Prof K Srinath ReddyPresidentPublic Health Foundation of India Professor of Cardiology All India Institute of Medical Sciences Bernard Lown Professor of Global Cardiovascular Health Harvard School of Public Health

CHRONIC NON-COMMUNICABLE

DISEASES

GLOBAL DIMENSIONS AND

DETERMINANTS

GLOBAL NCD EPIDEMIC SIX QUESTIONS

bull Are NCDs a growing global public health threat

bull What are the determinants and dynamics of this epidemic

bull Do NCDs pose a threat to economic development and health equity

bull Why have been NCDs neglected in global policy and funding

bull Will recent increase in attention translate into an increase in resources for NCD prevention

bull How do NCDs relate to sustainable development

GLOBAL DEATHS BY CAUSE 2004

0

5000

10000

15000

20000

HIVA

IDS TB

Malaria

CVD

Cance

r

Chronic

Res

pirato

ry

Diabete

s

(100

0s)

Preventing chronic diseases a vital investment WHO global report 2005

GLOBAL NCD EPIDEMIC SIX QUESTIONS

bull Are NCDs a growing global public health threat

bull What are the determinants and dynamics of this epidemic

bull Do NCDs pose a threat to economic development and health equity

bull Why have been NCDs neglected in global policy and funding

bull Will recent increase in attention translate into an increase in resources for NCD prevention

bull How do NCDs relate to sustainable development

GLOBAL DEATHS BY CAUSE 2004

0

5000

10000

15000

20000

HIVA

IDS TB

Malaria

CVD

Cance

r

Chronic

Res

pirato

ry

Diabete

s

(100

0s)

Preventing chronic diseases a vital investment WHO global report 2005

GLOBAL DEATHS BY CAUSE 2004

0

5000

10000

15000

20000

HIVA

IDS TB

Malaria

CVD

Cance

r

Chronic

Res

pirato

ry

Diabete

s

(100

0s)

Preventing chronic diseases a vital investment WHO global report 2005

23 LMIC

Chronic diseases account for 50 of total disease burden in these countries

(Abegunde D et al Lancet 2007)

Developing countries account for 80 of global mortality due to chronic diseases

As the working age population expands and if high death rates continue the burden of chronic disease will rest on the shoulders of workers

Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)

POTENTIALLY PRODUCTIVE YEARS OF LIFE LOST DUE TO CARDIOVASCULAR DEATHS

(AGE GROUP 35-64 YEARS )

7

1633

67

92

2032

105

179

USARussiaChinaIndia

In Millions

20302000

Estimated Economic Loss for India due to Heart Disease Stroke and Diabetes (2006-2015) US $ 237 Billion - WHO

Projected per capita income path conditional on different CVD scenarios

(Scenario 1 and 2 1 and 3 annual decline in mortality)

bull Demographic Shifts (Aging)bull Urbanizationbull Industrialisationbull Globalization (Marketing)bull Educationbull Culturebull Poverty (Access to Health)bull Built Environment (BarrierEnabler)

Vectors Tobacco Unhealthy Food

DETERMINANTS

(Living Habits)

(Beliefs)

Developing Countries are in the Big League

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Projected global numbers of deaths by cause for high- middle- and lowincomecountries (WHO 2008)

POTENTIALLY PRODUCTIVE YEARS OF LIFE LOST DUE TO CARDIOVASCULAR DEATHS

(AGE GROUP 35-64 YEARS )

7

1633

67

92

2032

105

179

USARussiaChinaIndia

In Millions

20302000

Estimated Economic Loss for India due to Heart Disease Stroke and Diabetes (2006-2015) US $ 237 Billion - WHO

Projected per capita income path conditional on different CVD scenarios

(Scenario 1 and 2 1 and 3 annual decline in mortality)

bull Demographic Shifts (Aging)bull Urbanizationbull Industrialisationbull Globalization (Marketing)bull Educationbull Culturebull Poverty (Access to Health)bull Built Environment (BarrierEnabler)

Vectors Tobacco Unhealthy Food

DETERMINANTS

(Living Habits)

(Beliefs)

Developing Countries are in the Big League

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

POTENTIALLY PRODUCTIVE YEARS OF LIFE LOST DUE TO CARDIOVASCULAR DEATHS

(AGE GROUP 35-64 YEARS )

