Non- communicable disease in low and middle income countries

1
Non- communicable disease in low and middle
income countries

• Richard Smith
• Director, UnitedHealth Chronic Disease Initiative

2
Agenda

• Objectives
• Values of the afternoon
• Who am I?
• What do we mean by NCDs?
• UN High Level Meeting
• Burden of disease from NCDs
• Why have NCDs not been taken seriously until now?
• What are the causes of NCDs?
• How best to respond to them in low and middle
  income countries?
• Your presentations
• Review how can I do better next time?

3
Objectives

• Know what is mean by NCDs
• Appreciate the burden of NCDs in LMIC
• Understand the causes of NCDs
• Discuss the best way of responding to NCDs in a
  community in a LMIC

4
Values of the course

• There are no right answers
• There are no stupid questions
• Not too much lecturing from me
• Stop me at any time to ask a question or make a
  point
• We should say what we think but avoid being rude
• Every criticism should be accompanied by a
  suggestion on how to do better
• Nobody should hog the conversation
• Everybody should contribute
• All teach, all learn
• Humour is good, sarcasm isn't
• Enjoy ourselves

5
Why me?

• Medically qualified (sort of)
• Former editor of BMJ and chief executive of BMJ
  Publishing Group
• Now director of UnitedHealth Chronic Disease
  Initiative
• A collaboration with NHLBI
• 11 centres (China, Bangladesh, India (2),
  Tunisia, Kenya, South Africa, US Mexico Border,
  Central America, Peru, Southern Cone)
• Altogether 30 countries and 80 institutions
• Working on research, capacity building, and
  policy development

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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

Source World Health Organization, 2005
7

• What do you think of the name? Have you a better
  suggestion?

8
What best to call these conditions?

• Non-communicable disease
• NCD
• Chronic disease
• Diseases of civilisation
• Lifestyle diseases

9
In September 2011 the UN held a high level
meeting on NCDs

• 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

10
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

11
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

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What didn't happen

• 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 buysmajor
  omissions
• Alcohol weak
• No champion countriesAustralia, Norway
• China and India not very visible too few G8
  champions
• Not many LMIC stepping forward
• Yet to engage the publicmust do by 2014

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Any questions or comments?
14
Burden of disease
15
Global Causes of Death (2006)
Chronic diseases
Infectious diseases
HIV/AIDS 4.9
Tuberculosis 2.4
Heart disease 30.2
Malaria 1.5
Total 58.0M
Other Infectious Diseases 20.9
Cancer 15.7
Injuries 9.3

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

Diabetes 1.9
Other chronic diseases 15.7
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Leading Causes of Mortality and Burden of
Diseaseworld, 2004
Mortality
DALYs

• 
  
• Ischaemic heart disease 12.2
• Cerebrovascular disease 9.7
• Lower respiratory infections 7.1
• COPD 5.1
• Diarrhoeal diseases 3.7
• HIV/AIDS 3.5
• Tuberculosis 2.5
• Trachea, bronchus, lung cancers 2.3
• Road traffic accidents 2.2
• Prematurity, low birth weight 2.0

• 
  
• Lower respiratory infections 6.2
• Diarrhoeal diseases 4.8
• Depression 4.3
• Ischaemic heart disease 4.1
• HIV/AIDS 3.8
• Cerebrovascular disease 3.1
• Prematurity, low birth weight 2.9
• Birth asphyxia, birth trauma 2.7
• Road traffic accidents 2.7
• Neonatal infections and other 2.7

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Burden of disease by broad cause group and
region, 2004
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Age-standardized DALYs for noncommunicable
diseases by major cause group, sex and country
income group, 2004
19
Deaths from chronic disease are displacing deaths
from infectious disease even in rural Bangladesh
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Shifting Patterns of Global Health
Deaths, of Total, 2005
Forecast Deaths, 2006-2015, Change
Total 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
0
5
10
15
20
25
-5
-10
Chronic diseases
Infectious diseases
21
(No Transcript)
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Ten leading causes of burden of disease, world,
2004 and 2030
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Yet only 3 of global health aid (21 billion)
goes to NCDs.
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Two points

• 1. Any comments or questions about the burden of
  disease?
• 2. Why do you think NCDs have been so neglected?

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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

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Two questions

• 1. What do you think are the causes of NCDs?
• 2. Why the increase in LMIC?

