Issue #12 - NCDs Time for a Change - Global Health Magazine

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LEVERAGING EXISTING PLATFORMS TO EXPAND SERVICES GRAPPLING WITH THE TENSIONS AROUND NCDs

18 & 23

NCDS AND THE PRIVATE SECTOR

ISSUE 12

FALL 2011 $4.95 U.S.

NCDs

TIME FOR CHANGE WWW.GLOBALHEALTHMAGAZINE.COM —

ADVERTORIAL

Non-Communicable Diseases: a partnership approach under-pinning Sanofi’s strategy

By Robert Sebbag, Vice-President, Access to Medicines, Sanofi

C

ancer, cardiovascular disease, diabetes, stroke, osteoporosis, and mental health disorders all have a tremendous effect on the lives of people affected by these diseases. They cause anxiety for the patient and their family; they may result in the patient working less and requiring more support from family, volunteers and government; and the escalating cost of managing these conditions is a public policy challenge we are increasingly facing up to.

With non-communicable diseases representing 43 percent of the burden of disease and projected to be responsible for 60 percent of the disease burden by 2020, there has never been a better time to consider the measures for the prevention and control of non-communicable diseases, and mitigate their impacts.

A collaborative, multi-stakeholder partnership approach must be pursued to effectively address this growing concern and will be key to our progress in addressing the challenges posed by NCDs.

At Sanofi, we are proud of a track record dating back many decades that has seen us playing our part in creating a positive environment for people living with NCDs. We work in collaboration with healthcare professionals, patient advocacy groups, payors, health service providers and governments on awareness and prevention campaigns, and chronic disease management programs. Our partnership approach has also under-pinned our strategy in developing countries.

Mental health disorders and epilepsy are indeed amongst the most prevalent health conditions in the developing world, just as they are in developed countries, yet most people do not receive treatment. Patients with these diseases not only live with disabling and life-threatening symptoms of the illness, but they are also further victimised by ignorance, discrimination and social stigma that leave them excluded.

The “Impact Epilepsy” and “Mental Health” programs have made considerable progress, and have contributed to Sanofi becoming the first pharmaceutical company to engage in concrete activities for mental disorders and epilepsy patients in developing countries in Africa, Asia and Latin America. Sanofi has a long term commitment to build a sustainable and comprehensive model to tackle the diseases on all fronts, from prevention to rehabilitation. Our programs make use of the core-skills of the company through training and education tools, suitably adapted medicines and a continuous research program to find new treatments, and a tiered pricing policy to make medicines affordable to all.

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ISSUE 12

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IN THIS ISSUE:

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06 NCDs: IT’S TIME FOR A CHANGE

COVER STORY: NCDs: TIME FOR CHANGE —

09 LEVERAGING EXISTING PLATFORMS TO EXPAND SERVICES

12 PUTTING A FACE ON CANCER AND OTHER NCDs

15 GRAPPLING WITH THE TENSIONS AROUND NCDs 17 NCDs IN THE DEVELOPING WORLD: LOOKING FOR SOLUTIONS 18 INDIA: THE PRIVATE SECTOR TAKES ACTION 21 BRAZIL: GETTING A MOVE ON NCDs 23 THE ROLE OF THE PRIVATE SECTOR

SCREENSHOTS —

04 TRENDS IN CASES OF CANCER 05 RAISED BLOOD PRESSURE BY REGION AND INCOME 05 TRENDS IN OVERWEIGHT INFANTS AND CHILDREN

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ISSUE 12

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letter FROM THE EDITOR

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GLOBAL HEALTH

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EXECUTIVE EDITOR

Tina Flores

GUEST EDITOR

Craig Moscetti INTERN

Gahan Furlane COPY EDITOR

Rhonda Stewart GRAPHIC DESIGN

Shawn Braley WEB

This issue of GLOBAL HEALTH magazine highlights the mounting global epidemic of non-communicable diseases (NCDs), such as heart diseases, cancers, chronic lung diseases and diabetes. Collectively, NCDs and their common risk factors of tobacco use, physical inactivity, abuse of alcohol and unhealthy diet are rising on the political agenda.

Indeed, senior government officials will gather this month at the United Nations for the two-day High Level Meeting of the General Assembly to focus international attention on the prevention and control of NCDs. NCDs arguably pose one of the greatest development challenges of the coming century. Though the success of the high level meeting will be judged largely by government commitments made in the political declaration, the meeting in and of itself can already count many achievements. It has served as a focal point to congregate stakeholders, provoke policy dialogue, and question fundamental approaches to global health. Coalitions and partnerships have emerged. A “health” challenge is being discussed based on non-health factors and determinants. Solutions are being viewed as systemic approaches, considering issues of sustainability and interaction with other components of global, national and local development systems. These issues and others defined by the uncertain political and economic environment constrain solutions, but also provide an opportunity to foster innovation in policy, advocacy, program implementation and development cooperation.

The scale and economic toll posed by NCDs is increasingly clear, requiring urgent action. The burden of NCDs is only projected to worsen, particularly among countries least able to respond. Solutions must come from a variety of fronts, and future social and economic progress will undoubtedly be shaped by how the global community understands, prioritize and responds to NCDs. Craig Moscetti Guest Editor, Chair NCD Roundtable Policy Manager, Global Health Council

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Winnie Mutch E-MAIL:

magazine@globalhealth.org GLOBAL HEALTH COUNCIL BOARD OF DIRECTORS

Joel Lamstein, SM, chair William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Christopher Elias, MD, MPH Elizabeth Furst Frank, MBA Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Reeta Roy GLOBAL HEALTH is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in GLOBAL HEALTH do not necessarily reflect the views of the Global Health Council, its funders or members.

Learn more about the Council at www.globalhealth.org This issue is sponsored by Sanofi and The Coca-Cola Company.

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GLOBAL HEALTH STATISTICS

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ESTIMATED NEW CANCER CASES AND DEATHS (MOST COMMON CANCERS, 2008)

HIGH INCOME

UPPER-MIDDLE-INCOME

MALES

PROSTATE

PROSTATE

LUNG

LUNG

COLORECTUM

COLORECTUM

BLADDER

STOMACH

STOMACH

BLADDER

KIDNEY

KIDNEY

NON-HODGKIN LYMPHOMA

LEUKAEMIA

MELANOMA OF SKIN

PANCREAS

PANCREAS BREAST

FEMALES

BREAST

LUNG

COLORECTUM

COLORECTUM

LUNG

STOMACH

STOMACH

CERVIX UTERI

NON-HODGKIN LYMPHOMA

BLADDER

MELANOMA OF SKIN

PANCREAS

PANCREAS

LEUKAEMIA

KIDNEY BLADDER

KIDNEY

0

1000

2000

3000

4000 5000 6000

NEW CASES

0

2000

3000

4000 5000 6000

3000

4000 5000 6000

DEATHS LOW-INCOME

LOWER-MIDDLE-INCOME LIVER

LUNG

MALES

1000

STOMACH

LUNG

LIVER

STOMACH

OESOPHAGUS

OESOPHAGUS

COLORECTUM

NON-HODGKIN

LEUKAEMIA

COLORECTUM LEUKAEMIA

LIP, ORAL CAVITY

FEMALES

LIP, ORAL CAVITY BREAST

CERVIX UTERI

CERVIX UTERI

BREAST

LUNG

LUNG

STOMACH

LIVER

COLORECTUM

STOMACH

LIVER

COLORECTUM

CORPUS UTERI

OESOPHAGUS

OESOPHAGUS

NON-HODGKINS

LEUKAEMIA

LIP, ORAL CAVITY

LIP, ORAL CAVITY

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0

1000

2000

3000

4000 5000 6000

LEUKAEMIA

0

1000

2000

Source: World Health Organization

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RAISED BLOOD PRESSURE PERCENTAGE OF ADULTS AGED 25+ YEARS (BY WHO REGION AND WORLD BANK INCOME GROUP) 70

