1. CARICOM Heads of Government Summit on Chronic Diseases
Presentation of Prime Minister Denzil Douglas

2. Overview of Presentation
Global situation with Chronic NCDs
Caribbean situation and costs
Caribbean Response
Exploding common myths
Review of effective interventions
The Way Forward
Addressing the risk factors
Globalisation and health
Colleagues, If I had had any doubt about the timeliness and importance of this Summit, the Economist of August 11 would have convinced me.-next slide

3. Globalisation and Health THE MALADIES OF AFFLUENCE
This shows the face of the noncommunicable diseases-the human face and the image of that most lethal legal killer known to man-tobacco. We in the caribbean have not escaped these maladies of affluence. The article points out and I quote---next slide
The Economist, August 11th 2007

4. The poor world is getting the rich world’s diseases
“Europeans have been exporting their maladies throughout history. They seem to be doing it again, but in a new way. In the past the problem was infection. Now illnesses associated with Western living standards are the fastest growing killers in poor and middle-income countries. Chronic disease has become the poor world’s greatest health problem”.
The Economist, August 11, 2007
The poor world is getting the rich world’s diseases. Europeans problem. Next slide

5. Chronic Diseases and their Causes
Heart Disease, Stroke, Cancer, Diabetes, Chronic Respiratory Disease ↑
Biological Risk Factors
Modifiable: overweight, high cholesterol, high blood sugar, high blood pressure
Non-modifiable: Age, Sex, and Genetics
Behavioral Risk Factors
Tobacco use, physical inactivity, unhealthy diet, alcohol abuse
Social and Environmental Determinants
Social, economic and political conditions such as income, living and working conditions, physical infrastructure, environment, education, agriculture, and access to health services
Global Influences
Globalization of food supply, urbanization, technology, migration
This shows the causes of the chronic diseases. They are rooted in global influences, are determined by the social and environmental determinants you see here and which create the risk factors that are both behavioral and biological. Note how many of these risk factors are modifiable and it is the exposure to these that lead to the chronic diseases.-next slide

6. Distribution of Deaths by Major Cause in the World
This shows the killers-the mass killers. 63 % of deaths world wide in 2005 were attributed to chronic diseases and notice heart disease leading the pack-almost one-third of all deaths.—Next slide

7. Distribution of Deaths from Infectious and Chronic Disease by Income Category, 2005
We are accustomed to thinking of the infectious diseases as the scourge of the poor and the rich countries suffer from the chronic diseases—NOT SO. Except for the poorest countries, chronic diseases kill more people than the infectious diseases and even among the poor the chronic diseases are important. Next Slide

8. Source: CAREC, based on mortality reports from countries
Look at the picture for our Caribbean where the death rates over the past 4 years have shown the consistent pattern of the chronic diseases responsible for the majority of deaths of our people. Heart disease, cancer, diabetes, stroke, hypertension are our big killers in the Caribbean.
Next Slide
Source: CAREC, based on mortality reports from countries

9. Leading Causes of Death in CARICOM Countries by Sex, 2004 (MINUS Jamaica)
MALES
FEMALES
Heart Disease
Cancers
Diabetes
Stroke
Hypertension
HIV/AIDS
Influenza/pneumonia
Injuries and violence
Heart Disease
Cancers
Injuries and violence
Stroke
Diabetes
HIV/AIDS
Hypertension
Influenza/pneumonia
This confirms the previous one and here we see the leading causes of death in males and females. Note that females are as affected by and die from the chronic diseases just as the men do. Note particularly that heart disease is the top cause of death in women, contrary to a common belief that men are much more at risk than women. There are some expected differences based on sex, such as cervical cancer affecting women and prostate cancer affecting men Next Slide
Source: CAREC, based on country mortality reports

10. This slide shows the potential years of life lost from the three main health problems in the region, NCDs, HIV/AIDS and Injuries – unintentional and intentional. This is an important part of the human cost of ill health. Note that the situation with AIDS has improved as the potential years of life lost between 2000 and 2004 have DECREASED by 27%. And we should be proud of that fact. However, The situation is the reverse for injuries and chronic diseases which have increased. We should not be proud of that fact, and that is the reason why we are gathered here. Next Slide

11. Disability Adjusted Life Years (000) 2002
This slide emphasizes the point that the NCDs represent a much greater burden of disease than the communicable or infectious diseases. The burden is measured in disability life years which is a composite measure of disability and premature mortality. Next Slide

