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The Control of Noncommunicable Diseases in Latin America and the Caribbean

Anselm Hennis, MD, MSc, PhD, FRCP, FACP Johns Hopkins University

Director, Noncommunicable Diseases and Mental Health

Pan American Health Organization / World Health Organization

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Noncommunicable Disease (NCD) Burden and Risk Factors

Section A

Global NCD Burden: Total Deaths by Broad Cause Group, by WHO Region, World Bank Income Group and by Sex, 2008

3 Source: Alwan, A., & World Health Organization. (2011). Global status report on noncommunicable diseases 2010. Geneva, Switzerland: World Health Organization. Available at: http://www.who.int/nmh/publications/ncd_report2010/en/. Accessed April 22, 2015.

AFR indicates African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South- East Asia Region; and WPR, Western Pacific Region.

Region of the Americas: Main Causes of Death (2010)

Source: Pan-American Health Organization (PAHO) Regional Observatory Database. Available at: http://www.paho.org/hq/index.php?option=com_ content&view=article&id=5542&Itemid=2391&lang =e. Accessed April 22, 2015. 4

The Facts in the Americas: Disease Burden

149 million smokers 25% – 30% adults with elevated

blood pressure 25% persons >15 years old obese

Approximately 200 million people living with an NCD in the Americas

36% deaths occur below age 70 years

Total NCD deaths (2010) 3.9 M

45% Cardio- vascular diseases

Cancer 30%

Diabetes 8%

Other NCDs 7%

Chronic resp.

disease 10%

Cardiovascular Diseases

45% Cardio- vascular diseases

Cancer 30% Diabetes 8%

Other NCDs 7%

Chronic resp.

disease 10%

Hypertension Prevalence by Gender in Latin America and the Caribbean

Source: Burroughs Peña, M. S., Mendes Abdala, C. V., Silva, L. C., & Ordúñez, P. (2012). Usefulness for surveillance of hypertension prevalence studies in Latin America and the Caribbean: the past 10 years. Revista Panamericana De Salud Pública = Pan American Journal of Public Health, 32(1), 15–21.

48.7 37.7

33.1 27.5 27.3

23.8 23.4

20.0 14.6 14.4

11.2 7.2

46.5 21.7

37.3 22.9

20.7 26.8

20.0 25.0

12.4 10.7

12.1 10.1

60.0 40.0 20.0 0.0 20.0 40.0 60.0

HAITI ARG

GUAD VEN CHI BRA CUB

MART COL PER MEX ECU

Female Male

Proportion of Deaths Due to Cardiovascular Diseases by Income Group in the Americas

Source: PAHO/WHO. (2012).

Cerebrovascular diseases Ischemic heart disease

Low and lower- middle income

High income

Upper- middle income

High income

Low and lower- middle income

Public policy and advocacy

Surveillance Health promotion and disease prevention

Integrated control of chronic diseases and their risk factors

 Multisectoral action and social determinants

 Universal coverage and equitable access to health services

 Integration and sustainability of interventions

 Integration of information systems

 Mortality records and risk factor surveillance

 Health services performance and economic assessments

 Information sharing  Technical capacity

 Tobacco  Salt intake  Healthy diet  Physical activity  Alcohol

 Competencies of health personnel

 Primary care, population risk stratification, and integrated health services networks

 Chronic care model  Hypertension and individual

total cardiovascular disease risk

 Quality and efficiency of clinical services

 Acute coronary syndrome and stroke

Priorities for Cardiovascular Health in the Americas: Key Messages for Policymakers (2011)

Source: Ordúñez García P, Campillo Artero C. (2011). Regional Consultation. Priorities for cardiovascular health in the Americas. Key messages for policymakers. Washington: Pan-American Health Organization. Available at: http://www1.paho.org/priorities/pdf-en/book.pdf. Accessed March 8, 2015. 9

Cancer

45% Cardio- vascular diseases

Cancer 30% Diabetes 8%

Other NCDs 7%

Chronic resp.

disease 10%

Lung Cancer

Source: PAHO. (June 19, 2013). Epidemiology of Lung Cancer in the Americas, 2014. Retrieved April 22, 2015, from http://www.paho.org/hq/index.php?option=com_docman&task=doc_details&gid=22070&Itemid=270&lang=en. 11

Lung cancer is the third most common cancer and the leading cause of cancer deaths in the Americas, with more than 324,000 new cases and nearly 262,000 deaths each year.

