THE CHANGING FACE OF GLOBAL HEALTH: SUSTAINABILITY IN AN AGE OF AFFLUENCE AND POVERTY
Prof Stephen Leeder AO
It is a great delight for my wife Kathy Esson and me and a high honour to be your guests in Thessaloniki. Kathy and I have enjoyed your hospitality and fellowship in full measure. We have formed new friendships and consolidated ones of long standing. It has been a rich experience indeed. I gladly acknowledge Kathy’s help in preparing my presentation to you today.
Introduction - understanding risk factors and health
I begin by paying tribute to Dr Anastasios Dontas whose energy and professionalism, and that of his late wife (who was a force in Greek preventive medicine for women) contributed mightily to the Greek/Australian International Medical and Legal Conferences but also to the organisation of large scale studies of the health of populations. It has been a delight to meet Drs Dontas’ daughters, Cleo and Ismene, who are present today.
Dr Dontas was an esteemed member of a team of epidemiologists who from 1958 studied heart disease among 13,000 men in seven countries in four regions - US, Northern Europe, Southern Europe and Japan.
The study ran for more than twenty years. It revealed the importance of risk factors - especially cholesterol and smoking - and emphasised the value of what is now called the Mediterranean diet.
The study was not without controversy, with polarised debate about the importance of dietary components including sugar.
But it was a beacon - a beacon that showed we could unravel the causal antecedents of heart disease and stroke and that prevention was possible.
The challenge of non-Communicable Disease
Building on the work of Dr Dontas, I want you to think with me about the greatest global health challenge of today and of tomorrow. It is the health equivalent of climate change which, in the imaginative eye of the Photoshopper, might obliterate Manhattan.
Whereas we used to think of cardiovascular disease and other non-communicable (non- infectious) diseases as mainly affecting the developed world, they now affect all countries in a big way.
As people in developing countries move from rural areas to the cities in search of greater affluence, we are facing a concurrent massive increase in the amount of non-communicable disease (NCD), principal among which are heart disease and stroke - in other words, cardiovascular disease.
As I will mention a little later, this is due not only to richer nations being able to afford better treatment, but to the effect that poverty has on diet, on ability to choose to eat healthily, to enjoy opportunities for physical activity, to enjoy social interaction, and to avoid junk food.
As Jeff McMullen stated in his splendid presentation in relation to Aboriginal people, despite lifestyle choices closely associated with NCDs being partially under our control, the freedom that we believe we have to make choices is often less than it first appears to be. Our ability to choose if limited by our environment. We are not completely in control of the way we live and work, the cities we build and the environments we create, the food we eat, and the lifestyles open to us to pursue. And this is even more the case in the developing world.
Unlike in the developed world these days, in developing countries about one-third of deaths from heart disease occur in people aged less than 65, as it was in Australia 50 years ago. And that is of great economic significance when you consider the need for a productive workforce to support development in these countries. It affects national economic sustainability.
NCDs are increasing as steadily and without the fanfare of an epidemic as the climatic temperature, and this increase owes as much to anthropogenic activity as does climate change. We must seek a new equilibrium, a new global homeostasis that guarantees human survival and human health, free of the non-communicable diseases.
Those of us who are public health practitioners need your help - not only that of the medical people here and beyond, but the help of lawyers, politicians, educators and communicators. Medical and health professionals cannot treat and prevent these health problems on their own. And in the rest of my talk I want to point to ways in which this necessary collaboration is already happening.
Causes of death
Let’s look first at what kills us. About 57 million people die each year. Here are the ten leading causes of death in the world now.
68% or 36 million of those deaths are due to non-communicable diseases. These patterns have been changing as seen in this graph, again from the WHO.
It depends which country you are in as to what the principal causes of death are.
These statistics locate the NCDs as important causes of death. Importantly, 80% of all deaths from NCDs occur in low and middle income countries.
Some people argue with no fear of contradiction that we all die of something, so why fuss about the NCDs?
The concerns generated by these statistics are principally ones about the human condition:
- at what age are people dying,
- what are the personal, family and economic consequences of these deaths, and
- what are the economic consequences of these illnesses, in terms of cost of care, foregone productivity and economic sustainability?
The Commission for Macroeconomics and Health
So what’s been the response to date? In the past two decades, there has been a growing appreciation of the tight connection between health and economic development.
In 2000, the WHO established a commission to explore the relationship between macroeconomics and health. The commission was headed by Professor Jeffrey Sachs, then at Harvard and now at the Earth Institute at Columbia University.
The Commission was based on the assumption that health is an intrinsic human right and good health is central to poverty reduction and socioeconomic development.