7

1633

67

92

2032

105

179

USARussiaChinaIndia

In Millions

20302000

Estimated Economic Loss for India due to Heart Disease Stroke and Diabetes (2006-2015) US $ 237 Billion - WHO

Projected per capita income path conditional on different CVD scenarios

(Scenario 1 and 2 1 and 3 annual decline in mortality)

bull Demographic Shifts (Aging)bull Urbanizationbull Industrialisationbull Globalization (Marketing)bull Educationbull Culturebull Poverty (Access to Health)bull Built Environment (BarrierEnabler)

Vectors Tobacco Unhealthy Food

DETERMINANTS

(Living Habits)

(Beliefs)

Developing Countries are in the Big League

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Projected per capita income path conditional on different CVD scenarios

(Scenario 1 and 2 1 and 3 annual decline in mortality)

bull Demographic Shifts (Aging)bull Urbanizationbull Industrialisationbull Globalization (Marketing)bull Educationbull Culturebull Poverty (Access to Health)bull Built Environment (BarrierEnabler)

Vectors Tobacco Unhealthy Food

DETERMINANTS

(Living Habits)

(Beliefs)

Developing Countries are in the Big League

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

bull Demographic Shifts (Aging)bull Urbanizationbull Industrialisationbull Globalization (Marketing)bull Educationbull Culturebull Poverty (Access to Health)bull Built Environment (BarrierEnabler)

Vectors Tobacco Unhealthy Food

DETERMINANTS

(Living Habits)

(Beliefs)

Developing Countries are in the Big League

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Developing Countries are in the Big League

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Risk factors tobacco use on the rise in developing countries

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Imports of French fries (frozen) into the Central American countries from the United States

Source FAO 2007

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Pastry biscuit and confectionary imports into Central America 1990-2004

Source FAO 2007

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Snack imports from the United States into Central America 1989-2006

Source FAO 2007

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

The Nutrition Transition in Developing Countries

Shift in diet structure ndash towards a high fat and refined sugar Western Diet

Accelerating rate of change in diet Shift in activity patterns Link between diet and activity

changes and increases in obesity Popkin 2001

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Mean Plasma Cholesterol Values in China

0

50

100

150

200

250

mg

dl

1958 1981 1997 2003

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Major risk for chronic diseases in Middle East

Overweight amp Obesity based on STEPwise Surveillance (BMIgt=25)

669 674563

812 764

539

0

20

40

60

80

100

Iraq Jordan Syria Kuwait Egypt Sudan

Perc

ent

Hypertension in the EMR Based on STEPwise Surveillance

255 26 288246

334

236

404

05

1015202530354045

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

DM in the EMR (STEPwise Surveillance)

104

16179

199167 165

192

0

5

10

15

20

25

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

Low Physical Activity

567

79

338 329

554 504

868

0

20

40

60

80

100

Iraq Jordan SaudiArabia

Syria Kuwait Egypt Sudan

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

THE ROSE PRINCIPLEldquoSick Individuals Arise From Sick Populationsrdquo

- Geoffrey Rose

WITHIN EACH POPULATION

bull The number of persons who will have undesirable levels of any risk

factor is related to the mean level of the risk factor in the population

bull A shift of the whole distribution to the left would mean better health

(less lsquocasesrsquo) and a shift to the right means worse health

(more lsquocasesrsquo)

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

THE WORLD AS ONE POPULATION If we plot the distributions of

bull BP

bull Cholesterol

bull Exposure to Tobacco Smoke (ActivePassive)

bull Physical Inactivity

bull Dysglycemia

bull Overweight amp ObesityAT THE GLOBAL LEVEL

WE WILL FIND A RIGHTWARD SHIFT

In Each Of Their Distributions Compared To 20-30 Yrs Ago

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Worldwide Mortality (2001) Versus Disbursements (2005) of World Bank US

Government Bill amp Melinda Gates Foundation Global Fund to fight HIVAIDS

Tuberculosis and Malaria (Sridhar and Batniji 2008)

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

POVERTY AND NCDs ndash

A TALE OF TEN YEARS

(1999-2009)

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

The World Bank Stand on NCDs (1999)