Proportion of new cases and deaths from lung cancer in the Americas, 2012

Prostate Cancer

Source: PAHO. (May 21, 2013). Epidemiology of Prostate Cancer in the Americas, 2014. Retrieved April 22, 2015, from http://www.paho.org/hq./index.php?option=com_docman&task=doc_details&gid=21593&Itemid=270&lang=en. 12

Prostate cancer is the most common cancer in men in the Americas, and the second leading cause of cancer deaths. There are more than 412,000 new cases and 85,000 deaths each year in the Americas.

Proportion of new cases and deaths from prostate cancer in the Americas

Breast Cancer

Source: PAHO. (October 10, 2014). Epidemiology of Breast Cancer in the Americas. Retrieved April 22, 2015, from http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=270&gid=21834&lang=fr. 13

Breast cancer is the most common cancer type in women and the second leading cause of cancer deaths among women in the Americas. There are more than 408,200 new cases and more than 92,000 deaths from

breast cancer annually in the Americas.

Proportion of new cases and deaths from breast cancer in the Americas, 2012

In Latin America and the Caribbean, 27% of new cancer cases and 15% of cancer deaths are due to breast cancer. Similarly, in North America, 30% of new cases and 15% of cancer deaths are caused by breast cancer.

Cervical Cancer in the Americas

 North America:  12,300 new cases per year  4,500 deaths per year

 Latin America and the Caribbean:  68,000 new cases per year  31,400 deaths per year

Source: Fuente: Globocan 2008. 14

 Promoting policies for tobacco control, alcohol, healthy eating, and physical activity

 Increasing immunization against infections that cause certain types of cancer, such as cervical cancer and liver cancer, and improving protection from carcinogens at the workplace and in the environment

 Increasing access to screening programs for early detection—for example, of cervical cancer and breast cancer

 Increasing cancer patients’ access to timely diagnosis and appropriate treatment

 Increasing access to palliative care for patients

PAHO’s Work

Diabetes

45% Cardio- vascular diseases

Cancer 30%

Diabetes 8%

Other NCDs 7%

Chronic resp.

disease 10%

Prevalence (%) of Diabetes Among Adults in the Americas

Source: Pan Am J Public Health 10(5), 2001; PAHO, CAMDI, Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care); Canada, Ontario Lipscombe & Hux 2007; US Mexico Border Project. Jamaica (Jamaica Health and Lifestyle Survey, 2008); C Rica, STEPS CR 2011

6 7 7 8 8 8 8 8 9 9 9 9 9 9

10 10 10 10 11 11

12 12 13

15 16 16 16

Honduras Urban Peru

Haiti US Whites

Brazil Jamaica

Colombia Guatemala

Bolivia Suriname

Mexican Americans Nicaragua

Canada (ON) Chile

US Total Argentina Paraguay US Blacks

Mexico C Rica Cuba

Belize Trinidad/Tobago

Mexican Side of US-Mexico… US-Mexico Border Region

US Side of US-Mexico Border Barbados

Estimated Prevalence of Diabetes Mellitus (Millions) per Subregion, 2011- 2030

25.1

37.7

62.8

39.9

51.2

91.1

100

America Central/Sur

Norte Am/Caribe Las Americas

2011

2030

 Risk Factor and Diabetes Survey conducted across Central America

 Interventions to improve management of diabetes implemented in Mexico, Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, Antigua, Anguilla, Grenada, Belize, Guyana, Suriname, and St. Lucia

 Course on Evidence-Based Chronic Illness Care implemented twice in collaboration with the University of Miami, and in Argentina, Chile, and Colombia

