Richard Smith: “Non-communicable disease and mental health in low and middle income countries”

1. Non- communicable disease and mental
health in low and middle income countries
Richard Smith
Director, UnitedHealth Chronic Disease Initiative

2. Agenda
• Definitions
• The UN meeting
• Scale of the problem
• Causes
• How best to respond (concentrating on NCDs)?
• What must be done?

3. Non-communicable disease
• WHO defines non-communicable disease (NCD) as
cardiovascular disease, diabetes, chronic respiratory
disease, and certain cancers.
• All of these have in common that they are caused
predominantly by smoking, poor diet, physical
inactivity, and the harmful use of alcohol.
• Doesn't include mental health and many other
chronic conditions
Source: World Health Organization, 2005

4. In September 2011 the UN held a high level meeting on
NCDs (did not include mental health)
• Only the second high level meeting of the UN on health
• The first in 2001 led to the Global Fund for AIDS, TB,
and malaria
• Led to a flurry of activity and a raising of consciousness
(although not among ordinary people)
• 130 countries spoke; 200 civil society representatives
attended; 40 side meetings
• Russia committed $60m and Australia $3.9m

5. Future commitments with target dates
• 2012: work with WHO and all stakeholders to
set targets
• 2013: review of the MDGs; integrate NCDs
• 2014: UN review of progress

6. What was achieved?
• On global agenda
• Meeting was a step change
• Understanding that a response must go well beyond
health sector
• “Whole of society, whole of government”
• Development issue
• Civil society movement important
• Beginning not the end

7. What didn't happen
• Nothing on mental health. Should there be another high level meeting?
• No new funding apart from Russia and Australia, didn't expect it
• WHO costing report and WEF report came too late, some best buys got
lost
• NCD Alliance has issues with best buys—major omissions
• Alcohol weak
• No champion countries—Australia, Norway
• China and India not very visible; too few G8 champions
• Not many LMIC stepping forward
• Yet to engage the public—must do by 2014

8. Burden of disease

9. Global Causes of Death (2006)
Chronic diseases: Infectious diseases:
HIV/AIDS 4.9%
Heart disease Tuberculosis 2.4%
30.2%
Malaria 1.5%
Total: Other
Infectious
58.0M Diseases
20.9%
Cancer
15.7% Injuries 9.3%
The total number of people
Diabetes dying from chronic diseases is
1.9% double that of all infectious
Other chronic diseases diseases including HIV/AIDS,
tuberculosis and malaria
15.7% (Nature, 2007).

10. Leading Causes of Mortality and Burden of Disease
world, 2004
Mortality DALYs
% %
1. Ischaemic heart disease 12.2 1. Lower respiratory infections 6.2
2. Cerebrovascular disease 9.7 2. Diarrhoeal diseases 4.8
3. Lower respiratory infections 7.1 3. Depression 4.3
4. COPD 5.1 4. Ischaemic heart disease 4.1
5. Diarrhoeal diseases 3.7 5. HIV/AIDS 3.8
6. HIV/AIDS 3.5 6. Cerebrovascular disease 3.1
7. Tuberculosis 2.5 7. Prematurity, low birth weight 2.9
8. Trachea, bronchus, lung cancers 2.3 8. Birth asphyxia, birth trauma 2.7
9. Road traffic accidents 2.2 9. Road traffic accidents 2.7
10. Prematurity, low birth weight 2.0 10. Neonatal infections and other 2.7
10

11. Burden of disease by broad cause group and region,
2004
11

12. Age-standardized DALYs for noncommunicable
diseases by major cause group, sex and country
income group, 2004
12

13. Deaths from chronic disease are displacing deaths from
infectious disease even in rural Bangladesh

14. Shifting Patterns of Global Health
Deaths, % of Total, 2005 Forecast Deaths, 2006-
Total 2015, % Change
Deaths, M
13.7
Low
12.3
2.5
Lower-middle
13.2
0.5
Upper-middle
2.7
0.5
High
7.1
0 20 40 60 80 100 -10 -5 0 5 10 15 20 25
Infectious diseases Chronic diseases

16. Ten leading causes of burden of disease,
world, 2004 and 2030
16

17. Causes of NCDs

18. Leading causes of attributable global mortality and
burden of disease, 2004
Attributable Mortality Attributable DALYs
% %
1. High blood pressure 12.8 1. Childhood underweight 5.9
2. Tobacco use 8.7 2. Unsafe sex 4.6
3. High blood glucose 5.8 3. Alcohol use 4.5
4. Physical inactivity 5.5 4. Unsafe water, sanitation, hygiene 4.2
5. Overweight and obesity 4.8 5. High blood pressure 3.7
6. High cholesterol 4.5 6. Tobacco use 3.7
7. Unsafe sex 4.0 7. Suboptimal breastfeeding 2.9
8. Alcohol use 3.8 8. High blood glucose 2.7
9. Childhood underweight 3.8 9. Indoor smoke from solid fuels 2.7
10. Indoor smoke from solid fuels 3.3 10. Overweight and obesity 2.3
59 million total global deaths in 2004 1.5 billion total global DALYs in 2004
18