MEN

WOMEN

BOTH SEXES

60 50 40 30 20 10 0

AFR

AMR

EMR

EUR

SEAR

LOWINCOME

WPR

LOWERMIDDLE INCOME

UPPERMIDDLE INCOME

UPPER INCOME

Source: World Health Organization

TRENDS IN OVERWEIGHT INFANTS AND YOUNG CHILDREN PERCENT OF POPULATION 2

4

7

5

3

5

1990 5

6

10

8

4

6

7

6

9

11

8

7

11

6

12

9

2015

2010 LOWER-MIDDLE INCOME

9

2000

1995

2005 LOW-INCOME

5

UPPER-MIDDLE-INCOME

HIGH-INCOME

Source: World Health Organization CLICK ON THE SOURCE AT C WWW.GLOBALHEALTHMAGAZINE.COM

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BY NELLIE BRISTOL

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NCDs:

It’s Time for a Change It took the patient, a farmer in his forties, an entire day to travel to the clinic in Karatu, Tanzania. He’d been in discomfort for a number of months. He had sought treatment from a traditional healer to little effect: the swelling all over his body, in his neck, groin and armpits, even his liver and spleen, was worsening and he felt sicker than ever. But even at the clinic, geared toward primary care, diagnostic and treatment alternatives were sparse. If he had come in earlier, and he’d had sufficient financing and family support to facilitate his care away from home, doctors could have sent him to a cancer hospital in Dar-es-Salaam, a 10-hour drive. As it was, his disease was too far along. “He obviously had a treatable lymphoma, but we had nothing. We couldn’t

do a biopsy, I couldn’t get him medicines and all we did was give him a non-steroidal and send him home to die,” said Sue Miesfeldt, an oncologist from Maine who was visiting the clinic in January 2010 on a self-funded tour of cancer care in the country. The five-year survival rate for what Miesfeldt suspected the patient had, non-Hodgkin’s lymphoma, is 65 percent in the United States with fairly straightforward and widely accessible treatment. The episode left a lasting impression on the Portland physician, who was used to being able to do much more for her patients, if even providing them with more effective palliative care. “I was angered…because just a little bit of distribution of just a piece of what we have in the United States would have gone such a

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Nellie Bristol is a freelance journalist specializing in health policy.

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ESTIMATES INDICATE, FOR EXAMPLE, THAT LESS THAN 5 PERCENT OF GLOBAL CANCER RESOURCES FUND CARE IN DEVELOPING COUNTRIES. distance over there. That was the most difficult lesson for me,” she said.

Miesfeldt’s experience is a familiar one in the developing world and the situation is only expected to get worse.

Deaths from non-communicable diseases (NCDs) like cancer, cardiovascular disease, chronic respiratory disease and diabetes totaled 36 million globally in 2008, a number that is expected to rise to 52 million by 2030.

“While popular belief presumes that NCDs afflicted only high income populations, the evidence tells a different story,” the World Health Organization said in its April Global Status Report on Noncommunicable Diseases.

More than 80 percent of cardiovascular and diabetes deaths, and almost 90 percent of deaths from chronic obstructive pulmonary disease occur in low- and middle-income countries, as do two-thirds of cancer deaths. The diseases also kill at a younger age than in the developed world – 29 percent of NCD deaths in low- and middle-income countries occur among people under 60, compared to 13 percent in high income countries. “No health problem in the history of the world has ever gone so hidden, misunderstood and underrecorded,” said John Seffrin, CEO of the American Cancer Society.

Despite the rapid growth in chronic disease, few resources are devoted to them. Estimates indicate, for example, that less than 5 percent of global cancer resources fund care in developing countries. “We’re seeing a huge spiraling effect [in disease growth] before anyone has started to do anything,” said Katie Dain, advocacy and programme development co-ordinator for the International Diabetes Federation (IDF).

Those in the field have seen the growing wave of NCD deaths and disability for years, brought on by increased urbanization, globalization and aging populations.

Fostering the diseases are increases in smoking rates, greater access to less nutritious foods and decreases in

physical activity. The developing world also has a higher prevalence of cancers related to infectious disease, especially cervical cancer, which often is detected and treated early in rich countries. Advocates and practitioners are frustrated by the lack of response from governments and donors who they say are operating under the premise the diseases require expensive and protracted treatment that can’t be sustained in resource poor settings and who are stuck in a disease-specific approach largely based on an infectious disease model. They view the NCD epidemic as a hindrance to development in general and to achievement of the Millennium Development Goals. “You don’t save a woman from dying in child birth to let her die of cervical cancer two years later when it could have been prevented,” said Felicia Knaul, director of the Harvard Global Equity Initiative.

Advocates hope the United Nations General Assembly High-Level Meeting on Non-communicable Diseases in September 2011 will increase momentum for NCD prevention and treatment worldwide. The conference has already promoted greater cooperation among disease specific civil society groups and had the effect of generating much needed research. For example, David Bloom, chair of the Department of Global Health and Population at Harvard, is examining the economic impact of the diseases in a project sponsored by the World Economic Forum. Early estimates show the global cost of new cancer cases totaled $300 billion in 2010 while costs for obstructive pulmonary disease totaled $4 billion. Further, the global decline in productivity related to NCDs would reach $35 trillion by 2030 if current trends continue.

While the additional attention is welcome, to really be successful the meeting needs to produce concrete and lasting efforts, advocates say. “We want more than a declaration,” said Loyce Pace Bass, director of health policy for LIVESTRONG. “There’s a gap between what we know and what we do and that’s the gap we’re trying to fill with this opportunity at the United Nations and thereafter,” she added.

Several high profile groups have issued specific action requests. The Lancet NCD Action Group and the NCD Alliance, for example, issued five recommendations in April, with a particular focus on leadership and primary prevention. The groups called for drastically curtailing tobacco use by 2040, reducing salt intake, aligning national policies to promote healthy diets and delivering cost effective affordable drugs and technologies, an agenda they predict would cost $9 billion per year globally and reduce NCD deaths by 2 percent a year (see page 17).

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ULTIMATELY, ADVOCATES SAY, POLICY MAKERS AT ALL LEVELS AS WELL AS DONORS NEED TO TAKE NCDS MORE SERIOUSLY AND MAKE CONCRETE COMMITMENTS TO ADDRESS THEM. In addition, experts are pushing movement toward a health systems-and-patient centered orientation that would provide care for a range of diseases largely using existing service delivery sites. While early detection and treatment of many chronic diseases is expensive in developed countries, advocates say a lot can be done by enhancing existing services and improving prevention messages. In several countries, Harvard’s Knaul said, community health workers are being trained in outreach for breast cancer detection. Lower cost ways of identifying cervical cancer also are being implemented. While early detection may not rival that in high income countries, cancer could be caught at stage I or II rather than the late stage disease that is commonly seen now. In addition, she added, programs can be designed to address barriers to care other than cost and access, including stigma and discrimination.

“Many women…believe they’re going to die no matter what...and they’re sure they’re going to be abandoned” if the disease is discovered, Knaul said. In addition, supply chains and affordability of diagnostics and treatments could be improved.

There also is a push for a multisectoral approach involving industry, government, donors and civil society.

While chronic disease often is attributed to personal choices, there are a variety of cultural, policy and commercial forces at work. “These used to be called lifestyle diseases and we very much moved away from that to saying these diseases are very much the result of larger movements and larger factors,” said IDF’s Dain. Risk factors for the diseases are “very much bigger than that person’s individual choices, particularly in low income countries,” she added.

The most obvious example is promotion of tobacco products internationally and in some places, like China, state involvement in cigarette production and sales.

Another example is urban planning that precludes safe walking or cycling. In other areas, changes in

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food distribution and production have “dramatically changed people’s health and their size and their risk of long term non-communicable diseases,” said Rachel Nugent of the University of Washington’s Department of Global Health. The UN meeting could spur changes that could improve disease prevention efforts, she said, but policies need to be comprehensive. She said, for example, that an “ingredient based approach” that just addresses salt and trans fat, would fall short. “I don’t disagree, but that’s certainly not enough,” she said.

Instead, policy makers should consider the entire food environment and enhance nutrition. “I think what we’re after here is cultural change,” she said.

International policy makers also need to come up with tool kits for countries to begin addressing the problem incrementally so that it’s not so overwhelming, Nugent said. “Beyond this meeting it needs to be taken much more to the country level,” she said.

Ultimately, advocates say, policy makers at all levels as well as donors need to take NCDs more seriously and make concrete commitments to address them.