 Implementation of the Chronic Care Model collaboration ongoing in Mexico, Argentina, Chile, Brazil, the Caribbean(10 countries), the Dominican Republic, Paraguay, and Honduras

Main Achievements

 The diabetes epidemic is a major public health challenge:  Rising burden of obesity  Management requirement for multidisciplinary approaches

 Quality of care for diabetes and other chronic diseases is suboptimal in most of the countries with available data

 Lack of integrated approaches, application of evidence-based clinical practice guidelines, suboptimal self-management support, absence of clinical information system, and system orientation to continuous evidence-based care

Main Challenges

Addressing NCD Risk Factors

Section B

Protective Actions: Addressing NCD Risk Factors

NCDs

Tobacco consumption

Harmful use of alcohol

Unhealthy diet

Lack of physical activity

Current Prevalence of Adult Smokers: WHO Regions

Source: Fonte: Global Health Risks, 2009.

0% 5% 10% 15% 20% 25% 30% 35%

World

EURO

WPRO

AMRO

SEARO

EMRO

AFRO

26%

33%

32%

24%

21%

18%

AFRO indicates African Region; EMRO, Eastern Mediterranean Region; SEARO, South-East Asia Region; AMRO, Americas Region; WPRO, Western Pacific Region; and EURO, European Region.

The “Gold” Standard: Tobacco Control

 WHO Framework Convention on Tobacco Control  Legally binding international treaty  Ratified by 176 countries

• 29 in the Americas  A baseline, not a goal, for tobacco control

measures

Source: Fuente: Informe OMS sobre la Epidemia de Tabaquismo, 2008. 4

FCTC Implementation: MPOWER

 MPOWER strategies:  M: Monitor tobacco use and prevention policies  P: Protect people from tobacco smoke  O: Offer help to quit smoking  W: Warn about the dangers of tobacco  E: Enforce bans on tobacco advertising, promotion,

and sponsorship  R: Raise taxes on tobacco

Source: World Health Organization, & Research for International Tobacco Control (Eds.). (2008). WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva: World Health Organization. Available at: http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf. Accessed April 22, 2015. 5

Countries With 100% Smoke-Free Laws (WHO FCTC Art. 8 Compliant)

Countries with 100% smoke-free laws:

1. Uruguay (2005/2008) 2. Panama (2008) 3. Canada (2008) 4. Guatemala (2008) 5. Colombia (2008/2009) 6. Trinidad y Tobago (2009) 7. Perú (2010) 8. Honduras (2010)

9. Barbados (2010) 10. Venezuela (2011) 11. Argentina (2011) 12. Ecuador (2011) 13. Brasil (2011) 14. Costa Rica (2012) 15. Chile (2013) 16. Surinam (2013)

Countries With Laws That Establish Health Warnings of 50%+ With Images (WHO FCTC Art. 11 Compliant)

Countries with laws that establish health warnings of 50%+ with images:

1. Canada 2. Brasil 3. Cuba (sin imagen) 4. Chile 5. Panama 6. Uruguay 7. Jamaica (sin imagen) 8. Venezuela 9. Bolivia 10. Colombia

11. Mexico 12. Estados Unidos 13. Peru 14. Honduras 15. Nicaragua 16. Argentina 17. Ecuador 18. El Salvador 19. Costa Rica 20. Surinam

Countries With Laws That Establish a Total Ban of Advertisement, Promotion, and Sponsorship (WHO FCTC Art. 13 Compliant)

Countries with laws that establish a total ban of advertisement, promotion, and sponsorship:

1. Panamá (2008) 2. Colombia (2009) 3. Brasil (2011) 4. Chile (2013) 5. Surinam (2013)

 WHO Framework Convention on Tobacco Control has 177 parties worldwide (29 in the Americas region)

 Seventeen countries of the region are 100% smoke-free in enclosed public spaces and workplaces and on public transportation

 Five countries of the region have a total ban on tobacco advertisement, promotion and sponsorship

