Overview of global health and
Chronic NCDs
Professor Brian Oldenburg
Summary of lecture
1.
2.
3.
4.
Health in a changing, global world
Causes of death and disease burden
Determinants of health
Differences in health between regions and
countries
1. Health in a changing, global
world
What is globalisation?
Defined as: „a set of processes that are
changing the nature of human
interaction by intensifying interactions
across certain boundaries that have
hitherto served to separate
individuals and population groups.‟
(Lee, 2003, p12)
Economics
Politics
Specializing and trading in
Western Europe
Airbus parts are made, moved, and assembled all over Western Europe
Netherlands
Great Britain
parts
wings
parts
Germany
Belgium
United States
France
body
vertical stabilizer
cockpit
wheels
vertical stabilizer
engines
Toulouse
assembly
Germany
G.B.
Belgium
wing
France
Spain
bod
y
horizontal
stabilizer
Spain
horizontal stabilizer
body
Germany
France
engine
U.S.
Loading and moving the fruits
of specialization
Airbus parts are made, moved, and assembled all over Western Europe
Not just computers—vigorous
trade flows in East Asia
Vigorous trade flows in East Asia, anchored by China and Japan
Division impedes market access
Internationally, Division is the common problem: Borders are “thicker” in developing
regions
The result?
The US, EU-15, China, India and Japan cover much of the
economic globe
Globalisation: the good, the bad and the
ugly!
Positive
Negative
Generating great wealth
Widening socioeconomic
inequalities
Integration & cooperation
across countries
Fragmentation of social groups
and structures
Breaking down borders
Reinforcing nationalism and
regionalism
Enabling democracy and equity
Widening gap between „haves‟
and „have nots‟
Facilitating cooperation
Facilitating competition
Lee, 2003, p9
Globalisation and health
• Effects of global market practices by
multi-national corporations
• Extent to which public health is
protected by WTO trade agreements
• Widening socio-economic inequities
and the health of adversely affected
populations
• Population mobility, displacement,
settlement
• Communication of health information,
disease surveillance, provision of
healthcare services
What is Global Health?
“Health problems, issues and concerns that
transcend national boundaries, may be
influenced by circumstances or experiences in
other countries, and are best addressed by
cooperative actions and solutions.”
United States Institute of Medicine (IOM) Report
Global health vs international health
Hygiene and Tropical Medicine
Public Health
Hygiene and Tropical Medicine
Sanitation (Snow)
Germ theory (Pasteur)
Tropical diseases (protecting
the West from the East)
International Health
Public Health
“…the science and art of
preventing disease,
prolonging life and
promoting health through
the organized efforts and
informed choices of society,
organizations, public and
private, communities and
individuals."
GLOBAL HEALTH
International Health
Health issues taking
place in a country
outside of one‟s own;
efforts require bilateral
cooperation.
Why Global Health?
• Health is inter-dependent among countries
• Influenced by world economy, technological
developments, communications, travel and migration
• Positive/negative influence of multi-national
corporations, government and non-government
organisations
• Epidemiology of major diseases/health issues has
changed a lot
• Burdens of chronic non-communicable diseases are
increasing
• ‘Globalization’ has emphasized major gaps between rich
and poor – within and between nations
Declaration of Human Rights
“Everyone has the right to a standard of living
adequate for the health and well being of
himself and his family, including food, clothing,
housing and medical care.”
Universal Declaration of Human Rights, 1948
Health Challenges: Need for a New Paradigm
• Health has multiple, interactive determinants or influences
• Many sectors and ‘stakeholders’ are involved – e.g. education,
nutrition, housing, transport, individual behaviors, etc.
• Health systems and services need better connections with other
sectors
• Prevention and treatment of acute and infectious diseases is still
important in many countries, particularly sub-Saharan Africa.