Article Title The burden of disease among the global poor

Authors Gwatkin DR Guillot M Heuveline P

Publication Lancet 1999 354 586-89

Method Comparison of disease burdens in the richest 20 and poorest 20

ldquoA faster decline in communicable diseases would

decrease the poor-rich gap in 2020 but under an

accelerated rate of overall decline in non-communicable

diseases the poor-rich gap would widenrdquo

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

GWATKIN et al 1999 Concluding Paragraph

ldquoCaution is needed before policy-makers embrace thecurrent shift in emphasis from communicable diseasesamong the young toward non-communicable disorders at older ages Such a shift is no doubt justifiable from anoverall global perspective but the figures developed here suggest that the shift turns away from the diseases of greatest importance for the worldrsquos poor and turnstoward those of less importance for the poor and ofgreater importance for the richrdquo

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Article Title The burden of disease among the global poor (Letter to the Editor)

Author K Srinath Reddy

Publication Lancet 1999 354 1477

Posers What about the middle 60 - they are from LMIC What about tobacco which is mainly a problem of the poor

REBUTTAL A LONE VOICE FROM LMIC

ldquoEpidemics of non-communicable diseases will increasingly burden the poor and more importantly the rising costs of clinical care for those with noncommunicable diseases will adversely affect the ability of less-developed countries to deal with the unfinished agenda of communicable diseases The control of communicable diseases and the prevention of non-communicable diseases must proceed simultaneouslyrdquo

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

ldquoThe only way to bridge the rich-poor gap in health is to

ensure equitable global development and speedy

redressal of poverty in less-developed countries

(including release from the debt trap) and not through

an artificial moratorium on public-health efforts to

contain non-communicable diseases Will the World

Bank help to address these real prioritiesrdquo

REBUTTAL THE CONCLUDING PARAGRAPH

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

NCDs THE SOCIAL GRADIENT

As socio-economic and health transitions advance within each countryhelliphellip

The Social gradient for NCD risk factors and for NCD events progressively reverses till

THE POOR BECOME MOST VULNERABALE

(Reddy KS et al PNAS 2007)

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

SES GRADIENTORDER OF REVERSAL FOR CVD RISK FACTORS

Tobacco

Blood Pressure

Plasma Cholesterol

darr Physical Activity

Obesity

Health Transition

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

Tanzania Smoking amp HT uarr in low SES BMI uarr in High SES Group(Bovet P 2002)

China Smoking HT Obesity inversely correlated with years of education in Chinese women (Zhije Yu 2000)

India Higher risk of MI in urban residents with low level of education and income (Rastogi T 2004)

In Industrial employees and families all CVD risk factors are inversely correlated with education (Reddy KS 2007)

Brazil Obesity rates declining in High SES Rising in Low SES(Bell 2000)

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

STROKE CHINA QUEST STUDY (2009)4739 Survivors of stroke71 Patients Experienced Catastrophic OOPE

- Heeley E et al Stroke 2009 402149-5

bull OOPE from Stroke pushed 37 of

patients and their families below

the poverty line 62 without

insurance went into poverty

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

CVD IMPACT ON HOUSEHOLDS (KERALA INDIA)

(Harikrishnan 2010)

bull Catastrophic health expenditures (729)Distress Financing Common (50)

bull 40 of CVD patients lost sources of income

bull 82 did not have health insurance

bull 13 could not continue medication due to cost factors

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

2007

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

The World Bank on NCDs (2007)

ldquoTo what extent do NCDs affect the poor The

answer depends to some extent on the country

and the indicator of the NCD burden that is

considered However in all countries and by any

metric NCDs account for a large enough share of

the disease burden of the poor to merit a serious

policy responserdquo

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

ECONOMIC IMPACT OF NCD ON HOUSEHOLDS

ldquoMany studies tend to underestimate the real cost of non-communicable diseases to individual people and their families which can cause a household to slip below the poverty linerdquo

ldquoAlthough these effects of poor health are not unique to NCDs the longer duration of chronic disease makes the financial costs heavier than in the case of acute illnessrdquo

- Joy Phumaphi Vice President of World Bankrsquos Global Development Network

(2007)

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

NOW helliphellip

bull A momentum appears established

bull ECOSOC meeting (2009)

bull UN Secretary Generalrsquos Meeting (2009)

bull World Health Assembly Resolution (2010)

bull UN General Assembly Special Session

(UNGASS 2011)

