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1 Centrale sundhedsmæssige udfordringer og indsatser frem mod 2030 Ib Bygbjerg, prof. dr. med. Global Sundhed, Institut for Folkesundhedsvidenskab, Kbh.s Universitet

2 Baggrund 1. Med udgangspunkt i MDG 4, 5 og 6 er det over de sidste femten år lykkedes at knække HIV-kurven og sikre et klart fald i børne- og mødredødeligheden. 2. SDG 3 er et nyt globalt sundhedsmål ( Ensure healthy lives and promote well-being for all at all ages ), som med sine 13 delmål er langt bredere og mere komplekst. 3. Hvad bliver de afgørende udfordringer på den globale sundhedsdagsorden frem mod 2030? 4. Vil det lykkes at få bugt med de store smitsomme sygdomme hiv/aids, malaria og tuberkulose? 5. Hvor stort et problem udgør såkaldte livsstilssygdomme (NCD erne) på sigt? 6. Hvordan håndterer vi nye sundhedsudfordringer som Antimikrobiel resistens (AMR)? 7. Hvordan forhindrer vi nye globale pandemier i at udvikle sig og reelt lamme verdensøkonomien? 8. Effektive sundhedssystemer står højt på enhver regerings dagsorden, og både forventninger og omkostninger stiger. 9. Grænseoverskridende udfordringer kræver, ikke kun at tænke i nationale løsninger. 10. Det har H1N1 og senest ebola-krisen og Zika-virusen vist. 11. Risikoen for globale pandemier bliver stadig større, og at der er behov for en mere fokuseret indsats til støtte for de lande, der ikke kan klare det selv. 12. Det stiller krav til den internationale sundhedsarkitektur og finansiering, men åbner også mulighed for 13. Større involvering af private aktører.

3 The 17 SDG (Post-MDG), to be reached by End poverty in all its forms everywhere 2.End hunger, achieve food security and improved nutrition, and promote sustainable agriculture 3.Ensure healthy lives and promote wellbeing for all at all ages 4.Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all 5.Achieve gender equality and empower all women and girls 6.Ensure availability and sustainable management of water and sanitation for all 7.Ensure access to affordable, reliable, sustainable and modern energy for all 8.Promote sustained, inclusive and sustainable economic growth, full and productive employment, and decent work for all 9.Build resilient infrastructure, promote inclusive and sustainable industrialisation, and foster innovation 10.Reduce inequality within and among countries 11.Make cities and human settlements inclusive, safe, resilient and sustainable 12.Ensure sustainable consumption and production patterns 13.Take urgent action to combat climate change and its impacts (taking note of agreements made by the UNFCCC forum) 14.Conserve and sustainably use the oceans, seas and marine resources for sustainable development 15.Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation, and halt biodiversity loss 16.Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels 17.Strengthen the means of implementation and revitalise the global partnership for sustainable development

4 Global Health definition: An area for study, research, and practice, that places a priority on improving health, advancing equity in health for all worldwide; emphasizes transnational health issues, determinants, and solutions; Involves many disciplines within and beyond healthsciences; promotes interdisciplinary collaboration; is a synthesis of population-based prevention, with individual-level clinical care. ref. Koplan et al. 2009

5 Tree of Health Blue: Health: basics and tools Green: paths and ways Red: risks and diseases Black: specialities and disciplines, and determinants I.B. 2013

6 SDG in Relation to Tree of Health 1. End poverty 2.End hunger 3.Ensure healthy lives 4.Ensure education 5.Achieve gender equality 6.Ensure water and sanitation 7.Ensure energy 8.Promote economic growth and work 9.Build infrastructure, industrialization, innovation 10.Reduce inequality 11.Make cities and settlements safe and sustainable 12.Ensure sustainable consumption and production 13.Take urgent action to combat climate change 14.Conserve oceans and ressources 15.Protect terrestrial ecosystems 16.Promote inclusive societies for sustainable development 17.Strengthen global partnership

7 Goal 3 targets & 13 major challenges By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births By 2030, end preventable deaths of newborns and children < 5 years, with all countries aiming to reduce neonatal mortality to at least 12 per 1,000 live births and < 5 mortality to at least 25 per 1,000 live births By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and alcohol By 2020, halve the number of global deaths and injuries from road traffic accidents By 2030, ensure universal access to sexual and reproductive health-care services, including family planning, information and education, and integration of reproductive health into national strategies and programmes Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination Strengthen implementation of the WHO Framework Convention on Tobacco Control in all countries Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, (Doha Declaration/ TRIPS Agreement and Public Health) for all Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

