Vision in a World of NCDs Prof K Srinath Reddy President, Public Health Foundation of India Bernard...
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Vision in a World of NCDs Prof K Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School
Vision in a World of NCDs Prof K Srinath Reddy President,
Public Health Foundation of India Bernard Lown Professor of
Cardiovascular Health, Harvard School of Public Health Sir John
Wilson Lecture
Slide 2
QUESTIONS THIS TALK WILL ADDRESS (Why) are NCDs (Finally)
receiving policymaker attention at Global Level? Why is Eye Health
not part of the UN/WHO NCD package? How will Ageing and NCDs impact
on Eye Health in the 21 st Century? How should Eye Health position
itself in the broader Health System framework and Rights
discourse?
Slide 3
Global Challenge of NCDs APATHY (2000) ATTENTION (2011) ACTION
?
Slide 4
Slide 5
Is NCD a global crisis? YES! Source: Beaglehole R, Bonita R,
Alleyne G, et al for the Lancet NCD Action group. UN HLM on NCDs:
Addressing four questions. Lancet 2011 POL June 13 2011
Slide 6
Cardiovascular disease (Age-standardized death rate per 100
000, males) Yach D., 2009 723-1030 3 47-390 391-426 427-464 542-722
723-1030 138-205 206-281 282-346 347-390 391-426 427-464 465-541
542-722 723- 1030 No Data
Slide 7
Projected global numbers of deaths by cause for high, middle
and low income countries (WHO, 2008)
Slide 8
Is NCD a development issue? YES! (and the case for investment
is strong) l NCDs are a cause and consequence of poverty l NCDs
entrench poverty-cycle of debt l Costs of loss of productivity and
care will increase as the burden rises l Inaction will pose
problems on fragile health systems l And action on NCDs will
contribute to progress for other global priorities, e.g. MDGs l
NCDs are a cause and consequence of poverty l NCDs entrench
poverty-cycle of debt l Costs of loss of productivity and care will
increase as the burden rises l Inaction will pose problems on
fragile health systems l And action on NCDs will contribute to
progress for other global priorities, e.g. MDGs
Slide 9
NCDs: Economic Impact l NCDs accounted for five of the six top
causes of economic loss in 2008 HHeart disease : $752bn HStroke:
$298bn HDiabetes: $204bn l NCDs accounted for five of the six top
causes of economic loss in 2008 HHeart disease : $752bn HStroke:
$298bn HDiabetes: $204bn NCDs cost developing countries up to 6.77%
of GDP; this economic burden is more than that caused by Malaria
(1960s) or AIDS (1990s) - IOM Report 2010 NCDs will lead to a loss
of 30 Trillion Dollars globally up to 2030 representing 48% of
global GDP in 2010 Harvard + WEF Study 2011
Slide 10
Are affordable cost-effective interventions available? YES!
Source: Cecchini M, Sassi F, Lauer J et al. Tackling unhealthy
diets, physical inactivity and obesity: health effects and
cost-effectiveness. Lancet 2010
Slide 11
UN ADOPTS NCDs! UNHLM September 2011 (New York) Political
Resolution Adopted Global Target Set For 2025 25% Reduction in NCD
Related Mortality Below 70 Yrs. UNHLM September 2011 (New York)
Political Resolution Adopted Global Target Set For 2025 25%
Reduction in NCD Related Mortality Below 70 Yrs. 25 By 25
Slide 12
What are NCDs? Why Only Four? (CVD; DM; Cancer: COPD) Linked by
Common Risk Factors What About: -Mental Health? -Oral Health? - Eye
Health? -Renal Diseases? -Genetic Disorders? Where Do Injuries and
Disabilities Fit In? Why Only Four? (CVD; DM; Cancer: COPD) Linked
by Common Risk Factors What About: -Mental Health? -Oral Health? -
Eye Health? -Renal Diseases? -Genetic Disorders? Where Do Injuries
and Disabilities Fit In?
Slide 13
UN Political Resolution 2011: Disease Burden & Determinants
High and Rising Health Burden Advancing in LMIC Preventable
Premature Deaths Common Risk Factors : Prevalence Social
Determinants Recognized Economic Cost of Neglect : Huge High and
Rising Health Burden Advancing in LMIC Preventable Premature Deaths
Common Risk Factors : Prevalence Social Determinants Recognized
Economic Cost of Neglect : Huge
Slide 14
Risk Factors Tobacco Unhealthy Diet Physical Inactivity Harmful
Use of Alcohol Others Mentioned: - Indoor Smoke - Breast Feeding -
Infections Tobacco Unhealthy Diet Physical Inactivity Harmful Use
of Alcohol Others Mentioned: - Indoor Smoke - Breast Feeding -
Infections
Slide 15
Global causes of blindness due to eye diseases, excluding
refractive errors (2002) Source: Eggleston K and Tuljapurkar S.
