Transcript Prof K Srinath Reddy_Sir John Wilson Lecturex

Vision in a World of NCDs
Sir John Wilson Lecture
Prof K Srinath Reddy
President, Public Health Foundation of India
Bernard Lown Professor of Cardiovascular Health,
Harvard School of Public Health
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 21st Century?
• How should Eye Health position itself in the
broader ‘Health System’ framework and ‘Rights’
discourse?
Global Challenge of NCDs
APATHY (2000)
ATTENTION
(2011)
ACTION ?
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
Cardiovascular disease
(Age-standardized death rate per 100 000,
males)
138-205
206-281
282-346
347-390
347-390
391-426
391-426
427-464
427-464
391-426
465-541
542-722
542-722
723-1030
7231030
No
Data
Yach D., 2009
Projected global numbers of deaths by cause for high, middle and low income
countries (WHO, 2008)
Is NCD a development issue? YES!
(and the case for investment is strong)
l
l
l
l
l
NCDs are a cause and consequence of
poverty
NCDs entrench poverty-cycle of debt
Costs of loss of productivity and care will
increase as the burden rises
Inaction will pose problems on fragile health
systems
And… action on NCDs will contribute to
progress for other global priorities, e.g. MDGs
NCDs: Economic Impact
NCDs accounted for five of the six top
causes of economic loss in 2008
Heart disease : $752bn
Stroke:
$298bn
Diabetes:
$204bn
NCDs cost developing countries up to 6.77% of GDP;
this economic burden is more than that caused by Malaria
(1960’s) or AIDS (1990’s) - 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
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
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.
25 By 25
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?
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
Risk Factors
•
Tobacco
•
Unhealthy Diet
•
Physical Inactivity
•
Harmful Use of Alcohol
Others Mentioned:
- Indoor Smoke
- Breast Feeding
- Infections
Global causes of blindness due to eye diseases,
excluding refractive errors (2002)
1% 4%
4%
Onchocerciasis
13%
5%
trachoma
5%
9%
childhood blindness
diabetic retinopathy
comeal opacities
47%
12%
AMD
glaucoma
catarat
Others
Source: Eggleston K and Tuljapurkar S. Aging Asia The Economic and Social Implication of
Rapid Demographic Change in China, Japan and South Korea
How will vision fare
in the 21st century?

Ageing

NCDs

Injuries

Climate Change
SILVER TSUNAMI
GLOBAL GRAYING
VERY ELDERLY
ELDERLY
AGEING
DEMOGRAPHIC TRANSITION
Global Ageing Trends (2012)
Per centage 60 or
over
0 to 9
10 to 19
20 to 24
25 to 29
30 or over
Global Ageing Trends (2050)
Ageing in LMIC
 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
Age Related Eye Problems
 Cataract
 Age Related Macular Degeneration
 Vitreous Degeneration
 Glaucoma
Risk Factors:
Tobacco Use on the Rise in
Developing Countries
Smoked Tobacco And The Eye
Cataract
3 fold higher risk
(nuclear cataract)
– Kelley et al 2005
AMD
R.R. of 2.2 (95% CI, 1.4 – 3.5)
for current smokers
Glaucoma O.R. of 2.9 (95% CI, 1.3 – 6.6)
– Cheng et al 2000
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
Prevalence of Diabetes in Asia-Pacific Countries
Country
China
Prevalence in 2010 (%)
9.7
India
Japan
Republic of Korea
Malaysia
7.1
7.3
9.0
10.9
Singapore
Thailand
Vietnam
12.7
7.7
2.9
United States
12.3
Source: For China, Yang et al. 2008. For all other countries, International Diabetes
Federation Diabetes Atlas, www.diabetesatlas.org/content/regional-data
Rising Prevalence of Diabetes in Urban India
Prevalence[%]
20
Over 14 years, DM prevalence increased by
72.3%
15
13.5
18.6
14.3
11.6
10
8.3
5
2.3
0
1971
1989
1995
2000
2004
2008
NUDS CURES
Prevalence rate – age standardized for Chennai Census
1991
Mohan et al, Diabetologia, 2006; 49: 1175
Ramachandran et al, Diabetes Care, 2008; 31: 893
The “TOP 10”
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)
Blood Pressure and Eye
• Hypertensive Retinopathy
• Interaction Between HBP And Diabetes
• Interaction Between HBP And Tobacco
CVD and Eye
A. CVD WITH OCULAR EFFECTS
 Stroke/ TIA
 Arrhythmias
 Vasculitis
 Drug Effects
B. COMORBIDITIES
 Assessment of surgical risk
Cancer and Eye
Tumours
 Primary
 Metastatic
Treatment
 Steroids
 Radiotherapy
HEALTH
SYSTEM
PEOPLE
SOCIAL
DETERMINANTS
(OF HEALTH &
NUTRITION)
- Workforce
Societal
Personal
- Infrastructure
- Water
- Income
- Sanitation
- Education
- Food System
- Occupation
- Financing
- Environment
- Social Status
- Information Systems
- Social
Stability
- Gender
- Governance
- Development
- Networks
- Drugs, Vaccines &
Technologies
Implications
for the Health System
Clinical
 Changing Spectrum
 Increased Caseload
Public Health
 Services
 Continuity of Care
 Workforce
 Awareness
Policy
 Integration
 Financing
Should Eye Health…..
• Remain a Vertical Programme
• Be part of a Horizontal Integration
of many Programmes?
• Seek a Diagonal Approach?
Health Workforce
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
Universal Health Coverage
Equity
Health System
Economy
Rights
21st
Century
Social Determinants
Human Resources
Sustainable Development
The Global Path to Universal Health Coverage
INDIA, 2012
South
Africa,
2011/12
Philippines, 1995; Taiwan, 1995;
Thailand,2002; Vietnam, 2009
Mexico, 2001
Rwanda, 2003;
Spain, 1986; Brazil, 1988;
Columbia, 1993
Ghana, 2004
Australia, 1975,
Italy 1978
South Korea; 1989
Scandinavia: Norway, 1912;
Sweden, 1955; Denmark, 1973;
NHIF, Kenya, 1966
Canada, 1966
Chile, 1952
UK, 1948 (NHS)
Sri Lanka, 1950
New Zealand, 1938
Beveridge Model, 1942
Germany, 1941
Japan, 1938
Bismarck Model
1883
BREADTH
UNIVERSALITY
EQUITY
HORIZONTAL VERTICAL
DEPTH
COVERAGE
BRIDGING
GAPS
“Universal Health Coverage
Based On
People Centric Primary Care’’
- Margaret Chan, DG of WHO (2012)
20th 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
21st 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)
HOW DO WE THEN GATHER
MORE STRENGTH
In our advocacy for adoption and
advancement of policies for eye health?
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)
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)
‘Value’ of Vision
Vision Impairment is the 6th 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
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
HEALTH EQUITY:
PHILOSOPHICAL CONSTRUCT
• Capability
Right Bentham
Rawls
• Utilitarian
Justice
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)
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
Eye Health is a Part of Health But….
• Isn’t It Also Related to EDUCATION?
• Isn’t It Also Related to EMPLOYMENT?
• Isn’t It Also Related to FOOD SECURITY?
• Isn’t It Also Related to GENDER EQUITY?
• Isn’t It Also Related to ENVIRONMENT?
• Isn’t It Also Related to URBAN DESIGN?
YES IT IS !!!
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
“If you travel alone, you will go
faster
If you travel together, you will go
farther ”
- Old Proverb
“The Universal is the Local
Minus the Walls”
- M.Torga
Differentiate
Universal from Uniform and Common
The World is a Family
“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)