8 Prioritise: baby -or elderly?

9 Metrics on disease burden: disability and death (HeaLY: Loss of Healthy Life from Disability and Death, expressed per population per year) DALY: Years of Life Lost (YLL) + Years Lived with disability (YLD): DALY = YLL + YLD. One DALY is equal to one year of healthy life lost. Japanese life expectancy statistics are used as the standard for measuring premature death, as the Japanese have the longest life expectancies. DALY may equal HeaLY, if age is not weighted (QUALY: essentially equal to YLD)

10 Q: why is the top-point of the curve around years of age?

11 A short story of Global Burden of Diseases: In 1993, the original GBD study was funded by the World Bank and featured in its landmark World Development Report 1993: Investing in Health. Co-authored by Christopher Murray, this GBD study served as the most comprehensive effort to systematically measure the world s health problems, generating estimates for 107 diseases and 483 sequelae (non-fatal health consequences related to a given disease) in 8 regions and 5 age groups. In 2010, the number of diseases and regions were expanded and Chris Murray et al. published the following Report:

12 Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, : a systematic analysis for the Global Burden of Disease Study 2010 Murray c. et al. Lancet2012;380:2197 Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account.

13

14 Another guru, Omran described already in 1971, how health and disease patterns change over time in societies, depending, amo, on rate of Demographic transition and Economic development, to result in an Epidemiological transition. Like individuals, societies have a life cycle : In a young society, infectious diseases and nutritional deficiencies dominate in children, diarrhoea and acute respiratory infections, including measles and malaria; in pregnant women, fetal loss, perinatal death from undernutrition, bleeding, and infection; in surviving adults, tuberculosis (TB) a.o. diseases related to poverty. When societes grow up accidents arrive. In ageing societies, Non-Communicable Diseases take over.

15 Development and transition Population Causes and Consequences of Leading Chronic Diseases: A Comparative Analysis of Prevailing Explanations DAVID STUCKLER, University of Cambridge Milbank QuarterlyVolume 86, Issue 2, Article first published online: 2 JUN 2008

16 Stuckler, ct. Findings: economic growth, market integration, foreign direct investment, and urbanization were significant determinants of long-term changes in mortality rates of heart disease and chronic noncommunicable disease; observed relationships with social and economic factors were roughly three times stronger than the relationships with the population s aging.

17 Blue arrow indicates the double burden of diseases Accidents A Source:LaPorte, 2003 Diabetes (NCDs) Coronary Heart Dis Cancer

18 Some emerging infections which Omran could/did not foresee HIV Dengue

19 Year 2015 has passed Some MDGs were not achieved amo. because of not enabling: MDG 7: Ensure Environmental Sustainability, & 8: Global Partnership for Development

20 Reaching Millennium Development Goal 4 Malcolm Molyneux, Elizabeth Molyneux Vol 4 March 2016 how close the world has come to achieving MDG 4 ie, to reduce <-5 mortality rate 2/ It has fallen by 53% resulting in 6 7 million fewer children dying in 2015 than in 1990, despite the overall increase in population. Of 195 countries with available data, 62 (32%) individually achieved 2/3 reduction goal: 12 in low-income countries, 10 in sub-saharan Africa.

21 P. falciparum prevalence in children and youngsters , rural NE-Tanzania. Data from Danida supported ENRECA project Bygbjerg et al.

22 M & M, ct. The question is not only whether, but how a country has achieved an improvement its child mortality (MDG 4). Using the Lives Saved Tool (LiST), major national programmes vaccinations, insecticide-treated bednets, HIV control, integrated management of childhood illnesses including diarrhoea and pneumonia, nutritional support, and obstetric care account for around 80% of the reduction since MDG 5 (to reduce the maternal mortality ratio by 75%)has been generally less well achieved than MDG 4, With a global reduction in maternal deaths of 45% (46% in developing countries).

23 M & M, ct. With 2016 begins the new era of Sustainable Development Goals, SDG, including goals to reduce < 5 mortality rate to 25 per 1000 livebirths, and neonatal mortality rate to 12 per 1000 livebirths, by Two principal requirements for the future are local capacity and sustained international cooperation, which are dependent on training, infrastructure, political will, peace, and the absence of corruption. Increased attention will be needed for reproductive, maternal, and neonatal services.

