Non communicable disease – A Race against time

Non communicable disease – A Race against time Professor Stephen R. Leeder Fudan University Tuesday 24th May 2011

Non communicable disease – A Race against time Professor Stephen R. Leeder Lanzhou University Friday 27th May 2011

Non communicable disease – A Race against time Professor Stephen R. Leeder Lanzhou University - Yuzhong Campus Tuesday 31st May 2011

RICHARD SAMANS Managing Director, World Economic Forum “Non-communicable diseases are a serious threat to global well-being … they are identified as one of themajor risks for businesses and economies; they represent a growing economic and social challenge for many developed and developing countries.”

Order of presentation • Outlining the problem of chronic disease • Microeconomic implications • Macroeconomic implications of the changing global demography • Ideas into action – Building for tomorrow! • Key messages

How big is the Problem? Diabetes, CVD, cancer and chronic respiratory disease cause 35 million deaths a year, 28 million of which occur in low- and middle- income countries Chronic diseases are by far the leading causes of mortality in the world They cause substantial morbidity, premature death, disability, reduced quality of life and financial cost to countries and families.

Epidemiological transition What is epidemiologic transition? The displacement of pandemics of infectious disease, malnutrition and complications of childbirth with emerging epidemics of non-communicable chronic diseases, such as heart disease, diabetes and cancers.

The link between diabetes and CVD • Diabetes mellitus and abnormal glucose metabolism due to insulin resistance are major risk factors for cardiac and vascular disease (CVD) • Their increasing prevalence among children and adults in association with rising levels of obesity is of special concern • CVD is the most costly complication of diabetes. American Diabetes Association: Direct costs of diabetes http://www.hhs.gov/news/press/2003pres/20030227a.html

What are the economic consequences? Initiative for Cardiovascular Health (IC-Health) Research: • Studied the microeconomic consequences in families of people admitted to hospital for heart disease in China, India, Argentina and Tanzania • A cross-sectional survey collected primary data from CVD patients at outpatient clinics in hospitals or at their residences • Family studies were supplemented by a review of the cost-effectiveness of preventive interventions.

Initiative for Cardiovascular Health (IC-Health) Microeconomic Impact Study • Each country chose 3 to 7 hospitals from different economically developed areas • Outpatients were sampled from: • poorest 40% • middle 40% • richest 20% • From each country, 500 individuals with acute coronary syndrome (ACS) or stroke were surveyed.

Data collection After obtaining consent from the patient, information was collected on: • Demography and CVD diagnosis and history • Care-seeking behaviour of individuals with a CVD incident • Expenditures on CVD treatment for most recent event • Tobacco use • Effect on productivity of household • Household economic information.

Data collection • China – Patients selected from three hospitals in Beijing and Henan Zhoukou City: Beijing Anzhen Hospital (high-income); Beijing Fangshan Hospital (middle-income); and Henan Zhoukou Hospital (low-income) • India – Patients randomly selected from six hospitals in Trivandrum district • Argentina – Patients selected from hospitals with specialized cardiology and neurology departments and outpatient clinics in hospitals in the province of Buenos Aires • Tanzania – Patients selected from nine facilities in Tanzania Mainland and Zanzibar.

Microeconomic CVD costs in China • Zhao and colleagues found that more than half of the households experienced catastrophic health expense due to CVD events, particularly among the lowest income group. • Although annual total CVD expenditures were high among patients belonging to the high income group, most of them were covered by health insurance. • Annual total out-of pocket CVD expenditures among high income patients were much lower than those of lowest income patients • High income: ¥ 3600; equivalent international dollar: $1731 • Low income: ¥ 7100; equivalent international dollar: $3413.

Secondary analysis of 3rd National China Health Service Survey, 2003 • Among the 3299 households with CVD patients, 62.9% had a daily expenditure below the poverty line and many of the households did not have enough money to pay for their treatments • The proportion of households below the poverty line due to health expenditure was much higher among households with family members hospitalized in the previous year • The poverty gap for those below the poverty line increased due to health expenditures.

