Injuries (Road Traffic Accidents and Alcohol)

In this chapter, we will be looking at one of the major rising causes of death and disability in the world which are injuries, especially road traffic accidents and alcohol which is Frequently related to these accidents and injuries. The global burden of disability study which looked at the contribution of different diseases to death and disability in 1990 as well as in 2010 categorized diseases and causes of death and disability into three major groups. First is the grouping of communicable diseases or infectious diseases with deaths related to pregnancy, early childhood, later childhood, and nutritional conditions which often result in death or disease because of severe under-nutrition in many forms. These are generally considered diseases associated with under-developed economies and are generally expected to decrease in terms of their contribution to the global burden of disease as countries advance economically and socially. The second category is one of non-communicable diseases, which are actually diseases of mal-adapted modernity and which have been rising quite a lot as a result of countries advancing economically, urbanizing and industrializing without appropriate balancing measures to prevent unhealthy lifestyles from becoming established as a pattern in society. These two are now a major cause of concern in the 21st Century. The third category is one of injuries. These can be intentional or unintentional. Of course injuries have been found as causes of death right from times immemorial. People could have died by being mauled by a wild animal, or being thrown off a horse, or being struck by an arrow fired by an enemy. But in modern times, you find many more people dying by being mauled by a speeding truck or a car or being shot by a bullet. And as we now see injuries rising in contribution, the major categories of injuries which are rising are those related to road traffic accidents, suicides as well as homicide. And these are contributing to a rising burden which now exceeds the burden contributed by HIVAIDS, tuberculosis, and malaria put together. About 5.8 million people die each year as a result of injuries. This accounts for about 10% of the world’s deaths and is considerably more than the number of deaths resulting from some of these major infectious diseases like HIV, TB and malaria. Men are the major victims of intentional as well as unintentional injuries in a variety of forms, whether it is homicide or suicide or drowning or falls or poisoning. And of course markedly in terms of being road traffic accident victims. But women seem to be outnumbering men in terms of being victims of fire related injuries. That’s mostly because they are the ones mostly in the, cooking. In terms of the global burden, male sustained about 68% of all injury related deaths in 2010. But what is really disconcerting is the fact that many of these injuries strike young. About 40% of all deaths in the age group of 15 to 24 years were accounted for by injuries. Fifty-two percent of deaths in males, age 15 to 29 years were due to injuries. Again, like in case of many of the non-communicable diseases, a large fraction of these injury related deaths occurs in low and middle income countries. Eighty-nine percent of all injury related mortality is in these countries. South Africa has injuries as the second leading cause of death in that country. And about 95% of deaths and disability adjusted life year loss from interpersonal violence that is often due to fights or homicide. All of these occurring between people, these are found in low and middle income countries. And we know that war and conflict causes a huge number of deaths, almost exclusively in the low and middle income countries, even if the conflicts, geopolitical causes of those conflicts arise from other parts of the world. We also recognize that transportation related injuries and intentional injuries are among the leading causes of death worldwide, among the entire injury spectrum. And of these, road traffic accidents really are at the very top. And they’re rising in different parts of the world which are particularly now on the faster development trajectory. And we find that in Africa and the Middle East, the rates of road traffic accident related deaths per 100,000 population are among the highest in the world. In terms of unintentional injuries, we can actually take a large number of public health measures which have been shown to be very effective, like compulsory helmets, use of seatbelts, imposition of speed limits, improved built environments and road conditions. All of these actually help mitigate some of the disease burdens. In terms of intentional injuries we do require a fair amount of counseling from the healthcare system to people who are likely to be having suicidal intent. So treatment of depression, preventing suicidal attempts and providing psychological support systems and counseling to prevent self-harm, all of these are going to be important. Also, conflict resolution and means to prevent interpersonal violence are also part now of the public health agenda. And gun control becomes a very important area. And we now recognize that in countries with poor levels of gun control, homicidal and other interpersonal violence related injuries are very high indeed. In terms of preventing injuries, we also have to look at the response systems, particularly in terms of the emergency healthcare response. We need to look at the pre-hospital stage where for example a traffic accident victim needs to be immediately attended to by first responders, we need improved communications and provision of appropriate emergency transport. At the same time, in the hospital, we need again, a multidisciplinary trauma team to look after the person who is injured, who may have multiple injuries which might require different specialized care. But we also require to train nonprofessional caregivers to provide care when trained staff are not available. We also need rehabilitation of people who have had injuries and have survived them and a large number of people living with disabilities, post-injury need sufficient rehabilitation support now. We recognize that road traffic accidents are indeed the major preventable cause of injuries. And about 1.3 million people die on the roads every year. That is about 3,500 every day. Something like ten jumbo jets crashing every day. Now 50 million people are left with injuries, many with severe disabilities. And particularly in the young population of 10 to 24 years age, we find road traffic accidents are the single biggest cause of fatality in that young age group. We recognize that in high income countries some progress is being made by a decline in the rate of road traffic accident related death rates. But in low and middle income countries the death rates are rising. And when we look at the middle income countries in comparison with the high income countries, while the vehicular numbers are almost comparable across these two income groups, the deaths are far, far higher in the middle income group. So these are countries which are modernizing with a higher vehicular density, but are still unable to implement adequate safety measures which can bring down the road traffic accidents and the fatalities associated with it. Now half of the deaths related to road traffic accidents are unfortunately among the very vulnerable road users like pedestrians, cyclists, motorcyclists. That means it’s not just the car drivers and the truck drivers who die because of careless driving, but also the innocents who fall victim are the people who use the roads in other ways. Now we need to take very effective measures in, in order to control the road traffic accident related damage to health and prevent the death and disability in different settings. The five factors that can be controlled for by effective legislation. Speed of the vehicles can be controlled by speed laws. Drinking and driving has to be strictly curbed. And testing alcohol content in the breath and blood of drivers who are suspected to be driving under the influence of alcohol is a very important measure. Applying child restraints in cars prevents them from tossing around and getting injured in a speeding vehicle. And motorcycle helmets must be made mandatory everywhere to prevent head injuries. Again, seatbelts have made a great difference to the degree and number of injuries obtained during road traffic accidents. But very few countries implement all of these laws. If you take any single one of them, you find that the use of these is still limited only to some countries among the huge number of countries across the world. For example, when you look at drunk driving laws, then these are in fact applied very, in very few places. Urban speed laws are also applied in very few places. So also child restraint laws. While seatbelt laws and motorcycle helmet laws are more frequently applied, how well they’re enforced is also a big question. When we look at what are the contributory causes to some of this, drink driving comes out as one of the top causes of road traffic accidents. Now in South Africa, about 50% of those involved in road traffic accidents had elevated blood alcohol concentrations in 2001. And this is true of many rapidly urbanizing cities in low and middle income countries now. About 3.3 million people die every year due to harmful use of alcohol. In the age group of 20 to 39 years, about 25% of all deaths are attributable to alcohol. This is of course not only because of road traffic accidents, but because of the other harmful effects of alcohol as well. And we know that alcohol is the cause of cirrhosis that is a liver problem which because of alcohol gets fibrosis in the liver. Cancers which are again, attributable to alcohol particularly gastrointestinal cancers. All of these are growing problems now. But alcohol consumption, especially immoderate alcohol consumption is also associated with mental illness. And that can lead to intentional injuries, particularly alcohol provoked interpersonal conflict. Alcohol consumption, especially heavy drinking has been linked to both suicide as well as violence. And all of these can aggravate the number of injury related deaths and disability. We also know that there are huge economic costs apart from the social costs of alcohol. We have direct costs like costs for healthcare services, costs related to law enforcement, costs related to increased crime and accidents, costs related to domestic violence. Now there are indirect costs from loss of productivity, reduced output and earnings as a result of alcohol use. Absenteeism. Or even people being away from productive occupations because they’re under the influence of alcohol. Then intangible costs which are assigned to pain and suffering and poor quality of life. So given all of this, alcohol has become a major public health challenge again, not only in the context of non-communicable diseases, but in the overall context of development. Many countries have started looking at ways by which they can control the problem of excessive alcohol consumption which is deleterious to health. And taxation has been shown to be one of the very important elements by which public health can address the problem of alcohol, by raising prices and reducing the demand. And the, the taxation in different countries has been linked to the quality of alcohol, quantity of alcohol, the concentration of alcohol and so on. But taxing adequately is important as a measure. Now restricting availability of alcoholic beverages is also an important element. Not only age related restrictions but some countries have also imposed restrictions on the total amount of alcohol that can be sold to individuals over a period of time. Implementing bans on alcohol advertisements is absolutely critical. Both direct and indirect forms of alcohol advertisement and sponsorship and promotion must be banned. The other effective measures are measures against drunk driving. The word ‘drink driving’ itself is very suggestive. It suggests that it’s not the human being who is driving, it is the drink that is actually driving the vehicle when the alcohol concentration has exceeded a particular limit. So we do need to enforce that kind of legislation where we have random breath-testing and people who are driving under the influence alcohol are taken off the street and are also stripped of their licenses to drive. And strict penalties are imposed in order to inhibit such practices. We also need of course support systems by way of de-addiction counseling and other support systems, the health system as well as social support systems can provide. And all of these measures can reduce the problem of alcohol in our society and remove one of the important contributory causes to road traffic accidents.