24

25 Risk factors, traditionally i.e.vertically Poor Dev country presented horizontally by IB source: MBM, Cpt. 10, p. 484, Table 10-2 Rank Middle income Rank High income Underweigh 1 Alcohol 1 Tobacco 1 Unsafe sex 2 Blood press 2 Blood press 2 Wat-san 3 Tobacco 3 Alcohol 3 No vacc 4 Traffic 4 Cholesterol 4 Indoor smo 5 Underweigh 5 Overweigh 5 Zn def 6 Overweigh 6 Low veg/fru 6 Iron def 7 Occup risk 7 Phys inact 7 VitA def 8 Cholesterol 8 Traffic 8 Blood press 9 Low veg/fru 9 Illicit drugs 9 Tobacco 10 Indoor smo 10 Occup risk 10 Occup risk 11 Wat-san 11 Lead expos 11 Rank

26 Diabetes and relation to obesity in Africa and SE-Asia not clear relation for 50-70%!

27 In brief: Prevention of Type 2 diabetes a.o. NCD should begin by averting both Low Birth Weight and High Birth Weight In India, optimal birth to avoid NCD is 2.9 kg; In USA 3.4 kg. weight In Africa, malaria in pregnancy lowers birth-weight by up to 0.25 kg

28 Top Ten In medical ward in a Tanzanian designated district hospital

29 Fig. The proportional distribution of disability adjusted life years (years lost due to death or disability), contributable to infectious diseases and NCDs for (top) the world, (middle) high-income countries, and (bottom) low-income countries for 2002 and Mathers CD, Loncar D, Updated projections of global mortality and burden of disease, PLoS Med Nov;3(11):e442. Infectious diseases: dark blue, Accidents: light blue Noncommunicable diseases: grey World High Low

30 MDG 6 combat HIV/AIDS, malaria and other diseases Question: Has introduction of HAART also to Africa combated HIV, AIDS or both?

31 HAART contributed to reducing AIDS mortality and increasing longevity but not HIV prevalence, which is increasing, and incidence which is just levelling off, cf. P = I x d Source:

32 Question What should a poor government prioritize with an increasing burden of noncommunicable diseases, and at the same time a remaining burden of communicable diseases, including neglected diseases, plus the unsolved problem of high maternal and neonatal mortality?

33 Black: 3 disease risk factors co-localised: 1. For high HIV 2. For overweight 3. For neglected infectious diseases

34 Neglected tropical disease disability-adjusted life year rates by cause and region in This figure excludes malaria

35 Addressing diabetes mellitus as part of the strategy for ending TB. Trans R Soc Trop Med Hyg Mar;110(3): doi: /trstmh/trv111. Harries AD et al. As we enter the new era of Sustainable Development Goals, the international community has committed to ending the TB epidemic by 2030 (SDG 3.3) Diabetes mellitus (DM) triples the risk of TB and increases the probability of adverse TB treatment outcomes such as failure, death and recurrent TB. The rapidly escalating global epidemic of DM (SDG 3.4) means that DM needs to be addressed, if TB-related milestones and targets are to be achieved. WHO and the International Union Against Tuberculosis and Lung Disease's Collaborative Framework for Care and Control of Tuberculosis and Diabetes, launched in 2011, provides a template to guide policy makers and implementers to combat the epidemics of both diseases. DM and TB collaborative care can also help guide the development of a more effective and integrated public health approach for managing noncommunicable diseases.

36 Joint risk factors for TB and DM include smoking and alcohol and urban living. DM is associated with an increased risk of developing TB. Yet, recognition from health authorities and strategies for action still need to make headway before all patients will profit from combined care and risk reduction. Ensuring good links The vast majority of tuberculosis patients (95%) and diabetes patients (70%) live in developing countries and this poses an extra challenge in terms of finding costeffective solutions. According to Dr. Knut Lönnroth who is Medical Officer at WHO's Stop Tuberculosis Department, the main challenge ahead for the double burden of tuberculosis and diabetes is to strengthen health systems. "Particularly primary health care in order to reduce the barriers for people with both diseases to access quality health care.