The Commission produced a multi-country, multivolume report that advocated a conjoint approach whereby Ministries of Finance, Planning and Health act with development agencies, civil society, philanthropic organisations, academia and the private sector because better health is in everyone’s interests. “Together”, the report argued, these agencies “can take forward a shared agenda for addressing financial and systemic constraints to the equitable and timely delivery of quality health and social services.”
This effort contributed to the formulation of the eight Millennium Development Goals, which were endorsed by the UN in 2000 that foresaw a halving of extreme poverty worldwide by 2015. This goal was achieved in 2012 and as The Economist observed, poverty is now intra- national, located in pockets in countries that may have high overall prosperity.
The MCH agenda was concentrated upon the major communicable diseases such as HIV, tuberculosis and malaria, maternal and child survival, basic education and social uplift. It attracted substantial financial support through the Gates Foundation and other agencies. It also emphasised maternal and child survival and great things have been achieved thus far this millennium in reducing infant mortality worldwide and absolute poverty.
This greater awareness of the connection between health and economic development is something I’ll return to.
I want now to focus on what’s being done about heart disease because it is a fine example of the global challenge of non-communicable disease. Also, remarkable progress has been made in recent years in preventing the occurrence of heart attack in many affluent communities and especially in deferring the age at which people experience heart attack.
In 2003-4, my wife Kathy Esson and I, together with a NY cardiologist Henry Greenberg and a development economist Susan Raymond who had served internationally with the World Bank, worked at the Earth Institute at CU in NY. Our aim was to extend the MCH approach and concentrated on CVD as an example of an NCDs. We explored its economic consequences in the developing world and identified from the research literature how best it could be both prevented and treated in sustainable ways.
Our report, A Race Against Time, examined the impact of heart disease in Brazil, South Africa, Tatarstan, India and China. I will say more about this in a moment, but having published the second edition of our report this year, I am in no doubt about the urgency and magnitude of the importance of economic factors in the determination of CVD and reciprocally what the adverse effects are of CVD in countries struggling to achieve optimal development.
Treating the problem
I digress briefly to explore the effect of treatment on heart disease before moving to the more challenging area of prevention. Clinical interventions have had a major impact. These include:
- ingenious surgical approaches to unblocking coronary arteries and dissolving clots, and
- keeping narrowed coronaries open with stents.
They have made a strong contribution to the decrease in heart disease deaths, particularly in the developed world. It wasn’t always thus.
As an intern in 1967 I worked in the new coronary care ward at Sydney’s Royal North Shore Hospital. It looked out on a neighbouring cemetery. Nowadays, survival is much higher and patients are usually quickly on their way - alive and vertical.
New therapies are becoming available. Many of us in this room are using one or more of them - statins and blood pressure lowering drugs - and more can be expected. However, treatment of heart disease is expensive and beyond the reach of the majority of people in less developed countries. This makes prevention all the more important.
So we enter the world of economics and heart disease, this time through the portal of treatment, just as we did when we were looking at the occurrence of CVD in the first place.
Variations in heart disease and prevention
In pursuit of sustainable preventive strategies, as Dr Dontas showed us, we need to explore natural variations in the rates of heart disease in different places.
Heart disease varies across countries and varies with time. The dynamic nature of heart disease is evident here in Europe, where heart disease death rates vary from country to country. The following table shows the national variations in deaths per 100,000 population from heart disease and stroke.
Portugal for example has enviable low rates of heart disease, while Russia following the disintegration of the Soviet Union had rates of heart disease death that were truly astronomical, especially among young men. Depending on where you look in the world you will find low, intermediate and high rates of heart disease deaths.
And the position of different countries has varied over time. In the case of Greece, the president of the Greek Cardiological Society, Dr Vlassis N. Pyrgakis, six years ago, observed how Greece’s rates for men aged 64 or less -the productive population - remained stable at about 50/100,000 for 30 years, but that the rates in other nations have changed, mostly falling.
Where does Greece belong he asked, by virtue of its heart disease death rates looking out over the past three decades?
In examining Greece’s changing position, Dr Pyrgakis observed that Greece looked like:
Changes in Greece’s position were not because of changing heart disease death rates in Greece: they were because of changing rates in the rest of Europe that saw Greece fall from third, to seventh, to twelfth and then to 15th among European nations.
Let us think a little further at this apparently fixed rate of heart deaths in Greece and examine a natural experiment that shows how important the environment is for the development of heart disease. Let’s visit Melbourne.
Melbourne is a dangerous city: the device in this picture is used to keep population numbers down. Many more people enter at the wide end of the funnel than come out at the narrow.
And then there is the matter of Melbourne’s beaches, extolled in tourist brochures but in fact fed with ice and snow from the Great Southern Ocean.
Despite these hazards Melbourne remains a popular destination and domicile for people of Greek origin. According to census figures, Melbourne has the largest Greek population in Australia (154,000 or around 47% of all Greeks in Australia in the 2011 census), and the largest Greek population of any city in the world outside of Greece.
