Impact and response to the Global Burden of Disease in China

Professor Sian GriffithsAPRU workshopOctober 2013

The presentation will…

• Review some key messages around GBD

• Asian challenges

• Some thoughts for future actions

From the WHO

• Life expectancy at birth increased globally by 6 years since 1990• Life expectancy at birth is based on the death

rates across all age groups in a population in a given year – children and adolescents, adults and the elderly

• A baby born in 2011 could expect to live to 70 years on average – around 60 years in low-income countries to 80 years in high-income countries

http://www.who.int/features/factfiles/global_burden/en/index.html10 facts on the state of global health

Pre term births: still a priority

• Preterm birth is the world’s leading killer of newborn babies• Every year 15 million babies – about one in ten

babies – are born preterm (born alive before 37 weeks of pregnancy)

• Preterm birth complications cause more than one million deaths each year

• More than three quarters of these babies’ lives could be saved with simple and cost-effective care

Maternal mortality: unequal progress

• 800 women die everyday due to complications of pregnancy and childbirth

• Maternal mortality: very wide gaps between rich and poor, between and within countries

• WHO works to improve maternal health by assisting countries to improve care before, during and after childbirth

Childhood deaths: cheap to avoid

• Around 7 million children under the age of five die each year

• Almost all of these children’s lives could be saved if they had access to simple and affordable interventions • exclusive breastfeeding,• inexpensive vaccines and medication, • clean water and sanitation.

• WHO is working with governments and partners worldwide to deliver integrated, effective care and strengthen health systems, both of which are crucial to saving children’s lives

Injuries and Accidents: an avoidable killer

• Nearly 3500 people die from road traffic crashes every day

• Road traffic injuries are projected to rise as vehicle ownership increases due to economic growth in developing countries

• Strong action to improve road-use policies and enforce road-safety laws is needed to avert this rise in injuries and deaths

NCDs: the growing threat

• Cardiovascular diseases are the leading causes of death in the world

• Three in ten deaths globally are caused by cardiovascular diseases

• At least 80% of premature deaths from cardiovascular diseases could be prevented through • a healthy diet • regular physical activity • avoiding the use of tobacco

Diabetes: a rampant epidemic • Almost 1 in 10 adults has diabetes• Almost 10% of the world’s adult population has

diabetes, measured by elevated fasting blood glucose (≥126 mg/dl).

• People with diabetes have increased risk of heart disease and stroke.

• Deaths due to diabetes have been increasing since the year 2000, reaching 1.4 million deaths in 2011

Mental health: so common but often forgotten

• Mental health disorders such as depression are among the 20 leading causes of disability worldwide

• Depression affects around 350 million people worldwide and this number is projected to increase

• Fewer than half of those people affected have access to adequate treatment and health care

GBD and Mental Health

• Despite the apparently small contribution of YLLs — with deaths in people with mental disorders coded to the physical cause of death and suicide coded to the category of injuries under self-harm — our findings show the striking and growing challenge that these disorders pose for health systems in developed and developing regions

• In view of the magnitude of their contribution, improvement in population health is only possible if countries make the prevention and treatment of mental and substance use disorders a public health priority

Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010Prof Harvey A Whiteford MD: 

Ageing and Disability: a growing problem • Hearing loss, vision problems and mental

disorders are the most common causes of disability

• These disorders can affect people's lives and livelihoods, but many are easily treatable and some are preventable

• Improved access to interventions such as hearing aids, corrective eyeglasses and cataract surgery can make a big difference to helping people live productively

Lancet editorial: painting the picture

The largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors

• The Global Burden of Disease Study 2010 (GBD 2010• Horton

GBD and policy making:health warning - not a panacea but a tool • There is value in a numerical perspective in setting

priorities- but beware of the data • Richard Peto

• Policy making depends on imperfect data • Charlotte Watts

• The idea that we should be seeking perfect data is an illusion. Policy making depends upon using imperfect data• GBD is a step -it makes the best use of all the available data

and it makes the measurement of uncertainty one of its central principles.

• Some do not reflect the science underpinning associations between certain exposures and outcomes.

