CARICOM Heads of Government
Summit on Chronic Diseases
Presentation of Prime Minister
Denzil Douglas
Overview of Presentation
•
•
•
•
•
•
Global situation with Chronic NCDs
Caribbean situation and costs
Caribbean Response
Exploding common myths
Review of effective interventions
The Way Forward
– Addressing the risk factors
• Globalisation and health
Globalisation and Health
THE MALADIES OF AFFLUENCE
The Economist, August 11th 2007
The poor world is getting the rich world’s diseases
“Europeans have been exporting their maladies
throughout history. They seem to be doing it
again, but in a new way. In the past the problem
was infection. Now illnesses associated with
Western living standards are the fastest growing
killers in poor and middle-income countries.
Chronic disease has become the poor world’s
greatest health problem”.
The Economist, August 11, 2007
Chronic Diseases and their Causes
Chronic Diseases
Heart Disease, Stroke, Cancer, Diabetes, Chronic Respiratory Disease
↑
Biological Risk Factors
Modifiable: overweight, high cholesterol, high blood sugar, high blood pressure
Non-modifiable: Age, Sex, and Genetics
↑
Behavioral Risk Factors
Tobacco use, physical inactivity, unhealthy diet, alcohol abuse
↑
Social and Environmental Determinants
Social, economic and political conditions such as income, living and working
conditions, physical infrastructure, environment, education, agriculture, and
access to health services
↑
Global Influences
Globalization of food supply, urbanization, technology, migration
Distribution of Deaths by Major Cause in the
World
Distribution of Deaths from Infectious and
Chronic Disease by Income Category, 2005
Crude Mortality Rates (per 100,000 population ) for Select Diseases: (2000-2004)
CARICOM Member States
140
120
Heart
Disease
Rates per 100,000 population
100
Cancers
80
Diabetes
Stroke
60
Injuries
Hypertensive
Diseases
40
HIV/AIDS
20
0
2000
2001
2002
Year
Source: CAREC, based on mortality reports from countries
2003
2004
Leading Causes of Death in CARICOM
Countries by Sex, 2004 (MINUS Jamaica)
FEMALES
MALES
1.
2.
3.
4.
5.
6.
7.
8.
Heart Disease
Cancers
Injuries and violence
Stroke
Diabetes
HIV/AIDS
Hypertension
Influenza/pneumonia
1.
2.
3.
4.
5.
6.
7.
8.
Heart Disease
Cancers
Diabetes
Stroke
Hypertension
HIV/AIDS
Influenza/pneumonia
Injuries and violence
Source: CAREC, based on country mortality reports
Potential Years of Life Lost <65
Potential
Years by
of Life
Lost <65years
by main causes,
years
main
causes,
20002000
& 2004, CARICOM countries (minus Jamaica)
and 2004, CARICOM countries
(minus Jamaica)
Injuries
Y2004
HIV/AIDS
Y2000
Chronic Disease
0
10000 20000 30000 40000 50000 60000 70000
Source: CAREC, based on country mortality reports
Note: Chronic Disease includes heart disease, stroke, cancer, diabetes, hypertension, chronic respiratory disease.
Injuries includes traffic fatalities, homicide, suicide, drowning, falls, poisoning
Disability Adjusted Life Years
2002
Disability Adjusted Life Years (000) 2002
300
250
200
Com Dis
NCDs
150
100
50
0
JAM
TRT
BAH
BAR
Mortality Attributable to Select Risk Factors (Latin America &
Caribbean), from DCP2
High BP
Obesity
Alcohol
Tobacco
High cholesterol
Low fruits & veg
Physical inactivity
Unsafe sex
0
100
200
300
Attributable Deaths (thousands)
400
500
Trends in Adult
Trends in Adult Overweight/Obesity
Overweight/Obesity
in
the
in the Caribbean
60
Caribbean
Prevalence (%)
50
40
30
Male
Female
20
10
0
1970s
1980s
YEARS
1990s
Prevalence (%) of diabetes among adults
in the Americas
16.4
Barbados
Trinidad/Tobago
Jam aica
Belize
Cuba
Mexico
USA
Nicaragua
Surinam e
Bolivia
Guatem ala
Colom bia
Costa Rica
Argentina
Brazil
Haiti
Paraguay
Urban Peru
Chile
Honduras
12.7
12.6
12.4
11.8
10.7
9.3
9
8.7
8.6
8.4
8.2
7.9
7.6
7.6
7.3
7.2
7.2
6.3
6.1
Source: Pan Am J Public Health 10(5), 2001; unpublished
(CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)
Caribbean trends in Diabetes mortality
80
Rate/100,000
70
60
Male
Female
50
40
30
20
1985
1990
1995
2000
A consequence of Diabetes
Amputations at the QEH 2002-2006
Diabetic
Non diabetic
Male
308
116
Female
379
120
Total
995
236
Source A. Hennis, 2007
Age adjusted death rates/100,000
population from Diabetes (2000)
120
100
80
60
40
20
0
BAH
BAR
GUY
JAM
SUR
TRT
CAN
USA