Advocates are trying in particular to get an increased response from the U.S. Ninety-three organizations, including NGOs, academics and industry, signed a letter requesting that President Barack Obama attend the UN meeting. They also are trying to alter the infectious disease mindset at the United States Agency for International Development (USAID). Acknowledging the diseases as “the next great frontier,” during a February speech at the National Institutes of Health, USAID Administrator Rajiv Shah added that the agency still will have as its primary goal for the next decade addressing “the basic communicable diseases.”

Nonetheless, an agency spokesperson said USAID is committed to health system advancements that will improve disease response in the future. “While USAID programs address a range of NCDs (e.g., nutritional deficiencies, maternal conditions, cervical cancer in HIV-positive women), they do not directly target most of the disease groups to be discussed at the upcoming UN High-Level Meeting on NCDs; that is, cancer, cardiovascular disease, chronic respiratory diseases and diabetes,” he said in a statement. “Nonetheless, through its strong support for health systems strengthening and integrated, holistic health care delivery, USAID is helping build the foundation upon which future NCD efforts can be based.”

Given budget constraints and the current political climate, that may be the best the U.S. can do.

Nonetheless, a growing contingency will certainly argue for better. Mortality rates “should not be [a function] of income or geography,” Knaul said. GH —

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BY PETER LAMPTEY, REBECCA DIRKS AND INOUSSA KABORE

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All Hands on Deck: Leveraging Existing Health Platforms to Expand NCD Services The amplified interest in the global epidemic of noncommunicable diseases (NCDs) is well-founded and long overdue. NCDs are responsible for the largest burden of disease globally. Since a significant proportion of deaths due to NCDs are premature (people younger than 60-years-old), they place considerable constraints on economic and social development.

Given limitations in funding and human resources, as well as the double burden of infectious diseases in many low- and middle- income countries, integration of NCD services into existing health platforms offers a cost-effective and efficient approach to scaling up NCD services. Natural linkages between NCDs and their risk factors exist with health programs targeting HIV and other infectious diseases, sexual and reproductive health, tuberculosis, maternal and child health, and nutrition.

While there is very limited research on models of NCDs integration and the efficiency and efficacy of integration of services, there are a host of potential benefits in integrating NCD services as compared to vertical service delivery. These benefits include: n Leveraging relatively well-developed but primarily

Peter Lamptey, MD, DrPH is president, Public Health Programs, FHI 360.

Rebecca Dirks, MA is technical officer, Program Sciences, FHI 360.

Inoussa Kabore, MD, MPH is director, strategic information, FHI 360.

Photo courtesey of FHI 360

Though many vertical health programs have improved individual elements of health systems, substantial weaknesses of overall health systems remain in most low-and middle-income countries. A strategic countrydriven improvement of the health system to address a multiplicity of health issues including NCDs is more likely to create efficient, sustainable and cost-effective national health programs. NCD integration would support improved supply chain management; a better financed and more motivated health workforce; an improved laboratory infrastructure; and a comprehensive health management information system.

vertical platforms for the delivery of multiple services; n Offering a “one-stop shop” for health clientele resulting in time and cost savings; n Reduced duplication and improved cost efficiency of

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health workforce, service infrastructure, management and financial resources; and n Improvement of country-driven and country-owned health systems for multiple diseases and conditions.

OPPORTUNITIES FOR NCD INTEGRATION Many low- and middle- income countries have already developed large-scale HIV, sexual and reproductive health, and child survival programs. Integration of NCD services into these platforms would improve access of multiple program services to various populations.

HIV programs are often the first large-scale chronic disease initiatives in low- and middle- income countries, offering local and effective models that can be emulated, adapted and expanded. HIV-supported improvements in health infrastructure for chronic disease management offer a unique opportunity to build upon these services for other chronic diseases.

These infrastructure platforms include electronic health management information systems; facility and community-based counseling and testing programs, innovative community-based adherence counseling and support services; well-developed laboratory services and improved pharmacy services linked with reliable supply chain management programs. To date, different NCD and HIV integration models have been piloted in a variety of locations, including Cambodia (Médecins Sans Frontières), Ethiopia (ICAP), Kenya (FHI 360), Nigeria (FHI 360), Swaziland (ICAP) and Vietnam (FHI 360); preliminary evidence from these programs demonstrates the value of NCD integration.

Integration of NCDs into prevention of mother-to-child transmission of HIV (PMTCT) programs, for instance, could include primary and secondary prevention of NCD risk factors such as: the promotion of healthy diet and nutrition to prevent excessive maternal weight gain during pregnancy and monitoring of weight gain in infants with low birth weight (both of which are a risk factors for cardiovascular disease during childhood), monitoring and treatment for elevated blood pressure, blood lipids and blood sugar; the prevention of tobacco use and exposure to second hand smoke during pregnancy; and the promotion of adequate physical activity.

HIV counseling and testing services, and care and treatment programs may be adapted to facilitate a reduction of NCD risk factors such as smoking, excessive drinking and dietary changes to reduce salt, sugar and fat intake. They may also provide treatment for those who are at greater risk of acquiring NCDs – people with elevated blood pressure, abnormal

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blood lipids, abnormal blood sugar and those who overweight or obese. The integration of services also provides the opportunity for the monitoring of patients on antiretroviral treatment for NCD-related complications. Moreover, it also allows for the provision of comprehensive palliative care for individuals with both HIV and an NCD. Sexual and reproductive health programs are often well established in low- and middle- income countries and offer unique access to girls and women. Integration of NCDs into SRH programs provide an opportunity to reach and improve the health of women and reduce the disparities in access to health care that women often face in these countries.

The integration of NCDs into maternal health programs, including family planning, may include screening and primary and secondary prevention of NCD risk factors such as the promotion of healthy diet and nutrition to prevent excessive maternal weight gain during pregnancy and monitoring of weight gain in infants with low birth weight, monitoring and treatment for elevated blood pressure, blood lipids and blood sugar; the prevention of tobacco use and second hand smoke during pregnancy; the prevention of sexually transmitted infections; the promotion of adequate physical activity; the prevention of exposure to cook stove smoke, and early childhood immunization for the prevention of human papillomavirus and early detection of cervical cancer; and the prevention and early detection of breast cancer.

There are also opportunities for integrating NCDs into child survival and youth programs. Many NCD risk factors are developed or acquired in childhood and adolescence, such as dietary habits, smoking, drinking, physical activity, immunization against cancers of infectious origins and risk factors for rheumatic heart disease. NCDs should be seen as childhood diseases with adult manifestations. HIV and SRH programs have traditionally targeted youth because of their vulnerability to HIV, STI and unintended pregnancies. The integration of NCDs into existing youth programs provides an excellent opportunity to prevent the development of risk factors such as smoking, excessive drinking, physical inactivity and detrimental dietary habits.

A valuable lesson learned from the HIV response is the important contribution of sectors other than health.

Integration of NCD and existing health programs should include the involvement of the community, stakeholders such as those living with NCDs, the private sector and

C SEE THE REFERENCES ONLINE AT WWW.GLOBALHEALTHMAGAZINE.COM

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CORE NCD RISK FACTORS BEHAVIORAL RISK FACTORS n n n n

TOBACCO USE DIET (LOW VEGETABLE AND FRUIT CONSUMPTION) PHYSICAL INACTIVITY HARMFUL ALCOHOL CONSUMPTION

BIOLOGICAL RISK FACTORS n n n n n n n n n

AGE GENDER HEIGHT AND WEIGHT - BODY MASS INDEX (BMI) WAIST CIRCUMFERENCE BLOOD PRESSURE CHOLESTEROL LEVEL BLOOD SUGAR LEVEL AGE AT FIRST SEX CURRENT OR ANTECEDENTS OF STIs

BEHAVIORAL RISK FACTORS n CD4 COUNT n TYPE OF ART REGIMEN n DURATION OF ART THERAPY

the broader civil society. We should aim to strengthen health systems for an improved delivery of facility- and community-based services.

CRITICAL ROLE OF DATA When designing and implementing models of NCD integration, monitoring and evaluation (M&E), surveillance and operations research will be critical to track prevalent risk factors and determine the most effective entry points for NCD integration.

