Impact and response to the Global Burden of Disease in China Professor Sian Griffiths APRU workshop October 2013
Dec 26, 2015
Impact and response to the Global Burden of Disease in China
Professor Sian GriffithsAPRU workshopOctober 2013
The presentation will…
• Review some key messages around GBD
• Asian challenges
• Some thoughts for future actions
From the WHO
• Life expectancy at birth increased globally by 6 years since 1990• Life expectancy at birth is based on the death
rates across all age groups in a population in a given year – children and adolescents, adults and the elderly
• A baby born in 2011 could expect to live to 70 years on average – around 60 years in low-income countries to 80 years in high-income countries
http://www.who.int/features/factfiles/global_burden/en/index.html10 facts on the state of global health
Pre term births: still a priority
• Preterm birth is the world’s leading killer of newborn babies• Every year 15 million babies – about one in ten
babies – are born preterm (born alive before 37 weeks of pregnancy)
• Preterm birth complications cause more than one million deaths each year
• More than three quarters of these babies’ lives could be saved with simple and cost-effective care
Maternal mortality: unequal progress
• 800 women die everyday due to complications of pregnancy and childbirth
• Maternal mortality: very wide gaps between rich and poor, between and within countries
• WHO works to improve maternal health by assisting countries to improve care before, during and after childbirth
Childhood deaths: cheap to avoid
• Around 7 million children under the age of five die each year
• Almost all of these children’s lives could be saved if they had access to simple and affordable interventions • exclusive breastfeeding,• inexpensive vaccines and medication, • clean water and sanitation.
• WHO is working with governments and partners worldwide to deliver integrated, effective care and strengthen health systems, both of which are crucial to saving children’s lives
Injuries and Accidents: an avoidable killer
• Nearly 3500 people die from road traffic crashes every day
• Road traffic injuries are projected to rise as vehicle ownership increases due to economic growth in developing countries
• Strong action to improve road-use policies and enforce road-safety laws is needed to avert this rise in injuries and deaths
NCDs: the growing threat
• Cardiovascular diseases are the leading causes of death in the world
• Three in ten deaths globally are caused by cardiovascular diseases
• At least 80% of premature deaths from cardiovascular diseases could be prevented through • a healthy diet • regular physical activity • avoiding the use of tobacco
Diabetes: a rampant epidemic • Almost 1 in 10 adults has diabetes• Almost 10% of the world’s adult population has
diabetes, measured by elevated fasting blood glucose (≥126 mg/dl).
• People with diabetes have increased risk of heart disease and stroke.
• Deaths due to diabetes have been increasing since the year 2000, reaching 1.4 million deaths in 2011
Mental health: so common but often forgotten
• Mental health disorders such as depression are among the 20 leading causes of disability worldwide
• Depression affects around 350 million people worldwide and this number is projected to increase
• Fewer than half of those people affected have access to adequate treatment and health care
GBD and Mental Health
• Despite the apparently small contribution of YLLs — with deaths in people with mental disorders coded to the physical cause of death and suicide coded to the category of injuries under self-harm — our findings show the striking and growing challenge that these disorders pose for health systems in developed and developing regions
• In view of the magnitude of their contribution, improvement in population health is only possible if countries make the prevention and treatment of mental and substance use disorders a public health priority
Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010Prof Harvey A Whiteford MD:
Ageing and Disability: a growing problem • Hearing loss, vision problems and mental
disorders are the most common causes of disability
• These disorders can affect people's lives and livelihoods, but many are easily treatable and some are preventable
• Improved access to interventions such as hearing aids, corrective eyeglasses and cataract surgery can make a big difference to helping people live productively
Lancet editorial: painting the picture
The largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors
• The Global Burden of Disease Study 2010 (GBD 2010• Horton
GBD and policy making:health warning - not a panacea but a tool • There is value in a numerical perspective in setting
priorities- but beware of the data • Richard Peto
• Policy making depends on imperfect data • Charlotte Watts
• The idea that we should be seeking perfect data is an illusion. Policy making depends upon using imperfect data• GBD is a step -it makes the best use of all the available data
and it makes the measurement of uncertainty one of its central principles.