12. But it is not enough to bewail the burden imposed by the chronic disease. If we are going to prevent them we must know the risk factors. What are those factors which lead to the chronic diseases if we are exposed to them. These data are for Latin America and the Caribbean, showing the numbers of deaths in thousands attributable to selected risk factors. The data for the Caribbean are identical-high blood pressure, obesity alcohol, tobacco…... And I wish you to note how many of them are modifiable with the right policies and we have these policies at our disposal. …Next slide

13. Let me focus for a bit on the risk factor which is assuming epidemic proportions in the world and the Caribbean—obesity. Our men and women are getting progressively fatter with corollaries of increased diabetes, hypertension, heart disease. Note that I say both men and women. It is a major source of concern when in the 1990’s almost 60% of our women were overweight or frankly obese and unfortunately the figure is probably higher now…Next slide

14. Prevalence (%) of diabetes among adults in the Americas
It is not a source of pride to any of us to see that four Caribbean countries have the highest prevalence of Diabetes in the Americas as these data from PAHO show. I would prefer us to occupy pride of place in some other area-not diabetes. Next Slide
Source: Pan Am J Public Health 10(5), 2001; unpublished (CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)

15. Caribbean trends in Diabetes mortality
But not only is diabetes high in the Caribbean; it is increasing. And the increased prevalence in the Caribbean brings with it an increased mortality and morbidity as we can see here, with mortality increasing steadily over the years. Next slide

16. A consequence of Diabetes
But it is the cost in human terms which strikes home to us. The adults going blind, dying from kidney disease and losing limbs as a result of that disease are social costs born by all of our countries. The amputation of this limb brings with it a cost to the individual, the family and the society, and we may have the opportunity cost of a relative having to stay at home to provide care…Next slide

17. Amputations at the QEH 2002-2006
Diabetic
Non diabetic
Male
308
116
Female
379
120
Total
995
236
The data from Barbados show that over 6 years there were almost one thousand amputations at the Queen Elizabeth hospital because of diabetes and I am sure these tragic data can be replicated in every one of our countries…Next slide
Source A. Hennis, 2007

18. Age adjusted death rates/100,000 population from Diabetes (2000)
It is perhaps invidious to make comparisons, but the mortality from diabetes is higher in the Caribbean countries than in Canada or the USA—in Trinidad it is about ten times higher. In Suriname it is at least twice as high. Next slide

19. From community surveys, the prevalence of hypertension in adults 25-64 years of age was:
Barbados %
Jamaica %
St. Lucia %
The Bahamas %
Belize %
Trinidad TBD
Control of blood pressure would reduce the death rates from Cardiovascular Disease by about 15-20%.
Let us look at another major chronic disease—hypertension, which will also cause heart disease and stroke.
The prevalence rates show that between a quarter and one third of our populations are hypertensive, and if we could but control this adequately we could substantially reduce the deaths from heart disease—and we can. Next slide

20. I have shown most data form the larger countries, but countries like mine are not exempt. This shows the reasons fro persons attending the clinics in St. Vincent & the Grenadines. Note the thousands of visits for hypertension and diabetes and every indication is that these are increasing. Next slide

21. Age adjusted death rates/100,000 population from Hypertension (2000)
I showed before the mortality from Diabetes and I do the same here for hypertension. In all our countries it is higher than in Canada or the USA—in the Bahamas more than ten times higher than in Canada. A Bahamian is more than ten times more likely to die from hypertension than his Canadian counterpart. Next slide

22. Projected national income lost from NCDs ( 2005-2015)
-2015,
$USBN
600
500
400
300
200
The burden of these diseases is not only social .but economic and this slide shows data from the world health Organization—the billions of dollars of national income lost from the chronic diseases, with Chile, india and Russia leading the way. Next slide
100
Bra
Can
Chi
Ind
Nig
Pak
Rus UK
Tan

23. Possible economic burden ($US Million, 2001)
BAH
BAR
JAM
TRT
Diabetes
27.3
37.8
208.8
494.4
Hypertension
46.4
72.7
251.6
259.5
Total
76.7
110.5
460.4
753.9
We have data for four of our countries on the economic impact in 2001 of the two most prevalent NCDs, diabetes and hypertension, taking into account the direct medical costs and the indirect costs to society. The cost is staggering. In Jamaica it would be $US 460 million dollars-and that was in The cost would undoubtedly be much higher now. Next slide

24. Total cost of DM and H/T as percent of GDP
If we relate this to our GDP the impact is equally stark . The combined cost represents a considerable impediment to our social and economic development. Note it would consume 8.0 percent of the GDP of Trinidad and Tobago. When we compute the human , social and economic cost of these diseases it has to be clear to all of us that this situation is simply not sustainable. Next slide