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

HEALTH CARE INDUSTRY IS INTERESTED

bull As incomes rise in MICs more drugs

and devices can be sold

bull As more governments adopt financing

mechanisms for universal health

coverage NCD Care can be

publicinsurance financed

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

FOOD INDUSTRYrsquoS RESPONSE PROACTIVE OR PREEMPTIVE

bull Regulatory Activism in HIC will it set the trend

for LMICndash Salt (UK)

ndash Trans-Fats (NY Denmark)

ndash Labeling (Many Countries)

bull Food Industry is responding with proposals for lsquoVoluntary Agreementsrsquo

bull Tobacco Control LawsLitigation feared as precedents as Obesity gains global attention

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

WILL RESOURCE FLOWS TO NDC PREVENTION AND CONTROL INCREASE

bull More Money For Tobacco Control (Bloomberg

Gates Countries Implementing FCTC)

bull More Money For NCD Research (NIH UK MRC

Global Alliance for Chronic Diseases

Wellcome Trust)

bull More Money For NCD Advocacy

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

FUNDING IS LIKELY TO INCREASE FOR DISEASE

CONTROL

bull BP Controlbull Diabetes Care

bull Drug Based Prevention of CVD

bull Cancer Detection amp Treatment

bull Treatment of Asthma

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

WILL NCD PREVENTION AND

CONTROL BE LEFT TO THE

lsquoMARKETrsquo

OR

WILL A COMPREHENSIVE

FRAMEWORK EMERGE FOR

MULTI-LEVEL ACTION

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

GLOBAL NATIONAL COMMUNITY FAMILY INDIVIDUAL

Development(stage and

speed)

Distribution(equity)

Demand- Supply(trade)

Beliefs

Behaviours

Biology

Perceptions(cultural)

Priorities(socio-economic)

Pathways(availability access)

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

THE HEALTH OF

PERSONS PEOPLE

POPULATIONS

CALLS FOR DIFFERENT LEVELS OF ACTION

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

POLICY APPROACHES(Global National Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and Maintain Healthy Choices

INDIVIDUALFAMILY

NEIGHBORHOOD COMMUNITY

Enhancement of Knowledge Motivation and Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATIONP

reve

ntiv

e D

iagn

ostic

Th

erap

eutic

R

ehab

ilita

tive

Ser

vice

s

HE

ALT

H C

AR

E D

ELI

VE

RY

WIDER SOCIETY

DE

TER

MIN

AN

TS

Globalization

Acc

ess

to C

are

Sys

tem

s In

frast

ruct

ure

Hea

lth

Wor

kfor

ceQ

ualit

y of

C

are

Dru

gs amp

Te

chno

logi

es

Demographic Change

Globalization

Social Determinants

Health Inequities

Cultural and Social Norms

Education

Biological Risk

Behavioral Risk

NUTRITION PYRAMID ADVERTISING PYRAMID

Colas and other sugary drinks Chips and salted snacks Biscuits chocolates and other candyFast food (Burgers pizzas etc)

COMMUNICATION TO CONSUMERS MIS-MATCH

BETWEEN SCIENCE AND COMMERCE

Occasional

IN MODERATION

PLENTY

MOULDING

THE

MARKETS

INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA

GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS

INDUSTRY PRACTICES

Private-Public Partnerships Health Dividend

CONSUMER CONCIOUSNESS

NATIONAL POLICY FRAME WORK

Political Economic Social Motivators

Health Professionals Civil Society Media

COMMUNITYLOCALITY

AgricultureGardens

Local markets

Health Care

PublicSafety

PublicTransport

ManufacturedImported

Food

Sanitation

Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg

POPULATION

OBESE

AND

OVER--WEIGHT

WORKSCHOOL HOME

SchoolFood ampActivity

Infections

Labour

Worksite Food amp Activity

LeisureActivityFacilities

Family ampHome

INDIVIDUAL

EnergyExpenditure

Food intake Nutrient density

Societal policies and processes influencing the population prevalence of obesity

NATIONAL REGIONAL

Education

Food amp Nutrition

Urbanization

Health

Social security

Transport

Media ampCulture

Nationalperspective

INTERNATIONAL FACTORS

Development

Globalizationof

markets

Media programs

amp advertising

CHRONIC DISEASE CONUNDRUM DEVELOPMENTAL DILEMMA

Economic Growth

IndustrialisationUrbanizationGlobalization

Among the Top 10 Threats To Global Economic Growth

Global Chronic Disease Epidemics

Unhealthy Living Habits

Life Expectancy

Good Health

World Economic Forum (2009 2010)