Respiratory Illnesses

We will be talking of respiratory illnesses in this chapter. Clearly the lungs can be affected by very many conditions. Infections which are acute, infections which are long-lasting, like tuberculosis or cancers, but what we will be talking about today is one of the major forms of non-communicable disease, the chronic obstructive pulmonary disease, or chronic obstructive airway disease as it is called. COPD is one of the major problems affecting the health of human beings across the world. And in 2010, it was estimated that 329 million people, that�s about 4.8% of the global population were affected by chronic obstructive pulmonary disease. In 2012, it was the third leading cause of death. But these numbers too appeared to be underestimates because COPD is not often registered as a cause of death because cause of death is attributed to other things like cardiovascular and so on which may coexist or which may actually result from COPD, because congestive heart failure is not an infrequent manifestation of lung disease which then stresses the heart. Most countries don’t have national registries or good population data for the disease and therefore this disease may be even more frequent than has been estimated. But even at the level of the burden that has been now measured, 90% of the deaths occur in low and middle income countries. In 2010, it was estimated that COPD resulted in an economic loss of $2.1 trillion dollars globally, half of which was occurring in the developing world. Now if 90% of the deaths are occurring in the developing world but only 50% of the economic burden is in the developing world, that’s not because the developing world suffers less, but because the wages are estimated to be lower in terms of lost productivity losses. So the low and middle income countries do suffer hugely, both in terms of health and economy. Of this $2.1 trillion, $1.9 trillion is because of direct costs of medical care, which again is sparse in some of the developing countries. About $.2 trillion are indirect costs of missed work. Tobacco smoke is the biggest single risk factor for chronic obstructive pulmonary disease, followed by exposure to air pollution, which can occur both indoor and outdoor. Of lifelong smokers, half develop chronic obstructive pulmonary disease, if they’re not claimed already by cancer or heart attacks. Secondhand smoke is responsible for about 20% of the disease, even in nonsmokers. So lung problems can occur in active as well as passive smokers. COPD is unfortunately not curable. The problem with COPD is that cigarette smoke or other forms of smoke destroy the small airways in the lungs. They shrink the functioning lung tissue which becomes less capable of filling air and extracting oxygen. They also denude the airways of fine hair-like structures which act like brooms to clear the mucous. And when that happens, mucous accumulates and can become the seat of infection. And treatment can slow down the progress but cannot totally reverse the damage that’s already been done on infections or respiratory failure can be the frequent problems in COPD. We also know that there are other risk factors like environmental exposures in the form of biomass fuel consumption. Now when solid fuels are burned in the kitchens for example of homes in low and middle income countries, we have smoke emanating from there and filling the lungs. About 3 billion people are exposed annually to such biomass related air pollution. Outdoor air pollution or ambient air pollution is another major cause of air pollution which can damage the lungs. In addition, there are occupational exposures to a variety of dusts. Like for example the coal dusts in so-called anthracosis or sand in so-called silicosis. All of this dust can also enter the lungs and damage the lungs. In terms of air pollution, we now recognize it as the one, the largest single environmental health risk. In 2012, seven million people died prematurely due to air pollution. And in the same year, 2.7 million of these 7 million deaths were attributable to ambient or outdoor air pollution; 4.3 million premature deaths were attributable to household air pollution. The ambient air pollution is of particular importance where there is a fair amount of pollution because of a large number of causes, particularly industrial pollution as well as transport related pollution. These pollutants contain ozone, nitrogen dioxide, sulfur dioxide and particulate matter, all of which can damage the lungs and cause chronic obstructive pulmonary disease, apart from some of them being also cancer causing. In terms of particulate matter, this is a complex mixture of solid and liquid particles of organic and inorganic substances. And you have sulfates, nitrates, ammonia, sodium chloride, black carbon, mineral dust and water in a fairly deadly mix of pollutants which can damage the lungs very severely. But the particulate size also matters. What we call PM10, or particulate matter under the size of 10 microns, these lodge themselves deep inside the lungs and can cause cardiovascular disease, respiratory diseases and lung cancer. Whereas smaller particles, less than 2.5, what we call PM2.5 can cross into the bloodstream and cause damage to the blood vessels, can also cause a variety of diseases, including cardiovascular disease. Therefore when we are looking at all of these materials, we are really concerned about the quantity as well as the size of the particulate matter. In terms of households air pollution, about 3 billion people cook with solid biomass fuels. And in low and middle income countries, this is the kitchen’s curse, where women cook with these fuels, often holding small babies in their arms or babies have, the children are playing around in the kitchen. And about 50% or more of the under-five deaths in children are due to pneumonia who are exposed to this risk factor, which is soot inhaled from the households air pollution. Women too suffer and you have diseases like pneumonia, stroke, ischemic or coronary heart disease, chronic obstructive pulmonary disease and lung cancer resulting from exposure to indoor smoke from solid fuels. The countries of South Asia, India, Nepal, and others shoulder the biggest burden of households air pollution. It has been said that having an open fire in your kitchen is like burning 400 cigarettes an hour. And that is a level of pollution to which women and children in these countries are exposed when they use solid fuels in the kitchen. In terms of ambient air pollution, which is outdoor air pollution, about 16,000 cities worldwide monitor and report air pollution. But only 12% of the people living in all of these cities have air quality which meets the standards set by the World Health Organization. The most polluted cities in the world, no surprise, are in the low and middle income countries. Karachi, New Delhi, Katmandu, and Beijing are among the most polluted ones in Asia. Whereas Lima and Arequipa are among the most polluted in Latin America and Cairo in African cities. But obviously many others in these regions also have very high levels of air pollution. If you are looking at use of solid fuels for cooking, worldwide it has gone up in the last 20 years and particularly in Africa and South Asia. When we look at the health effects of air pollution, we see a number of diseases which can result. Stroke, heart disease, lung cancer, chronic as well as acute respiratory disease, including infections and a lot of childhood asthma. Childhood asthma can be provoked by multiple smoke exposures, including tobacco smoke or dust. About 80% of outdoor air pollution related deaths were due to ischemic or coronary heart disease, 14% due to chronic obstructive pulmonary disease and 6% due to lung cancer. In 2013, the International Agency for Research on Cancer concluded that air pollution is definitely carcinogenic to humans. When it comes to particulate matter, as we have said there is absolutely no safe threshold and therefore we must try and minimize the exposure to particulate matter both in terms of quantity, size and duration of exposure. When it comes to households air pollution, we ought to make sure that we have alternative fuels because biomass cookstoves or safe cookstoves as they’ve been called, which have tried to protect people who are continuing to use solid fuels, have not had a substantial reduction in the amount of exposure to some of these potential disease causing agents. And obviously we now require better fuel which can be utilized in the form of liquid petroleum gas or a greater supply of electricity which makes it possible for women to use induction heaters. So energy security becomes a very important issue when we’re dealing with households air pollution. And it’s important for us to recognize that when we’re dealing with ambient air pollution too, if we control vehicular emissions by reducing vehicular density, that also contributes to energy security. So we are moving in public health to areas of energy security rather than just looking at air pollution as a health problem alone. When we are looking at ambient air pollution clearly we require a multisectoral approach. We do require to curb industrial emissions which are one of the major sources of ambient air pollution all over the world. We need to reduce transport related air pollution and emissions by reducing vehicular density across the crowded cities of the world. We need to reduce also construction related air pollution in countries which are rapidly expanding their cities. We need to provide more green spaces and by providing greater access to public transport which has an effect on reducing the number of vehicles on the road, we can actually curb a fair amount of air pollution. So by linking up many of these public health measures to urban design, urban transport, energy security and of course tobacco control, we can actually make a dent in what is otherwise an incurable disease.

