NON-COMMUNICABLE DISEASES: THE COMING PLAGUE Where we are and where we are going

1. NON-COMMUNICABLE DISEASES: THE COMING PLAGUE Where we are and where we are going Shah Ebrahim London School of Hygiene & Tropical Medicine & South Asia Network for Chronic Diseases Public Health Foundation of India

2. Where we are - • Strong evidence of NCD burden • Remarkable success in MCH • An ageing population = increases in NCDs • Technical solutions but limited action • Vested interests

3. Global Burden of Disease, 1990 EME: established market economies FSE: former socialist economies CHN: China LAC: Latin America/ Caribbean OAI: Other Asia & Islands MEC: Middle East IND: India SSA: Sub-Saharan Africa Murray C, Lopez A, Jamison D. Bull World Health Organization, 1994;72: 495-509

4. Global burden of disease: DALYs Low & middle income countries High income countries Lopez et al, Lancet 2006:367:1747

5. Rates of NCDs are higher in poorer than affluent countries

7. Dramatic declines in child mortality - globally UN Inter-agency group on child mortality estimation. Levels and trends in child mortality, 2011

9. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 1960

10. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 1970

11. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 1980

12. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 1990

13. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 2000

14. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 2010

15. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 2020

16. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 2030

17. Africa Asia Eastern Europe Latin America/Caribbean North America/Oceania Western Europe Percent population 80+ years 2040

18. HelpAge International; www.un.org/esa/population/ageing/ageing2009chart.xls

19. Successful maternal child health programmes result in reductions in fertility and increased life expectancy – an ageing population

20. Lancet October 5th, 2005

21. World Health Organization &World Bank have emphasised need for chronic diseases in low and middle income countries to be taken seriously

23. Many Calls to Action on NCDs... but so has everything else • Adapted from Ebrahim, Int J Epidemiol 2008

24. THE LANCET “No serious conversation about global health can now take place without at least citing chronic diseases as a critical part of international health strategies” 8-14 December 2007 Chronic diseases December 8th 2007 “36 million deaths from chronic diseases could be postponed by public health and primary care in the next 10 years at a cost of US$1.50 per person per year” Beaglehole, Ebrahim, Reddy et al, Lancet 2007

25. WHO’s 2007 strategy for low and middle income countries • Population wide: tobacco control, salt restriction (awareness, voluntary code) • High risk strategy: all those with CVD + those at high risk (1.5% annual risk of death) defined by risk factor profiles (age, sex, smoking, BP, BMI) treated with “multi-drug regimen”

26. Tobacco: consumption and tax association in China Wang et al Lancet 2005;366: 1821-4

27. Salt control: voluntary code for food industry, advice to reduce salt in the home

28. A pill to prevent 80% of heart attacks 28 June 2003 BMJ Polypill would contain a statin, three antihypertensives, folic acid and aspirin

29. Potential impact of interventions on death rates over 10 years Asaria et al, Lancet 2007;370:2044-2053

30. The UN High Level meeting on NCDs United States, Europe, and key Western allies, blocked consensus on action on NCDs Food companies lobbying for increased LMIC markets (by Obama’s former Comms. Executive) Philip Morris – Project Sunrise – subversive operations against anti-tobacco lobby Civil society NGOs receive funding from food, alcohol and pharmaceutical industries Bill & Melinda Gates Foundation – own 10% of global Coca Cola stock Stuckler, Basu, McKee. Commentary: UN high level meeting on non-communicable diseases: an opportunity for whom? BMJ 2011;343doi: 10.1136/bmj.d5336

31. Where we are going • UN High Level meeting • Alliances: not disease specific silos • Global Health not NCDs • Getting political

33. United Health* & NHLBI collaborating centres of excellence *“We're in the business of helping people live healthier lives”

34. Global Alliance for Chronic Disease National Health Medical Research Council, Australia Canadian Insititutes of Health Research Chinese Academy of Medical Sciences Medical Research Council UK NIH – NHLBI & Fogarty Indian Medical Research Council - 80% of public health research funding

35. SANCD, CCDC, PHFI AGA KHAN: Karachi Lucknow ICDDR,B: Dhaka CCDC factory sites SNEHA: Mumbai VHS: Chennai SANGATH Goa ARAVIND: Pondicherry Wellcome Strategic Award for building research capacity for chronic diseases (£4.5 million), 2009-2013 • mHealth: diabetes, hypertension, depression • Population-based research • National Family Household Survey, NSSO analyses • Andhra Pradesh Children & Parents Study • Genetics: COPD, DBT • Policy: insurance, DfID CCMB, NIN, Hyderabad Inst Research & Development, Sri Lanka South Asia Network for Chronic Disease, Public Health Foundation of India

36. Talking about global health

37. Joe the Plumber says: • HIV • -Hunger • -Poverty • Siegel and Stuckler 2010 in preparation

38. What do we need to do? Geneau et al Lancet 2010;376:1689-98

39. Political Process Model • Reframing the Debate • -Create Political Opportunities • -Mobilise Resources

40. Reframing the Debate: Social Causes “Isn’t obesity a sign of progress?” • Diseases of choice: victim-blaming • Diseases of affluence • ‘Us’ and ‘them’ Personal Communication, author of World Bank World Development Report 2003

41. The causal chain goes from the political to the pathological Health care costs + economic productivity Social & Economic Determinants Common chronic diseases Common risk factors Failure to meet MDGs

43. Health care costs + economic productivity Coronary heart disease increases Political choice: palm oil not soya oil Blood cholesterol levels Failure to meet MDGs

44. Political opportunities • UN High Level meeting level • Older people vote • Social inequalities + civil unrest • Understanding the opposition

45. Not a headline grabber...

46. Compared with a decade ago...

47. Buenos Aires, protest against UN High Level Meeting on NCDS ignoring older people http://www.helpage.org/newsroom/latest-news/un-meeting-on-ncds-ageing-and-dementias-now-included/

48. Commission on Social Determinants of Health • Life expectancy • Infant mortality • Income • Employment • Gender • Education • Ethnicity • Health care • Social support

49. “India’s 12th Plan will be a health plan” Manmohan Singh, PM • Public & private sector providers • Funding 1.2% GDP up to 3% • But no role for health insurance

50. Mobilising Resources • Advocate Global Health • Co-benefits & common cause • MDGs, climate change, early life health system • Pathways to Prevention • (eg Lazarus Effect) • Clear message • “3FOUR50”? • “Roll back Malaria” • “No health without mental health”