• Some do not reflect the science underpinning associations between certain exposures and outcomes.
• Dave Leon• Lancet
Key messages from GBD study
• Poverty• Infectious diseases, maternal and child illness,
and malnutrition now cause fewer deaths and less illness than they did twenty years ago
• Non Communicable Diseases • such as cancer and heart disease, become the dominant
causes of death and disability worldwide• Fewer children are dying every year, but more young
and middle-aged adults are dying and suffering from disease and injury
• Disability• Since 1970, men and women worldwide have gained
slightly more than ten years of life expectancy overall, but they spend more years living with injury and illness
Messages for Asia
• Large variations across Asia/Pacific in extending life expectancy
• Progress in reducing child (and maternal) mortality throughout Asia over past 20 years rapid (& sustained)
• Premature adult mortality now a leading cause of health loss in all populations in the region, including from major Non-Communicable Diseases and injuries
• Progressive rise in burden of disability (low back pain, depression, injuries and NCDs) across the Region
Ref Lopez
Challenges for Asia
Challenges
• Poverty and inequalities have not gone away
Post MDG agenda
• A Renewed Global Partnership for Development in March 2013. • universal commitments calling for actions from all
countries, according to their national capabilities
• build on existing commitments such as those reflected in the MDGs, the Monterey Consensus and the Johannesburg Plan of Implementation
• also be broadened and strengthened to address the large array of global challenges we face today
Unfinished MDG business:Addressing inequalities• India has the largest number of child deaths of any
country in the world, and has wide local variation in under-5 mortality
• Worldwide achievement of the UN 2015 Millennium Development Goal for under-5 mortality (MDG 4) will depend on progress in the subregions of India
• At current rates of progress, MDG 4 will be met by India around 2020—by the richer states around 2015 and by the poorer states around 2023
• Accelerated progress to reduce mortality during the neonatal period and at ages 1—59 months is needed in most Indian districts
The Lancet Global Health, Volume 1, Issue 4, Pages e219 - e226, October 2013
Poverty in Hong Kong
HK Oxfam Study on food prices• HK has more than 100,000 people with a
net worth of US$1 million or more• 144,400 families with children aged 15 or
below could be called poor (monthly income less than half the median household income of HK$9,500)
Source: http://www.oxfam.org.hk/en/news_1630.aspx
MDG’s: Education
Food for thought
• Malnutrition linked to literacy problems in quarter of world’s schoolchildren
• Experts have warned that around a quarter of schoolchildren globally could have serious literacy problems as a result of malnutrition.
• A report published by the charity Save the Children on 28 May claims that a child’s ability to read and write simple sentences and answer basic mathematical questions correctly is severely damaged if they do not have a nutritious diet.
BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3569 (Published 31 May 2013)Cite this as: BMJ 2013;346:f3569
Challenges
• Poverty and inequalities have not gone away• Prevention needs to move upstream
Lifecourse view of NCD
Plasticity
Life course
No intervention
Mother & infant: biomarkers of risk
Detrimental effects of Lifestyle challenges
Young adult: Screening may not
reduce risk
Affected adult: interventions have
limited effect
Early intervention
Late intervention
Child/ adolescent: effective point to
intervene
Risk
Challenges
• Poverty and inequalities have not gone away• Prevention needs to move upstream • The balance is changing and NCDs pose a
greater threat
NCD alliance
The next global development framework must therefore accommodate for both “unfinished business” in health and the new challenges, including NCDs.
NCD’s and increasingly affluent lifestyles
Group Qian Jin Zu (Hit rap song: “So What If I’m Fat”)
Movie in Hong Kong, 2010
NCDs in China (I)
• Challenges
• a shift to chronic disability
• urbanisation
• rising incomes
• ageing
NCDs in China (II)
• Leading causes of DALYs in 2010 • cardiovascular diseases (stroke and ischaemic
heart disease)• cancers (lung and liver cancer)• low back pain• depression
• Largest number of attributable DALYs• Dietary risk factors• high blood pressure• tobacco exposure
Global challenges of tobacco
Health and Humanities Symposium Taipei 29 October 2012
Tobacco in China
Health and Humanities Symposium Taipei 29 October 2012
The Lancet - June 3 2013
• Reduction of population exposures from poor diet , high blood pressure, tobacco use, cholesterol and fasting glucose are public health priorities for China
• As are control of ambient and household air pollution
Challenges
• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a
greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change
and the environment need to be high on the health agenda
GBD
• Ambient air pollution ranked fourth (third to fifth; the second highest in the G20) and household air pollution ranked fifth (fourth to sixth; the third highest in the G20) in terms of the age-standardised DALY rate in 2010.