Cancers

Cancer is the most dreaded of all non-communicable diseases. Indeed, it’s been called the emperor of maladies. It caused about 8.2 million deaths worldwide in 2012 and is rapidly rising now to possibly cause 22 million deaths by 2030 as per projections. The low and middle income countries of Africa, Asia, Central and South America account for 60% of all annual new cancers and 70% of cancer deaths across the world. Indeed, the most common cancers are those of lung, liver, stomach, colorectal cancer, or the cancers of the large bowel and breast cancer. And these are found almost everywhere in the world. They do differ however across gender in terms of men having more of lung cancer deaths and women having more of breast cancer deaths. But even among women where smoking rates are high, now lung cancer is rapidly rising. Breast cancer among women accounts for about 23% of all new cancer cases and 14% of all cancer deaths. Whereas in men, the lung cancer accounts for about 17% of all new cancer cases and 23% of all cancer deaths. In terms of risk factors, while we do classify cancers among non-communicable diseases and cancers indeed are linked to other non-communicable diseases through common risk factors like low fruit and vegetable intake, high body mass index or overweight and obesity, that is a high percentage of body fat, lack of physical activity, tobacco use and alcohol use. There are other conditions which give rise to cancers as well, including infections. About 30% of all cancer deaths however are related to these major risk factors of non-communicable diseases and are therefore eminently modifiable and preventable. Among the very many risk factors for cancer, tobacco is the single most important one. Indeed, 20% of all cancer deaths and 70% of all lung cancer deaths are attributable to tobacco. The idea that tobacco is a deadly killer also came up from the study of lung cancer in the first place. But we now know that apart from smoke forms of tobacco, which cause cancer, even the chewed forms of tobacco can cause oral cancer. About 90% of all oral cancer deaths are due to chewed tobacco. We also know that alcohol is an important risk factor for cancers of the food pipe and also of some of the other organs in the body. So, given that alcohol and tobacco which are imminently preventable risk factors, we ought to focus a great deal of public health attention on those. But in addition we also know that cancer can be caused by viral infections. Hepatitis B virus, hepatitis C virus and the human papillomavirus which causes cancer of cervix, all of these viruses together contribute to about 20% of all cancers in low and middle income countries. Urban air pollution is an increasing cause of cancer risk and again, is becoming a problem in many developing countries. Indoor smoke from households use of solid fuels where women burn solid fuels for cooking also is a contributor to increase in cancer risk. Exposure to radiation is a major  problem whenever there is a massive radiation exposure, for example, what we found after Hiroshima and Nagasaki. But even other levels of radiation, for example, those who are undergoing repeated x-rays or exposed to radiation and other forms also have an increased risk of cancer. Now we know that cancer is not only deadly but causes a huge economic loss both in terms of life years lost and in terms of the costs of treatment. It’s been estimated that about $895 billion dollars represent a loss due to cancer. And when we consider the fact that cost of reducing exposure to key risk factors like smoking, drinking, and poor diet costs only $1.8 billion dollars, there is absolutely no reason why we should not invest more in prevention rather than suffer the huge economic and health consequences of cancer that’s not been prevented. We know cost effective solutions exist. By reducing smoking, by reducing immoderate consumption of alcohol, and by promoting healthy diets we can prevent one in three cancer cases. In terms of cancer control, we ought to be looking at different types of strategies at different levels of prevention. Firstly we have what’s called primordial prevention that

is preventing the acquisition or augmentation of risk in the first place. Like for example, preventing people from taking up smoking, from becoming overweight, or consuming alcohol in huge amounts. Secondly, we also ought to be looking at primary prevention. That means people have already acquired the risk factor, like for example, smokers. They need to be encouraged to give up smoking before they run the risk of developing cancer. Similarly encouraging people to shift to healthier diets or abstain or moderate their intake of alcohol, all these come under primary prevention. Now in terms of secondary prevention, this is where screening and early detection of cancer in its early stages is very helpful, where we can prevent it from going into advanced stages, or where we can actually cure it. Now tertiary intervention is where the cancer has actually advanced and we have treated, but we are preventing recurrence and trying to insure that cancer does not become a problem again in the life course of that individual. But we also have to look at people who have reached a stage of cancer where treatment has failed. And their palliative care and end of life care become very important to make the last few months or years pain free and relatively comfortable even if cancer still is an unresolved problem. Now in terms of prevention, again, it is worth emphasizing that tobacco control remains one of the major public health interventions. Promotion of healthy diets is very important. We now know that fruit and vegetables and healthy fats are important for cancer prevention as well. And a balanced diet is probably one of the best things that we can do in order to prevent cancer. Physical activity does reduce the risk of cancer, especially that of large bowel or colorectal cancer. Exposure to sun, particularly in people who do not have much of melanin pigment in their skin can cause skin cancer and we therefore need to reduce the exposure to skin or protect ourselves against ultraviolet irradiation. At the same time prevention of exposure to viruses or treatment of those viral conditions very promptly is also helpful. Alcohol use should certainly be very moderate if at all and that again is an important measure of cancer prevention. Now in terms of detection, there are several tests that are often used in order to detect cancer early, like the pap test for cervical cancer, mammography for breast cancer, fecal occult blood test for cancer of the large bowel or the colon. And sigmoidoscopy for again, looking at colorectal cancer and prostate specific antigen for looking at prostate cancer in men. Now all of these tests are frequently employed, but we need to look at guidelines where they can be most optimally employed in the most cost effective manner. And periodically these guidelines are produced by expert groups to ensure that we pick up the…. We increase the pickup rate of cancer detection without unnecessarily undertaking extensive high cost screening in all people. Now in terms of cancer care, early detection helps us to initiate early treatment. And cancer screening is often used in order to pick up cancer in the pre-cancerous stage or in the very early stages of cancer where definitive treatments can be very useful in curing cancer and then subsequently we may have to follow with other therapy for prevention of recurrence. Therefore screening should be fairly optimally employed in order to prevent advanced cancer being the first clinical manifestation and where we can actually pick up very early on and prevent complications. It’s been clearly shown that organized screening substantially reduces the age standardized mortality of cancer death rates in populations and that is an important public health measure. In terms of treatment however, we see across the world, huge inequalities between developed and developing countries. For example, many of the developing countries have very few machines or no machines for cancer therapy in their health systems, particularly in their hospitals for treatment of cancer, when already detected. In the United States, there is one machine per 250,000 population, whereas over 20 countries, mostly African countries have no machines at all within their countries. And the existing machines are also poorly maintained or when they are available, do not have trained radiotherapists and physicists to operate them. And we do see that there is a huge variation of the number of people served by radiotherapy across different countries. Countries which have very high burden have very limited treatment coverage. We also know because of these reasons of late pickup and poor treatment, we have varied mortality rates of cancer across different countries. And these vary by national income levels. Those countries which belong to low income levels have much higher rate of mortality for any given level of incidence of cancer, whereas those in high income countries for the same level of incidence have much lower mortality. Therefore the case fatality rates are much lower in the high income countries and this is because of their health systems being much better endowed both for early detection and more effective treatment. And one of the clear-cut inequalities is demonstrated in the use of anti-cancer drugs which frequently are very expensive. And we see that whereas the burden of cancer is mostly in the low and middle income countries, for example in the African, in Asia and Latin America, the actual use of drugs is very limited in those countries. And we find that countries of the United States and Europe and Japan use a very large fraction of the anti-cancer drugs in the world just because they can afford it. At the same time, while we are trying to make anti-cancer drugs more widely available, accessible and affordable to all populations across the world, we must also recognize that those who have advanced to end stage of cancer are now suffering in many developing countries because of denial of appropriate pain relieving therapies. This is where palliative care becomes very important. It is an approach that improves the quality of life of patients and their families when they are faced with life-threatening illness through prevention and relief of suffering by early identification and management of pain and other problems which require physical, psychosocial and spiritual approaches for their management. Indeed cancer becomes one of the largest reasons for requiring palliative care. And because we recognize that 34% of all palliative care needs globally are due to cancer, of course other chronic conditions also require palliative care when they reach an end stage. We have to particularly focus on insuring adequate pain relief and supportive therapy for cancer patients. And unfortunately, our health services which ought to be better organized for providing palliative care to the terminally ill and also providing support to the patients and their families are found wanting in this respect across many health systems. Physical, social, psychological and spiritual support of patients with a life limiting illness has to be delivered by a multidisciplinary team. Not merely doctors but nurses, physiotherapists, psychological counselors, all of them are required and Nutritionists. But unfortunately we do not have in many countries such teams easily available. Indeed many trials of early palliative care have shown that the groups that have received palliative care have done much better both in terms of quantity of life being prolonged and quality of life being much improved. But one of the main areas of palliative care and pain relief is opioid treatment. And unfortunately opioids for pain relief are not widely available in many countries or even permitted by their legal systems to be used. And therefore we see a huge discrepancy in the amount of opioids consumed for pain relief in palliative care between the United States, which consumes a very large amount per case as opposed to people in China, India, Mexico, Uganda or in Haiti. And this again is a huge inequity, if people are condemned to live in pain, this is indeed an injustice. So we really have to gear up our health systems to be much more sensitive to the issue of palliative care and pain relief of the terminally ill, especially the cancer patients who do not have much hope of cure. And therefore we require a public health approach to cancer, in terms of prevention of cancer, because much of cancer is still very much preventable, whether it is the living habits like diet, tobacco, or alcohol and physical inactivity that need to be addressed or elimination of viral infections which cause cancer cervix, or cancer of the liver, which again are very amenable to public health interventions, or early screening for effective detection of early stages of cancer or precancerous conditions so that treatments can be applied in order to cure and prevent them from proceeding to advanced stages, or in advanced stages too, providing the appropriate therapies with adequately equipped health systems and health services. And finally by providing palliative care and pain relief to all those who need it without really denying drugs to people in low and middle income countries, merely because of price related factors. All these become public health priorities and in a global scenario where cancer is becoming an increasing global threat, all of these issues need to be addressed, not merely at the national level, but as a part of a global health response.