From community surveys, the prevalence of
hypertension in adults 25-64 years of age was:
Barbados
27.2 %
Jamaica
24.0 %
St. Lucia
25.9 %
The Bahamas 37.5%
Belize
37.3%
Trinidad
TBD
Control of blood pressure would reduce the death
rates from Cardiovascular Disease by about 1520%.
Principal Clinic Visits,
20,000
Saint Vincent & the Grenadines, 2000 vs 2003
15,000
2000
10,000
2003
5,000
0
HTN or HTN/DM
DM or DM/HTN
Arthritis/Muscu
Age adjusted death rates/100,000
population from Hypertension (2000)
50
45
40
35
30
25
20
15
10
5
0
BAH
BAR
GUY
JAM
SUR
TRT
CAN
USA
Projected National Income Lost from NCDs
Projected national income lost from NCDs ( 2005-2015)
2005 -2015, $USBN
600
500
400
300
200
100
0
Bra
Can
Chi
Ind
Nig
Pak
Rus
UK
Tan
Possible economic burden
($US Million, 2001)
BAH
BAR
JAM
TRT
27.3
37.8
208.8
494.4
Hypertension 46.4
72.7
251.6
259.5
Total
110.5
460.4
753.9
Diabetes
76.7
Total cost of DM and H/T as percent of GDP
8
7
6
5
4
3
2
1
0
BAH
BAR
JAM
TRT
Exploding the Myths
• Myth: Chronic diseases are a problem
of the rich countries
Fact: Non-communicable disease
account for more than half the burden
of disease and 80% of the deaths in the
poorer countries which carry a double
burden of disease.
Developing countries carry a
double disease burden
Percentage of deaths by cause
Low- and Middle-income countries
High-income countries
6%
10%
7%
54%
36%
87%
non-communicable diseases
communicable diseases
injuries
Exploding the Myths
Myth: NCDs are a problem only of the elderly
Fact: Half of these diseases occur in adults
less than 70 years of age and the problems
often begin in the young e.g., obesity
Myth: NCDs affect men more than women
Fact: NCDs affect women and men almost
equally and globally, heart disease is the
largest cause of death in women.
Exploding the Myths
Myth: NCDs cannot be prevented
Fact: If the known risk factors are
controlled, at least 80% of heart
disease, stroke and diabetes and 40 %
of cancers are preventable, and in
addition
there
are
cost-effective
interventions available for control.
Exploding the Myths
• Myth: people with NCDs are at fault and
to be blamed because of their unhealthy
lifestyles
• Fact: individual responsibility, while
important, only has full effect where
people have equal access to healthy
choices. Governments have a crucial role
to play by altering the social environment
to help make the healthy choice the
easy choice.
Exploding the myths
• Myth: “my grandfather smoked and lived to
90 years”, and “everyone has to die of
something”
• Fact: While some people who smoke will live
a normal lifespan, the majority will have
shorter, poorer quality lives. And yes,
everyone has to die, but death does not need
to be slow, painful or premature, as is so
often the case with NCDs
What works?
• A small shift in average population levels of
several risk factors can lead to a large reduction
in chronic diseases
• Population wide approaches form the central
strategy for preventing and controlling chronic
disease epidemics, but should be combined with
interventions for individuals
•
Many interventions are not only effective, but
suitable for resource constrained settings
Finland: Dramatic Declines in NCD
Mortality
Relation of fitness to mortality
T&T, St. James Cardiovascular Study
• 1309 men had blood sugar, cholesterol,
fitness measured at baseline and then
followed up carefully for 7 years.
• Unfit men compared with fit men were:
- 3.6 times more likely to die
- 2.5 times more likely to have a heart
attack
Caribbean Responses
• Since the 1960s, history of collective action in health,
formalized in 1986 as the Caribbean Cooperation in Health
(CCH) initiative.
• Countries, CAREC, CFNI and CHRC, CARICOM
secretariat, PAHO/WHO and partners have had successes
e.g.,, malnutrition and gastroenteritis, vaccine preventable
diseases, HIV/AIDS (p (PANCAP).
• CCH now entering 3rd phase: major thesis that Caribbean
health can be improved through actions taken
universally and collectively.
• Current priorities for action under CCH include chronic
diseases where the cited goals are to reduce deaths by 2%
per year and to reduce serious, costly complications such as
amputations or renal failure.
Caribbean Responses Summarised
A
N
G
A
N
T
B
A
H
National focal point,
Department or Unit