A paper published from Melbourne in 1989 by Professor Mark Wahlquist, a nutritionist, and colleagues compared the mortality experience of 189 older Greek people who had been living in Melbourne for about 30 years compared with an age-matched group from the Greek rural town of Spata.
In 1989, the rates of coronary disease were much higher in the Melbourne Greeks. Detailed studies of their diets showed a shift towards animal products (meat), legumes, protein, margarine, polyunsaturated fats, beer and lower intakes of cereals, carbohydrates, wine and olive oil. The Greeks in Melbourne had more abdominal fatness and so more risk of heart disease.
In the previous three decades about which Dr Pyrgakis was writing, heart disease death rates had fallen dramatically in Australia while remaining stable in Greece.
In Australia the peak of the heart disease epidemic was in the late 1960s when it was much higher than in Greece.
So coming from Greece now and settling in Australia is quite different to thirty years ago. Migration no longer increases your risk of heart disease, although this picture from the annual Greek festival might suggest otherwise.
The outcome of detailed analyses of what caused this favourable change in heart disease in Australia and other Western countries, was that prevention and treatment shared 50:50. From these observations we can draw ideas for deliberate preventive and therapeutic actions that can reduce the risk of heart disease.
I want now to return to the more general theme of NCDs and what we can do about them.
Taking International Action for Sustainability
As I have demonstrated, we have a global problem with cardiovascular disease and other chronic diseases. In the developed world, we have seen encouraging signs with CVD that when risk is reduced, whether through the use of medications or preventive measures, death rates fall. A major risk factor for heart disease and various cancers is tobacco smoking. It is in this area that much has and can be done to reduce NCDs.
In 2005, a dramatic event occurred in international law that should save millions of lives, from cancer and heart disease and emphysema due to tobacco smoking. The World Health Organization’s first international treaty was transacted.
This has been the most successful international response to the global epidemic of tobacco- related diseases to date. It is the culmination of about 50 years of policy work in relation to tobacco, and is called the Framework Convention for Tobacco Control (FCTC). It came into force in 2005 with 168 signatory countries. There are 193 nations in the UN. The US and Indonesia (a big tobacco country that makes 11 billion cigarettes a year) have not signed.
The WHO says of it:
The WHO FCTC was developed in response to the globalization of the tobacco epidemic
… [due to] trade liberalization and direct foreign investment. Global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contraband and counterfeit cigarettes have also contributed to the explosive increase in tobacco use.
Here was an instrument of law and politics driving the international health agenda. Many signatory countries have ratified the treaty and begun the hard work of translating its protocols into laws that limit the production, advertising and sale of tobacco.
The FCTC has two arms. The first comprises demand-side controls covering pricing and taxation, and non-price tactics to protect people from others’ smoke and to regulate packaging and labelling, advertising and sponsorship.
Supply-side measures such as the reduction in tobacco production — the second arm of the FCTC— are especially difficult to enact. Derek Yach, a principal contributor to the development of the treaty, wrote on its tenth anniversary that:
State monopolies … from China, Indonesia and India are poised to soon be the dominant manufacturers by volume of traditional tobacco products.
A media release from WHO says about the FCTC:
During the past decade, the WHO FCTC has enabled Parties to make many significant achievements in tobacco control, including the following:
Full implementation of the WHO FCTC would support global commitments to achieving a 25% reduction in premature deaths from non-communicable diseases by 2025, including a 30% reduction in the prevalence of tobacco use in persons aged 15 years and over.
To reduce supply, efforts are needed to ensure greater vigilance over illicit trade in tobacco products and tighter regulation over sales to and by minors. There is also a need to support alternatives to tobacco production for farmers otherwise dependent on tobacco for their livelihood. This may seem odd until we realise that in many developing countries tobacco farming has in the past been encouraged, including by the IMF, because it is easy to grow and profitable. Farmers in sub-Saharan African states had entered into arrangements with tobacco companies whom they came to depend on. When the global financial crisis hit, tobacco companies came to the rescue.
I attended a satellite meeting of the UN NGOs in Melbourne five years ago where representatives from developing countries would not sign petitions and motions calling for more forceful enactment of the FCTC because they depended on money from big tobacco as their home governments have cut their funding in the GFC. So changes are not always easy.
In Australia, ratification of the tobacco treaty gave the Commonwealth government greater responsibility for tobacco control, which had previously been shared with the States. Cigarettes are now sold only in packs that carry no brand promotion and instead show pictures of diseased organs.
So you can see that the law - whether in the form of an international treaty or national packaging practice - has had already a major contribution in addressing the rising tide of NCDs, although not in all countries.