Upon initiating an integrated NCD program, biological and behavioral surveillance surveys are key, as they establish a baseline of prevalence and behaviors related to risk factors, as well as inform the design of integration programs. If funding allows, collection of qualitative data would provide information on community perceptions, values and misconceptions toward NCDs. As integration models continue to be piloted, robust M&E and surveillance systems and operations research

are critical to generate evidence on which integration models are most effective – both in terms of quality of services and cost. Depending on the entry points, a core set of NCD risk factors should be considered for regular monitoring (see Box). The integration of NCD-related indicators into existing health management information systems should be implemented to avoid double counting of clients and support the effective monitoring of health outcomes. Inclusion of a routine cost tracking component into NCD integration projects is necessary to elucidate the financial and staffing requirements.

Lastly, as we endeavor to test and scale-up new integration models, we must answer the following questions: n What is the impact of integration on quality of services? n What is the cost and cost effectiveness? n What is the impact on providers’ workload? n What is the acceptability of integration by service providers and clients? n Is the model sustainable?

THE WAY FORWARD Given the potential benefits to be achieved, countryled national responses to NCDs should be designed to integrate NCD services within their existing health platforms. In order to make NCD integration a reality, the following steps should be considered: n Careful assessment and documentation of the key lessons learned from current vertical and integrated programs that can be replicated; n Further operational research to define various integration models, what works, what to integrate and what not to integrate, what is cost-effective, and how best to make it work; n Development of a country-driven overarching strategy for strengthening of health services in LMIC at various levels of development and based on their needs and priorities; n Development of evidence-based integration models for various programs and for different health systems; n Development of “how to” kits for the integration of NCDs into existing health programs; n Policy dialogue at the national and international levels to adopt evidence-based integration as a key element of future developmental assistance programs; and n Leveraging resources from national governments, donors, private sector and civil society to support integration implementation. GH —

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BY LOYCE PACE-BASS AND KIRA O’CONNOR

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The People behind the Policy

Putting a Face on Cancer and other NCDs In one way or another, we are all affected by cancer, cardiovascular disease, diabetes and chronic respiratory diseases. Whether you, a friend or a family member has a non-communicable disease (NCD), NCDs affect everyone. NCDs are the world’s leading silent killer. In fact, NCDs count for two out of three deaths each year worldwide. By 2030, eight out of 10 leading causes of death will be linked to NCDs. We are facing a global epidemic. The numbers are staggering yet not enough is being done to prevent, combat and manage these diseases. We need to examine the need for immediate action against the NCD pandemic, the consequences

MR. AND MRS. DETSI ENDO- “A community to share opinions and [to] be compassionate with one another is . . . very important,” Mr. Endo, a prostate cancer survivor living in Japan, told us. His story illustrates the social complexities a family can face dealing with cancer. Upon learning of his diagnosis at age 66, he sought treatment in the U.S. without immediately informing his wife because of the fear of death that a diagnosis can bring.

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if action is not taken, and the importance of the United Nations High-level Meeting on Non-communicable Diseases in September 2011. More importantly, let’s consider the people who are affected by lifesaving policies and programs and the impact of meaningful government and civil-society commitments at the UN and beyond.

THE FACES OF NCDS Behind every diagnosis there is a person whose family will deal with the risk, diagnosis and treatment or management of their NCD. There is a real need to focus less on the disease itself and more on the person with the disease. Of the 8 million cancer deaths that occur worldwide (more than half in low-income and middleincome countries) many can be avoided with early detection and treatment. And millions of patients with advanced or untreatable cancer – without access to true palliative care – will die with great and preventable suffering. Many will be impoverished from attempting to meet even the most basic treatment costs. We cannot sit back and let those living with NCDs suffer and die needlessly.

Putting the focus on people enables both government entities and civil society agencies to visualize the importance of acting swiftly to combat NCDs and the social and economic issues associated with these diseases. The widespread prevalence of noncommunicable diseases is more than just a health issue.

The social and cultural challenges that accompany them are often founded in the stigma attached to cancer

Loyce Pace-Bass is director of policy at LIVESTRONG. Kira O’Connor is a member of the LIVESTRONG health policy team.

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BINU-A father of three young children from Muttacaud, India, he was diagnosed with an inoperable, unknown form of cancer. Despite being isolated by many in his community, he stayed positive about his life with the love and support of his family, until he lost his battle with cancer in 2008.

discrimination and improve access to prevention and health care services. We need to support those with NCDs as well as those who are not aware of what it really means to be an NCD patient or survivor. If we empower patients, families, or those at risk to speak out about NCDs, we can further elevate the national dialogue and open the door to critical local and global responses to this health priority.

WENDELL VITBOY-A 41-year-old cancer survivor living in Cape Town, South Africa Wendell Vitboy was, like many, shocked to be diagnosed because “cancer is not looked after as much as AIDS is looked after [in South Africa].” He never realized the magnitude of the problem until he was diagnosed. Wendell’s story is common- but shows the need for more policies and programs in countries which traditionally haven’t prioritized cancer as a key issue.

and other NCDs. Because many people around the world are not aware of their options once diagnosed, they often conclude it is a death sentence. In the case of cancer, this can keep people from seeking help to prevent or treat the disease.

Stigma also limits systemic responses to NCDs. Putting a face on non-communicable diseases will help prevent

The economics of NCDs, namely their associated personal health costs, also serve as a face of the burden. An NCD diagnosis not only affects the person, it affects their entire family. The person’s ability to earn an income or do any type of work is significantly reduced, if not completely lost. People living with NCDs around the world face poverty as a result of catastrophic health costs. Furthermore, global NCDs pose a significant risk to national and global economies in a way that hinders the broader global development agenda.

NEED FOR ACTION Despite the growing pandemic, cancer and other NCDs are notably absent from the global health and development agenda, including key global health targets such as the Millennium Development Goals.

According to the World Health Organization, up to 40 percent of cancers and 80 percent of precursors to cardiovascular disease and diabetes could be prevented through limited exposure to tobacco, a healthy diet and

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DAVID MKEFA- A throat cancer survivor, David is an outspoken advocate on the issue in his community of Soweto, South Africa. David recently shared his story at the Voice of Cancer Survivor Forum, a LIVESTRONG-supported initiative held in Cape Town which empowered local NGOs to bring survivors, civil society, media, and decision-makers together to take national action on key cancer issues.

NORMA PATRICIA RODRÍGUEZ GUTIÉRREZ AND JORGE ESTRADA VÁSQUEZ-Norma Patricia Rodríguez Gutiérrez had to cope with the economic toll of cancer first-hand after being diagnosed with non-Hodgkins Lymphoma in Mexico City. When LIVESTRONG met Norma in 2008, she faced such immense discrimination and stigma as a cancer survivor that she could not find employment and her family was struggling to make ends meet.

adequate physical activity. Many of these solutions are related to policy changes that, if enacted, could leverage limited resources for significant impact. The bottom line is that something can be done.

We can provide education, diagnostics, patient support and other essential services to low- and middle-income countries. We need to act now and implement policies or programs that can accommodate and adapt to the limitations of resource-constrained environments.

Working with the resources countries already have – however minimal – is vital to the success of effective action against NCDs. CONSEQUENCES OF COMPLACENCY Many of the diseases that pose the greatest burden in developing countries are cancers and NCDs that are preventable or responsive to treatment. If nothing is done, these diseases will continue to unnecessarily hinder or take the lives of mothers, fathers and children during or even before their most productive years.

The challenge to us all is not to identify what works; we already know that. The challenge is the call to action for governments, civil society and other stakeholders to apply what we know works so that all people have equitable access to the highest attainable standard of health, regardless of what country they live in or their place in society.

Getting NCDs recognized on a global level can seem like an uphill battle. But that’s what people were still saying about the HIV/AIDS epidemic just 10 years ago

TATSUYO SAITO-“I am thankful that I am alive, and my gratitude becomes my strength,” 61-year-old Tatsuyo Saito told us when we interviewed her about her experience as a kidney cancer survivor in Tokyo, Japan. She expresses what so many survivors feel when she says that “getting cancer was a chance to reflect on my life.”

and the progress with that disease has been remarkable.

The failure to act in response to the NCD epidemic has dire consequences. We must weigh the impact of smart investments with the inevitable losses – both the human and economic toll – due to inaction or indecision. No, we cannot do everything and we certainly cannot do it all at once. But we must take steps toward addressing this current problem, however incremental. We owe this to both the people living with and at risk for NCDs worldwide.