• Escalating importance of chronic diseases in many countries
• Other emerging health challenges related to environment, climage
change etc…
• Shortages of health professionals in most LMICs requires
innovative education
2. “Causes” of death, disease
burden and health
Life expectancy (global)
Between 1950 and 1999, average life expectancy at
birth increased from 46 to 64 years.
However, this broad perspective fails to recognise
health inequalities within and across countries:
Life expectancy
within countries
• Life expectancy is 17yrs
shorter for black men in
Washington DC than for white
men in Montgomery County
WHO, 2008
Life expectancy
between countries
• Life expectancy is 43yrs
shorter for women in Zambia
(LE=43) than for women in
Japan (LE=86)
WHO, 2008
Deaths in the world by “cause of death”
(2002)
Noncommunicable diseases:
Infectious diseases:
HIV/AIDS 4.9%
Tuberculosis 2.4%
Heart disease
30.2%
Malaria 1.5%
Total:
58.0M
Cancer
15.7%
Diabetes
1.9%
Other chronic diseases
15.7%
(WHO, 2005)
Other
Infectious
Diseases
20.9%
Injuries 9.3%
Deaths in the world by “cause”
(2004-2030)
(WHO, 2008)
Noncommunicable diseases >
Global Burden of Disease Study
• Before GBD study, health measured in terms of life or
death (mortality statistics).
• What information is lacking in mortality statistics?
Quality of life.
• In 1990, WHO and World Bank undertook a study to
examine global patterns of death and disability
(morbidity).
• 100 diseases, 8 world regions
Global Burden of Disease study
• Introduced new metric – the Disability-Adjusted
Life Year (DALY)
• A single measure to quantify the burden of
diseases, injuries and risk factors (see next slide).
The DALY is based on years of life lost
from premature death and years of life
lived in less than full health.
DALYs
Disease or injury in 2004
DALYs
(millions)
Projected burden of disease in 2030
1
Lower respiratory infections
94.5
Unipolar depressive disorders
2
Diarrhoeal diseases
72.8
Ischaemic heart disease
3
Unipolar depressive disorders
65.5
Road traffic accidents
4
Ischaemic heart disease
62.6
Cerebrovascular disease
5
HIV/AIDS
58.5
Chronic obstructive pulmonary disease
6
Cerebrovascular disease
46.6
Lower respiratory infections
7
Prematurity and low birth weight
44.3
Hearing loss, adult onset
8
Birth asphyxia and birth trauma
41.7
Refractive errors
9
Road traffic accidents
41.2
HIV/AIDS
10
Neonatal infections and other
40.4
Diabetes mellitus
Source: http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
Demographic-Epidemiologic Transitions
• Shift from dominance of acute-communicable to
chronic-degenerative conditions
• Ageing populations in most countries
•
All countries are affected, even Sub-Saharan countries
• Re-emergence of some common infectious diseases and
problems of drug resistance
• Prevention vs Cure versus Care
EPIDEMIOLOGIC TRANSTION
Age
Pestilence
and famine
Receding
pandemics
Predominant
CVD
Rheumatic
heart disease
Hypertension- CHD, stroke,
related
diabetes at
diseases
young ages
CHD, stroke at
older ages
% of deaths
due to CVD
5-10
10-35
35-65
<50
Current
examples
Sub-Saharan
Africa
Rural China
Urban India
North
America,
Australasia
Global CVD
Degenerative
“man-made”
diseases
Delayed
degenerative
diseases
From S Yusuf et al. Circulation 2001;104:2746-5
Chronic Diseases – the so-called cardiometabolic conditions….
• Major cause of death and disability worldwide
• CVD, diabetes, obesity, cancer and respiratory
conditions
• High glucose levels, high blood pressure,
obesity, and inactivity - “metabolic syndrome”
• Dietary habits and physical activity –
Really important risk factors
What are chronic non-communicable
diseases?
Chronic diseases are diseases of long duration
and generally slow progression, such as heart
disease, stroke, cancer, chronic respiratory
diseases and diabetes.