Cardiovascular Disease

Heart diseases and blood vessel diseases are together known as cardiovascular disease. There are of various types. The leading cardiovascular diseases are coronary heart disease, also known as ischemic heart disease, which is because of blockages in the blood vessels of the heart, ultimately resulting in heart attacks and damage to the heart muscle and sudden cardiac deaths in some instances. Cerebral vascular disease is also called stroke or brain attack. Some of the earlier manifestations of coronary heart disease and stroke are called angina or transient ischemic attack. Also you have peripheral vascular disease which is disease of the blood vessels elsewhere in the body. Now these, the coronary heart disease, stroke and peripheral vascular disease are all united by common risk factors, which cause these blood vessel blockages and the subsequent damages in the brain or in the heart. And these risk factors are high blood pressure, high blood fats, also called dyslipidemia, diabetes and its precursor impaired glucose tolerance, smoking, both active and passive, physical inactivity and there are several other risk factors also implicated, but less important. For example, genes are also frequently talked about, but they do not contribute to much of the disease variants that we see within populations or across populations. All of these factors often combine to cause serious blood vessel damage. There are other forms of heart disease like congenital heart disease which are cardiac malformations present in birth and which can manifest at different periods of life. Then you also have heart muscle disease which are basically cardiomyopathies. Then there are some diseases of the heart which are related to infections, like rheumatic heart disease which affects the heart valves but is principally because of the body’s reaction against streptococcal sore throat. And you have other forms of blood vessel disease also called aorta arthritis. But the most frequent ones which are the major killers in the world are coronary heart disease and stroke. Cardiovascular diseases are now by themselves the number one killer in the world. Indeed, according to the global burden of disease study in 2010, ischemic heart disease or coronary heart disease accounted for about 13.3% of global deaths and stroke or brain attack accounted for about 11.1%. Now if you combine coronary and cerebrovascular disease, then together their contribution to global deaths has risen from 1 out of 5 deaths in 1990 to 1 out of 4 deaths in 2010. And you have other problems also now occurring arrhythmias, or electrical disturbances of the heart are increasing, particularly with aging populations and one of the common problems that we are seeing in the elderly now is atrial fibrillation which has risen over 200% between 1990 and 2010. When we look at what the trends in cardiovascular disease death rates are across the world, then we see that in high income countries for example, the United States we find cardiovascular disease death rates are declining over the last 20 or 30 years. In fact they’ve risen sharply in the early part and mid part of the 20th Century and they started declining towards the latter part of the 20th Century and seem to be relatively on a stable decline even now. On the other hand, in developing countries like China and India and elsewhere, in Latin America, and parts of Africa, you are seeing cardiovascular mortality rates rising, particularly age standardized cardiovascular mortality rates are sharply on the rise. In China, cerebrovascular disease or stroke  is the prominent form of death. Unlike coronary heart disease is the dominant form of cardiovascular disease in Europe or in United States. This variation between coronary heart disease and stroke is happening across different parts of the world because of different stages of health transition. Now early on in health transition high blood pressure which in one of the most important risk factors for coronary heart disease and stroke results in a bleeding stroke where there is bleeding into the brain from the blood vessels, called hemorrhagic stroke, or hypertensive heart failure where the heart model fails because of longstanding uncontrolled high blood pressure. However as other risk factors are added in the population, like for example increased blood lipids because of abnormal blood fats going up due to unhealthy fat intake or smoking or diabetes, the clotting tendency in the blood increases and the same uncontrolled high blood pressure now results in a clotting stroke and coronary heart disease or blockages in the blood vessels of the heart. So the differences that we see across different regions are not because of marked ethnic differences but because of different pace of progression of the epidemic in different regions of the world. Ultimately it is likely that we will see that most parts of the world will have a very high burden of coronary heart disease and thrombotic stroke. Obviously, many of the risk factors are common, both to stroke and to coronary heart disease. Though blood pressure by and large is the most important risk factor for stroke, it also has other risk factors like smoking, diabetes and abnormal blood fats. But for coronary heart disease, all of these are almost equally important. And then of course you have physical inactivity, dietary issues like reduced fruit and vegetable consumption. All of these which contribute both to coronary heart disease and also to raised blood pressure. Now raised blood pressure also can result in kidney disease. So some people look at hypertension as a disease, others would like to look at it as a risk factor. And then look at what causes high blood pressure? High salt intake, low fruit and vegetable intake, physical inactivity and so on. However way we look at it, it is very clear that high blood pressure and smoking are among the most important risk factors along with physical inactivity and unhealthy diets. And we need to act upon all of them. Now the Framingham study which started in 1948 in the United States in a small village in Massachusetts called Framingham, actually came up with the concept of risk factors and identified smoking, high blood pressure, and high cholesterol as some of the most important risk factors for coronary heart disease. Now we know across the world from studies such as the INTERHEART which studied 52 different populations across the world that virtually all of the world has common risk factors for the heart attack. And by studying people with the first heart attack, they identified that smoking, abnormal fats, high blood pressure, diabetes, abdominal fat deposition, psychosocial risk factors, low intake of fruit and vegetables and lower levels of physical activity and variable intake of alcohol have all been responsible for 90% of the risk in populations across the world for the first heart attack. So much as we may differ in the manifestations of stroke and coronary heart disease at different stages of the epidemic, we recognize that the risk factors are fairly common across the world. And now we are also seeing new risk factors coming up in terms of their contribution being identified. For example we recognize that air pollution is an increasingly incriminated risk factor across the world. Previously this was not thought to be a problem for the heart, it was only thought to be a problem for the lungs. But now we know that air pollution can damage blood vessels everywhere in the body and can result in an increased risk of acute heart attack or even stroke. So we also have to look at other risk factors which are not conventional risk factors. For example, again, in the last 15 to 20 years we have come to recognize that low birth weight also is an important risk factor, particularly if there is a gain in weight between the ages of two and twelve in a low birth weight baby. So what we call rebound adiposity which means an increased amount of body fat at the expense of muscle can happen in such babies and this can set the stage for heart attacks and diabetes and strokes later on in life, especially in early adulthood. We now know that cardiovascular disease is the number one problem all across the world. But in terms of the economic impact, it has a very serious negative influence on developing countries because of the prematurity of deaths. As we know, most of the non-communicable diseases are killers at a younger age in the developing countries and this is true of cardiovascular disease as well. Indeed, about 80% of all cardiovascular deaths occur in the low and middle income countries and most of the premature deaths below the age of 65 years that occur because of cardiovascular disease globally are in these countries. So we have a huge loss of productivity. We have high healthcare costs. Indeed, as a cardiologist, I know that all affairs