25. Exploding the Myths
Myth: Chronic diseases are a problem of the rich countries
Fact: Non-communicable disease account for more than half the burden of disease and 80% of the deaths in the poorer countries which carry a double burden of disease.
Sometimes I have been led to believe that our failure to take collective action before is because there have been certain myths that have gained currency in our societies and the time has come to explode these myths-to let our populations know the facts. I begin with the myth that the chronic diseases are a problem of the rich countries. Fact---Next slide

26. Developing countries carry a double disease burden
Percentage of deaths by cause
Low- and Middle-income countries
High-income countries
Health policy makers face continuing challenges.
In the next two decades, as people around the world live longer, major noncommunicable diseases—including heart disease, cancers, and major psychiatric disorders—will fast replace traditional scourges—particularly infectious diseases and undernutrition in children. Both are counted among communicable diseases in the striped blue section. Next slide
Already, in high-income countries, communicable diseases are responsible for fewer than 10% of deaths.
It’s a different story in lower- and middle-income countries, which suffer a “dual burden” of communicable and noncommunicable diseases.
Noncommunicable disease accounts for more than half of deaths worldwide.

27. Exploding the Myths Myth: NCDs are a problem only of the elderly
Fact: Half of these diseases occur in adults less than 70 years of age and the problems often begin in the young e.g., obesity
Myth: NCDs affect men more than women
Fact: NCDs affect women and men almost equally and globally, heart disease is the largest cause of death in women.
Here are two other myths and the facts that we must recognize. (READ) Next slide

28. Exploding the Myths Myth: NCDs cannot be prevented
Fact: If the known risk factors are controlled, at least 80% of heart disease, stroke and diabetes and 40 % of cancers are preventable, and in addition there are cost-effective interventions available for control.
Here is another myth and the fact that if we control the risk factors we can prevent these chronic diseases—at lease 80% of heart disease, stroke and diabetes and 40% of cancers are preventable. We must prevent them! Next slide

29. Exploding the Myths
Myth: people with NCDs are at fault and to be blamed because of their unhealthy lifestyles
Fact: individual responsibility, while important, only has full effect where people have equal access to healthy choices. Governments have a crucial role to play by altering the social environment to help make the healthy choice the easy choice.
Here is another myth. For too long many of us have laid the blame for the chronic diseases on the individual and blamed him or here for an “unhealthy life style”, and we have ignored the role that governments can and must play to help make the healthy choice the easy choice. We have the tools to do this. Next Slide

30. Exploding the myths
Myth: “my grandfather smoked and lived to 90 years”, and “everyone has to die of something”
Fact: While some people who smoke will live a normal lifespan, the majority will have shorter, poorer quality lives. And yes, everyone has to die, but death does not need to be slow, painful or premature, as is so often the case with NCDs
Here is a common myth and I urge that none of us take this line—my grandfather etc.(read) next slide

31. What works?
A small shift in average population levels of several risk factors can lead to a large reduction in chronic diseases
Population wide approaches form the central strategy for preventing and controlling chronic disease epidemics, but should be combined with interventions for individuals
Many interventions are not only effective, but suitable for resource constrained settings
Do we have enough information on what works –what has been shown to work in other countries?. I make three categorical statements based on empirical data from other countries (READ) next slide

32. Finland: Dramatic Declines in NCD Mortality
This slide shows that the interventions work. You can see the dramatic declines in mortality form chronic diseases in Finland. This is a famous example, but there are others which I will not show. If it has worked there why cannot it work here? Next slide

33. Relation of fitness to mortality T&T, St. James Cardiovascular Study
1309 men had blood sugar, cholesterol, fitness measured at baseline and then followed up carefully for 7 years.
Unfit men compared with fit men were:
- 3.6 times more likely to die
- 2.5 times more likely to have a heart
attack
But we must insist on the physical activity as preventing mortality. This study from trinidad and Tobago shows quite clearly unfit men, men who did not exercise were more likely to die prematurely and were 2.5 times more likely to have a heart attack during the 7 year period of the study. Next slide

34. Caribbean Responses
Since the 1960s, history of collective action in health, formalized in 1986 as the Caribbean Cooperation in Health (CCH) initiative.
Countries, CAREC, CFNI and CHRC, CARICOM secretariat, PAHO/WHO and partners have had successes e.g.,, malnutrition and gastroenteritis, vaccine preventable diseases, HIV/AIDS (p (PANCAP).
CCH now entering 3rd phase: major thesis that Caribbean health can be improved through actions taken universally and collectively.
Current priorities for action under CCH include chronic diseases where the cited goals are to reduce deaths by 2% per year and to reduce serious, costly complications such as amputations or renal failure.
I do not wish to give the impression that nothing has been done in the Caribbean and here I show some of the examples of collective action in health eg combating malnutrition and gastroenteritis, vaccine preventable diseases and we have established a successful partnership against HIV/AIDS( PANCAP. You are all familiar with the Caribbean Cooperation in health now entering its third phase and one of the priority ares is chronic diseases and a goal is reduce deaths from these by 2% per year. Next Slide

