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
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
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
Global burden of disease: DALYs
Low & middle income countries
Lopez et al, Lancet 2006:367:1747
High income countries
Rates of NCDs are higher in poorer than
affluent countries
Dramatic declines in child mortality - globally
UN Inter-agency group on child mortality estimation. Levels and trends in child mortality, 2011
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1960
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1970
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1980
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
1990
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2000
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2010
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2020
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2030
Africa
Percent population 80+ years
Asia
Eastern Europe
Latin America/Caribbean
North America/Oceania
Western Europe
2040
HelpAge International;
www.un.org/esa/population/ageing/ageing2009chart.xls
Successful maternal child health
programmes result in reductions in
fertility and increased life expectancy
– an ageing population
Lancet October 5th, 2005
World Health Organization & World Bank
have emphasised need for chronic diseases
in low and middle income countries to be
taken seriously
Many Calls to Action on NCDs...
but so has everything else
-Adapted from Ebrahim, Int J Epidemiol 2008
December 8th 2007
THE LANCET
8-14 December
2007
“No serious conversation
about global health can now
take place without at least
citing chronic diseases as a
critical part of international
health strategies”
Chronic diseases
“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
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”
Tobacco: consumption and tax
association in China
Wang et al Lancet 2005;366: 1821-4
Salt control: voluntary code for food industry,
advice to reduce salt in the home
BMJ
28 June 2003
A pill to prevent 80% of heart attacks
Polypill would contain a statin, three antihypertensives, folic acid
and aspirin
Potential impact of interventions
on death rates over 10 years
16.5 million
deaths
prevented
13.2 million
deaths not
avoidable
18 million
deaths
prevented
Population
High risk
Asaria et al, Lancet 2007;370:2044-2053
Not avoided
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
Stuckler, Basu, McKee. Commentary: UN
high level meeting on non-communicable
diseases: an opportunity for whom?
Civil society NGOs receive
funding from food, alcohol and
pharmaceutical industries
BMJ 2011; 343 doi: 10.1136/bmj.d5336
Bill & Melinda Gates
Foundation – own 10% of
global Coca Cola stock
Where we are going
•
•
•
•
UN High Level meeting
Alliances: not disease specific silos
Global Health not NCDs
Getting political
United Health* & NHLBI
collaborating centres of excellence
* “We're in the business of helping people live healthier lives”
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
AGA KHAN:
Karachi
SANCD,
CCDC, PHFI
Lucknow
CCMB, NIN,
Hyderabad
SNEHA:
Mumbai
SANGATH
Goa
Inst Research &
Development,
Sri Lanka
Wellcome Strategic
Award for building
research capacity for
chronic diseases (£4.5
million), 2009-2013

mHealth: diabetes,
hypertension,
depression

Population-based
research
ICDDR,B:
Dhaka
CCDC factory
sites
VHS:
Chennai
ARAVIND:
Pondicherry

National Family
Household Survey,
NSSO analyses

Andhra Pradesh
Children & Parents
Study

Genetics: COPD, DBT

Policy: insurance, DfID
South Asia Network for Chronic Disease,
Public Health Foundation of India
35
Talking about global health
Joe the Plumber says:
-HIV
-Hunger
-Poverty
-Siegel and Stuckler 2010 in preparation
What do we need to do?
Geneau et al Lancet 2010;376:1689-98
Political Process Model
-Reframing the Debate
-Create Political Opportunities
-Mobilise Resources
Reframing the Debate: Social Causes
- Diseases of choice: victim-blaming
- Diseases of affluence
- ‘Us’ and ‘them’
“Isn’t obesity a sign of progress?”
Personal Communication, author of World Bank
World Development Report 2003
The causal chain goes
from the political to the
pathological
Social &
Economic
Determinants
Common risk
factors
Health care costs +
economic productivity
Common
chronic
diseases
Failure to meet
MDGs
Health care costs +
economic productivity
Political choice:
palm oil not
soya oil
Blood
cholesterol
levels
Coronary heart
disease
increases
Failure to meet
MDGs
Political opportunities
•
•
•
•
UN High Level meeting level
Older people vote
Social inequalities + civil unrest
Understanding the opposition
Not a headline grabber...
Compared with a decade ago...
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-dementiasnow-included/
Commission on Social Determinants of Health
• Life
expectancy
• Infant mortality
• Income
• Employment
• Gender
• Education
• Ethnicity
• Health care
• Social support
•“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
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”
Framework
convention on
tobacco control:
ratified but not
implemented
India banned
smoking in public
places before
England
But multi-national
corporates move
fast...
Corporate agendas for health and happiness? Who
benefited here?
The debate is not about priorities for
child survival or cataract surgery for old
men. Both young and old require a
functioning primary health care service
– adequate, accessible, affordable
Summary
• Chronic diseases are THE major cause of death
and disability in most developing countries
• Demographic and epidemiologic transitions are
due to remarkable success stories in
development
• We have effective means of controlling
population risk factor levels – we need to
implement them
• A new political process is required to achieve
action focused on development for health