Aging Asia The Economic and Social Implication of Rapid Demographic
Change in China, Japan and South Korea
Slide 16
How will vision fare in the 21 st century? Ageing NCDs Injuries
Climate Change Ageing NCDs Injuries Climate Change
Slide 17
SILVER TSUNAMIGLOBAL GRAYING VERY ELDERLY ELDERLY DEMOGRAPHIC
TRANSITION AGEING
Slide 18
Global Ageing Trends (2012) 0 to 9 10 to 19 30 or over 25 to 29
20 to 24 Per centage 60 or over
Slide 19
Global Ageing Trends (2050)
Slide 20
Slide 21
Slide 22
By 2050, 80% of older people will live in LMIC Chile, China and
Iran will have a greater proportion of older people than USA. By
2050, 400 million persons over 80 years; 100 million in China alone
Ageing in LMIC
Slide 23
Cataract Age Related Macular Degeneration Vitreous Degeneration
Glaucoma Age Related Eye Problems
Slide 24
Risk Factors: Tobacco Use on the Rise in Developing
Countries
Slide 25
Smoked Tobacco And The Eye Cataract3 fold higher risk (nuclear
cataract) Kelley et al 2005 AMD Glaucoma R.R. of 2.2 (95% CI, 1.4
3.5) for current smokers O.R. of 2.9 (95% CI, 1.3 6.6) Cheng et al
2000
Slide 26
Smokeless Tobacco And The Eye Raju et al (2006) O.R. for
Nuclear Cataract = 1.67 (9.5% CI, 1.16 2.39) Iyamu et al (2002) SLT
Raises Intra Ocular Pressure
Slide 27
Slide 28
CountryPrevalence in 2010 (%) China9.7 India7.1 Japan7.3
Republic of Korea9.0 Malaysia10.9 Singapore12.7 Thailand7.7
Vietnam2.9 United States12.3 Prevalence of Diabetes in Asia-Pacific
Countries Source: For China, Yang et al. 2008. For all other
countries, International Diabetes Federation Diabetes Atlas,
www.diabetesatlas.org/content/regional-data
Slide 29
Rising Prevalence of Diabetes in Urban India Mohan et al,
Diabetologia, 2006; 49: 1175 Ramachandran et al, Diabetes Care,
2008; 31: 893 Over 14 years, DM prevalence increased by 72.3%
Prevalence rate age standardized for Chennai Census 1991 NUDS
CURES
Slide 30
The TOP 10
Slide 31
Diabetes And The Eye People with Diabetes Are 25 Times More
Likely To Go Blind From Diabetic Retinopathy And Cataract Than
Those Without Diabetes - Patel and Ireland (Sightsavers)
Slide 32
Blood Pressure and Eye Hypertensive Retinopathy Interaction
Between HBP And Diabetes Interaction Between HBP And Tobacco
Slide 33
A.CVD WITH OCULAR EFFECTS Stroke/ TIA Arrhythmias Vasculitis
Drug Effects B. COMORBIDITIES Assessment of surgical risk CVD and
Eye
Slide 34
Tumours Primary Metastatic Treatment Steroids Radiotherapy
Cancer and Eye
Slide 35
HEALTH SYSTEM PEOPLE SOCIAL DETERMINANTS (OF HEALTH &
NUTRITION) SocietalPersonal -Water-Income -Sanitation-Education
-Food System-Occupation -Environment-Social Status -Social
Stability -Gender -Development-Networks -Workforce -Infrastructure
-Drugs, Vaccines & Technologies -Financing -Information Systems
-Governance
Slide 36
Clinical Changing Spectrum Increased Caseload Public Health
Services Continuity of Care Workforce Awareness Policy Integration
Financing Implications for the Health System
Slide 37
Should Eye Health.. Remain a Vertical Programme Be part of a
Horizontal Integration of many Programmes? Seek a Diagonal
Approach?