19. Deaths attributed to 19 leading factors,
by country income level, 2004
19

20. We can make a difference: death rates in the US,
1900-1996
Decline

21. Yet only 3% of global
health aid ($21 billion)
goes to NCDs and mental
health.

22. Pervasive myths that have prevented action
• Global economic development will improve all health
conditions
• Chronic disease results from freely adopted risk
• Chronic diseases are diseases of the elderly
• Chronic diseases are diseases of the rich
• Benefits of countering chronic disease accrue only to the
individual
• We can fix chronic disease as we are fixing infectious disease
• We should wait until we've controlled infectious disease
• Screening and treating patients is the the most cost effective
way to go

23. How best to respond?

24. How best to respond?
• “We need a whole
of government and
a whole of society
response”
• Margaret
Chan, director
general, WHO

25. Need for a broad strategy
Comprehensive and
integrated action is
the means to prevent
and control chronic
diseases

26. Difficult questions
• What is the best level at which to intervene? Social
determinants? Behavioural risk factors? Biological risk factors?
Treatment? Or rather how much to intervene at each level?
• What are the best buys?
• What should be the priorities?
• What MUST be done?
• What is the best system of governance?
• What to do if very few (even no) resources are available?
• What to do in this particular country?
• How to think about these difficult questions at the same time?

27. Some preliminary answers to some
of the questions?

28. What is the best level at which to intervene? Or rather how much
to intervene at each level?
• Social determinants?
– Acting at this level may bring benefits beyond NCDs—for
example, on poverty, trade, agriculture, education
– Some cannot be controlled—ageing of the population,
globalisation
• Behavioural risk factors?
– We have strong evidence on how to act on some of
these—for example, raising taxes on tobacco and alcohol,
banning smoking in public places
– Can be very cost effective
– Interventions on diet and physical activity are more
complicated, but there are some relatively simple ones—
like banning trans fats, reducing salt in food

29. What is the best level at which to intervene? Or rather how much
to intervene at each level?
• Biological risk factors?
– Later in the disease process than acting on behavioural risk
factors, less cost effective
– How much can the health system achieve alone?
– Strengthening the health system helps patients with other
problems, counteracting to some extent the criticism aimed at
“vertical systems”
– Strong evidence on the benefits of treating cardiovascular risk,
but depends on some sort of health system and tends to work
poorly even where there are well functioning health systems
(rule of halves)
– Poor effectiveness on obesity
– Good evidence on prediabetes and prehypertension (doesn't
depend on doctors and nurses)

30. •What is the best level at which to intervene? Or rather how much
to intervene at each level?
• Treatment?
– The major cost of developed world systems (over 90%)
– Least cost effective
– Hard to change once you have it, huge vested interest
– Hard even to reshape existing systems—stronger primary
care, less dependency on doctors, fewer hospitals, closer
links with social services, more disease management,
stronger palliative care, etc
– But people expect “the sick to be treated”
– Health systems are traditionally concerned with the sick not
the “healthy” Could it be different?

31. Best buys for reducing the burden of NCDs (WHO):
(none of them depend on health systems)
• Protecting people from tobacco smoke and banning smoking in public places
• Warning about the dangers of tobacco use
• Enforcing bans on tobacco advertising, promotion and sponsorship
• Raising taxes on tobacco
• Restricting access to retailed alcohol
• Enforcing bans on alcohol advertising
• Raising taxes on alcohol
• Reduce salt intake and salt content of food
• Replacing transfat in food with polyunstaurated fat
• Promoting public awareness about diet and physical activity, including through mass
media

32. Interesting question
What might an entirely new system for
preventing and controlling NCDs in a low
income country look like?

33. It’s a more complicated problem than countering
infectious disease
acute childhood infections maternal chronic, life long infectious and non-
deaths infectious diseases
Simple technologies Complex interventions
Rapid impact Decades before impacts
Controlled by health services Main levers outside health service
control
Within the remit of the health campus Takes a whole university and all
and the health department government!

34. View from Scotland on best way to look after people
with long term conditions

35. Best system for responding to NCDs in LMIC
• High level task force that is whole of government and
whole of society
• Emphasis on public health and prevention with an
emphasis on structural changes
• Patients TRULY in charge
• Extensive use of community health workers
• Extensive standardisation and use of protocols
• Emphasis on primary care
• Few hospitals and specialists—to avoid capture of
resources

36. 11 UnitedHealth and NHLBI Collaborating Centres of Excellence to
counter chronic disease

37. Outcomes proposed by UnitedHealth NHLBI Centers of
Excellence
• A strong commitment to action by the UN and member states with
global and national plans for action
• Creation of a global partnership with all groups able to join, clear
governance, and a global plan with with targets and regular reporting
• Energetic implementation of the Framework Convention on Tobacco
Control
• Action on other risk factors
• Universal access to essential drugs and technology
• Strengthening of health systems (benefits all patients)
• Emphasis on research, particularly implementation research

38. What are the “must dos” in the many
countries that are currently doing very
little?

39. What MUST be done?
• National plan
• “Infrastructure”--government apparatus
• Surveillance
• Advocacy
• Implement Framework Convention on Tobacco
Control (not all countries have signed)

40. Conclusion
• NCDs present a major challenge to health, particularly in the developing
world
• Problem will get rapidly worse without action
• So far very few resources devoted to NCDs
• There is now high level commitment, but public consciousness of the
problem needs raising
• The response must be “all of government and all of society”
• It is possible to prevent most premature deaths from NCDs
• There are many cost effective interventions, most of them outside the
health system
• We need a global plan (with targets) and national plans. They are
coming.