However, many other chronic conditions and
diseases also contribute significantly to the burden
of disease: mental disorders, vision and hearing
impairment, oral diseases, bone and joint
disorders, and genetic disorders.
WHO, 2005
www.who.int/chp
Did you know??
Chronic diseases
Cardiovascular disease,
mainly heart disease and stroke
Cancer
Chronic respiratory diseases
Diabetes
10 widespread understandings
about chronic disease - and the
reality



Chronic disease epidemic is rapidly evolving
Global recognition and response has not kept pace
Misunderstandings can be dispelled by the
strongest evidence
Reality: 80% of premature heart disease,
stroke and type 2 diabetes can be prevented
"Chronic diseases
can't be prevented"
Reality: very cost-effective and inexpensive
interventions
"Chronic disease
prevention and control
is too expensive"
What works?
Comprehensive and
integrated action
is the means to
prevent and control
chronic diseases
Chronic Disease Pressures on Health Costs
• Treatment is long-term
• Negative effects on productivity
• Represents 60% of health care costs in
the U.S. and UK
• China, India and UK estimated to lose $558
billion, $237 billion, and $33 billion, respectively,
in national income over the next decade as a
result of largely preventable heart disease,
strokes, and diabetes
Source: Science Daily (Sep. 15, 2010)
Economic impact: billions
WHO, 2005
Millennium Development Goals (UN, 2000)
Health-related MDGs
Millennium Development Goals
• International community working together
• To be reached by 2015
• Global and local: tailored by each country to
suit specific development needs.
Source: http://www.who.int
3. Determinants of health and
disease
Relationship between social structure, health & disease
Social structure
Material factors
Work
Social environment
Psychological
Brain
Health behaviours
Neuroendocrine
and immune
response
Pathophysiological
changes
Organ impairment
Early
life
Genes
Culture
Well-being
Morbidity
Mortality
Source: WHO Commission on Social Determinants of Health 2005
Major risk factors for NCDs
“CAUSES OF THE CAUSES”
THESE CAN
BE CHANGED
WHO, 2005
Impact of major risk factors: mortality
Each year at least:
• 4.9 million people die as a result of tobacco use
• 1.9 million people die as a result of physical inactivity
• 2.7 million people die as a result of low fruit and vegetable consumption
• 2.6 million people die as a result of being overweight or obese
WHO, 2005
Chronic diseases and their risk factors
Tobacco
Tobacco use is a risk factor for six of the eight leading causes of death in the world
Tobacco use
•
•
•
•
•
More than one billion smokers in the world.
More than 80% of the world's smokers live in
low- and middle-income countries.
Tobacco use kills 5.4 million people a year - an
average of one person every six seconds - and
accounts for one in 10 adult deaths worldwide.
100 million deaths were caused by tobacco in
the 20th century. If current trends continue,
there will be up to one billion deaths in the
21st century.
Rates of tobacco use among 13–15 year-olds
are higher than previously expected. Current
tobacco use among males in this age group
is:
– 29% in India
– 21% in Brazil
– 14% in China
Many children begin
smoking before the
age of 10 years.
WHO, 2005
Overweight and obesity
• Globally, there are more than 1 billion overweight
adults, at least 300 million of them obese
• Approximately 22 million children under the age
of five years are obese.
WHO, 2005
Globalisation
• “Nutrition transition”: populations in low- and middle-income countries are
now consuming diets high in total energy, fats, salt and sugar.
• Supply and demand of health-harming products…
Increased
income and
reduced time
to prepare
food.
Increased
production,
promotion and
marketing of
processed foods and
those high in fat, salt
and sugar, as well as
tobacco.
WHO, 2005
Urbanisation
• In the second half of the 20th century, the proportion of
people in Africa, Asia and Latin America living in urban
areas rose from 16% to 50%.