of the heart are expensive, not merely in the poetic sense. So, we now recognize that even as the epidemic advances most of the deaths in the developing countries are going to be occurring below the age of 70 years, especially below the age of 65 years. And in India for example, it has been estimated , we lost about 9.2 million potentially productive years of life because of premature cardiovascular deaths in the age group of 35 to 64 years and if the epidemic proceeds as projected, we will lose close to about 18 million potentially productive years of life in year 2030. This is 570% more than what the United States lost in the year 2000 and will be 900% more than what the U.S. will lose in that age band in terms of potential productive years by 2030. So developing countries cannot afford this hemorrhaging of human resources in midlife. When we look at what happens to individual families as well we see that many of them are pushed into poverty because they suffer catastrophic health expenditure. In China for example, about 37% of the patients who survive stroke were pushed into poverty and 62% of those without insurance went into poverty. This again brings into question not only the devastating economic effect on families, but also the whole health system issue of whether people have financial protection when they have a serious health problem, whether it’s a stroke or a heart attack. For example, in Kerala in India, we also observed that about 73% of those who survived a cardiovascular event had experienced catastrophic health expenditure. And 50% of them had distressed financing. That means they had to sell some part of their property. Forty percent of the patients who survived lost sources of income. And this again is essentially because of not only the high healthcare costs but because of lack of financial protection. So we not only need to prevent disease, but we also need to bring in universal health coverage in order to take care of people who do develop health problems. But prevention is absolutely the critical priority. And we look at both the population based strategy as well as the high risk strategy when addressing prevention through risk reduction. Now the population based strategy essentially says that the risk factor is distributed across the population. There is a rising gradient of risk at all levels of rising risk factors. So even if you have a blood pressure of 140, you are at a higher risk than a person with a blood pressure of 130 and that person is at a higher risk than a person with blood pressure of 120. So we try and bring about small shifts in the average risk factor levels of the population so that the cumulative benefits across the population are quite massive. But at the same time we try and identify individuals at a high risk, either because of a markedly elevated single risk factor or more commonly because of a combination of multiple risk factors which are modestly elevated. But together they add up to a huge amount of absolute risk. And therefore we try and focus our interventions in terms of therapy which could mean either change in living habits, of diet, giving up smoking, et cetera, or even addition of drugs in people with high risk. But bringing about changes for example in the salt consumption in a population or an increase in fruit and vegetable consumption in a population or increase in physical activity across a population can have huge benefits through population shifts and risk factors. Now even small reductions in the blood pressure, if they occur across a population can result in marked reductions in the number of strokes and heart attacks and the deaths because of those diseases across the population. It might not make much of a difference in terms of clinical management, but across the population, the benefits can be quite huge. And indeed, it has been shown by modeling studies across different countries where the risk factors as well as heart attack death rates have fallen, that more than 50% in most of the countries of the fallen death rates has been attributed to fallen risk factor levels. And less than 50% in most cases in attributable to treatments. We need both but certainly focusing on risk factor reduction through population wide strategies is absolutely a priority. And this is best illustrated by Finland, which in the early ’60s was the table leader in terms of coronary mortality across the world. And many of the people were dying young and therefore the government of Finland initiated a major study called the North Karelia Study in which a large number of behavioral shifts were brought about in the population, partly by changing the nature of the food consumption, including salt reduction in processed foods, increased production of berries instead of dairy products and so on. So a combination of policy and public education resulted over the next 20 years in a dramatic decline in the cardiovascular mortality rates in Finland, making it a sort of poster child for prevention in Europe and elsewhere in the world. And much of this could be attributed to shifts in the population levels of smoking, high blood pressure and cholesterol. Now the Finnish success story is remarkable indeed, between 1971 and 1995, cardiovascular mortality decreased in North Karelia by 73% and by example, the rest of Finland followed and across the nation, it declined by 65%. So we know great changes can be brought about by these kind of interventions at the population level. But at the same time we must recognize that poverty is a major barrier and that is where the problem is within populations of developed countries and also across populations in the low and middle income countries. We talked about the Barker hypothesis where children born malnourished are at a greater risk of cardiovascular disease in later life. And then as they grow up, poor people consume more of tobacco; they are forced to consume unhealthy diets. They have poor access to information and services. And in adult life, because they cannot access health services, onset of cardiovascular disease deprives them of appropriate healthcare, wage loss, job loss or even death, which affects their families. And in the elderly, if they’re uninsured, the high healthcare costs will have a huge out-of-pocket expenditure. We therefore need to act upon risk factors at various levels. And the important thing for us it to distinguish between how we look at risk. Most of the researchers will be looking at what’s called relative risk. That is, does a person who is exposed to a particular risk factor, what is the level of additional risk he or she has as compared to a person who is not exposed? Like a smoker versus a nonsmoker. But that does not tell you how widely prevalent that risk factor is in the population. Now if the risk factor has a high risk in terms of relative risk, but has low prevalence in the population, it does not require as energetic a policy response as a risk factor which has a modest relative risk, but is widely prevalent in the population. Smoking for example, therefore because smoking has a huge population attributable risk, because of its wide prevalence in the population, it requires a very strong policy response. Now there is also something called the absolute risk where multiple risk factors combine in an individual to raise the overall absolute risk of getting a heart attack. Therefore, you may have a person with modest elevation of blood pressure, a modest elevation of cholesterol, each of which may not carry much risk by itself at that level, but cumulatively they carry a huge risk. And particularly if you add smoking to the mix. So in terms of clinical decision-making, absolute risk becomes important. And public health also has to insure that health systems recognize the importance of absolute risk thresholds while managing patients in health system practice. So relative risk for research, absolute risk for clinical decision-making thresholds and population attributable risk for policy. All three are important instruments in public health. And if we actually look at risk factors as the major areas for intervention, we will be able to prevent cardiovascular disease across the population. Remember, today’s risk behaviors are tomorrow’s risk factors. Today’s risk factors are tomorrow’s heart attacks and strokes. So we need to promote healthy behaviors. We need to detect risk factors early and reduce them before they go on to fatal heart attacks or strokes anywhere in the world.

Diet and Physical Activity-I

Two of the most important risk factors that have been identified for non-communicable disease are diet and physical activity. Indeed, they feature very prominently among the goals set by the World Health Organization and the United Nations for reducing NCD related premature mortality. We recognize of course that the world today sees two faces of malnutrition.

