 1

00,0

00 p

opul

atio

n

StrokeDiabetes

Injuries

HypertensiveDiseases

HIV/AIDS

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Leading Causes of Death inCARICOM Countries bySex, 2004 (MINUS Jamaica)

1. Heart Disease2. Cancers3. Injuries and violence

1. Heart Disease2. Cancers3. Diabetes

MALES FEMALES

j4. Stroke5. Diabetes6. HIV/AIDS7. Hypertension8. Influenza/pneumonia

4. Stroke5. Hypertension6. HIV/AIDS7. Influenza/pneumonia8. Injuries and violence

Source: CAREC, based on country mortality reports

Potential Years of Life Lost <65years by Main Causes, 2000& 2004, CARICOM Countries (minus Jamaica)

HIV/AIDS

Injuries

Y2004Y2000

0 10000 20000 30000 40000 50000 60000 70000

Chronic Disease

Note: Chronic Disease includes heart disease, stroke, cancer, diabetes, hypertension,chronic respiratory disease

‘Injuries’ includes traffic fatalities, homicide, suicide, drowning, falls, poisoning

Source: CAREC, based on country mortality reports

200

250

300

Disability Adjusted Life Years (000) 2002

0

50

100

150

JAM TRT BAH BAR

Com DisNCDs

Mortality Attributable to Select Risk Factors (Latin America & Caribbean)from DCP2

Tobacco

Alcohol

Obesity

High BP

0 100 200 300 400 500

Unsafe sex

Physical inactivity

Low fruits & veg

High cholesterol

Attributable Deaths (thousands)

30

40

50

60ce

(%)

Trends in Adult Overweight/Obesityin the Caribbean

0

10

20

30

Prev

alen

ce (%

)

1970s 1980s 1990s

YEARS

MaleFemale

Prevalence (%) of diabetes among adults inthe Americas

8 68.799.3

10.711.812.412.612.7

16.4

Bolivia

Suriname

Nicaragua

USA

Mexico

Cuba

Belize

Jamaica

Trinidad/Tobago

Barbados

6.16.3

7.27.27.37.67.67.98.28.48.6

Honduras

Chile

Urban Peru

Paraguay

Haiti

Brazil

Argentina

Costa Rica

Colombia

Guatemala

Bolivia

Source: Pan Am J Public Health 10(5), 2001; unpublished(CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)

Caribbean Trends in Diabetes Mortality

60

70

80

000

20

30

40

50

Rat

e/10

0,00

0

1985 1990 1995 2000

MaleFemale

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A Consequenceof Diabetes

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Amputations at theQEH 2002-2006

Diabetic Non diabetic

Male 308 116

Female 379 120

Total 995 236

Source A. Hennis, 2007

Age adjusted death rates/100,000population from Diabetes (2000)

80

100

120

0

20

40

60

BAH BAR GUY JAM SUR TRT CAN USA

From community surveys, theprevalence of hypertension in adults 25-64 years of age was:

Barbados 27.2 %Jamaica 24.0 %

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St. Lucia 25.9 %The Bahamas 37.5%Belize 37.3%

Control of blood pressure would reduce thedeath rates from Cardiovascular Disease byabout 15-20%.

Principal ClinicVisits,Saint Vincent &theGrenadines, 2000vs2003

15,000

20,000

2000

0

5,000

10,000

HTNor HTN/DM DMor DM/HTN Arthritis/Muscu

2003

Age adjusted death rates/100,000population from Hypertension (2000)

3035404550

05

1015202530

BAH BAR GUY JAM SUR TRT CAN USA

Projected national income lost from NCDs ( 2005-2015)Projected National Income Lost from NCDs

2005 -2015, $USBN

400

500

600

0

100

200

300

Bra Can Chi Ind Nig Pak Rus UK Tan

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EstimatedEconomic Burden($US Million, 2001)

BAH BAR JAM TRT

Diabetes 27.3 37.8 208.8 494.4

Hypertension 46.4 72.7 251.6 259.5

Total 76.7 110.5 460.4 753.9

Estimated Cost of Diabetes andHypertension as percent (%) of GDP

5

6

7

8

0

1

2

3

4

5

BAH BAR JAM TRT

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6%

Developing countriescarry a doubledisease burden

Percentage of deaths by cause

Low- and middle-income countries High-income countries

36%

10%

54%

non-communicable diseasescommunicable diseasesinjuries

87%

7%6%

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Exploding theMyths

Myth: Chronic diseases are a problemof the rich countries

Fact: Non-communicable diseaseaccount for more than half theburden of disease and 80% of thedeaths in the poorer countries whichcarry a double burden of disease.

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Myth: NCDs are a problem only of the elderly

Fact: Half of these diseases occur in adults lessthan 70 years of age and the problems

Exploding theMyths

y g poften begin in the young e.g., obesity

Myth: NCDs affect men more than women

Fact: NCDs affect women and men almostequally and globally, heart disease is thelargest cause of death in women.

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Exploding theMyths

Myth: NCDs cannot be prevented

Fact: If the known risk factors areFact: If the known risk factors arecontrolled, at least 80% of heartdisease, stroke and diabetes and40 % of cancers are preventable,and in addition there arecost effective interventions availablefor control.

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Exploding theMyths

Myth: people with NCDs are at fault andto be blamed because of theirunhealthy lifestyles

Fact: individual responsibility, while important,only has full effect where people haveequal access to healthy choices.Governments have a crucial role to playby altering the social environment to helpmake the healthy choice the easychoice.

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Exploding themyths

Myth: “my grandfather smoked and lived to90 years”, and “everyone has to die ofsomething”

Fact: While some people who smoke will livea normal lifespan, the majority will haveshorter, poorer quality lives. And yes,everyone has to die, but death does notneed to be slow, painful or premature,as is so often the case with NCDs

CARICOMWhat Works?