National law, legislation,
decree

B
A
R
G
U
Y
H
A
I
J
A
M
 
S
U
R
T
R
T




National Objectives
Implementation of DPAS

 


National system of
Health reports, survey
and surveillance
 


Demonstrative
community-based
programs

National standards and
protocols for treatment



Implementation of FCTC

Quality assurance of
care
Financial resources




Source: PAHO Survey of NCD National Response Capacity, 2005
Addressing the risk factors
Tobacco and alcohol
• Increase taxes with proceeds to prevention and
treatment
• Ban smoking in public places
• Ban smoking in all schools
• Ban cigarette and tobacco advertising near to
schools
• Curtail promotion of alcohol products targeted
to women and children
• Establish target dates for passage of the legal
provisions in the FCTC already ratified.
Addressing the risk factors
Physical activity
• Have physical education compulsory in
schools and provide the facilities
• Provide healthy, secure exercise spaces
• Provide wellness centers
• Give tax relief for worksite exercise
facilities
Addressing the risk factors
Improve dietary practices
• Promote a standard of meals in public eating places
eg. eliminating trans fats
• Provide healthy school meals
• Establish community based networks for training in
preparation of health foods
• Mandate RNM to investigate the trade issues which
impact negatively on healthy food imports
• Promote elimination of trans fats from Caribbean diets
Addressing the risk factors
In the case of cancer
• Primary prevention
Eg screening and vaccination to prevent
cervical cancer
Promote screening for breast cancer
Secondary prevention
• Screening programs for NCDs
• Provide health services with resources to
apply the established cost-effective
interventions
• Establish mechanisms to ensure
availability of the medications necessary
for the long term treatment of NCDs when
they occur
Critical other recommendations
• Establish national level Commissions on
NCDs
• Mandate CAREC to establish a system of
behavior and risk factor surveillance
• Insist on the updating of the Caribbean
Regional Plan of Action for NCDs
• The Caribbean should name a
“CARIBBEAN WELLNESS DAY”
Involve Partners
• PAHO/WHO
• Financial institutions
• Caribbean social partners – private sector
and civil society
Monitoring and evaluation
• Designate CARICOM/PAHO as the joint
Secretariat with responsibility for monitoring
and reporting progress in the control of the
NCDs.
The way forward
First: We can utilize the policy instruments
at our disposal
legislation
taxation
regulation
Second: We should establish partnerships
Third: We must take personal
responsibility and lead by example
CONCLUSIONS
• The Caribbean has a very serious problem - getting worse
• Economically and socially, it is not sustainable
• There are cost-effective interventions that work; why not utilise
them?
• We must put into effect National and Caribbean-wide (CCH)
plans
• It is CRITICAL to strengthen health services to for management
and control of chronic diseases
• Deepened partnership with public and private sector, and civil
society absolutely needed