THE TRILLION DOLLAR QUESTION

How Then Do We Reconcile The Economic

Aspirations of Countries Like India With

Protection Of Cardiovascular Health And

Prevention of Chronic Diseases

This is where public health meets

sustainable development and social justice

DEVELOPMENT CHOICES TO BE MADE

Q Do we wish to see continued development

A Yes Of Course

Q What kind of developmental pattern should we seek

A Economic Development ndash Good

Economic Development With Greater Equity ndash Better(Inclusive Growth)

Sustainable Development With Equity In Key -- BestHuman Development Indices

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

MOULDING

THE

MARKETS

INTERNATIONAL AGENCIES TRANS-NATIONAL TRADE AND MEDIA

GLOBAL COVENANTS COMMERCE amp COMMUNICATIONS

INDUSTRY PRACTICES

Private-Public Partnerships Health Dividend

CONSUMER CONCIOUSNESS

NATIONAL POLICY FRAME WORK

Political Economic Social Motivators

Health Professionals Civil Society Media

COMMUNITYLOCALITY

AgricultureGardens

Local markets

Health Care

PublicSafety

PublicTransport

ManufacturedImported

Food

Sanitation

Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg

POPULATION

OBESE

AND

OVER--WEIGHT

WORKSCHOOL HOME

SchoolFood ampActivity

Infections

Labour

Worksite Food amp Activity

LeisureActivityFacilities

Family ampHome

INDIVIDUAL

EnergyExpenditure

Food intake Nutrient density

Societal policies and processes influencing the population prevalence of obesity

NATIONAL REGIONAL

Education

Food amp Nutrition

Urbanization

Health

Social security

Transport

Media ampCulture

Nationalperspective

INTERNATIONAL FACTORS

Development

Globalizationof

markets

Media programs

amp advertising

CHRONIC DISEASE CONUNDRUM DEVELOPMENTAL DILEMMA

Economic Growth

IndustrialisationUrbanizationGlobalization

Among the Top 10 Threats To Global Economic Growth

Global Chronic Disease Epidemics

Unhealthy Living Habits

Life Expectancy

Good Health

World Economic Forum (2009 2010)

THE TRILLION DOLLAR QUESTION

How Then Do We Reconcile The Economic

Aspirations of Countries Like India With

Protection Of Cardiovascular Health And

Prevention of Chronic Diseases

This is where public health meets

sustainable development and social justice

DEVELOPMENT CHOICES TO BE MADE

Q Do we wish to see continued development

A Yes Of Course

Q What kind of developmental pattern should we seek

A Economic Development ndash Good

Economic Development With Greater Equity ndash Better(Inclusive Growth)

Sustainable Development With Equity In Key -- BestHuman Development Indices

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

COMMUNITYLOCALITY

AgricultureGardens

Local markets

Health Care

PublicSafety

PublicTransport

ManufacturedImported

Food

Sanitation

Modified from Ritenbaugh C Kumanyika S Morabia A Jeffery R Antipathies V IOTF website 1999 httpwwwiotforg

POPULATION

OBESE

AND

OVER--WEIGHT

WORKSCHOOL HOME

SchoolFood ampActivity

Infections

Labour

Worksite Food amp Activity

LeisureActivityFacilities

Family ampHome

INDIVIDUAL

EnergyExpenditure

Food intake Nutrient density

Societal policies and processes influencing the population prevalence of obesity

NATIONAL REGIONAL

Education

Food amp Nutrition

Urbanization

Health

Social security

Transport

Media ampCulture

Nationalperspective

INTERNATIONAL FACTORS

Development

Globalizationof

markets

Media programs

amp advertising

CHRONIC DISEASE CONUNDRUM DEVELOPMENTAL DILEMMA

Economic Growth

IndustrialisationUrbanizationGlobalization

Among the Top 10 Threats To Global Economic Growth

Global Chronic Disease Epidemics

Unhealthy Living Habits

Life Expectancy

Good Health

World Economic Forum (2009 2010)

THE TRILLION DOLLAR QUESTION

How Then Do We Reconcile The Economic

Aspirations of Countries Like India With

Protection Of Cardiovascular Health And

Prevention of Chronic Diseases

This is where public health meets

sustainable development and social justice

DEVELOPMENT CHOICES TO BE MADE

Q Do we wish to see continued development

A Yes Of Course

Q What kind of developmental pattern should we seek

A Economic Development ndash Good

Economic Development With Greater Equity ndash Better(Inclusive Growth)