Environment & Sustainability
SCMP HEADLINE OCT 28 2013: Regional think tank proposed to curb air pollution problems
• Cross-border air pollution has become a heated subject in Hong Kong, with many blaming the use of coal-fired power plants north of the border. A recent air quality study commissioned by Greenpeace linked 3,600 deaths and 4,000 cases of child asthma in 2011 to air pollution in the region caused by 96 plants in Guangdong and Hong Kong.
• Air quality in Beijing, Tianjin and Hebei failed to meet government air quality standards on 62.5 per cent of days in the third quarter.
Slide source: Clean Air Network HK
Climate change
Climate change in Asia
• Modelling suggests that the absence of climate mitigation will further increase the intensity and frequency of typhoons, tropical storms, floods and landslides in South/East Asia.
• A warmer and more humid climate is favourable for propagation and invasiveness of infectious insect vector; eg) dengue incidence in metropolitan Manila varies with changing rainfall patterns
• Heat islands in cities, sprawling unhygeinic slums, poverty……
Samet
Impact on Asia• South/East Asia, with vast coastal areas and vector-
prone climate, is one of the most vulnerable regions, facing a range of adverse health outcomes of climate change
• many impoverished inhabitants and its coastal cities and megacities are at risk from the direct and indirect stressors associated with climate change
• For the short-term, adaptive strategies are needed for heat waves and other extreme weather events
• For the longer-term, the success of global mitigation strategies will be critical, particularly if sea-level rise is to be slowed, and the threat to agriculture and water security minimised
Samet
Clean Water: this week in the BMJ • India plans joint project with World Bank to improve
safe water supply
• India’s Ministry of Drinking Water and Sanitation has launched a new initiative to provide a safe water supply for drinking, cooking, and other domestic purposes in rural areas of the country
• A safe water supply in rural areas is an important health related issue in India. WaterAid, an international, non-profit organisation headquartered in the United Kingdom, said, “It is estimated that around 37.7 million Indians are affected by waterborne diseases annually, 1.5 million children are estimated to die of diarrhoea alone and…”
BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6359 (Published 21 October 2013)Cite this as: BMJ 2013;347:f6359
Challenges
• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a
greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and
the environment need to be high on the health agenda
• Infectious disease has not gone away
Paradox of economic progress: impacts on patterns of ID
• Over 60% of the world's population lives in Asia• ID still remain a major burden in Asia: 47% of the estimated 2.1
million deaths in children <5 in SE Asia in 2010• Deforestation and forest encroachment result in increases in
infectious diseases, such as the Oropouche virus, Chagas disease and Hantaan virus
• A direct and predictable effect of reduced access to clean water for low-income families is an increased risk of water-washed diseases such as trachoma and scabies, and water-borne diseases such as typhoid, cholera, and hepatitis A and E.
• Unquantified risks arising from the intensification of agriculture include fresh water pollution with pesticides and fertilisers, loss of biodiversity and land abandonment by small-scale farmers.