UN NCD SUMMIT & GLOBAL COMMITMENTS In order to highlight the need for focused action and an organized response at the national and international levels to adequately address NCDs, the United Nations General Assembly is holding a high level meeting on NCDs. This summit will be attended by UN member states’ Heads of State and Heads of Government. At the end of the summit, governments are expected to issue an action-oriented outcome document that outlines their commitments to address NCDs on a global level.

Follow-through by member states will be essential in ensuring the success of the summit. In other words, the real work starts after the world’s leaders and their advisors return to their home countries. That is when they must remember the burden faced by their citizens, the increasing risk of NCDs to their societies and the power of implementing key policies and programs to prevent and treat these diseases. If we remember the faces of NCDs, we can save millions of lives and do right by the world. GH —

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BY SIR GEORGE ALLEYNE, ALAFIA SAMUELS AND KAREN SEALEY

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Grappling with the Tensions around NCDs

Recent global health conferences have highlighted many of the issues that health and other sectors must address to prevent and control non-communicable diseases (NCDs). This growing awareness about NCDs, coupled with the United Nations High-Level Meeting on Non-communicable Diseases, marks a significant milestone in the effort to raise the political priority of NCDs. However, this has brought to the fore several tensions inherent in focusing on any particular health problem.

First, there will inevitably be challenges that arise from the nature of the diseases or health problems themselves, as different constituencies attempt to promote one or other group of diseases, and clamoring to highlight “their” category of disease or heath issue – for example, communicable diseases vs. NCDs. Further strain emerges within disease groupings, with “factions” and advocates using one or other metric to claim priority for their disease, e.g. within NCDs, cancer vs. chronic respiratory diseases. It is also salutary to note that there are also tensions within the communicable disease community as arguments arise over the attention paid to malaria versus other infectious diseases such as HIV/AIDS. Although these tensions may be decried as being unhelpful, they do exist, must be recognized and, if possible, converted into sources of creative energy for improving health.

Here we explore the nature and geneses of some of the tensions around NCDs, but in particular those between NCDs and communicable diseases, and

Sir George Alleyne is director emeritus of the Pan American Health Organization. T. Alafia Samuels is senior lecturer at the Faculty of Medical Sciences, University of the West Indies. Karen Sealey is senior adviser, UN Matters and Partnerships at the Pan American Health Organization.

indicate possible means of reduction or resolution. We should be clear that the discordance between groups of advocates for one or other disease exists predominantly in the developing countries and within the international community. While it is true that NCDs have not had the priority that they merit on a global level, this is not the case in wealthy nations. In these countries, with their aging populations, enormous burden of NCDs and relatively low burden of communicable diseases, little or no tension exists, and expenditure is heavily slanted toward the care of patients with non-communicable diseases.

In the international arena, there is apprehension over the attention currently being paid to NCDs and conversely, the possibility of a lessened focus on communicable diseases. The argument is that communicable diseases still contribute the majority of health problems in the poorest countries, and it is irresponsible to address NCDs before resolving existing challenges. While it is true that in sub-Saharan Africa, communicable diseases still account for the major part of the burden of illness, this is not the case in any other region of the world.

Further, sub-Saharan Africa is the region in which the incidence of NCDs is rising fastest.

Indeed, in 2008, about two-thirds of the 57 million deaths globally were due to NCDs; 80 percent of those who died were in developing countries. By 2030, the burden of disease from NCDs will be three times greater than that of communicable diseases and maternal, perinatal and nutritional conditions combined. As the Secretary-General of the United Nations Ban-Ki Moon

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THE WORLD WILL NOT ACHIEVE THE TARGETS SET FORTH BY THE MDGS WITHOUT TAKING NCDs INTO ACCOUNT.

said recently, “NCDs have emerged relatively unnoticed in the developing world and are now becoming a global epidemic.”

Framing the discussion in terms of one set of diseases versus the other stems, in part, from one of the many misconceptions about the epidemiological transition and a need to raise awareness about what is important at the population level. During the epidemiological transition, as communicable diseases decline, NCDs emerge, but there is no sharp temporal division in disease profile. Thus, there will be a stage of coexistence or double burden, the NCDs and their behavioral risk factors coexisting with communicable diseases. Some countries must continue to suffer a double burden of both communicable and noncommunicable diseases for some time. The HIV epidemic and the recent H1N1 pandemic have made it clear that all countries still have to deal with communicable diseases.

The tension is also due in part to the nature of the two groups of diseases. Communicable diseases are, in general, acute in onset with external, often dramatic manifestations, with a definitive end result – recovery, disability or death. NCDs are often imperceptible in onset, of long duration and, in the popular perception, without a cure. However, therapeutic developments are leading to cures for some NCDs, for example some cancers. Also, attention to the predominant risk factors can actually prevent disease and appropriate treatment can extend the patient’s life.

Some tension has also arisen in the public because of the fear engendered by communicable diseases – a feeling which does not extend to the same degree to NCDs. There are no initial outward acute manifestations of NCDs and they are not contagious in the main population. In developed countries, the acute, more

obvious communicable diseases are viewed as the urgent issues on which the health community and the political directorate should focus, rather than problems which are perceived to primarily affect the elderly.

Other challenges lie in the fact health services remain disease- as opposed to patient-centered, with insufficient regard for holistic disease management.

In some populations, HIV+ patients are being treated in single purpose, easily identified facilities, thus compromising their anonymity. If the same patient also has diabetes or heart disease (more likely, given the atherogenic effects of anti-retroviral therapy) these patients are sent to a different, often under-resourced, sub-par facility.

A significant source of international tension has been the omission of NCDs as a health or development issue in the Millennium Development Goals. Indeed, there has been resistance to even the idea of expanding the MDGs to include NCDs, even though it is now clear that there is a close relationship between noncommunicable diseases and many of the MDG goals.

The world will not achieve the targets set forth by the MDGs without taking NCDs into account. To give one very pertinent example, research shows low birth weight that occurs as a result of maternal nutritional deprivation is a major predicting factor for adult high blood pressure and diabetes.

Perhaps the major source of tension is in the funding of health globally. In this current constrained economic climate, there is a natural anxiety that funds may be diverted from what is described as the unfinished agenda of communicable diseases to address NCDs. There is concern that there may be a call for new funding to address the NCDs in the same way that funds were mobilized for HIV/AIDS. The tension is fueled by the fact that many in the NCD community point out that most of the parameters that should lead to establishing NCDs as a priority for funding are present, yet funding for the NCDs remains low by any standard both at national level and among the development partners. The development agencies of developed countries may be concerned that any effort will deviate their funding from established programs which are not yet completed, but to which long-term commitments have already been made. One possible example of such a program is PEPFAR. There is also the view that because communicable diseases from the global South can threaten the health of those in the global North, the heavy funding for communicable diseases is really self-serving for those in wealthier countries.

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BY NELLIE BRISTOL

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NCDs in the Developing World:

Looking for Solutions Diagnosing and treating non-communicable diseases (NCDs) can be a complicated and expensive proposition. Trying to do so in a low resource setting with poor health infrastructure and a dearth of doctors, particularly specialists, makes it that much more difficult. Nonetheless, according to experts, many of the most common chronic diseases like diabetes and cardiovascular disease, can be mitigated through population-wide measures including a variety of policy changes. The World Health Organization in its Global Status Report on Noncommunicable Diseases 2010, released in April, listed several “best buys” in reducing NCDs in a cost effective manner. They include banning smoking in public places and warning about the dangers of tobacco, raising taxes on alcohol and tobacco, reducing salt in food and eliminating trans fats.

A high powered group of health experts including Partners in Health Founder Paul Farmer and Julio Frenk, dean of the Harvard School of Public Health, listed a range of cancers responsive to prevention and treatment in low- and middle-income countries as part of a call to action in an August, 2010 Lancet. For example, curbing tobacco use could prevent lung, head and neck, and bladder cancers while reducing human papillomarvirus infections could cut cervical, head and neck cancer.

In addition, early detection could reduce the impact of cervical, breast and colorectal cancer while several lymphomas could be curable with systemic treatment.

In the technology area, a number of groups and manufacturers are working to develop low cost ways to screen, diagnose and treat NCDs in resource poor settings. For example, PATH is working with several partners to develop simple cost effective methods for diabetes screening. Diagnosing diabetes in developed

countries is often a multi step process that requires patients to fast and to return to a health care provider several times. To work in a low resource setting, according to Bernhard Wiegl, director of PATH’s Center for Point-of-Care Diagnostics for Global Health, mechanisms must be inexpensive, quick, easy to maintain and require no preparation by the patient.