Microeconomic CVD Costs in India • Harikrishnan and colleagues found that 72.9 % of households experienced catastrophic health spending • Patients with the lowest income were most affected - distress financing (borrowing money from relatives, selling assets or taking loans) ranged from 36% (highest income) to 51% (lowest income) • Income loss was highest for low income patients and they had less chance of undergoing invasive procedures like angioplasty • Acute coronary patients spent more on treatment and a significant percentage were unable to afford all the medications prescribed, compared to stroke patients.

Microeconomic CVD Costs in Argentina • Pichon-Riviere and colleagues found catastrophic health spending was highest in the lowest income bracket (15.3%); extended family formed the major (36.8%) source of financing to cover health expenses • The highest income group were able to manage expenses using health care coverage in 30.3% of the cases • Low income households experienced the greatest change in income following an event – as a consequence, patients reported emotional problems (72.4%) and feeling limited (86.7%) • All patients experienced a decrease in their ability to work after a CVD event, manifest as decreased hours or limitations in the scope of their work activities.

Microeconomic CVD costs in Tanzania • Ramaiya and colleagues found 69.8% patients experienced catastrophic expenditure - the biggest burden was on the lowest income groups (94% of the financing came from out-of-pocket payments) • About one third of patients did not take their medication as prescribed; this was largely due to the unaffordable costs of medication (76%) • Strokes accounted for majority of thecases (60%) and occurred frequently in younger patients (mean age: 54). Most did not reach the hospital, and the traditional healers treated such cases. Mostly the high income group approached the hospitals after an event but hospitals were ill equipped to deal with strokes.

Key findings from Race against Time • CVD strikes the labor force of developing countries more forcefully than in the OECD • While male death rates are higher than female, women in developing countries fare far worse than their OECD sisters • The costs of CVD, both directly to health care and indirectly to economic productivity are enormous • The labor force effect threatens the current low dependency “window” in these economies, a window that will begin to close in two decades. Zhang Huimin (张敏)

Economic costs: millions of productive person-years of life lost* - Race against Time *these estimates use conservative estimates of CVD mortality

Percentage of total dependency attributable to the 65+ population, 2000 and 2040 60 40 20 0 Percent total dependency 2040 2000 China Brazil Russia India South Africa A Race against Time A race against time Source: World Bank Development Indicators

The Window of Demographic Opportunity • For 20 y, dependency will decline with ↓ BR. • Then ↑ not 0-4 but in 65+ people. • Person >65 costs 3X child. • Window to re-invest from productive labor is now, and closing.

A Race against Time CVD age-specific mortality in the working age population expressed as a rate per 100,000 population (in 2000)

A Race against Time A race against time Cumulative percentage of all CVD deaths, 2000-2030, occurring in males and females aged 35-64

Macroeconomic consequences • Surcke and Rocco studied the macroeconomic costs of CVD mortality in Argentina, China, Czech Republic, India, Tanzania and Ukraine • They estimate that a reduction in CVD deaths by 10 per 100,000 of the population adds 7% to the country’s per capita income • The potential large economic consequences of chronic illness, whether measured in growth or welfare terms, provide a rationale fordedicating greater attention to PREVENTING diabetes and CVD.

Taking action through prevention • Prevention programs must be locally tailored and sustainable. Countries should take the first step in program development themselves, remembering that success will require a sustainable collaborative effort built on commitment from all elements in civil society and professional capability in prevention and treatment. • Commitment from the highest levels of government is essential for comprehensive heart disease and stroke prevention. Business must be at the table. Public health people need to open their minds to new collaborations. Civil society is a very important player here.