 Seventeen countries of the region have graphic health warnings on packaging of tobacco products of 50% or more of the principal surfaces

 Some countries of the region have raised tobacco taxes, with earmarks for public health

WHO Main Achievements

 Challenges include …  Tobacco industry interference  Lack of political will at country level to comply with the mandates of the WHO

FCTC  Lack of human and financial resources

 Only six countries have recent information that is representative and periodically collected (at least every five years) for young people and adults

 Only two countries, Panama and Costa Rica, have reached the recommended level in tax increase in proportion to the final cost of the tobacco products

Main Challenges

Main Psychoactive Substances Accountable for Treatment Entry Globally, 2008 (WHO, 2010)

 Alcohol is the leading risk factor among 15- to 49-year-olds in 26 countries:  Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil,

Canada, Colombia, Costa Rica, Dominica, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, Saint Vincent and the Grenadines, United States, Uruguay, Venezuela

Harmful Use of Alcohol

 Regional plan of action adopted in 2011

 Virtual courses on alcohol policy and brief interventions

 Collaborative research and publications (various)

Main Achievements

 Unregulated market and marketing

 Need to build capacity for alcohol policy making

 Need for political commitment to reduce alcohol consumption

 Interference of the alcohol industry

 Need for increased knowledge base at country level (surveillance, research)

 Limited financial resources

Main Challenges

NCD Risk Factors: The Case of Consumption of Sugary Drinks

Source: Brownell K., et.al. (2011). Unpublished observations. 15

Sugar Consumption in the Past 10 Years and Risk of Diabetes

Source: Basu, Stuckler, et.al. (2012). 16

Marketing and Risk Factors of NCDs

17 Source: The Coca-Cola Company reinforces commitment in the fight against obesity. Retrieved April 23, 2015, from http://www.coca-colacompany.com/press-center/press- releases/the-coca-cola-company-reinforces-its-commitment-to-help-america-in-the-fight-against-obesity

“Coming Together” “Be OK”

UN High-Level Meeting on NCDs

Best buy:

Country Survey year (mg/day) g/day Source

Argentina 2004 12 g/day Encuesta nacional de nutrición y salud (http://www.msal.gov.ar/htm)

Brazil 2003-2004 (4500 mg/day) 11.25 g/day Sarno, Moreira Claro, et al.

Chile 2009 (3600 mg/day) 9.0 g/day Encuesta Nacional de Salud 2010 (www.minsal.cl)

U.S. 2005-2006 (3466 mg/day) 8.66 g/day NHANES study

Barbados 1991-1994 6.78±3.15 Cooper, et al. (Am J Public Health 1997;87:160–68)

Canada 1990-1999 7.98±13.80 IOM citing Health Canada (Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulphate)

Jamaica 1994-1995 8.45±6.62 Cooper, et al. (Am J Public Health 1997;87:160–68)

Panama 12.35±9.15 Hollenberg , et al. (Hypertension 1997;29:171–76)

St. Lucia 1991-1994 8.58±3.68 Cooper, et al. (Am J Public Health 1997;87:160–68)

Venezuela 5.32 Negretti de Bratter (Metal Ions in Biology and Medicine)

Salt Intake Data in the Region

19 Adapted from: Brown, I. J., Tzoulaki, I., Candeias, V., & Elliott, P. (2009). Salt intakes around the world: implications for public health. International Journal of Epidemiology, 38(3), 791–813. http://doi.org/10.1093/ije/dyp139 (updated with recent information from the region)

Estimated Road Traffic Death Rates per 100,000 Population in the Americas, by Country, 2010

 Road traffic injuries caused an estimated 149,992 deaths in 2010

 Among subregions, the road traffic death rate per 100,000 population ranges from 11.0 in North America to 22.2 in the Latin Caribbean

 The average rate for the Region was 16.1 deaths per 100,00 population

Source: PAHO. Road Safety Facts in the Region of the Americas, 2013. Available at: http://www.who.int/violence_injury_prevention/road_safety_status/2013/report/factsheet_paho_en.pdf. Accessed April 22, 2015. 20

Proportion of Reported Road Traffic Deaths in the Region of the Americas, by Type of Road User and Subregion, 2010

What Do We Do?

