Non communicable disease – A Race against time Professor Stephen R. Leeder

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
Managing Director, World Economic Forum
“Non-communicable diseases are a
serious threat to global well-being …
they are identified as one of the major
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
• 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 middleincome 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 noncommunicable chronic diseases, such as heart disease, diabetes and
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
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
What are the economic
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
– 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)
– Patients selected from hospitals with specialized
cardiology and neurology departments and outpatient clinics in hospitals in
the province of Buenos Aires
– Patients selected from nine facilities in Tanzania
Mainland and Zanzibar.
– Patients randomly selected from six hospitals in Trivandrum
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
• 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 the cases (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.
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
Key findings from Race against Time
• CVD strikes the labor force of developing
countries more forcefully than in the OECD
Zhang Huimin (张敏)
• 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.
Economic costs: millions of productive personyears of life lost* - Race against Time
South Africa
In 2000…
*these estimates use conservative estimates of CVD mortality
Race against
against Time
AA race
Percentage of total dependency attributable
to the 65+ population, 2000 and 2040
Percent total
Source: World Bank Development Indicators
The Window of Demographic
• For 20 y, dependency will
decline with ↓ BR.
• Person >65 costs 3X
• Window to re-invest from
productive labor is now,
and closing.
% Population Dependent
• Then ↑ not 0-4 but in 65+
Dependency Rates
S Africa
A Race against Time
CVD age-specific mortality in the working age population
expressed as a rate per 100,000 population (in 2000)
Race against
against Time
AA race
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
• 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
for dedicating greater attention to PREVENTING diabetes and
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
– the causes of high blood pressure and the benefits of control
– the causes of hyperlipidaemia and dietary recommendations;
– stress and strain reduction in the workplace.
Cost-effectiveness of policy
Gaziano and colleagues assessed government spending
for the prevention and control of CVD based on different
strategies for controlling risk factors
– 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.
Order of presentation
• Outlining the problem of chronic disease
• Microeconomic implications
• Macroeconomic implications of a changing
• Ideas into action in China – Building for
• 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
• 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
• 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 treat diabetes and CVD
Prevention should be on the agenda for everyone, including women and
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!
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