1. Learning from responses to
the pandemic of non-
communicable disease (NCD)
in low and middle income
countries
Richard Smith
Director, UnitedHealth Chronic Disease Initiative

2. Agenda
• What do we mean by NCD?
• Global pandemic of NCD
• Global response
• UnitedHealth Chronic Disease Initiative
• General learning from LMIC
• Community health workers
• Polypill
• M-health
• Community Interventions for Health
• Conclusions

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
• NCD is the preferred term

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

5. Shifting Patterns of Global Health
Deaths, % of Total, 2005 Forecast Deaths, 2006-2015,
Total % 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

6. Multimorbidity in rural Bangladesh
(among people over 60)

7. Causes of NCDs

8. Changing global causes of death 1990-2010

9. Changing global causes of death 1990-2010

10. Global deaths aged 15-49 (2010)

11. Changing global causes of DALYs 1990-2010

12. Risk factors for DALYs 2010

13. Changes in global risk factors for DALYs1990-2010

14. Proportion of DALYs due to ischaemic heart
disease from individual risk factors 2010

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

16. Yet only 3% of global
health aid ($21 billion)
goes to NCD

18. Priorities of the UN Secretary General
• “Whole of government, whole of society response”
• Complete government wide action on risk factors
• Sustained primary health care with prioritised
packages plus palliative and long term caregivers
• Surveillance and monitoring
• Learning from and integration with AIDS, TB, and
malaria programmes
• Governments, private sector, civil society, and
international organisations must all work together

19. Future commitments with target dates
• 2012: work with WHO and all stakeholders to
set targets
– Currently arguments over targets
– Can targets be sensibly set?
– Will the targets set some countries up to
fail?
• 2013: review of the MDGs; integrate NCDs
• 2014: UN review of progress
• 2015: Sustainable Development Goals

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

22. Best buys for reducing the burden of NCDs (WHO)
• 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

23. Further “best buys” from WHO (health system
examples)
• Counselling and multidrug therapy, including
glycaemic control for diabetes for people over 30 with
a 10 year risk of 20% of a cardiovascular event
• Aspirin therapy for acute myocardial infection
• Screening for cervical cancer once at age 40 with
removal of any cancerous lesions
• Biennial mammography for women 50-70
• Early detection of colorectal and oral cancer
• Treatment of persistent asthma with inhaled
corticosteroids and beta-2 agonists

24. Cost effectiveness of different interventions for
preventing and controlling NCDs in Mexico

25. 11 UnitedHealth and NHLBI Collaborating Centres of
Excellence to counter chronic disease

27. Work of the centres in relation to WHO priorities
• Surveillance (Bangladesh, Delhi, Tunisia, Kenya, Peru, Southern
Cone)
• Tobacco control (Tunisia)
• Reducing biofuels (Kenya, Peru)
• Better nutrition (Tunisia, Northern Mexico, Central America, China)
• Increase physical activity (Tunisia, Northern Mexico)
• Risk assessment (China, South Africa, Peru)
• Better Dx and Rx (China, Delhi, Bangalore, South Africa, Central
America)
• Strengthen primary care, more community health workers (China,
Delhi, Bangalore, South Africa, Northern Mexico, Central America)
• Social determinants (Bangladesh, Delhi, all centres in joint studies)

29. Learning from low and
middle income countries

31. 10 ways in which developed countries benefit and
learn from partnerships with developing countries
• Rural health service delivery
• Skills substitution
• Decentralisation of management
• Creative problem-solving
• Education in communicable disease control
• Innovation in mobile phone use
• Low technology simulation training
• Local product manufacture
• Health financing
• Social entrepreneurship

32. Community health workers
• Most centres working with community health
workers
• In many places doctors and nurses simply not there;
and if there in short supply
• CHWs are not just supplemental; they usually speak
the same language and share the same culture as
local people
• Working on primary, secondary, and tertiary
prevention
• Evidence from a Cochrane review of their
effectiveness, particularly with communicable
disease, vaccination, and maternal and child health

33. Global workforce

35. Disease management
• RCT in India and Pakistan
• CHW plus decision support software
supporting physicians treating patients
with diabetes versus usual care

36. Polypill trials

37. Polypill concept
• Combine antihypertensive drugs, a statin, and possibly
aspirin into one pill taken once a day
• Many polypills
• Antihypertensives (usually three and usually at half dose)
• “Agreement” on use in secondary prevention. FDA may
license in 2013
• Trial with clinical endpoints underway for primary
prevention
• Most radical idea—offer to everybody at 55
• Individual lifestyle modification—costly and
unsustainable

43. Polypill prevention trial
• 86 people over 50 no established disease took polypill
and placebo in cross over trial of 12 weeks each
• Polypill (amlodipine 2.5 mg, losartan 25 mg,
hydrochlorothiazide 12.5 mg and simvastatin 40 mg)
• All taking individual components before
• 84/86 completed both arms
• 98% of participants took more than 85% of their
allocated pills
• 24 reported one or more symptoms on the Polypill
compared with 11 on the placebo, but none considered
them troublesome enough to stop treatment.

48. Proportion of Medicaid patients
achieving 80% adherence 2011

49. Mobile phones in health

50. M-health
• Trials underway of using text messaging
to prompt patients to take drugs and
change lifestyle

51. Community interventions for health

53. Community interventions for health
• Work with schools, employers, health services, local
politicians, and media to create a healthier environment
• Make healthy choices the easy choices
• Emphasis on “structural changes”—healthier food in
schools, environmental changes to encourage walking
and cycling and discourage driving (Increased physical
activity is the closest we come to a panacea, halving the
chance of a heart attack)
• Being tested in Sousse, Tunisia against control areas
• Being implemented in New Haven

54. Conclusions
• There is a pandemic of NCD in low and middle
income countries
• The world is beginning now to take the problem
seriously
• Response must be “whole of government and whole
of society”
• United together with NHLBI has been leading the
way
• There should be learning for high income countries,
particularly around community health workers, the
polypill, m-health, and creating healthier
communities