First is the huge problem of undernourishment where we find a large number of children and young women in the developing countries having low body weight or anemia or even both. At the same time we are also see a rising burden of overweight and obesity across the world. Not just in the developed countries, but also in the developing countries. Interestingly, both of these problems while perceived as quite different from each other, have a profound impact on the risk of non-communicable diseases which can arise even from underweight or overweight. The whole idea that children are born small for size and underweight are much more susceptible to adult cardiovascular disease, diabetes, and some cancers was first proposed by Forstal and David Barker then in U.K. And this hypothesis known as the Barker hypothesis as acquireda great deal of evidence over the last 30 years. We know that children who are born with low birth weight, if they acquire what’s called rebound adiposity, that if they start gaining weight, even within the normal range, between the age of 2 to 12 years, especially between 2 to 6 years, they are much more likely to put on fat rather than muscle. And this is likely to result in early onset of adult diabetes, heart disease and even some cancers and reduce lung function. So we now recognize that there is a link even between under-nutrition and non-communicable disease. But when we look at the larger picture of what are the risk factors for disease and disability across the world according to the global burden of disease study and we take all diseases and all causes of death and all causes of disability into account we find that there are ten leading causes, almost all of them are related to non-communicable diseases, but the vast majority of them are related to diet and physical inactivity. Indeed, when you cluster all the risk factors responsible for death and disease which is avoidable across the world, then the diet and physical inactivity cluster is the largest cluster. So the good news is that we can actually modify much of this by altering the dietary patterns of people across the world and making them more physically active. Now when we look particularly at non-communicable diseases we recognize that apart from smoking and certain other risk factors like high blood pressure and cholesterol which of course are also related to diet and physical activity we find low intake of fruit and vegetables, high intake of unhealthy fats, low intake of nuts, low intake of fish, all of these have been recognized to be important risk factors for non-communicable diseases. And when we look at how diet can best prevent non-communicable diseases we can think of it in terms of what’s called primordial prevention. Preventing the acquisition of risk factors whether it is diabetes, high blood pressure, high cholesterol, or overweight. So if you prevent it in the first place by having a healthy diet across the life course, there can be nothing better. But even when risk factors have been acquired, a person has developed high blood pressure or diabetes or overweight or high cholesterol for that matter, we can actually reduce those risk factors substantially by what’s called primary prevention, effectively using diet and physical activity. But even people who have had a heart attack or a stroke can actually get much benefit from diet and physical activity and prevent a recurrence of heart attack or early death. So whether it is primordial prevention of risk factors or primary prevention by reducing risk factors before they get into disease, or secondary prevention of preventing recurrence of events, diet and physical activity have a potent influence in protecting us against non-communicable diseases. Now clearly we are looking at various elements of nutrition. Diet is what we eat, but nutrition is what we get out of it. Unfortunately most of nutrition science so far has focused on individual nutrients and occasionally on food items. So we have been talking about either saturated fat or monounsaturated fat or trans-fat or refined carbohydrate or we have been talking about other elements like antioxidants. All of them as though they were isolated in terms of their action on health. All of these need to be taken together, not merely as nutrients or food items, but as composite dietary patterns. But even for that, let’s look at the science behind it. Among the various types of fats we have the good fats, what have been called the good fats, the omega 3 fatty acids and the unsaturated fatty acids called monounsaturated and polyunsaturated fatty acids. Then there are the fats which have been considered bad, the saturated fatty acids as well as dietary cholesterol. Though the current evidence suggests that this may not be entirely true. Taken in moderation, these are actually helpful for building some of the essential body structures like cell membranes and hormones and so on. But taken in excess, they can also contribute excess calories. But the real ugly fats are the trans fats, or the partially hydrogenated fats which are not naturally produced, but are usually industrially hydrogenated fatty acids. Now the industrial hydrogenation is done in order to prolong the shelf life of these fats. But anything that lengthens shelf life unfortunately shortens human life. And this is very true of Trans fatty acids where a 2% increase in energy intake from trans fatty acids is associated with a 23% increase in the incidence of coronary heart disease or heart attacks. You can’t have a worse fat than that. Now there’s been a huge amount of debate about which type of fat and how much of fat and so on. But I think there is a reasonable consensus that has been built up now which says, it is not so much the quantity of fat that matters, it is the quality of fat that matters. Quantity does matter to the extent that you don’t want to take too many calories. But within that caloric limit it is the quality of fat that is much more important. You need more of monounsaturated and polyunsaturated fatty acids, less of saturated fats and certainly very little or none at  all of Trans fats. And there is that kind of consensus that’s been built up. One of the problems of course has been in trying to reduce the total amount of fat in the diet. Many people have advocated the introduction of high carbohydrates as a substitute for fat. That’s been a big mistake because introduction of carbohydrates to substitute fat actually increases certain types of abnormal fat patterns in the blood and also increases the risk of diabetes. So we can actually take fat, but prefer to take healthy fats rather than unhealthy fats. We recognize of course that omega 3 fatty acids are principally derived from fish, though they can also be produced from certain other fats that we can take in from some of the vegetables as well, particularly certain types of nuts and so on. And of course flax seed and others are sources. But mainly they’re derived from fish oils. Even as we are trying to increase the amount of healthy fats, we ought to pay attention to the carbohydrates, which have assumed a lot of importance recently, not only in the causation of diabetes, or increase in overweight but also in coronary heart disease. That refined carbohydrates are particularly dangerous and we need to take a lot more fiber through unrefined carbohydrates in our diet. Indeed, what’s called the glycemic load of the food has become very important. The carbohydrates in your diet, how quickly do they release sugar and how quickly does the sugar peak? That is what’s called the glycemic load. How much of sugar is released and how quickly? And that is the glycemic load which can actually cause overweight, obesity and increase the risk of heart attacks apart from the risk of diabetes. Now this can be offset of course by taking more of fruit and vegetables. Now salt is also a major issue that has been debated considerably. We don’t want to take too much excess salt in our diet and somewhere between five to six grams appears to be the optimal as recommended by the World Health Organization. But one of the things that people don’t seem to recognize very clearly is dietary sodium, the effect of which is on blood pressure and of course on stroke and heart attacks can be substantially countered by dietary potassium, which comes through fruit and vegetables, the natural sources.Therefore if you take more fruit and vegetables you are preventing high blood pressure, you are preventing stroke, you are preventing heart attacks. You are preventing a variety of cancers. And this is now emerging as one of the very protective elements in our diet and that’s what the global burden of disease studies says, that low intake of fruit and low intake of nuts, all of these protective elements in the diet is now a major cause of disease burden, especially through non-communicable diseases. Now we recognize that taking fruit and vegetables in a fair amount, particularly more than three times a day, preferably five times a day  can substantially reduce the incidence of stroke by 27% and lower the mortality due to stroke by 42%, reduce coronary mortality that’s due to heart attacks by 24%. Reduce overall cardiovascular mortality by 27% and lower all-cause mortality by 15%. Now if a single dietary item can change the disease burden so profoundly then there are public health implications that we have to make sure there is access to it. However we ought to be really looking at dietary patterns rather than looking at individual food items. And there have been several diets that have been studied like the Mediterranean diet, which has been quite celebrated now as being very protective against heart attacks and being very good for health. The DASH diet which looks at low sodium and a balanced diet with better fats and which reduces blood pressure. Then the Okinawa diet in Japan which has been attributed to be responsible for the high longevity in those populations. Again, a strong fruit and vegetable based diet. Low in unhealthy fats, high in fish. But the Mediterranean diet for example has a composite character. It’s rich in grains, fruit, vegetables, herbs, spices, nuts, beans, dairy food, seafood and healthy oils. Now even when you’re a non-vegetarian, for example, there is a simple rule to remember, fish is better than fowl and fowl is better than flesh. And if there’s a lot of red meat consumption, you’re in danger, but on the other hand, fish consumption is protective. Now we have seen that in a major secondary prevention trial of coronary heart disease in France that the risk of a second heart attack and sudden cardiac death was substantially reduced by a modification of the Mediterranean diet. But that led to further studies on primary prevention. Can we prevent the first heart attack with the Mediterranean diet? And it has been very clearly shown that in women, and, as well as in men, that the risk of getting a heart attack can be substantially reduced at the composite nature of the diet moves towards the full Mediterranean diet. More of the elements in your diet resemble that of the Mediterranean diet, the greater the protection from a heart attack. There has been a major study called the PREDIMED trial which has actually shown very clearly in Spain that if you have the Mediterranean diet with extra virgin olive oil, then the risk of heart attack and death actually substantially decrease and similarly we also see that if you actually add nuts, then also there is a substantial benefit. So the composite diet really matters in terms of protection. But we don’t have to borrow the Mediterranean diet everywhere in the world. What we are really aiming for is a prudent diet which resembles the Mediterranean diet but can be culturally and contextually adapted. For example, it’s been shown, even in the United States in large cohort studies that those who have a prudent pattern of diet will have a higher amount of vegetables, fruit, legumes, whole grains, fish and poultry. On the other hand the western pattern of diet classically consists of higher red meat, processed meat, refined grains, sweets and dessert, French fries, high fat dairy products. It has been shown, again, as I said, within large American cohorts that as you move towards a higher level of prudent diet from a very low level of prudent diet, you get a 30% lower risk of getting a heart attack or a cardiovascular death. And similarly if you move to a higher pattern of western diet from a low pattern of western diet, then you get a 64% higher risk of getting a heart attack or a cardiovascular death. So the dietary pattern matters very much and in each country we ought to be able to provide the population with dietary choices which will enable them to get their culturally appropriate fruit and diet. But this is becoming increasingly difficult. We are seeing vegetable oil consumption rising across the world. Now this may not be a bad thing in terms of providing energy to populations which are poor, but if the oils are unhealthy rather than healthy oils, if they´re mostly rich in trans fats and saturated fat, then actually they’re compounding the problem by creating non-communicable disease. And that’s where we ought to insure that the oils that are available are the healthier oils. Similarly, fruit and vegetable consumption across the world is fairly low, especially in low and middle income countries. In India for example, the per capita consumption of fruit and vegetables is a 130 grams per day as opposed to the WHO recommendation of 500 grams per day. So we need to correct this situation as well. And unfortunately when we look at the global production patterns we are seeing a fall in the availability of fruit and vegetables, now from a 22% shortage of supply of fruit and vegetables as compared to the need, by 2025, we will see a 34% shortage and by 2050 we will see a 43% shortage. So when we are looking at sustainable development we ought to be able to look at how best we can produce enough fruit and vegetables to meet the population needs and protect health. At the same time we are seeing a huge explosion in meat consumption and meat production. Red meat certainly is problematic from point of view of heart disease, obesity, cancers, but it also consumes a huge amount of grain because the animals are grain fed. And that also causes environmental problems in terms of a huge release of greenhouse gases from these grain fed cattle. But we ought to be able to really look at how we can balance our dietary patterns  by looking at agricultural livestock systems so that the healthier food options are available which are also environmentally friendly, rather than unhealthy options which are bad for health and bad for environment.