• Dave Leon• Lancet

Key messages from GBD study

• Poverty• Infectious diseases, maternal and child illness,

and malnutrition now cause fewer deaths and less illness than they did twenty years ago

• Non Communicable Diseases • such as cancer and heart disease, become the dominant

causes of death and disability worldwide• Fewer children are dying every year, but more young

and middle-aged adults are dying and suffering from disease and injury

• Disability• Since 1970, men and women worldwide have gained

slightly more than ten years of life expectancy overall, but they spend more years living with injury and illness

Messages for Asia

• Large variations across Asia/Pacific in extending life expectancy

• Progress in reducing child (and maternal) mortality throughout Asia over past 20 years rapid (& sustained)

• Premature adult mortality now a leading cause of health loss in all populations in the region, including from major Non-Communicable Diseases and injuries

• Progressive rise in burden of disability (low back pain, depression, injuries and NCDs) across the Region

Ref Lopez

Challenges for Asia

Challenges

• Poverty and inequalities have not gone away

Post MDG agenda

•  A Renewed Global Partnership for Development in March 2013. • universal commitments calling for actions from all

countries, according to their national capabilities

• build on existing commitments such as those reflected in the MDGs, the Monterey Consensus and the Johannesburg Plan of Implementation

• also be broadened and strengthened to address the large array of global challenges we face today

Unfinished MDG business:Addressing inequalities• India has the largest number of child deaths of any

country in the world, and has wide local variation in under-5 mortality

• Worldwide achievement of the UN 2015 Millennium Development Goal for under-5 mortality (MDG 4) will depend on progress in the subregions of India  

• At current rates of progress, MDG 4 will be met by India around 2020—by the richer states around 2015 and by the poorer states around 2023

• Accelerated progress to reduce mortality during the neonatal period and at ages 1—59 months is needed in most Indian districts

The Lancet Global Health, Volume 1, Issue 4, Pages e219 - e226, October 2013 

Poverty in Hong Kong

HK Oxfam Study on food prices• HK has more than 100,000 people with a 

net worth of US$1 million or more• 144,400 families with children aged 15 or 

below could be called poor (monthly income less than half the median household income of HK$9,500)

Source: http://www.oxfam.org.hk/en/news_1630.aspx

MDG’s: Education

Food for thought

• Malnutrition linked to literacy problems in quarter of world’s schoolchildren

• Experts have warned that around a quarter of schoolchildren globally could have serious literacy problems as a result of malnutrition.

• A report published by the charity Save the Children on 28 May claims that a child’s ability to read and write simple sentences and answer basic mathematical questions correctly is severely damaged if they do not have a nutritious diet.

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3569 (Published 31 May 2013)Cite this as: BMJ 2013;346:f3569

Challenges

• Poverty and inequalities have not gone away• Prevention needs to move upstream

Lifecourse view of NCD

Plasticity

Life course

No intervention

Mother & infant: biomarkers of risk

Detrimental effects of Lifestyle challenges

Young adult: Screening may not

reduce risk

Affected adult: interventions have

limited effect

Early intervention

Late intervention

Child/ adolescent: effective point to

intervene

Risk

Challenges

• Poverty and inequalities have not gone away• Prevention needs to move upstream • The balance is changing and NCDs pose a

greater threat

NCD alliance

The next global development framework must therefore accommodate for both “unfinished business” in health and the new challenges, including NCDs.

NCD’s and increasingly affluent lifestyles

Group Qian Jin Zu (Hit rap song: “So What If I’m Fat”)

Movie in Hong Kong, 2010

NCDs in China (I)

• Challenges

• a shift to chronic disability

• urbanisation

• rising incomes

• ageing

  

NCDs in China (II)

• Leading causes of DALYs in 2010 • cardiovascular diseases (stroke and ischaemic

heart disease)• cancers (lung and liver cancer)• low back pain• depression

• Largest number of attributable DALYs• Dietary risk factors• high blood pressure• tobacco exposure

Global challenges of tobacco

Health and Humanities Symposium Taipei 29 October 2012

Tobacco in China

Health and Humanities Symposium Taipei 29 October 2012

The Lancet - June 3 2013

• Reduction of population exposures from poor diet , high blood pressure, tobacco use, cholesterol and fasting glucose are public health priorities for China

• As are control of ambient and household air pollution

Challenges

• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a

greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change

and the environment need to be high on the health agenda

GBD

• Ambient air pollution ranked fourth (third to fifth; the second highest in the G20) and household air pollution ranked fifth (fourth to sixth; the third highest in the G20) in terms of the age-standardised DALY rate in 2010.