Sustainable Development With Equity In Key -- BestHuman Development Indices

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

CHRONIC DISEASE CONUNDRUM DEVELOPMENTAL DILEMMA

Economic Growth

IndustrialisationUrbanizationGlobalization

Among the Top 10 Threats To Global Economic Growth

Global Chronic Disease Epidemics

Unhealthy Living Habits

Life Expectancy

Good Health

World Economic Forum (2009 2010)

THE TRILLION DOLLAR QUESTION

How Then Do We Reconcile The Economic

Aspirations of Countries Like India With

Protection Of Cardiovascular Health And

Prevention of Chronic Diseases

This is where public health meets

sustainable development and social justice

DEVELOPMENT CHOICES TO BE MADE

Q Do we wish to see continued development

A Yes Of Course

Q What kind of developmental pattern should we seek

A Economic Development ndash Good

Economic Development With Greater Equity ndash Better(Inclusive Growth)

Sustainable Development With Equity In Key -- BestHuman Development Indices

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

THE TRILLION DOLLAR QUESTION

How Then Do We Reconcile The Economic

Aspirations of Countries Like India With

Protection Of Cardiovascular Health And

Prevention of Chronic Diseases

This is where public health meets

sustainable development and social justice

DEVELOPMENT CHOICES TO BE MADE

Q Do we wish to see continued development

A Yes Of Course

Q What kind of developmental pattern should we seek

A Economic Development ndash Good

Economic Development With Greater Equity ndash Better(Inclusive Growth)

Sustainable Development With Equity In Key -- BestHuman Development Indices

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

DEVELOPMENT CHOICES TO BE MADE

Q Do we wish to see continued development

A Yes Of Course

Q What kind of developmental pattern should we seek

A Economic Development ndash Good

Economic Development With Greater Equity ndash Better(Inclusive Growth)

Sustainable Development With Equity In Key -- BestHuman Development Indices

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

CONVERGENCE OF CONCERNS

In The Policy Arenahellip

Common Determinants Link

bull NCDs and Environment

bull NCDs and Zoonotic Pandemics

bull NCDs and Food Security

bull NCDs and Human Rights

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

CONVERGENCE IN RECOMMENDATIONS

bull Protection of Environment

bull Chronic Disease Prevention

Sustainable Development Needs

bull Urban environments which reduce vehicular congestion promote

physical activity and energy efficiency

bull Diets which promote appropriate nutrient intake through

sustainable consumption patterns at the population level

bull RemovalReduction of pollutants amp toxic chemicals from the

environment

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

TOBACCO AND THE ENVIRONMENTbull Deforestation due to

- lsquoFlue Curingrsquo- Packaging

bull Subsoil Water Depletionbull Soil Erosionbull Pesticide Usebull Forest Firesbull Litterbull Environmental Tobacco Smoke

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

INDUSTRIAL SCALE LIVESTOCK BREEDING

ObesityCVDCancer

Climate Change(uarr Methane Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

Global Meat Production Will Double From 229 Million Tonnes in 2009 To 465 Million Tonnes In 2050

+ +

WATER

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

Praise without end the go-ahead zeal of whoever it was invented the wheel but never a word for the poor soulrsquos sakethat thought ahead and invented the brake

- Howard Nemerov(ldquoTo the Congress of the United States

Entering Its Third Centuryrdquo) 1989

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

INTER-GENERATIONAL IMPACT OF NCD RISK FACTORS NEW KNOWLEDGE FROM

EPIGENETICS

bull Epigenetic effects of Diet Physical Activity and Smoking Are Being Increasingly Recognized

bull Risk of CVD DM and Cancers may be partly mediated through such epigenetic effects

bull These epigenetic alterations and influences may be transmitted across several generations

NCD RISK FACTORS MAY THWART THE DEVELOPMENTAL POTENTIAL OF SEVERAL FUTURE

GENERATIONS- IT IS A RIGHTS ISSUE

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

ldquoShould medicine ever fulfill its great ends it must enter into the larger political and social life of our time it must indicate the barriers which obstruct the normal completion of the life cycle and remove them Should this ever come to pass Medicine whatever it may then be will become the common good of allrdquo

- Rudolf Virchow (1821-1902)

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

SUSTAINABLE DEVELOPMENT

PUBLIC HEALTH

MEDICINE20th Century

21st Century

Persons

PeoplePopulations

PLANET

Persons

PeoplePopulations

PLANET