Section C

Economies

• Reduced labor supply • Reduced labor outputs (e.g.,

cost of absenteeism) • Additional costs to employers

(e.g., productivity, insurance) • Lower returns on human capital

investments • Lower tax revenues • Increased public health and

social welfare expenditures

Health systems

• Increased consumption of NCD- related healthcare

• High medical treatment costs (per episode and over time)

• Demand for more effective treatments (e.g., cost of technology and innovation)

• Health system adaptation (e.g., organization, service delivery, financing) and adaptation costs

Households and individuals

• Reduced well-being • Increased disabilities • Premature deaths • Household income decrease,

loss, or impoverishment • Higher health expenditures,

including catastrophic spending • Savings and assets loss • Reduced opportunities

NCDs Have a Significant Impact on Economies, Health Systems, and Households

Source: World Bank analysis by the authors in “Chronic Emergency: Why NCDs Matter.” Health, Nutrition, and Population Discussion Paper. 2011. Washington DC: World Bank. 2

Country productivity and competitiveness

Fiscal pressures

Health outcomes

Poverty, inequity, and opportunity loss

Example impact areas

The Estimated Global Costs Will Multiply Almost Exponentially: Output Losses Will Speed Up Over Time

3 Source: Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., et al. (2011). The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum. Available at: http://www.hsph.harvard.edu/program-on-the-global-demography-of-aging/WorkingPapers/2012/PGDA_WP_87.pdf. Accessed April 22, 2015.

Health Spending Projections by Chronic Condition in Brazil, 2008–2050

Source: Glassman, A., Gaziano, T. A., Buendia, C. P. B., & de Aguiar, F. C. G. (2010). Confronting the chronic disease burden in Latin America and the Caribbean. Health Affairs, 29(12), 2142–2148. http://doi.org/10.1377/hlthaff.2010.1038 © 2010 by Project HOPE - The People-to-People Health Foundation, Inc. 4

NCDs: Global and Regional Context

UN General Assembly, 2011

Commitments from Heads of State and

Government

World Health Assembly, 2012

Adopt a global target of 25% reduction in premature

mortality from NCDs by 2025

World Health Assembly, May

2013

WHO Global NCD Action Plan 2013- 2020, including 9 global targets and

25 indicators

PAHO Directing Council,

September 2013

PAHO Regional NCD Action Plan 2013- 2020, fully aligned with WHO Global

Action Plan

UN General Assembly NCD Review 2014: Review and assessment of the United Nations General Assembly of the progress achieved in

the prevention and control of NCDs

 UN High-Level Meeting (UNHLM) Political Declaration calls on Member States to:  Respond to the challenge with a whole-government and whole-society effort  Reduce risk factors and create health-promoting environments  Strengthen national policies and health systems  Strengthen international cooperation, including collaborative partnerships  Support research and development  Strengthen monitoring and evaluation  Follow up—UNGA 2014

UN High-Level Meeting Political Declaration

What Have We Gained With the UNHLM?

UNHLM Declaration

Political commitment

Raise awareness of the problem

Mobilization of resources

Coordination of efforts

Inclusion of other sectors

Increased accountability

What Has Happened Since the UN Political Declaration on NCDs in 2011?