Environment & Sustainability

SCMP HEADLINE OCT 28 2013: Regional think tank proposed to curb air pollution problems

• Cross-border air pollution has become a heated subject in Hong Kong, with many blaming the use of coal-fired power plants north of the border. A recent air quality study commissioned by Greenpeace linked 3,600 deaths and 4,000 cases of child asthma in 2011 to air pollution in the region caused by 96 plants in Guangdong and Hong Kong.

• Air quality in Beijing, Tianjin and Hebei failed to meet government air quality standards on 62.5 per cent of days in the third quarter.

Slide source: Clean Air Network HK

Climate change

Climate change in Asia

• Modelling suggests that the absence of climate mitigation will further increase the intensity and frequency of typhoons, tropical storms, floods and landslides in South/East Asia.

• A warmer and more humid climate is favourable for propagation and invasiveness of infectious insect vector; eg) dengue incidence in metropolitan Manila varies with changing rainfall patterns

• Heat islands in cities, sprawling unhygeinic slums, poverty……

Samet

Impact on Asia• South/East Asia, with vast coastal areas and vector-

prone climate, is one of the most vulnerable regions, facing a range of adverse health outcomes of climate change

• many impoverished inhabitants and its coastal cities and megacities are at risk from the direct and indirect stressors associated with climate change

• For the short-term, adaptive strategies are needed for heat waves and other extreme weather events

• For the longer-term, the success of global mitigation strategies will be critical, particularly if sea-level rise is to be slowed, and the threat to agriculture and water security minimised

Samet

Clean Water: this week in the BMJ • India plans joint project with World Bank to improve

safe water supply

• India’s Ministry of Drinking Water and Sanitation has launched a new initiative to provide a safe water supply for drinking, cooking, and other domestic purposes in rural areas of the country

• A safe water supply in rural areas is an important health related issue in India. WaterAid, an international, non-profit organisation headquartered in the United Kingdom, said, “It is estimated that around 37.7 million Indians are affected by waterborne diseases annually, 1.5 million children are estimated to die of diarrhoea alone and…”

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6359 (Published 21 October 2013)Cite this as: BMJ 2013;347:f6359

Challenges

• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a

greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and

the environment need to be high on the health agenda

• Infectious disease has not gone away

Paradox of economic progress: impacts on patterns of ID

• Over 60% of the world's population lives in Asia• ID still remain a major burden in Asia: 47% of the estimated 2.1

million deaths in children <5 in SE Asia in 2010• Deforestation and forest encroachment result in increases in

infectious diseases, such as the Oropouche virus, Chagas disease and Hantaan virus

• A direct and predictable effect of reduced access to clean water for low-income families is an increased risk of water-washed diseases such as trachoma and scabies, and water-borne diseases such as typhoid, cholera, and hepatitis A and E.

• Unquantified risks arising from the intensification of agriculture include fresh water pollution with pesticides and fertilisers, loss of biodiversity and land abandonment by small-scale farmers.

• Horby

Infectious diseases

• Emerging infections • MERS• Avian flu • Response to AMR

• Neglected diseases of poverty • Helminthic diseases very common and cheap to treat

• Chronic infections• TB; HIV/AIDS; malaria ; diseases of poverty

4646

Lessons from SARS

Health and Humanities Symposium Taipei 29 Ocotber 2012

• H7N7, H7N9, etc, …

New and Emerging Diseases

HIV/AIDS: a chronic disease

Haven Youth Center (Kensington)