Slide 38
Primary Care: Physicians Non Physician Health Care Providers
Task Shifting Task Sharing Outreach Services (IT enabled) Secondary
Care: Ophthalmologists + Allied Health Professionals Other
Physicians Tertiary Care: Specialists Referral Services Supportive
Supervision Health Workforce
Slide 39
Universal Health Coverage Sustainable Development Health System
Equity Rights Social Determinants Human ResourcesEconomy 21 st
Century
Slide 40
The Global Path to Universal Health Coverage Bismarck Model
1883 Beveridge Model, 1942 Japan, 1938 New Zealand, 1938 UK, 1948
(NHS) Scandinavia: Norway, 1912; Sweden, 1955; Denmark, 1973; NHIF,
Kenya, 1966 Canada, 1966 Spain, 1986; Brazil, 1988; Columbia, 1993
South Korea; 1989 Rwanda, 2003; Ghana, 2004 South Africa, 2011/12
Philippines, 1995; Taiwan, 1995; Thailand,2002; Vietnam, 2009
INDIA, 2012 Chile, 1952 Australia, 1975, Italy 1978 Mexico, 2001
Germany, 1941 Sri Lanka, 1950
Universal Health Coverage Based On People Centric Primary Care
- Margaret Chan, DG of WHO (2012)
Slide 43
20 th Century Health Care Clinician Centred Focus on Benefits
of Treatment Increase Quality Patient as Passive Complier Good Care
for Known Patients Hospital as Focus Operates Through Bureaucracy
Driven by Finance High Carbon Usage Challenges met by Growth 21 st
Century Health Care Patient-Centred Focus on Prevention of Disease
and Harm Reduce Waste and Increase Value Patient as Co Producer
Equitable Care for Populations Focus on systems Operates Through
Networks Driven by Knowledge Low Carbon Usage Challenges met by
Transformation -Sir Muir Gray (2007)
Slide 44
HOW DO WE THEN GATHER MORE STRENGTH In our advocacy for
adoption and advancement of policies for eye health?
Slide 45
A Framework for Determinants of Issue Attention in Global
Health (i)The collective strength of the actors mobilising around
an issue; (ii)The ideas they use to portray and position the issue;
(iii) The issue characteristics that pertain to inherent features
of the issue; and (iv) The nature of the political context or
features of the environment that individuals confront as they seek
to advance attention of the issue, including other actors who do
not work on the issue (Jeremy Shiffman, 2010)
Slide 46
The Economic Argument Cause and Consequence of Poverty
Productivity Losses Cost-Effective Treatments (Best Buys) Global
cost of Visual Impairment and Blindness = USD 3 Trillion Patel and
Ireland (Sightsavers)
Slide 47
Vision Impairment is the 6 th largest cause of DALY loss (3%) -
WHO How is Vision Loss weighted for estimation of Disability? -
Perspective of Physicians - Perspective of Patients - Perspective
of People Quality of Life is an important message to convey Value
of Vision
Slide 48
Why Do We Need A Rights Argument Economic arguments work BUT
there are competing demands (within and beyond the Health Sector)
Voice of Patients and Civil Society needed - e.g. HIV-AIDS, Tobacco
Control
Slide 49
HEALTH EQUITY: PHILOSOPHICAL CONSTRUCT Capability Right
Utilitarian Justice Bentham Rawls Sen A well ordered society would
ensure that all individuals have the capability to be healthy and
at a level that is commensurate with human dignity in the modern
world, which is their right - Sridhar Venkatapuram. Health Justice;
Polity (2011)
Slide 50
WHAT NEXT? Post 2015 UN Agenda: Sustainable Development Goals
(SDH) Four Pillars - Inclusive Economic Development - Inclusive
Social Development - Environmental Sustainability - Peace and
Security Nine Thematic Working Groups Inter-Governmental Leadership
Group (UK, Indonesia, Liberia) Position Eye Health Wherever
Possible
Slide 51
Eye Health is a Part of Health But. Isnt It Also Related to
EDUCATION? Isnt It Also Related to EMPLOYMENT? Isnt It Also Related
to FOOD SECURITY? Isnt It Also Related to GENDER EQUITY? Isnt It
Also Related to ENVIRONMENT? Isnt It Also Related to URBAN DESIGN?
YES IT IS !!!
Slide 52
Slide 53
Coalitions: Looking Beyond The Profession How to Make Friends
and Influence People? - Join Forces with Natural Allies (e.g. NCD
Alliance) - Support THEIR cause - Show them how YOUR cause connects
with their cause Position Eye Health in the Health Systems
Discourse (Politics of Presence) - Health Systems and Policy
Research - Global Health Workforce Alliance - Universal Health
Coverage Movement
Slide 54
If you travel alone, you will go faster If you travel together,
you will go farther - Old Proverb
Slide 55
The Universal is the Local Minus the Walls - M.Torga
Differentiate Universal from Uniform and Common
Slide 56
Ayam nijah parovetthi gananam laghu-chetasaam. Udaar charitanam
tu vasudhaiva kutumbakam "Myself, this is mine, that is yours is a
petty way of people in seeing reality; for those with noble
consciousness, the whole world is a family. Maha Upanishad, Verse
71 (Upanishads: Ancient Indian Philosophical Treatises)
(Upanishads: Ancient Indian Philosophical Treatises) The World is a
Family