Impact of Tobacco abuse

Now I want to introduce you to the number one mass killer in the world, tobacco. In the 20th Century tobacco killed 100 million people. And this was more than all the wars of that very violent century put together. But in the 21st Century, it is estimated by the World Health Organization that tobacco could kill one billion people if we do not take measures to stop it. The problem about tobacco is that it is killing people all over the world, especially poor people.

Even as of now, about six million people die each year because of tobacco and about 70% of them are in the developing countries. By year 2030, tobacco will be killing at least eight million people each year and about 80% of them will be in the developing countries. It is the largest preventable cause of death in the world today. Tobacco is consumed in many forms across the world, mostly in the form of cigarettes in the western world and in many of the developing countries. But there are other forms of tobacco consumption, whether it is the hand-rolled beedi in India or the shisha in the Middle East, or even oral tobacco, because tobacco is chewed in many forms in South Asia and now increasingly in Africa and the Middle East. Indeed, you would find that deaths due to oral cancer are much higher in the South Asian countries because of the habit of chewing tobacco which is now the leading form of tobacco consumption in India. Tobacco steals away about eight years of a person’s life on an average. And the British Physicians Study which first brought this to light showed that people who smoke even small numbers of cigarettes stand to lose some part of their life expectancy compared to those who do not smoke at all. And those who smoke in large quantities are likely to die much younger because of the effects of tobacco which are far reaching in terms of more than 25 diseases. You have cardiovascular diseases which are the number one killer because of tobacco, followed closely by cancers and then by respiratory diseases. And all of these serve to take people away prematurely into death or disability. But the good news is that if people stop consuming tobacco, especially before the age of 35 years, then much of this risk can be reversed. Most of the risk of cardiovascular disease can be reversed within three years. Some of the risk of cancer can continue up to 20 years. But if you want to ensure that your life expectancy is almost similar to that of a nonsmoker, better give up tobacco consumption early on, especially before 35 years where there’s a huge gain because of cessation. Tobacco steals not only health, but also steals income and an opportunity for development. For example in most households where tobacco is consumed in poor families you find that education as well as children’s nutrition suffer. In the Philippines, the poorest households were spending more on tobacco than on education, health and clothing combined. In fact about 20% of the household income in a smoker’s family was going to tobacco. And similarly in China, India and Thailand, everywhere we find that there is a developmental cost to tobacco in terms of lost educational opportunities for children, for nutrition, and many other ways in which tobacco affects household welfare. And we recognize that as tobacco is increasingly becoming a global threat, there are very many ways we can prevent the harm from tobacco and reduce the consumption of tobacco, especially among the poor and the young and the women who are being targeted by the tobacco industry. There is evidence available from a number of countries, particularly from the high income countries, but also from the low income countries that measures such as taxation, advertising bans, smoke-free policies which ensure smoke-free public places and indoor work places as well as effective health warnings, especially pictorial health warnings are very effective in reducing tobacco consumption. Indeed, in the United Kingdom in the 20-year period between 1981 and 2000, 48.1% off all deaths averted, the entire mortality reduction in the U.K., 48% of that was because of reduced smoking. You can’t have a more effective public health intervention than that. And much of this has now been codified into what’s called the MPOWER Package developed together by the World Health Organization as well as the CDC in the United States. In year 2003, about 178 countries subscribed to the Framework Convention on Tobacco Control which was developed by the WHO as the first public health treaty in the world. And the measures that are advocated for implementation of that treaty and which are captured in the MPOWER package are effective surveillance and monitoring, protection against secondhand smoke, that is, ban on public and indoor smoking in workplaces and cessation support, that is offer of help to quit, effective health warnings on tobacco product packaging, enforcement of comprehensive advertising bans and raising tobacco taxes. Of these, tobacco taxes have been identified both by the World Health Organization and the World Bank to be the most effective way of reducing tobacco consumption because raising taxes raises prices and those with low disposable incomes like the poor, the young, and others who have low incomes like women in many developing countries are less likely to consume tobacco or are more likely to give up tobacco if that happens And this has been shown to be quite effective in many countries. For example, in France as well as in South Africa it has been shown that if you raise tobacco prices threefold, then you halve the consumption and double the income that the government earns from tax revenue. And in the Philippines now, they have not only raised the taxes but are using 70% of that to finance universal health coverage. So much good can come not only by lowering consumption, but by also using the revenue for improving public health. Also we recognize that banning of smoking in public places and indoor work places can have tremendous health benefits. For example, it has been shown in a number of countries that if you ban smoking in public places, hospital admissions due to heart attacks come down within six months. In fact, it has been shown by combining all the data from many studies in many countries that at least 17% reduction in hospitalization due to acute heart attacks can happen. Within months, if you ban smoking in public places. So there can be tremendous benefit from some of these policies. But we also know that effective pictorial health warnings, especially showing the harm in terms of cancer, heart attacks and effects on children, small babies who are born to smoking mothers, all of these can motivate smokers to give up smoking and these health warnings are now being implemented across the world. Started in Canada, went onto Brazil, Thailand, now the European Union, United Kingdom and even in developing countries like Thailand and India, you see these pictorial warnings. But we cannot merely content ourselves by warning people against tobacco and expecting them that they would give up gradually. We have to accelerate the movement towards a tobacco-free century. And for this, we have been looking at what goals the WHO has set. And the WHO say it’s between 2010 and 2025 there should be a 30% reduction in tobacco consumption the world over. But some of the countries have been more ambitious. They’ve been looking at a 40% reduction and a 50% reduction. Some countries like Norway, New Zealand and others have said, between 2025 and 2040, they will bring down the consumption to less than 5%. They call it, the endgame for tobacco. So really we are looking at trying to accelerate the decline in tobacco consumption to levels lower than 5% when it ceases to be a norm and it is possible to regulate it away from society. So we can actually achieve a tobacco-free society by an endgame for tobacco, we just need to be more ambitious in our goals as well as more effective in our tobacco control measures. But we ought to not, not, not only look at tobacco as a threat to health; we now recognize tobacco is a threat to sustainable development. We have talked about one billion deaths like to happen in the 21st Century, but tobacco kills trees too. In order to cure tobacco leaf you have to burn wood. And for 300 cigarettes smoked anywhere someone, somewhere has killed a tree, because you have to burn wood. Also a modern cigarette manufacturing machine consumes about four miles of paper per hour because of the wrapping of cigarettes. So trees are harmed. We have air pollution because of secondhand smoke. Tobacco is a water intensive crop and can accentuate water insecurity. Four million hectares of arable land which could and should have been used for growing nutritious crops are now being wasted on a killer crop. So it’s a threat to food insecurity. Tobacco lands families in poverty because they’re consuming the resources that should have been used for economic welfare of their family on tobacco and they’re actually pushed into poverty each year because of that. So in a number of ways, tobacco is a threat to both health and sustainable development and that is why the United Nations is identifying it as an important component for action under the health goal, but also is looking at it under the sustainable development goals framework. So we recognize that tobacco is the number one public health threat as well as a major threat to economic and sustainable development in the 21st Century. If we do nothing, about one billion lives will be lost in the century because of tobacco. But if we act effectively, especially through tobacco taxes, through ban on smoking in public places and indoor work places, effective health warnings and then promote cessation among people who are already addicted to the habit, we can substantially bring down the number of deaths. And the world is now responding by not only setting goals of 30% reduction in tobacco consumption by 2030, or 2025, but is looking to a tobacco-free century by asking for an endgame for tobacco. And indeed, sustainable development in the 21st Century cannot become a reality unless we eliminate tobacco from the world within this century