• Urbanisation  exposure to new products,
technologies, marketing of unhealthy goods, less
physically active types of employment.
• Unplanned urban sprawl can reduce physical activity
levels by discouraging walking or bicycling.
WHO, 2005
Economics,
development,
urbanisation
and health in a
global world
Population Ageing
• Number of people aged 70 years or more
worldwide is expected to increase from 269
million in 2000 to 1 billion in 2050
• High income countries will see their elderly
population (70 yrs+) increase from 93 million to
217 million over this period
• In LMICs, the increase will be 174 million to 813
million – more than 466%
WHO, 2005
Political determinants
• Policies shape opportunities for people to
make healthy choices
–
–
–
–
–
–
Food
Agriculture
Media advertising
Trade
Transport
Urban design
In an unsupportive policy
environment it is difficult for
people, especially those in
deprived populations, to benefit
from existing knowledge on the
causes and prevention of the
main chronic diseases.
WHO, 2005
Economic determinants – “double burden”
Struggle to control both
communicable and noncommunicable diseases
WHO, 2005
RETINAL VESSELS: A MIRROR ON THE
CIRCULATION
In children (6-8 years) in Sydney
and Singapore retinal arteriolar
narrowing was strongly
associated with higher BP levels.
T Wong et al. Hypertension 2007; 49:
1156-1162
In the same two cohorts, retinal
venular dilatation strongly
associated with higher BMI.
Obesity 2007 & International J Obesity
(in review)
Tien Wong (Personal comm)
4. What is happening by regions,
countries …..?
Burden of disease by broad cause group
and region (2004)
WHO, 2008
Chronic non-communicable diseases (2005-2015)
2005
Geographical
regions (WHO
classification)
2006-2015 (cumulative)
Total
deaths
(millions)
NCD
deaths
(millions)
NCD
deaths
(millions)
Trend: Death
from infectious
disease
Trend: Death
from NCD
Africa
10.8
2.5
28
+6%
+27%
Americas
6.2
4.8
53
-8%
+17%
Eastern
Mediterranean
4.3
2.2
25
-10%
+25%
Europe
9.8
8.5
88
+7%
+4%
South-East Asia
14.7
8.0
89
-16%
+21%
Western Pacific
12.4
9.7
105
+1
+20%
Total
58.2
35.7
388
-3%
+17%
WHO projects that over the next 10 years, the largest increase in deaths from
cardiovascular disease, cancer, respiratory disease and diabetes will occur in
Africa, the Middle East and Asia
(WHO, 2005)
Noncommunicable diseases >
Global burden of Ischemic Heart
Disease – projected 1990-2020
Mortality (000s)
7000
6000
5000
4000
Total developed countries
Total developing countries
3000
World
2000
1000
0
1990
2020
Women
1990
2020
Men
Yusuf et al Global Burden of Cardiovascular Diseases: Part I: General Considerations, the Epidemiologic Transition, Risk
Factors, and Impact of Urbanization Circulation 2001; 104;2746-2753
Deaths due to CVD, cerebrovascular &
diabetes by country
Age-standardized death rates per 100,000 by cause
450
400
Cardiovascular diseases
350
Rheumatic heart disease
300
Hypertensive heart disease
250
200
Ischaemic heart disease
150
Cerebrovascular disease
100
Inflammatory heart diseases
50
0
Diabetes mellitus*
China
Japan
*Diabetes mellitus not classified as CVD
Vietnam
Malaysia
Thailand
India
Australia
Summary (I)
• Global trends in cause of deaths and chronic
NCDs – these are now a big problem.
• Commonality of risk factors, pathways and
solutions
• The living environment and culture are
important
• Development and cascading of risk over the
life-course
Summary (II)
• NCDs rarely attract the headlines
like SARS or H1N1 but they are very
important
“…One of the most difficult public health
challenges is to ensure the urgent does not
crowd out the important…”
McGuiness and Foege (JAMA)