• Horby
Infectious diseases
• Emerging infections • MERS• Avian flu • Response to AMR
• Neglected diseases of poverty • Helminthic diseases very common and cheap to treat
• Chronic infections• TB; HIV/AIDS; malaria ; diseases of poverty
4646
Lessons from SARS
Health and Humanities Symposium Taipei 29 Ocotber 2012
• H7N7, H7N9, etc, …
New and Emerging Diseases
HIV/AIDS: a chronic disease
Haven Youth Center (Kensington)
Health and Humanities Symposium Taipei 29 Ocotber 2012
Impact
• Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in China
• These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks
Challenges
• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a
greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and
the environment need to be high on the health agenda
• Infectious disease has not gone away • Providing universal care through primary
care based health systems
Health services face
Lancet : the three great transitions: demographic, epidemiological ; disability
• Ageing• Chronic disease• Urbanisation • Migration • Inequity • Innovation – robotics; personalised medicine,• Expectation • Cost
Challenge of Ageing
• Japan’s healthcare system is globally praised for its universal coverage and exemplary health indicators, while having the lowest rate of healthcare spending to GDP of the developed nations
• Japan’s high life expectancy is attributed to this universal healthcare system which relies on revenue from premiums in which working individuals support elderly populations
• As the Japanese continue to live longer, there have been corresponding increases in age-associated disability including chronic disease, as well as physical and mental impairment• Hokama and Cash
Health systems strengthening
• Population approaches • Primary Care • Prevention :
• primary ; secondary ; tertiary
• Public Private Partnerships • Public Engagement
• Community Health Services (CHS) Basis of urban public health system & basic medical services
Community based approaches
1. Division of Primary and Women’s Health, Ministry of Health – “Opinions on Development of Community Health Services in the Cities”. MOH .No.326 document. Jul 16, 1999. Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/pfybj/200804/18183.htm.
Six-in-one comprehensive care package1
Prevention
Treatment& Referral
Health Maintenance
Health Education
Family Planning
Rehab
Community Clinics in China
The village doctor
56
Recommendations
• Move to longer term comprehensive and integrated responses
• Reorient to prevention and early treatment • Effective intersectoral collaboration is needed
• eg) Health in All Policies
• Gain buy in: • Politicians• Policy makers• Profession• Public
Challenges
• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a
greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and
the environment need to be high on the health agenda
• Infectious disease has not gone away • Providing universal care through primary care
based health systems
What should we global health professionals be doing? Some suggestions:
• Education • eg) Curriculum for healthcare students to include climate
change and disaster response • Engage health services in addressing inequity
• Universal care; primary care; MCH outreach • Advocacy
• Responsibility of healthcare professionals to engage in climate change
• Research• New ways to engage in the community ; new metrics; new
funding opportunities• Networking
• Use this meeting to link the global community
Education for a global perspective
Photo Curtsey and Copyright 2011, CCOUC
Climate change: the challenge for all healthcare professionals
• The key conclusions of the Intergovernmental Panel on Climate Change are profoundly worrying, not only for our environment but also for public health
• Warming of the climate system is unequivocal, and, since the 1950s, many of the observed changes have been unprecedented over decades to millennia
• The atmosphere and ocean have warmed, the amounts of snow and ice have diminished, the sea level has risen, and concentrations of greenhouse gases have increased relentlessly
BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6060 (Published 9 October 2013)Cite this as: BMJ 2013;347:f6060 Costello et al
Health workers: consider five actions1. Mitigation: We cannot escape our responsibility to
reduce carbon emissions any more than that for alleviating poverty or reducing tobacco use
2. Shout from the rooftops that climate change is a health problem
3. Climate change is about poverty and equity. We must speed up our attainment of sustainable development goals and protect the most vulnerable populations
4. Advocate for political leadership and high level intergovernmental bodies to reduce the risk of climate change.
5. Advocate the mass scale-up of currently available solutions (insulation, recycling, conservation in energy and agriculture, solar power) in the health sector and beyond
Research : NCDs are under recognised • Research to evaluate innovative strategies is
crucial to control the pandemic of NCDs sweeping through low-income and middle-income countries.
• Currently only about 3% of global health aid is devoted to NCDs.
• Basic surveillance data and systems are poor in many low-income and middle-income countries,• Richard Smith
Challenges
• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a
greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and
the environment need to be high on the health agenda
• Infectious disease has not gone away • Providing universal care through primary care
based health systems
Thank you
Useful reference
• Trends in Death and Disability in Asia and the• Pacific: Key Findings from the Global Burden of• Disease 2010 Study• Professor Alan Lopez• School of Population Health, The University of Queensland• Brisbane, Australia• [email protected]