Introduction to NCDs

In this lecture we will be discussing the most important public health challenge of the 21st Century in terms of the global burden of death and disability, that is, non-communicable diseases. In September 2011, the United Nations convened a high level meeting of heads of state to discuss the response to this growing global threat. The second time ever that heads of state met to discuss a health issue under the United Nations. The first one being a meeting on HIVAIDS in 2001. This is because the four major non-communicable diseases, cardiovascular diseases, cancer, respiratory diseases and diabetes together account for the largest number of deaths as well as the highest burden of disability in the world. Of course there are other non-communicable diseases that are chronic diseases like for example cirrhosis of the liver or kidney diseases and of course mental health which is a very major chronic disease. And we also have other problems like oral health, or eye health, which also qualify for non-communicable diseases. But if you take these four major disorders, that is heart diseases and blood vessel diseases, cancers, respiratory diseases and diabetes, they’re linked by four common risk factors. That is, unhealthy dietary patterns, physical inactivity, tobacco and alcohol consumption. And that’s why these were clumped together in that high level meeting which the United Nations and the WHO convened. If we look at how this has become a major global threat from 57% of all deaths occurring in the world in 1990, it has grown to contribute to over 65% of deaths in the world by 2010. But that’s not the only problem.

The problem is that a large majority of these deaths are occurring in the developing countries and are occurring in very young people. If you look at the deaths that occurred in 2008, about 60% of all deaths in the world were because of non-communicable diseases. But 80% of them occurred in the developing countries. A quarter of all NCD related deaths occurred below the age of 60 years. And 90% of them occurred in the developing countries, the low and middle income countries. So it is the question of prematurity of these deaths in the productive prime of midlife which is a major threat to development and sustainable development. And the pattern of these diseases also has been changing. In the developed countries heart attacks or ischemic heart disease and stroke or brain attacks due to blood vessel disease of the brain have been the dominant killers over the last 20-25 years and have remained so. However, in the developing countries, infections, particularly among children used to be the major cause of death in 1990, but now both stroke or brain attacks and ischemic heart disease or heart attacks have risen to the top, even among the developing countries. And this is a major threat to development. And we find that because people are dying young in the developing countries, what we call the age standardized mortality rates are much higher in the low and middle income countries. Even though, at the proportion of deaths occurring in the population, the high income countries still have NCDs as the major killer. But even the proportional mortality is rising in the developing countries and the problem of premature death continues to haunt them. And this is a major consequence for development, because we do recognize that as health transition occur, the poor among countries and the poor within countries are increasingly becoming vulnerable. This has been so in the high income countries for the last 30 years. But even in the developing countries, we are now finding that the poorer socioeconomic groups are much more affected by chronic diseases because of the risk factors are becoming much more common among them. And even deaths due to non-communicable diseases are occurring much more frequently among the poor than among the rich who now know how to protect themselves. So this is a huge directed development and sustainable development. And the economic impact of this is tremendous. NCDs by themselves have been estimated by a study of the Harvard School of Public Health to lead to a cumulative loss of $30 trillion dollars globally between 2011 and 2030. And if you add the loss due to mental illness, this loss rises to $47 trillion dollars. And many of the developing countries are going to be experiencing a serious threat to their economic and social development if we do not stem this epidemic with concerted global response. And we recognize also that this is a threat to health equity because the poor are suffering much more, because of lack of knowledge, lack of access to health services, and inability to obtain timely and efficient care. But it’s also a threat to the sustainable development because many of the determinants of NCDs are also linked to the determinants of environmental degradation. And we need to look at this as a common problem in the context of what we are attempting for sustainable development over the next 15 years. As NCDs rise year by year, between 2010 and ’25, we will see a rise of NCD related deaths by 10.5 million per year. And 9.5 million of these additional 10.5 million deaths in 2025 will be in the low and middle income countries. But fortunately we have the knowledge to act and save many of these. It has been estimated that about 37 million lives can be saved in these 15 years if we act on six risk factors of non-communicable diseases, which have been identified as targets for action by the United Nations and the World Health Organization. And if we act even more effectively on tobacco we will be able to reduce it even further in terms of the total number of deaths that can be prevented. And if we add effective treatments which are available but become, need to become more accessible, then we are likely to save even more lives. So we do have the knowledge and tools to bring about a substantial reduction in the total burden of non-communicable diseases if we act effectively. And in order to help us do that, the United Nations has now set up a goal globally for 25 by ’25, which means that we need to try and reduce the number of premature deaths in the age group of 30 to 70 years which are occurring because of non-communicable diseases, by 25% by the year 2025 compare to the baseline year of 2010. So 25 by 25 means we are preventing premature deaths by utilizing effective interventions against risk factors as well as effective treatments. So now we recognize that non-communicable diseases are the major public health challenge of this century affecting not only the developed countries, but sweeping across the low and middle income countries, where it is particularly a threat because of the age at which these diseases kill. Cardiovascular diseases or heart and blood vessel diseases, cancers, diabetes and chronic respiratory diseases are now accounting for the largest number of deaths in the world, but are also killing a large fraction of them in the developing countries below the age of 60 years. And this is a major threat to economic development, particularly in these countries and is a threat to sustainable development globally. But fortunately we also recognize that these risk factors are modifiable and many of these diseases are treatable. And in that, we can save many valuable lives through effective interventions. We know that by acting on the important modifiable risk factors like tobacco, healthy dietary patterns and alcohol consumption, we can substantially modify the projected disease burden of non-communicable diseases and by coupling it with effective treatments we can save many lives across the world. And that is why the goal of 25 by 25 which asks us to reduce premature mortality due to NCDs by 25% by the year 2025 is not unrealistic. We can do it.