 WHO Global NCD Action Plan 2013-2020 (and one WHO Plan on NCDs)

 WHO Comprehensive implementation plan on maternal, infant, and young child nutrition, 2012-2025

 Global coordination mechanism for the prevention and control of NCDs

 UN Interagency Task Force

Source: World Health Organization. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Available at: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1. Accessed April 22, 2015. 8

1. A 25% relative reduction in risk of premature mortality from CVDs, cancer, diabetes, chronic respiratory diseases

2. At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context

3. A 10% relative reduction in prevalence of insufficient physical activity 4. A 30% relative reduction in mean population intake of salt/sodium 5. A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years 6. A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence

of raised blood pressure, according to national circumstances 7. Halt the rise in diabetes and obesity 8. At least 50% of eligible people receive drug therapy and counselling (including glycaemic

control) to prevent heart attacks and strokes 9. An 80% availability of the affordable basic technologies and essential medicines, including

generics, required to treat major NCDs in both public and private facilities

Nine Global Voluntary Targets by 2025

9 Source: WHO | About 9 voluntary global targets. (n.d.). Retrieved April 23, 2015, from http://www.who.int/nmh/ncd-tools/definition-targets/en/.

PAHO Plan of Action for the Prevention and Control of Noncommunicable Diseases

 Adopted October 3, 2013, by Ministers of Health of the Americas

 First line of action:  Multisectoral policies and partnerships

for NCD prevention and control, including civil society, academia, media, and voluntary associations

Source: PAHO. (2013). CD52/7, Rev. 1: Plan of Action for the Prevention and Control of Noncommunicable Diseases. US1.1. Available at: http://iris.paho.org/xmlui/handle/123456789/4400. Accessed April 22, 2015. 10

 NCD Regional Strategy 2012 and Plan of Action with regional targets and indicators 2013-2019  Aligned with WHO Global NCD Plan

 Technical cooperation with Member States

 Continue advocacy in global forums:  Social Determinants, G8/G20, Summit of the Americas, etc.

 Promote multisector partnerships  Pan American Forum for Action on NCDs

 Broader engagement in NCDs with other regional UN agencies

What Has Happened Regionally Since the UN Political Declaration on NCDs in 2011?

Focus of PAHO’s NCD Plan of Action 2013-2019

Four diseases: CVD, cancer, diabetes, CRD

Four risk factors: tobacco, diet, alcohol, physical

inactivity Other regional issues:

obesity, mental health, CKD

NCDs as development issue Whole-government, whole-society

approach

NCDs in social protection schemes

and UHC

Protective factors and determinants of

health

Change of model of care within PHC

Access to technology and

medicines

Monitor advances

 Competing national priorities

 Insufficient investment in prevention and control of NCDs

 Low regulatory capacity at the national level

 Interference from big economic corporations

 Complexity of monitoring and reporting systems (reduces country capacity to report progress on NCDs and risk factors)

 Failure to comply with international mandates such as WHO FCTC

Challenges of the PAHO NCD Action Plan

PAHO Technical Guidelines

14 Source: www.paho.org.

NCD Recommended “Best Buys”

Source: First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control (Moscow, 28-29 April 2011). Discussion Paper: Prevention and Control of NCDs: Priorities for Investment . Available at: http://www.who.int/nmh/publications/who_bestbuys_to_prevent_ncds.pdf. Accessed April 22, 2015.

Risk factor / disease Interventions

Tobacco use

Raise taxes on tobacco Protect people from tobacco smoke Warn about the dangers of tobacco Enforce bans on tobacco advertising

Harmful use of alcohol Raise taxes on alcohol Restrict access to retailed alcohol Enforce bans on alcohol advertising

Unhealthy diet and physical inactivity

Reduce salt intake in food Replace trans-fat with polyunsaturated fat Promote public awareness about diet and physical activity

Cardiovascular disease (CVD) and diabetes

Provide counseling and multidrug therapy (including blood sugar control for diabetes mellitus) for people with medium-high risk of developing heart attacks and strokes (including those who have established CVD) Treat heart attacks (myocardial infarction) with aspirin

Cancer Hepatitis B immunization beginning at birth to prevent liver cancer Screening and treatment of precancerous lesions to prevent cervical cancer

 The fight against NCDs is not only about individual choices

 Best buys already working for tobacco control and can be adapted to the food, beverage, and alcohol industries

 Multisectoral approaches are the only way to effectively tackle the NCD epidemic

Conclusion: NCDs, a Shared Responsibility

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