• A small shift in average population levels ofseveral risk factors can lead to a largereduction in chronic diseases

• Population wide approaches form the centralstrategy for preventing and controllingchronic disease epidemics, but should becombined with interventions for individuals

• Many interventions are not only effective, butsuitable for resource constrained settings

Finland: Dramatic Declines in NCD Mortality

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Relation of Fitness toRisk of Death, T&T,St. JamesCardiovascular Study

• 1309 men had blood sugar, cholesterol,fitness measured at baseline and thenfollowed up carefully for 7 yearsfollowed up carefully for 7 years.

• Unfit men compared with fit men were:- 3.6 times more likely to die- 2.5 times more likely to have a heart

attack

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CaribbeanResponses

• Since the 1960s, history of collective action in health,formalized in 1986 as the Caribbean Cooperation in Health(CCH) initiative.

• Countries, CAREC, CFNI and CHRC, CARICOM Secretariat,PAHO/WHO and partners have had successes e.g.,,p g ,,malnutrition and gastroenteritis, vaccine preventablediseases, HIV/AIDS (p (PANCAP).

•• CCH now entering 3rd phase: major thesis that Caribbean

health can be improved through actions taken universallyand collectively.

• Current priorities for action under CCH include chronicdiseases where the cited goals are to reduce deaths by 2%per year and to reduce serious, costly complications such asamputations or renal failure.

Caribbean Responses Summarised

���Im p le m e n ta t io n o f F C T C

�N a t io n a l O b je c t iv e s

��N a t io n a l la w , le g is la t io n ,d e c r e e

�����N a t io n a l fo c a l p o in t ,D e p a r tm e n t o r U n it

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HAI

GUY

BAR

BAH

ANT

ANG

���Im p le m e n ta t io n o f F C T C

�N a t io n a l O b je c t iv e s

��N a t io n a l la w , le g is la t io n ,d e c r e e

�����N a t io n a l fo c a l p o in t ,D e p a r tm e n t o r U n it

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����F in a n c ia l r e s o u r c e s

�Q u a li t y a s s u r a n c e o fc a r e

�N a t io n a l s ta n d a rd s a n dp ro to c o ls fo r t re a tm e n t

�D e m o n s t r a t iv ec o m m u n it y -b a s e dp r o g r a m s

����N a t io n a l s y s te m o fH e a lth r e p o r ts , s u r v e ya n d s u r v e il la n c e

����Im p le m e n ta t io n o f D P A S

p

����F in a n c ia l r e s o u r c e s

�Q u a li t y a s s u r a n c e o fc a r e

�N a t io n a l s ta n d a rd s a n dp ro to c o ls fo r t re a tm e n t

�D e m o n s t r a t iv ec o m m u n it y -b a s e dp r o g r a m s

����N a t io n a l s y s te m o fH e a lth r e p o r ts , s u r v e ya n d s u r v e il la n c e

����Im p le m e n ta t io n o f D P A S

p

Source: PAHO Survey of NCD National Response Capacity, 2005

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Addressing therisk factors

Tobacco and alcohol• Increase taxes with proceeds to prevention

and treatment• Ban smoking in public places• Ban smoking in all schools• Ban cigarette and tobacco advertising near

to schools• Curtail promotion of alcohol products

targeted to women and children• Establish target dates for passage of the

legal provisions in the FCTC already ratified.

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Addressingthe risk factors

Physical activity

• Have physical education compulsory inh l d id th f ilitischools and provide the facilities

• Provide healthy, secure exercise spaces

• Provide wellness centers

• Give tax relief for worksite exercise facilities

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Addressing therisk factors

Improve dietary practices

• Promote a standard of meals in public eating placeseg. eliminating trans fats

• Provide healthy school meals

• Establish community based networks for training inpreparation of health foods

• Mandate RNM to investigate the trade issues whichimpact negatively on healthy food imports

• Promote elimination of trans fats from Caribbeandiets

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Addressing therisk factors

In the case of cancer

• Primary preventione.g. screening and vaccination to

prevent cervical cancer

Promote screening for breast cancer

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Secondaryprevention

• Screening programs for NCDs

• Provide health services with resourcesto apply the established cost effectiveto apply the established cost-effectiveinterventions

• Establish mechanisms to ensureavailability of the medicationsnecessary for the long term treatmentof NCDs when they occur

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Critical otherrecommendations

• Establish national level Commissions on NCDs

• Establish a system of behavior and risk factorsurveillance with support of CAREC and UWI

• Insist on the updating of the Caribbean RegionalPlan of Action for NCDs

• The Community should name a “CARICOMWELLNESS DAY”

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Involve Partners

• PAHO/WHO• Financial institutions• Caribbean social partners – private sector and civil

society

Monitoring and evaluation

• Designate CARICOM/PAHO as the joint Secretariatwith responsibility for monitoring and reportingprogress in the control of the NCDs.

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The WayForward

First: We can utilize the policy instrumentsat our disposal

legislationtaxationtaxationregulation

Second: We should establish partnerships

Third: We must take personal responsibilityand lead by example

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CONCLUSIONS

• The Caribbean has a very serious problem - gettingworse

• Economically and socially, it is not sustainable

• There are cost-effective interventions that work; why notutilise them?

• We must put into effect National and Caribbean-wide(CCH) plans

• It is CRITICAL to strengthen health services formanagement and control of chronic diseases

• Deepened partnership with public and private sector, andcivil society is absolutely needed

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Th k YThank You

Regional Summit on Chronic Non-Communicable Diseases, Trinidad and Tobago, 15 Sept, ‘07