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Causes of NCDs
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Leading causes of attributable global mortality
and burden of disease, 2004
Attributable Mortality
Attributable DALYs

• 
  
• High blood pressure 12.8
• Tobacco use 8.7
• High blood glucose 5.8
• Physical inactivity 5.5
• Overweight and obesity 4.8
• High cholesterol 4.5
• Unsafe sex 4.0
• Alcohol use 3.8
• Childhood underweight 3.8
• Indoor smoke from solid fuels 3.3
• 59 million total global deaths in 2004

• 
  
• Childhood underweight 5.9
• Unsafe sex 4.6
• Alcohol use 4.5
• Unsafe water, sanitation, hygiene 4.2
• High blood pressure 3.7
• Tobacco use 3.7
• Suboptimal breastfeeding 2.9
• High blood glucose 2.7
• Indoor smoke from solid fuels 2.7
• Overweight and obesity 2.3
• 1.5 billion total global DALYs in 2004

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Deaths attributed to 19 leading factors,by
country income level, 2004
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Comorbidity US data
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We can make a difference death rates in the US,
1900-1996
Decline
32
How best to respond?
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How best to respond?

• We need a whole of government and a whole of
  society response
• Margaret Chan, director general, WHO

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Need for a broad strategy

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

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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?

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Some preliminary answers to some of the questions?
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First set of 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?

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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
  NCDsfor example, on poverty, trade, agriculture,
  education
• Some cannot be controlledageing of the
  population, globalisation
• Behavioural risk factors?
• We have strong evidence on how to act on some of
  thesefor 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 oneslike banning trans fats, reducing
  salt in food

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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)

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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 systemsstronger
  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?

41
Interesting question

• What might an entirely new system for preventing
  and controlling NCDs in a low income country look
  like?

42
Its 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!

43
View from Scotland on best way to look after
people with long term conditions
44
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 specialiststo avoid capture of
  resources

45
What do you think might be best buys for
responding to NCDs?
46
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

47
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

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Cost effectiveness and feasibility of best buys
Intervention Avoidable burden Cost effectiveness Implementation cost Feasibilty
Public health actions on tobacco 30m DALYS ltGDP/person Very low Highly
Public health actions on alcohol 10m DALYS ltGDP/person Very low Highly
Reduce salt intake, ban trans fats 5m DALYS (salt only) ltGDP/person Very low Highly
Mass media promotion physical activity Not known ltGDP/person Very low Highly
Counselling to smokers Not known lt3xGDP/person Quite low Feasible
Promote health eating in schools Not known gt3xGDP/person Quite low Highly
49
Cost effectiveness of population based strategies
Strategy Cost per DALY

Tobacco price controls 13 (3-85)
Tobacco non-price interventions 100 (55-761)
Trans fat substitution 1865 (0-7188)
Salt reduction (population level) 1320 (9-2761)
Cervical screening 769
Mammography 1350
Diabetes screening 5000
50
Individual based interventions

Strategy Cost/DALY
ACE inhibitor for congestive heart failure 0
Aspirin after myocardial infarction 0
Polypill secondary prevention 350
Nicotine replacement 400
Streptokinase after myocardial infaction 634
Primary prevention polypill 900
Diabetes control 3000
tPA after myocardial infaction 15900
Coronary artery bypass graft 27000
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Priorities of the UN Secretary General

• 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

52
Five priority interventions proposed by the Lancet
53
11 UnitedHealth and NHLBI Collaborating Centres
of Excellence to counter chronic disease
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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

55
Priorities of Sir George Alleyne, former director
of PAHO

• Action on risk factors, and most importantly of
  all implementation of the Framework Convention on
  Tobacco Control. He wonders whether there could
  be something like the FCTC for salt and fat.
• Monitoring and surveillance
• Improvement of health systems, concentrating on
  information, financing, and people.
• Access to simple technologies like drugs for
  hypertension

56
Countries implementing various parts of the
Framework Convention on Tobacco Control (174
countries have signed, 120 implemented)
Strategy Yes

Comprehensive plan 51
Infrastructure 81
Tax 90
Workplace restriction 87
Public transport restriction 86
Indoor public place restriction 81
Health warnings on products 111
Advertising ban 74
Cessation programmes in health facilities 57
57
What do you think of the concept of the
polypill? Might this be especially important in
LMICs?
58
The concept

