learning from low and middle income countries about responding to non-communicable disease

Learning from responses to the pandemic of non-

communicable disease (NCD) in low and middle income

countries

Richard SmithDirector, UnitedHealth Chronic Disease Initiative

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

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

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

Upper-middle

Low

Lower-middle

High

0 20 40 60 80 100 0 5 10 15 20 25-5-10

Deaths, % of Total, 2005

Forecast Deaths, 2006-2015, % ChangeTotal

Deaths, M

0.57.1

0.52.7

2.513.2

13.712.3

Chronic diseasesInfectious diseases

Shifting Patterns of Global Health

Multimorbidity in rural Bangladesh (among people over 60)

Causes of NCDs

Changing global causes of death 1990-2010

Changing global causes of death 1990-2010

Global deaths aged 15-49 (2010)

Changing global causes of DALYs 1990-2010

Risk factors for DALYs 2010

Changes in global risk factors for DALYs1990-2010

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

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

Decline

Yet only 3% of global health aid ($21 billion)

goes to NCD

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

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

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

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

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

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

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

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)

Learning from low and middle income countries

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 

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

Global workforce

Disease management

• RCT in India and Pakistan

• CHW plus decision support software supporting physicians treating patients with diabetes versus usual care

Polypill trials

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

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.

Proportion of Medicaid patients achieving 80% adherence 2011

Mobile phones in health

M-health

• Trials underway of using text messaging to prompt patients to take drugs and change lifestyle

Community interventions for health

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

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