How are we doing? University of Melbourne Laureate Professor, Alan Lopez, contributed data collection and analysis to a study “Smoking Prevalence and Cigarette Consumption in 187 countries, 1980-2012,” published in 2014. He concluded that overall, age-standardized smoking prevalence decreased by 42 per cent for women and 25 per cent for men between 1980 and 2012.
In Australia, smoking prevalence has decreased markedly since 1980. Smoking prevalence amongst males almost halving, from 34.3 percent in 1980, to 18.3 per cent in 2012 and is now even lower. Similarly, smoking prevalence among women decreased from 27.3 per cent in 1989 to 15.4 percent. Despite population growth in Australia, the number of smokers has decreased, from 3.35 million (across both men and women) in 1980, to 2.96 million in 2012. The rates are about double in our Indigenous populations. So while better, it is still not good. Imagine, as one commentator put it, a passenger jet crashing in Australia every Wednesday: this is how many people (approx. 290 people) die from smoking every week.
The UN high-level meeting on NCDs.
A second ray of hope in seeking international solutions to the NCD epidemic came in 2011 when the UN held its second-only high-level summit on health, following the one on HIV/AIDS in 2008.
This was a meeting of the General Assembly on the Prevention and Control of NCDs. The aim of the meeting was to:
- Increase the political prioritization of NCDs.
- Recognise the impact of NCDs as not just a health issue, but also as a major economic burden and obstacle to global health.
For the UN to act in its overarching capacity as it did in convening the high-level summit means that a matter of serious international import is under consideration.
The meeting owed much to a consortium of non-government organisations comprising the Non-Communicable Disease Alliance - the world Heart Federation, The International Diabetes Federation, the International Union against Cancer and several others. Their influence through years of lobbying was critical to getting the UN meeting to happen.
From it came a political statement, a communique, that among other things energized the
WHO to develop an agenda for global action on NCDs and that is playing out as we speak.
On a parallel track, The Lancet, a medical journal that has frequently taken the lead in convening groups to show academic leadership in relation to global problems such as infectious disease and child survival, has also been active in relation to heart disease and other NCDs, led by Lancet editor Richard Horton and Professors Robert Beaglehole and Ruth Bonita from Auckland.
They have defined a preventive goal of achieving a 25% reduction in premature mortality, that is, death before 65, from non-communicable diseases (NCDs) by 2025 (the 25 x 25 target). Many governments signed on in 2012, including many developing countries. They argue that the 25% target could be achieved through more multi-sectoral action on risk factors such as smoking, dietary salt and fat.
We should be encouraged by these international movements - the FCTC and programs of the UN and WHO - that are bringing NCDs onto national and international agendas. They recognise that it is political and economic action, not lifestyle choices by individuals, that will really make a difference.
On the other side of the equation, many of us hold grave fears for the gains won through the FCTC and UN being undermined by the Trans-Pacific Partnership Agreement (TPPA), currently being finalized under a shroud of commercial secrecy. This will affect poorer Pacific nations, as well as Australia, with regard to pharmaceutical pricing and the food we eat.
So we have a massive global problem but it is within our capacity to extend our preventive activities so that its worst effects - premature mortality and morbidity - are ameliorated. We are making great clinical advances. We have done well. There are major challenges with regard to equity.
We need citizens such as you to take up the cause. Here is a global ethical challenge worthy of our commitment as part of our global citizenship. Will we, as articulate professionals, lend support to efforts that seek a sustainable health future including through the exercise of law both nationally and internationally over those products, practices and environments that damage health? How much are we willing to pay to achieve a greater degree of health equity?
Looking forward to better health
Meetings such as ours have for three decades reached across continents and oceans to establish networks of committed lawyers and doctors. Medicine and law are truly wonderful professions and all of us in them are immensely privileged. And with that privilege comes awesome accountability.
I put the proposition to you that each person here today has a responsibility to support preventive programs in your own community, to advocate for tobacco control in your nation, and to seek out opportunities to reinforce international efforts such as the FCTC and the WHO
The legacy of a program such as the Greek/Australian Legal and Medical Conference with its sustained cross-cultural, cross-continental fellowship and learning surely lies in the elevation of our understanding of our global citizenship, a heightened acknowledgement of our interdependence as humans wherever we live, whatever our culture and an increased interest in the preservation of this world of beauty and good health for future generations.
By our values, expressed in our actions towards our own citizens and those of countries less fortunate than ours, using all the professional instruments available to us, we can achieve a sustainable healthy future - not a state of perfection, not utopian immortality any more than could the gods on Mount Olympus.
But a sustainable healthy future is a good goal and one, I hope, that the founding fathers and mothers of this organisation, such as Dr Anastasios Dontas and his wife, would find to be to their satisfaction. Indeed - an awesome thirty years!
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What doctors should know about the Trans-Pacific Partnership Agreement
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