• By giving people at relatively low risk of a
  heart attack or a stroke a pill once a day
  containing 4 to 6 different drugs it may be
  possible to reduce the incidence of heart attacks
  and stroke by three quarters
• The concept has developed in the past decade from
  several sources. There was good evidence
  different drugs (antihypertensives,
  antiplatelets, antilipidaemics) worked in
  different ways and that there effect was additive
• Most people who have heart attacks or stroke are
  actually at low riskbecause there are many more
  of them. PREVENTION PARADOX
• Most people at low risk are not treated, and even
  those who have had heart attacks or stroke dont
  get the treatments they should
• Thus the medical model of preventing heart
  attacks and strokes (diagnose and treat) is not
  working, but nor is the public health model of
  getting people to adopt healthier lifestyles
  working fast enough or in all sections of the
  community (its harder for the poor to change)

59
The concept

• The polypill might be given to those at 7.5-15
  risk of having a heart attack or stroke in the
  next 10 years (which obviously necessitates
  health workers assessing riskmeasuring blood
  pressure and lipids etc) or it might be given to
  everybody at age 55 without testingthe logic
  being that age is by far the most powerful
  predictor of risk (apart from having had a heart
  attack or stroke)
• Importantly the polypill can be manufactured for
  about 1 a month the component drugs are
  generic. This allows treatment of the poorin
  developed and developing countries
• People could take the different pills everyday
  (and many older people do already), but the hope
  is that taking one pill a day will greatly
  improve adherence

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The evidence

• Strong evidence that the individual drugs reduce
  deaths from heart attack and stroke, particularly
  in those at higher risk
• We know that the drugs work in different ways and
  that the effect is additive
• Some evidence that combinations of the drugs will
  reduce heart attacks and strokes
• We dont have evidence from RCTs that the
  polypill will reduce heart attacks and strokes in
  people at low risk and be safe. It would be
  surprising if it didnt, but this is the trial
  that is now neededand different versions of the
  trial are proposed
• There have been feasibility studies of whether
  people will take the polypill regularly and
  whether it will lower blood pressure, blood
  lipids, and platelet stickiness. One has now
  been published in the Lancet
• Effects of a polypill (Polycap) on risk factors
  in middle-aged individuals without cardiovascular
  disease (TIPS) a phase II, double-blind,
  randomised trial. Indian Polycap Study (TIPS),
  Yusuf S, Pais P, Afzal R, Xavier D, Teo K,
  Eikelboom J, Sigamani A, Mohan V, Gupta R, Thomas
  N.Lancet. 2009 Apr 18373(9672)1341-51.

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Current state of play

• There are at least five versions of the polypill,
  three from India, one from Iran and one from
  Spain
• There are five groups pursing the idea
• It has taken longer than expected to manufacture
  the pills and test for bioequivalence etc
• The manufacturer in the lead (Dr Reddys
  Laboratories from India) hopes to be able to get
  a polypill onto the market for secondary
  prevention (for those with established disease)
  within 18 months based on bioequivalence
• Another group (led by Sir Nicholas Wald in
  London) has a patent on the polypill in Europe
  amd a patent pending in the US. How this would
  effect Dr Reddys pill being used is unclear, but
  they might have to pay a licence fee.
• The Wellcome is funding an outcome study of
  primary prevention in India. They have allocated
  5m.

62
Major barriers

• The major difficulty is bringing the polypill to
  market. Plus doctors seem reluctant to use it.
• Major research based pharma companies are not
  interestedbecause the polypill (a breakthrough
  technology) may destroy existing lucrative
  markets for drugs not off patent
• It will not be possible to get regulatory
  approval for the polypill in people at low risk
  without the results of an efficacy trialbut at
  least major trials now look likely. Results will
  not be available for five years.
• Dr Reddy hopes to sell the polypill for about
  1.50 a month in India, 5 in other emerging
  markets, and 15 in the US and Europe. (Once the
  drug is on the market for secondary prevention
  physicians will be able if they want to prescribe
  it for those at low risk.)
• BUT THE PROBLEM IS THAT AS GENERIC COMPANIES THEY
  ARE NOT USED TO MARKETING AND HAVE NO WAY TO
  MARKET DRUGS TO CARDIOLOGISTS AND OTHER
  PHYSICIANS. THIS ALSO MAKES IT DIFFICULTY TO
  JUSTIFY INVESTMENT WITH THE COMPANY.
• Ideally they would like a major purchaser of
  drugslike the NHS in the UKto agree to a bulk
  purchase

63
What are the must dos in the many countries
that are currently doing nothing?
64
What MUST be done?

• National plan
• Infrastructure--government apparatus
• Surveillance
• Advocacy
• Implement Framework Convention on Tobacco Control
  (not all countries have signed)

65
Your presentations
66
How can I do better next time?
67
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