Examples of policy interventions • Providing information and other programs addressing: • the dangers of obesity and warnings about diabetes; • the importance of good nutrition and physical exercise in weight control and cardiovascular health; • the risks of smoking, the value of excise and taxes aimed at reducing smoking uptake and intensity, restrictions on smoking in public places and smoking advertising and smoking cessation treatment; • the causes of high blood pressure and the benefits of control strategies; • the causes of hyperlipidaemia and dietary recommendations; and • stress and strain reduction in the workplace.

Cost-effectiveness of policy interventions • Excise tax on tobacco in South Africa, the most cost effective option assessed, is estimated would cost $196 million to implement and bring in $2.7 billion in tax revenue • Community health workers to improve compliance with hypertension management in India, with prevalence of 20%, would save: • $700,000 in hospital costs per million persons • Avert 700 deaths and 750 hospitalisations for stroke or myocardial infarction per million persons. Gaziano and colleagues assessed government spending for the prevention and control of CVD based on different strategies for controlling risk factors

Order of presentation • Outlining the problem of chronic disease • Microeconomic implications • Macroeconomic implications of a changing demography • Ideas into action in China – Building for tomorrow! • Key messages

Stroke prevention • Major national programmes to promote healthy behaviour and prevent chronic diseases have not yet taken hold in China. • Pilot programmes show promising results! • Here are two examples – one in the community and one in the workplace.

Example 1 – Community • Three cities - Beijing, Shanghai, Changsha – piloted a community-based intervention in 1992 and 2000 • Consisted of blood-pressue screening, treatment of hypertension, health education • Two cities (140,000 participants) plus control city • After 9 years, strokes fell by 51.5% in men and by 52.7% in women compared with 7.3% and 15.7% respectively in the control city. Lancet 2008; 372: 1697–705 Yang et al.

Example 2 – Workplace • Factories owned by the Capital Iron and Steel Company were assigned to intervention and comparison groups. • The intervention, for cerebrovascular disease, involved blood-pressure screening, treatment of hypertension, restriction of salt intake, and programmes to lose weight. • After 8 years, the average blood pressure and proportion of people with hypertension were lower in the intervention group (2.5 mm Hg) than in the comparison group (2.2 mm Hg).

The challenges The most pressing problems in the prevention of chronic disease in China relate to tobacco use and high blood pressure

What can be done by researchers? Change relating to the broader public health issues of tobacco control, urban design, and the accessibility and supply of nutritious foods, particularly in schools, may be outside of the sphere of influence of researchers, BUT: • Physicians and PH researchers can be effective advocates in the prevention of chronic disease, and • Research may be used to inform policy.

Research informs health policy • Effective health policy depends on a strong base of science and research. • There is considerable potential for health research to contribute to improved health services, programs, and outcomes. • Chronic disease prevention and management are multi-faceted issues requiring action - and research - in a wide range of areas. Researchers and physicians can assist by: • Collecting, analysing and presenting monitoring data; • Helping to establish and maintain disease registries; and • Becoming involved in conducting clinical trials.

Order of presentation • Outlining the problem of chronic disease • Microeconomic implications • Macroeconomic implications of the changing global demography • Ideas into action in China – building for tomorrow! • Key messages

The key messages • Diabetes and CVD are cutting into productive workforces in developing countries now • The entire world is aging and this will only exacerbate the costs of managing chronic disease • The good news: we know how to prevent and treatdiabetes and CVD • Prevention should be on the agenda for everyone, including women and children • Prevention programs need to be locally sustainable. • More research on, and programs to prevent and treat, chronic disease will be needed – Chinese Universities can make a difference!

Acknowledgements Thank you to all of the IC-Health Collaborators: • Dr Ajay VS • Dr Harikrishnan S • Tom Gaziano • Shifalika Goenka • Adrianna Murphy • Andres Pichon-Riviere • Dr Prabhakaran D • Kaushik Ramaiya • Krishna Rao • Dr Reddy KS • Lorenzo Rocco • Marc Surcke • Dong Zhao

Non communicable disease – A Race against time