Several possibilities are now being explored, including one that simply involves a patient placing an arm on a device which tests for diabetes related abnormalities through the skin. Groups also are working to reduce the amount of blood sugar testing required to monitor the disease, currently a time consuming and expensive undertaking.

In addition, several vaccines, if priced right and distributed adequately, could go a long way toward reducing the incidence of certain cancers. The HPV vaccine, which became widely available in the U.S. over the last five years, would actually be much more useful in the developing world where regular Pap smears are not available and 88 percent of cervical cancer deaths occur. Unfortunately, the series of vaccines can run $300 per patient in the U.S. But movement is seen there too. The GAVI Alliance announced in June that Merck will offer the group the HPV vaccine for $5 per dose, a 67 percent reduction in the current lowest public price.

While NCD detection and treatment will likely lag in the developing world for some time, new efforts and technologies could whittle down the disparity. “I’m not saying everybody’s going to get on a treatment plan any time soon, but I think diabetes treatment can certainly reach farther down the economic strata than it currently does,” Wiegl said. GH —

Nellie Bristol is a freelance journalist specializing in health policy.

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BY MURUGA VADIVALE AND APARNA THOMAS

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India: The Private Sector Takes Action on NCDs

India is the second most populous nation in the world with nearly 1.2 billion inhabitants. The impact of chronic and infectious diseases on patients, families and society is significant. In addition to the obvious effects on quality of life, morbidity and mortality, the burden of these diseases to the country’s economy is substantial in terms of loss of productivity, loss of employment, and health care expenditures.

The scope and impact of non-communicable diseases (NCDs) such as cardiovascular disease, cancer and diabetes are so complex that all stakeholders, including governments, NGOs, academia and the private sector need to participate in developing solutions. The common challenge – and opportunity – for all stakeholders is to save millions of people from premature death and debilitating health complications, as well as promoting social and economic development.

Health care in India has shown remarkable improvement since independence in 1947. However, in 2004, out of the estimated 10.3 millions deaths, 1.1 million (11 percent) were due to injuries, 4 million (39 percent) to communicable diseases and 5.2 million (50 percent) to NCDs. In 2005, 9.2 million years of productive life were lost in India due to heart diseases, stroke and diabetes. This translated into US$ 9 billion of lost national income. The projected 2005-2015 cumulative loss of national income for India due to these premature deaths is US$ 237 billion.

India’s total health care spending was 4.2 percent of gross domestic product (GDP) in 2008-09. Public spending on health (0.93 percent of the GDP) was ISSUE 12 FALL 2011

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among the lowest in the world, and the reason for private expenditures accounting for 78 percent of total health spending in the country.

Although India’s economy is witnessing remarkable growth, inadequate health care infrastructure continues to be a barrier to access to basic health services. For example, there are only 60 physicians per 100,000 people as compared to 140 per 100,000 globally.

Likewise, India has only 130 nurses per 100,000 people whereas the global average is 280 per 100,000.

It is estimated that more than 46 percent of patients travel more than 100kms from small towns to urban facilities to seek proper medical care. Knowing that 71 percent of the population is living in rural areas, accessibility to health care infrastructure is a major issue.

Therefore, in cooperation with other stakeholders (such as doctors, hospitals, institutes and policy makers), Sanofi India is organizing a number of actions to understand the real burden of disease, raise awareness of diabetes and increase access to health care in rural areas.

ESTIMATING THE PREVALENCE AND RISK FACTORS OF DIABETES AND HYPERTENSION The International Diabetes Federation estimates that India has the second highest prevalence of diabetes in the world with 50.8 millions diabetes patients in 2010.

Indians with hypertension are projected to number 214 million in 2025, up nearly 100 million since 2000.

Hypertension is an important worldwide publichealth challenge because of its high frequency and Dr. Muruga Vadivale is senior director, Medical and Regulatory Affairs, Sanofi India. Aparna Thomas is senior director, Communications and Public Affairs, Sanofi India.

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concomitant risks of cardiovascular and kidney disease.

Reliable information about the prevalence of hypertension and diabetes is essential to the development of health policies for prevention and control of these conditions.

Therefore, in January 2009 Sanofi launched SITE (Screening India’s Twin Epidemic), a cross-sectional study to estimate the prevalence of diagnosed and undiagnosed cases of diabetes and hypertension in outpatient settings in major cities across India.

As of July 2011, SITE has enrolled 15,662 patients from 802 centers across eight states in India (Maharashtra, Delhi, West Bengal, Tamil Nadu, Andhra Pradesh, Karnataka, Gujarat, and Madhya Pradesh) and has partnered with 800 general practitioners and consulting physicians to conduct the screenings, record and report the results. The study was conducted in waves over two years, one state at a time, with 2,000 patients screened from each state over two days per wave.

“Through SITE we hope to identify gaps in treatment needs at the first point of contact for a patient,” said Dr. Shashank Joshi, a consultant endocrinologist at the Lilavati Hospital and the national coordinator of the study. “SITE will give us important insights on how we screen patients for risk factors and how well we manage them versus current guidelines.”

The results obtained in the different cities are progressively communicated at congresses. When the results of the New Delhi screenings were announced, medical researchers, public health officials and physicians were able to compare the prevalence of diabetes and hypertension in Maharashtra and New Delhi. The findings were both alarming and revealing: ■ The twin epidemics of diabetes and hypertensions

do exist in both states, although more serious in

Maharashtra where 29 percent of the patients

were both diabetic and hypertensive, as compared

to 21 percent in New Delhi.

■ Hypertension is more prevalent than diabetes in

both states.

■ Less expected, were the regional differences:

both diabetes and hypertension are more

prevalent in Maharashtra (40 percent and 56

percent, respectively) than in New Delhi (33 percent

and 48 percent, respectively).

■ As troubling were the rates of patients who had

been diagnosed and treated, but whose conditions

were still uncontrolled.

■ In Maharashtra, three-quarters of known diabetics

had uncontrolled blood sugars (Hba1c levels), as

compared to two-thirds in New Delhi.

■ Uncontrolled hypertension was also a serious

problem in both states and occurred at about the same rate: 79 percent in Maharashtra and 77 percent in New Delhi.

Through partnerships with doctors, hospitals and other organizations in these eight States, SITE has already started to raise disease awareness of the risk factors, symptoms and treatment of diabetes, hypertension and other related conditions, such as cardiovascular diseases.

CELEBRATING DIABETES CONTROL According to Dr. Shailesh Ayyangar, general manager of Sanofi in India and vice president of Sanofi in South Asia, “The diabetes epidemic makes it essential to create awareness about diabetes control. The ‘I Am A Champ’ program will help patients who are in control to reach out to others with their inspiring testimonials.

Treatment regimens must be complemented by a more comprehensive approach to diabetes management for the health and well-being of a patient.”

Through the program patients and caregivers are learning that a positive attitude and few lifestyle changes to support their treatment regime can empower them to improve their health and well-being.

India’s first ever Diabetes Awards Ceremony was the first step to kick start the ‘I Am A Champ’ program which is based on the model of peer-to-peer counselling. Champions from various regions in the country were assessed on various parameters such as their understanding of diabetes, awareness about diabetes complications, their fitness and diet regime, and the ‘champ’ factor. In their role as ‘Champions of Diabetes’, they will be the face and voice of this awareness program in their respective cities.

Sanofi provides the 42 (seven national and 35 regional) ‘champs’ with platforms to share their testimonials, create awareness amongst other diabetes patients in their respective cities and address their concerns on managing the disease. These individuals symbolize triumph over diabetes and are a beacon of hope for countless other diabetics who often believe that ‘life is over’ once they are diagnosed with diabetes.

EMPOWERING DOCTORS IN RURAL INDIA Prayas, meaning endeavour in Sanskrit, focuses on empowering doctors in rural India with the latest developments and updates in medicine.

The government is doing extensive work through the National Rural Health Mission (NHRM) to provide effective health care to India’s rural population.

