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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
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 CausesChronic Diseases
Heart Disease, Stroke, Cancer, Diabetes, Chronic Respiratory Disease↑
Biological Risk FactorsModifiable: overweight, high cholesterol, high blood sugar, high blood pressure
Non-modifiable: Age, Sex, and Genetics↑
Behavioral Risk FactorsTobacco 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 InfluencesGlobalization of food supply, urbanization, technology, migration
Crude Mortality Rates (per 100,000 population ) for Select Diseases: (2000-2004)CARICOM Member States
0
20
40
60
80
100
120
140
2000 2001 2002 2003 2004
Year
Rat
es p
er 1
00,0
00 p
op
ula
tio
n
Heart Disease
Stroke
Diabetes
Injuries
Hypertensive Diseases
Cancers
HIV/AIDS
Source: CAREC, based on mortality reports from countries
Leading Causes of Death in CARICOM Countries by Sex, 2004 (MINUS Jamaica)
1. Heart Disease
2. Cancers
3. Injuries and violence
4. Stroke
5. Diabetes
6. HIV/AIDS
7. Hypertension
8. Influenza/pneumonia
1. Heart Disease
2. Cancers
3. Diabetes
4. Stroke
5. Hypertension
6. HIV/AIDS
7. Influenza/pneumonia
8. Injuries and violence
MALES FEMALES
Source: CAREC, based on country mortality reports
Potential Years of Life Lost <65years by main causes, 2000 & 2004, CARICOM countries (minus Jamaica)
0 10000 20000 30000 40000 50000 60000 70000
Chronic Disease
HIV/AIDS
Injuries
Y2004
Y2000
Note: Chronic Disease includes heart disease, stroke, cancer, diabetes, hypertension, chronic respiratory disease.Injuries includes traffic fatalities, homicide, suicide, drowning, falls, poisoning
Source: CAREC, based on country mortality reports
Mortality Attributable to Select Risk Factors (Latin America & Caribbean), from DCP2
0 100 200 300 400 500
Unsafe sex
Physical inactivity
Low fruits & veg
High cholesterol
Tobacco
Alcohol
Obesity
High BP
Attributable Deaths (thousands)
0
10
20
30
40
50
60
Pre
vale
nce
(%
)
1970s 1980s 1990s
YEARS
Trends in Adult Overweight/Obesityin the Caribbean
Male
Female
Prevalence (%) of diabetes among adults in the Americas
6.16.3
7.27.27.37.67.67.98.28.48.68.799.3
10.711.812.412.612.7
16.4
Honduras
Chile
Urban Peru
Paraguay
Haiti
Brazil
Argentina
Costa Rica
Colombia
Guatemala
Bolivia
Suriname
Nicaragua
USA
Mexico
Cuba
Belize
Jamaica
Trinidad/Tobago
Barbados
Source: Pan Am J Public Health 10(5), 2001; unpublished (CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)
Caribbean trends in Diabetes mortality
20
30
40
50
60
70
80
Ra
te/1
00
,00
0
1985 1990 1995 2000
Male
Female
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)
0
20
40
60
80
100
120
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 15-20%.
Principal Clinic Visits,
Saint Vincent & the Grenadines, 2000 vs 2003
0
5,000
10,000
15,000
20,000
HTN or HTN/DM DM or DM/HTN Arthritis/Muscu
2000
2003
Age adjusted death rates/100,000 population from Hypertension (2000)
0
5
10
15
20
25
30
35
40
45
50
BAH BAR GUY JAM SUR TRT CAN USA
Projected national income lost from NCDs ( 2005-2015)Projected National Income Lost from NCDs
2005 -2015, $USBN
0
100
200
300
400
500
600
Bra Can Chi Ind Nig Pak Rus UK Tan
Possible economic burden($US Million, 2001)
BAH BAR JAM TRT
Diabetes 27.3 37.8 208.8 494.4
Hypertension 46.4 72.7 251.6 259.5
Total 76.7 110.5 460.4 753.9
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.
36%
10%
54%
non-communicable diseasescommunicable diseasesinjuries
87%
7%6%
Developing countries carry a double disease burden
Percentage of deaths by cause
Low- and Middle-income countries High-income countries
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
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
Relation of fitness to mortalityT&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
Financial resources
Quality assurance of care
National standards and protocols for treatment
Demonstrative community-based programs
National system of Health reports, survey and surveillance
Implementation of DPAS
Implementation of FCTC
National Objectives
National law, legislation, decree
National focal point, Department or Unit
TRT
SUR
JAM
HAI
GUY
BAR
BAH
ANT
ANG
Financial resources
Quality assurance of care
National standards and protocols for treatment
Demonstrative community-based programs
National system of Health reports, survey and surveillance
Implementation of DPAS
Implementation of FCTC
National Objectives
National law, legislation, decree
National focal point, Department or Unit
TRT
SUR
JAM
HAI
GUY
BAR
BAH
ANT
ANG
Source: PAHO Survey of NCD National Response Capacity, 2005
Addressing the risk factorsTobacco 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