37 A world of cities and the end of TB. Trans R Soc Trop Med Hyg Mar;110(3):151-2 Prasad, Ross, Rosenberg, Dye. The WHO's End TB Strategy aims to reduce TB deaths by 95% and incidence by 90% between 2015 and As the world rapidly urbanizes, more people could have access to better infrastructure and services to help combat poverty and infectious diseases, including TB. Yet large numbers of people live in overcrowded slums, with poor access to urban health services, amplifying the burden of TB. An alignment of the Sustainable Development Goals (SDGs) for health (SDG 3) and for urban development (SDG 11) provides an opportunity to accelerate the overall decline in infection and disease, and to create cities free of TB.

38 A key question At a time of global financial crisis and shrinking health budgets: is the sharp demarcation between communicable and non-communicable diseases justified, when both may hit the same individuals and societies? Source: Bygbjerg IC, Science 2012:337;

39 Opsummering af 13 Baggrunds udsagn: 1. Med udgangspunkt i MDG 4, 5 og 6 er det over de sidste femten år lykkedes at knække HIV-kurven og sikre et klart fald i børne- og mødredødeligheden. 2. SDG 3 er et nyt globalt sundhedsmål ( Ensure healthy lives and promote well-being for all at all ages ), som med sine 13 delmål er langt bredere og mere komplekst. 3. Hvad bliver de afgørende udfordringer på den globale sundhedsdagsorden frem mod 2030? Svar: NCDs, ulykker, dobbelte eller triple sygdomsbyrde, og manglende integrering af indsatsen 4. Vil det lykkes at få bugt med de store smitsomme sygdomme hiv/aids, malaria og tuberkulose? Svar: formentlig bedre kontrol, men ikke bugt med, og næppe hvis vertikale indsatser alene fortsættes 5. Hvor stort et problem udgør såkaldte livsstilssygdomme (NCD erne) på sigt? Svar: Hovedbyrden 6. Hvordan håndterer vi nye sundhedsudfordringer som Antimikrobiel resistens (AMR)? Svar: bla ved one health approach og kontrol af overforbrug 7. Hvordan forhindrer vi nye globale pandemier i at udvikle sig og reelt lamme verdensøkonomien? Svar: for influenza, reformering af fjerkræ/grise/menneske markeder og hushold i Kina, bedre overvågning, hurtigere intervention 8. Effektive sundhedssystemer står højt på enhver regerings dagsorden, og forventninger og omkostninger stiger. Svar: derfor forebyggelse og prioritering i sundhed, og systemforskning og reformer 9. Grænseoverskridende udfordringer kræver, ikke kun at tænke i nationale løsninger. Svar: WHO grundlagt 1948 og må også tage ledelsen sammen med andre FN organisationer og civilsamfundet i Global Health 10. Det har H1N1 og senest ebola-krisen og Zika-virusen vist. Svar: se 7, 8 & Risikoen for globale pandemier bliver stadig større, og at der er behov for en mere fokuseret indsats til støtte for de lande, der ikke kan klare det selv. Svar: ja, også for vor egen skyld, jfr. Ebola, polio og mæslinger 12. Det stiller krav til den internationale sundhedsarkitektur og finansiering, Svar: ja, og derfor er mindre investering i WHO og lignende organisationer en farlig kurs 13. Større involvering af private aktører. Svar: ja global social responsability, både blandt direkte health relaterede som medicinal branchen, men i mindst lige så høj grad fødevare- vand og sanitets branchen, urban planners, energi sektoren etc.

40 Dengue in Sri lanka, controlled by collecting and eliminating plastic bottles after the Tsunami In 2004, post-tsunami 15,463 suspected cases and 88 deaths of Dengue. After it was devastated by the tsunami, the fishing village of Mahaskaduwa in Kalutara district of Sri Lanka is back on its feet. The Proud Mothers women s collective has swept the garbage off the streets, provided a livelihood for the villagers and improved health and sanitary conditions. They decided to segregate their household refuse into dry waste such as plastics, glass, paper and cardboard, and degradable waste such as vegetable peels and food leftovers. This controlled the breeding sites for Aedes mosquitoes transmitting Dengue (and Chikungunya and Zika!)

41 As Ban Ki-moon said, There is no question that we can deliver on our shared responsibility to put an end to poverty, leave no one behind and create a world of dignity for all. Ref, UN. The Millennium Development Goals report New York, NY: United Nations, 2015.

42 Relevant Summer Courses in relation to SDGs, at School of Global Health, University of Copenhagen Copenhagen School of Global Health

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