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BACKGROUND

ROLE

Top end specialist clinicians in urban India 48 ACROSS 14 STATES

Guide the development of a particular therapy area Train mentors on relevant topics for improving the quality of Prayas

Post graduates in internal medicine or other subjects practicing at semi urban areas 574 ACROSS 14 STATES Primary care practitioners in Tier II towns in India 11,500 ACROSS 14 STATES

KOLs

MENTORS

PRIMARY CARE PRACTITIONERS

Considering the magnitude of the task, NHRM has incorporated public-private partnerships in its strategic roadmap for achieving its public health goals. This was echoed by Shomita Biswas, joint secretary, Public Health, Government of Maharashtra, citing,“Two major problems that government is facing at the grass root level is lack of infrastructure and adequately trained human resources. There is also an acute need of training institutes for developing nursing and paramedic professionals at the rural level. These are some of the areas where government will look forward to getting support from the private organizations.”

Launched in 2009,Prayas is aimed at bridging the diagnosis-treatment gap through a structured continuing education program for rural doctors across India. In Prayas, specialists from semi-urban areas share latest medical knowledge, clinical experience and practical insights through structured workshops for general practitioners- from smaller towns and villages in the interiors of India - through a ‘mentor-mentee’ model.

As of July 2011, 4,700 workshops have been conducted across 14 states for more than 11,500 rural doctors.

Forty-eight expert doctors and 574 mentors have so far lent their support to Prayas. The workshops cover major acute-care therapy areas like respiratory diseases,

Train mentee doctors per curriculum. Share one’s own experience through case studies and provide material to improve the knowledge base and skills of mentees Participate in Prayas workshops once in 2 months Transfer aquired knowledge and skills in treating patients in line with available evidence

infections, allergies, gastrointestinal disorders, etc.

Each course is validated and certified by reputable international medical associations such as the American College of Physicians and the American Gastroenterology Association, amongst others.

Progressively disease awareness camps were organized to improve awareness and treatment seeking behaviour of patients in these regions. These camps focus on topics like child health, anaemia and malnutrition, and diarrhea which are in line with the needs of the patients.

With plans to cover new doctors under the program on a continual basis, there should be 100,000 mentees by 2015.

To complement this knowledge-based program, the Hoechst Business Unit, a Sanofi Unit has also launched a new range of quality medicines at affordable prices in these geographical areas. The product range helps address the challenges of accessibility, affordability and availability of quality medicines to patients in remote villages. In addition, a new distribution model with emphasis on availability of drugs to the most rural interiors is being established. The next step is to adapt this model to the fight against diabetes which is also developing in rural areas. GH —

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C SEE THE SOURCES ONLINE AT WWW.GLOBALHEALTHMAGAZINE.COM

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BY ELIZABETH NUSSBAUMER, THEA JOSELOW AND NALINI SALIGRAM

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Brazil: Getting a Move on NCDs

All people, rich and poor, are affected by the NCD epidemic, but none more so than the poorest populations in developing countries, as NCDs increase poverty, which in turn causes rising rates of disease.

Changing behavior – such as getting people to exercise – is one of the hardest challenges in chronic disease prevention.

Since the 1970s, Brazil has experienced rapid economic growth, resulting in significant lifestyle changes.

Unfortunately, the consequence of these shifts was considerably higher levels of non-communicable diseases. The book Sick Societies: Responding to the Global Challenge of Chronic Disease asserts that in 2004, chronic diseases accounted for 70.1 percent of all deaths in Brazil. Additionally, an estimated $49.2 billion (2.5 percent of Brazil’s GDP) has been lost due to disability or death from chronic disease. It is imperative to Brazil’s continued development that it contains and prevents NCDs. That is why Arogya World is highlighting the Agita São Paulo initiative which increases physical activity levels for an estimated 520,000 people each year in São Paulo, Brazil. The framework and its remarkable success in a developing country at minimal cost make the Agita method adaptable in other high-risk populations worldwide.

A MOVEMENT FOR MOVEMENT In 1996, the Agita São Paulo initiative was created in response to the growing level of physical inactivity in Brazil and increasing number of deaths due to chronic

disease, especially within the state of São Paulo.

The word agita means to move the body, or to move the crowd, as well as changing ways of thinking and becoming more active. The initiative seeks to achieve two objectives: increasing both the public’s knowledge of physical activity’s importance and its physical activity levels. Additionally, Agita fosters partnerships with governmental and non-governmental organizations, currently working with more than 350 partner institutions.

Fundamentally, the initiative promotes simple behavior changes to achieve 30 minutes of moderate physical activity each day. A smiling clock mascot, the “half hour man,” was created to remind citizens that little time is needed to achieve their health goals. The Agita approach is effective, especially because it focuses on moderate rather than vigorous activity, and reminds citizens that physical activity can be accumulated in manageable intervals throughout the day. By so framing the daily physical activity requirements, people found the goals to be more achievable. It especially appealed to the women of São Paulo who traditionally disliked vigorous exercise.

The initiative targets students, workers and the elderly, reaching large groups through large events (reaching at least 1 million citizens) and community-level activities with partner organizations. The Agita Galera mega event, for example, is held at 6,000 public schools each August in partnership with the Department of Education.

Agita conducts classes and students take part in walks, sports and other creative activities that increase CONTINUED ON NEXT PAGE

C FOR MORE CASE STUDIES, VISIT WWW.AROGYAWORLD.ORG

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their level of physical activity and educate them on its benefits. Physical activity levels in these public schools were 33 percent higher than in non-participating private schools.

Furthermore, from 2002 to 2008, the proportion of insufficiently active people dramatically declined from 43 percent to about 11 percent, whereas moderate physical activity increased from about 50 percent to 70 percent. In 2004, the Centers for Disease Control found that Agita was not only cost-effective, but also a cost saving intervention, and in 2006, the World Bank found that the initiative represented $310 million in savings per year in the health sector.

The Agita São Paulo model is applicable at local, national or global levels. The key is simplicity, and the following actions can help promote physical health in the community: n Promote 30 minutes of physical activity per day and remember that anyone can engage in physical activity, at any age, anywhere;

n Build

partnerships to promote the importance of physical activity; n Adapt to the culture, beliefs, and values of your community to ensure sustainable success; n Provide scientific information on the benefits of physical activity; n Hold large events or health days to spread awareness.

Agita São Paulo’s model now includes 72 countries, and forges global alliances to promote health, creating a strong framework for implementing physical activity initiatives around the world.

However, a persistent challenge remains in the social perception of the threat of NCDs. In the words of Victor Matsudo, the head of Agita São Paulo, “Social perception of risk is equal to the relative risk times indignation. In the case of NCDs, relative risk from sedentary lifestyles is quite high, but because indignation is low, the social perception of the risk is low.” GH —

GRAPPLING WITH THE TENSIONS AROUND NCDS - CONTINUED FROM PAGE 16 The resolution of these tensions will come principally from the dissemination of information and communication between the different “communities” and a focus on the appropriate interventions to address all the health problems of the world’s populations. In this context, it was gratifying to see the major NCD non-governmental organizations formed the NCD Alliance to join forces, press for focus on common risk factors, and exert pressure at national and global levels for greater political, technical and financial attention to NCDs. It is important to focus on the health system as the common final pathway for addressing both, since patients will present with both communicable and noncommunicable diseases.

Until recently, primary care services focused on maternal and child health, and acute problems, both with finite resolution. It is now necessary to reorient health systems to provide continuing care that is patient centered, disregards the nature of the health problem or its duration, involves secondary and tertiary care facilities and promotes community involvement and

participation. The articulation of all the inputs needed for care, regardless of the nature of the problem, should be coordinated at the primary level with continuity of oversight.

Optimistic prospects for the world’s health are based on the view that with more attention to the social determinants of health, there will be a steady decrease in communicable diseases with concomitant relative and absolute increase in the incidence of NCDs. Given the steady aging of the world’s population, there is a certain inevitability of NCDs, so the target must be to reduce avoidable mortality from NCDs. But it is equally certain that we will never be able to rid the world of the microbes which cause communicable diseases which, in some cases, because of the nature of the infection will be chronic, e.g. HIV/AIDS. The sooner we recognize the origins, nature and overlap between the two sets of problems, the sooner some of the tensions described will be resolved and the sooner will it be possible to address all the health problems of the world’s people regardless of origin. GH —

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BY RHONA APPLEBAUM

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Partnering for Change:

The Role of the Private Sector

The global burden of non-communicable diseases (NCDs) is growing at an alarming rate. NCDs have reached every corner of the world, overtaking infectious diseases to become the leading cause of death, illness and disability, as well as a central factor in escalating health costs.