35. Caribbean Responses Summarised
But there is still a great deal to be done. This slide represents the results of surveys in several countries to examine whether we had in place the structures and services to deal adequately with chronic diseases. I am sad to say that several deficiencies were found. For example, only one country had explicit national objectives. The idea is not to point fingers ,but to indicate the areas we must cover if indeed we wish to address these diseases. Next slide
Source: PAHO Survey of NCD National Response Capacity, 2005

36. Addressing the risk factors
Tobacco and alcohol
Increase taxes with proceeds to prevention and treatment
Ban smoking in public places
Ban smoking in all schools
Ban cigarette and tobacco advertising near to schools
Curtail promotion of alcohol products targeted to women and children
Establish target dates for passage of the legal provisions in the FCTC already ratified.
I turn now to the risk factors which I mentioned earlier and I wish to draw your attention to each one of these, beginning with tobacco and alcohol. I am proposing seriously that we increase taxes with proceeds---etc (read) next slide

37. Addressing the risk factors
Physical activity
Have physical education compulsory in schools and provide the facilities
Provide healthy, secure exercise spaces
Provide wellness centers
Give tax relief for worksite exercise facilities
Physical activity. I am proposing four concrete actions that we should take ( READ) next slide

38. Addressing the risk factors
Improve dietary practices
Promote a standard of meals in public eating places eg. eliminating trans fats
Provide healthy school meals
Establish community based networks for training in preparation of health foods
Mandate RNM to investigate the trade issues which impact negatively on healthy food imports
Promote elimination of trans fats from Caribbean diets
Diet. Here again are the proposals to which I wish to draw your attention and which we must consider seriously if we are to address te problem of the Chronic diseases. (READ) next Slide

39. Addressing the risk factors
In the case of cancer
Primary prevention
Eg screening and vaccination to prevent
cervical cancer
Promote screening for breast cancer
In the case of cancer, I place stress on screening especially for cancer of the cervix and breast. I know some of you are contemplating introducing the vaccine against the human pappiloma virus which is the major cause of cancer of the cervix. Next slide

40. Secondary prevention Screening programs for NCDs
Provide health services with resources to apply the established cost-effective interventions
Establish mechanisms to ensure availability of the medications necessary for the long term treatment of NCDs when they occur
But with the increasing life expectancy of our people we canot avoid entirely the chronic diseases. Therfore we must engage in secondary prevention or preventing the undesirable complications of these diseases. It is critical that our health services have the resources and medications for the treatment of these disease when they occur and must be controlled. next slide

41. Critical other recommendations
Establish national level Commissions on NCDs
Mandate CAREC to establish a system of behavior and risk factor surveillance
Insist on the updating of the Caribbean Regional Plan of Action for NCDs
The Caribbean should name a “CARIBBEAN WELLNESS DAY”
There are other measures we should take ( READ) I hope that we can leave here today having made the decision to establish a Caribbean wellness day-a day to be marked throughout the region by an emphasis on the actions needed to keep us well –a day that should be a time of reckoning about what we have achieved during the past year on this score. Next slide

42. Financial institutions
Involve Partners
PAHO/WHO
Financial institutions
Caribbean social partners – private sector and civil society
Monitoring and evaluation
Designate CARICOM/PAHO as the joint Secretariat with responsibility for monitoring and reporting progress in the control of the NCDs.
But history has shown us that in any major social venture, we must involve partners and here I list only a few critical ones. One of the more critical of the partnerships will be that between PAHO and CARICOMwhich has been successful in the past and from which we expect much in terms of the monitoring and evaluation of the decisions we take today. Next slide

43. The way forward
First: We can utilize the policy instruments at our disposal
legislation
taxation
regulation
Second: We should establish partnerships
Third: We must take personal responsibility and lead by example
And finally. Let us look at the way forward and I pose three critical ingredients. In order to address the risk factors which I mentioned, there is no doubt that we have at our disposal the policy instruments to effect change if we so wish and I cannot stress enough the fact that we as leaders have to set a personal example for our people to follow. FINAL SLIDE

44. CONCLUSIONS The Caribbean has a very serious problem - getting worse
Economically and socially, it is not sustainable
There are cost-effective interventions that work; why not utilise them?
We must put into effect National and Caribbean-wide (CCH) plans
It is CRITICAL to strengthen health services to for management and control of chronic diseases
Deepened partnership with public and private sector, and civil society absolutely needed