AFG Venture Group Dispatches

Corporate advisory and consultancy in Australia, South East Asia and India.

Global Trends in Health

Anushka Patel
Senior Director and Chair of the Chronic & Critical Conditions Theme, The George Institute for Global Health

What causes most disease and ill-health in China and India? Most people would immediately identify infections such as cholera, typhoid, tuberculosis, malaria and HIV, along with problems relating to maternal and child health. These diseases of poverty do remain an enormous challenge for low and middle income countries, but it surprises many to learn that chronic non-communicable diseases, along with injuries, cause more illness and premature death in virtually all parts of the world with the exception of a few countries in sub-Saharan Africa.

Chronic non-communicable diseases are those conditions that are most commonly associated with an ageing population in relatively wealthy countries, such as those in North America, Western Europe and Australasia. A number of conditions are considered to be “chronic non-communicable diseases”, including heart disease, stroke, cancer, chronic lung conditions, mental illness and arthritis. Many of these problems arise through the development of risk conditions such as diabetes and hypertension, which in turn are influenced by lifestyles that include cigarette smoking, poor diet and physical inactivity.

Chronic diseases, particularly those relating to heart attack and stroke (cardiovascular diseases), remain the leading cause of ill-health and premature death in high income countries. However, although rates have steadily declined in these countries from a peak in the 1960s, there is increasing concern that this trend will not continue, given rising levels of overweight and obesity as well as continued aging of “Western” populations.

Cardiovascular diseases currently account for about 60% of deaths worldwide. What is not commonly known is that 80% of these deaths occur in low and middle income countries, representing a rapid socio-demographic transition in such populations. The reasons for this transition are several. First, there have been important gains in relation to combating infectious diseases and improving maternal and child health in poorer countries; as a result, the average life expectancy has increased, leading to larger numbers of middle-aged and older people who are more likely to develop chronic conditions. Second, economic development and increasing urbanisation of populations due to greater migration from rural to urban centres, as well as industrialisation of traditionally rural areas, have resulted in marked societal and environmental changes. These, in turn, have been linked to major lifestyle changes such as reduced levels of physical activity and altered dietary patterns, which directly influence the risk of developing chronic conditions in general, and cardiovascular diseases in particular. Within a single generation, communities that farmed using non-mechanised equipment are now using tractors. Even in rural regions, leisure time is increasingly occupied by sedentary activities such as watching television, and processed food with high salt and fat content are increasingly becoming a part of usual dietary habits. In all these settings, people now use motorised transport, where their parents used to walk or ride bicycles.

For both richer and developing poorer countries of the world, the economic consequences of chronic diseases are major. In high income countries, socio-economically deprived communities suffer the brunt of the burden of cardiovascular diseases. Such groups have both higher rates of, and poorer outcomes from, cardiovascular diseases, with these observations incompletely explained by different levels of known major cardiovascular risk factors. Other factors likely to contribute to these differences include poor access to health care, a more toxic physical environment (e.g. less access to good food choices, more and cheaper fast food, less opportunities for physical activity and more pollution), and less social support for those with disease. In poorer countries, where people are affected by cardiovascular disease at much younger ages than in high income countries, the anticipated socio-economic effects of chronic non-communicable diseases are catastrophic, unless effective strategies for prevention and management of these conditions are urgently deployed to scale.

Part of any solution must include re-orientation of existing health care structures and services to meet the challenge of preventing and treating chronic non-communicable diseases while still maintaining a focus on other health priorities for that country or region. Fortunately, a lot is known about how to prevent or delay the onset of chronic disease, most of which must be implemented in primary health care settings.  For example, changes in lifestyle as well as appropriate long-term use of preventative drugs (particularly those targeting blood pressure and cholesterol) are well established as effective approaches to prevent cardiovascular diseases.

Despite this knowledge, these treatments are very poorly implemented in practice, even in high income countries. As a result, a major focus for ongoing research in this area is related to “implementation” rather than “discovery”. This approach requires partnerships between health care funders and providers, industry and researchers to develop and test innovative approaches to translate existing evidence into everyday policy and practice. For example, The George Institute has worked extensively with a pharmaceutical industry partner to address the complexity and cost of preventative drugs for cardiovascular disease prevention by developing a “polypill” (a single inexpensive capsule that includes all the 4-5 known effective drugs to prevent cardiovascular disease). This is now being evaluated in large populations globally. Another example of our work involves collaboration with the information technology industry to develop innovative E-health solutions to help healthcare workers make appropriate treatment recommendations, individualised for each patient and delivered in real time.

At a population level, effective solutions to target “upstream” determinants of chronic non-communicable diseases are crucial and will require partnership with many other sectors of society, including government and other policy makers (e.g. healthcare providers, urban planners), industry (e.g. food industry and pharmaceutical companies) and multinational agencies such as the United Nations (UN) and the World Bank. An example of The George Institute’s efforts in this area is the development of public-private partnerships to reduce the salt content in the food supply chain, in a way that will minimise impact on the bottom line for manufacturers of highly processed food products.

Understanding the threat that an impending chronic disease pandemic brings, the UN General Assembly unanimously resolved to convene a high-level meeting about non-communicable diseases to be held in September, 2011. This meeting aims to bring all stakeholders representing different sectors of society together to develop major policy initiatives to combat the rise of chronic diseases globally. This will be only the second global health summit that the UN has convened, the first being in response to the HIV / AIDS threat in 2001.

What do these trends mean? The economic and health consequences of what has been described by some as a “tsunami” of chronic non-communicable diseases are now clearly recognised as urgent global problems requiring global solutions. While health systems and health services do need to rise to the challenge worldwide, a policy focus with multi-sectoral and multi-national approaches is likely to be central to most successful strategies. For countries such as China and India, facing a double burden of persisting communicable diseases as well as rapidly increasing levels of chronic non-communicable diseases, the need for such strategies to be developed, implemented and evaluated is already urgent.

About the Author

Anushka Patel is a Senior Director and Chair of the Chronic & Critical Conditions Theme at The George Institute for Global Health, headquartered in Sydney, Australia. She is also currently Executive Director of The George Institute India, which is located in Hyderabad.

Anushka is Associate Professor in the Sydney Medical School and a cardiologist at Royal Prince Alfred Hospital in Sydney. She completed her undergraduate medical training at the University of Queensland, and her training in cardiology (leading to Fellowship of the Royal Australian College of Physicians) in Sydney. She has a Master of Science degree from Harvard University and a PhD in Medicine from the University of Sydney. Anushka also currently holds an Australian National Health & Medical Research Council Senior Research Fellowship.