NCDs are no longer primarily identified with development and wealth. On the contrary, the impact of such ailments is far greater in low- and middle-income countries, where 80 percent of NCD-related deaths occur. Moreover, NCDs are a leading threat to social and economic development, and they exacerbate inequalities between countries and populations.

Key factors fueling this rapid growth in NCDs include increased life expectancy and the aging population, urbanization with changes in consumption patterns and lifestyle, including tobacco use, physical inactivity, drug and alcohol abuse, and unhealthy diets. Nearly 35 million people and about 3.5 million children die annually from NCDs related to micronutrient inadequacies.

NCDs are a growing threat to global health and we need focused interventions to keep non-communicable diseases from becoming an even greater burden on society. Otherwise, based on current trends, deaths from NCDs will continue to increase and cause even greater worldwide stress.

ADDRESSING THE PROBLEMS The WHO 2010 Global Status Report on Noncommunicable Diseases demonstrated progress over the last decade. However, it also reinforced the

Rhona Applebaum, PhD, is vice president, and chief scientific and regulatory officer for The Coca-Cola Company.

fact that governments and civil society cannot succeed alone. Collaboration with the private sector and partnering across sectors will increase the likelihood of finding workable solutions that result in sustainable improvements.

Today, we’re entering a new era of global collaboration, driven by a shared awareness that problems such as NCDs affect all of society and that each sector has an appropriate role to play and contribution to make.

Addressing the problem of NCDs requires the concerted will, effort and expertise of government, civil society and the private sector. Harnessing the power of every sector can lead to synergies to affect positive change.

The September 2011 United Nations General Assembly High-level Meeting on the Prevention and Control of Non-communicable Diseases is an historic opportunity to elevate NCDs on the global agenda and increase the worldwide urgency toward overcoming this challenge.

As the world prepares for this meeting, it’s essential that we build an ongoing and robust dialogue among all stakeholders. Broad engagement will ensure a true multi-sectoral response that drives informed, effective and systemic action.

THE ROLE OF THE PRIVATE SECTOR Private sector organizations can play a substantive, positive role in helping to identify and advance workable solutions to NCDs. The private sector should work closely with key stakeholders – including governments, academia, health professionals and civil society – to promote active, healthy lifestyles, healthy diets and adequate physical activity.

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Private sector companies should evaluate their expertise and infrastructure to identify unique advantages and areas of expertise they can lend to broaden the impact of global health programs. For example, The CocaCola Company is now lending its extensive distribution system to deliver medicine, health messages and vaccines to communities in Africa that previously had little or no access to these life-saving health supplies.

Then there are things every company, regardless of size or expertise can and should do, like focusing on promoting healthier lifestyles among its employees, consumers and the communities that it serves. For example, in our workplaces, we provide smoke-free facilities, annual health checks, flu vaccinations and well-being incentives to encourage a healthy and active workforce.

AN INDUSTRY-WIDE EFFORT Just as collaboration across sectors is essential to affect real change, collaborations comprising private sector companies within industries can lead to synergistic effects.

In 2008, The Coca-Cola Company, along with seven other major international food and non-alcoholic beverage companies, made voluntary global public commitments to action in support of continuing efforts to implement the 2004 WHO Global Strategy on Diet, Physical Activity and Health.

These commitments include reformulating and introducing new products to provide consumers with options they can use in building sensible, balanced diets; providing easy-to-understand and meaningful, fact-based nutrition labelling and information; changing how and what the industry advertises to children; supporting nutrition education and physical activity programs; and participating in national and regional efforts with governments, NGOs and professional organizations to promote healthy lifestyles in the workplace and in communities.

The International Food & Beverage Alliance, a group of food and non-alcoholic beverage companies with a presence in more than 200 countries worldwide, was also formed in 2008 with a goal of helping consumers in all nations achieve balanced diets and healthy lifestyles.

Over the past three years, the food and beverage industry has made significant and substantial progress in all the areas listed in the preceding paragraph and we will continue to commit time, resources and expertise to do our part.

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Another collaboration, the Consumer Goods Forum – a global network of more than 650 retailers, manufacturers, service providers and other stakeholders across 70 countries – works together to address consumer health and wellness. CGF has adopted resolutions to address three primary areas: availability of products and services that support healthier diets and lifestyles; transparent, fact-based information that helps consumers make informed choices; and communication and educational programs to raise awareness and inspire healthier lifestyles.

These coordinated efforts demonstrate one industry’s commitment to contribute to efforts to the promotion of active, healthy living for all.

ONE COMPANY’S EXPERIENCE At The Coca-Cola Company, we strive to make a lasting difference everywhere we engage. We are committed to refining, strengthening and expanding our role in decreasing the growth of NCDs, working toward the day that they are no longer a global threat. We firmly believe that we can do well as a global company by doing good as a responsible corporate citizen.

We don’t have all the answers, but we recognize a need to think differently, challenge ourselves constantly and form new partnerships that will help find workable solutions to some of society’s most pressing problems.

We are keenly aware that leading an active, healthy lifestyle is a complex proposition for many. Experts believe that it is important to balance the calories you take in with the calories you burn by consuming a sensible, balanced diet combined with regular physical activity. This concept of balancing calories in and out is what the experts refer to as ‘energy balance.’ That’s why our efforts focus on three areas – education, variety and physical activity, “THINK, DRINK, MOVE” – to

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help educate associates, consumers and communities about the importance of energy balance. We encourage active, healthy living through energy balance programs that offer physical activity and nutrition education.

Examples include Moderation, Balance, Diversity, a school program in Greece and Triple Play, a program delivered through the Boys and Girls Club of America that has reached more than 4 million children in the U.S. Having the necessary information for making informed choices is essential, which is why we are committed to transparency about our products’ nutrition profile. Our global policy on front-of-pack energy labelling has been in effect since 2009.

While proper nutrition is essential, other factors play an important role in maintaining a healthy lifestyle.

According to the World Health Organization, tobacco kills more than 5 million people a year. Our company, therefore, prohibits smoking inside its facilities. Physical inactivity and sedentary lifestyles have also been identified as a major underlying cause of NCDs. There is strong evidence that school, workplace and community physical activity programs can make a difference in reducing risk factors associated with NCDs. That’s why we sponsor more than 250 physical activity and nutrition education programs in more than 100 countries. By 2015, we hope to have at least one such program in every country we operate.

We also support others who are in positions to provide training and/or perform key research aimed at reducing the incidence and impact of NCDs. Our unrestricted grant to the U.S. Centers for Disease Control and Prevention (CDC) Foundation supports efforts to build global capacity for NCD prevention in low-and-middle income countries. With support from this grant, CDC is more effectively and concretely interacting with key global partners for NCD prevention and supporting the training of a critical future generation of researchers.

We support similar efforts in other parts of the world as well as a variety of additional programs to help develop workable solutions to this very complex problem. With complex, multi-faceted problems like obesity and NCDs, the right answers aren’t always simple and the simple answers aren’t always right. Thus a multi-disciplinary approach, new thinking, and creative partnerships across all stakeholder groups are essential ingredients.

Through product innovation, we’re also seeking to address micronutrient shortages in certain countries.

For instance, NutriJuice® is a fortified drink specifically focused on providing iron to iron-deficient children in the Philippines. We’re working to replicate this concept in other parts of the world.

THE TIME TO ACT IS NOW Today, NCDs represent one of our most significant global challenges and should be collectively addressed by all key sector stakeholders – private and public– working together. Our goal is simple – to help harness the synergies of these different sectors to affect positive change. Our combined efforts will have far greater impact than those of one sector alone, giving us the greatest opportunity to reverse negative health trends and improve the health of society as a whole.

As a global citizen, the world’s largest beverage company and one of the largest multi-national employers, The Coca-Cola Company embraces the opportunity to help find workable solutions and we encourage our private industry colleagues and all interested stakeholders to heed the call to do what they can to support these efforts, and to consider what we have long recognized: the health of any business is interwoven with the health of its employees, its consumers and the communities in which it operates.

We can indeed do well, by doing good. GH —

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