Health and Humanities Symposium Taipei 29 Ocotber 2012

Impact

• Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in China

• These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks

Challenges

• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a

greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and

the environment need to be high on the health agenda

• Infectious disease has not gone away • Providing universal care through primary

care based health systems

Health services face

Lancet : the three great transitions: demographic, epidemiological ; disability

• Ageing• Chronic disease• Urbanisation • Migration • Inequity • Innovation – robotics; personalised medicine,• Expectation • Cost  

Challenge of Ageing

• Japan’s healthcare system is globally praised for its universal coverage and exemplary health indicators, while having the lowest rate of healthcare spending to GDP of the developed nations

• Japan’s high life expectancy is attributed to this universal healthcare system which relies on revenue from premiums in which working individuals support elderly populations

•   As the Japanese continue to live longer, there have been corresponding increases in age-associated disability including chronic disease, as well as physical and mental impairment• Hokama and Cash

Health systems strengthening

• Population approaches • Primary Care • Prevention :

• primary ; secondary ; tertiary

• Public Private Partnerships • Public Engagement

• Community Health Services (CHS) Basis of urban public health system & basic medical services

Community based approaches

1. Division of Primary and Women’s Health, Ministry of Health – “Opinions on Development of Community Health Services in the Cities”. MOH .No.326 document. Jul 16, 1999. Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/pfybj/200804/18183.htm.

Six-in-one comprehensive care package1

Prevention

Treatment& Referral

Health Maintenance

Health Education

Family Planning

Rehab

Community Clinics in China 

The village doctor

56

Recommendations

• Move to longer term comprehensive and integrated responses

• Reorient to prevention and early treatment • Effective intersectoral collaboration is needed

• eg) Health in All Policies

• Gain buy in: • Politicians• Policy makers• Profession• Public

Challenges

• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a

greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and

the environment need to be high on the health agenda

• Infectious disease has not gone away • Providing universal care through primary care

based health systems

What should we global health professionals be doing? Some suggestions:

• Education • eg) Curriculum for healthcare students to include climate

change and disaster response • Engage health services in addressing inequity

• Universal care; primary care; MCH outreach • Advocacy

• Responsibility of healthcare professionals to engage in climate change

• Research• New ways to engage in the community ; new metrics; new

funding opportunities• Networking

• Use this meeting to link the global community

Education for a global perspective

Photo Curtsey and Copyright 2011, CCOUC 

Climate change: the challenge for all healthcare professionals

• The key conclusions of the Intergovernmental Panel on Climate Change are profoundly worrying, not only for our environment but also for public health

• Warming of the climate system is unequivocal, and, since the 1950s, many of the observed changes have been unprecedented over decades to millennia

• The atmosphere and ocean have warmed, the amounts of snow and ice have diminished, the sea level has risen, and concentrations of greenhouse gases have increased relentlessly

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6060 (Published 9 October 2013)Cite this as: BMJ 2013;347:f6060 Costello et al

Health workers: consider five actions1. Mitigation: We cannot escape our responsibility to

reduce carbon emissions any more than that for alleviating poverty or reducing tobacco use

2. Shout from the rooftops that climate change is a health problem

3. Climate change is about poverty and equity. We must speed up our attainment of sustainable development goals and protect the most vulnerable populations

4. Advocate for political leadership and high level intergovernmental bodies to reduce the risk of climate change.

5. Advocate the mass scale-up of currently available solutions (insulation, recycling, conservation in energy and agriculture, solar power) in the health sector and beyond

Research : NCDs are under recognised •  Research to evaluate innovative strategies is

crucial to control the pandemic of NCDs sweeping through low-income and middle-income countries.

• Currently only about 3% of global health aid is devoted to NCDs.

• Basic surveillance data and systems are poor in many low-income and middle-income countries,• Richard Smith

Challenges

• Poverty and inequalities have not gone away• The balance is changing and NCDs pose a

greater threat • Prevention needs to move upstream • Sustainability , pollution , climate change and

the environment need to be high on the health agenda

• Infectious disease has not gone away • Providing universal care through primary care

based health systems

Thank you

Useful reference

• Trends in Death and Disability in Asia and the• Pacific: Key Findings from the Global Burden of• Disease 2010 Study• Professor Alan Lopez• School of Population Health, The University of Queensland• Brisbane, Australia• a.lopez@sph.uq.edu.au