Reducing Adult Deaths From Chronic Diseases in Asia: Evidence and Opportunities

Reducing Adult Deaths From Chronic Diseases in Asia: Evidence and Opportunities

by Prabhat Jha and Ian Anderson

 

Martin Wolf, the noted columnist for the Financial Times, recently commented that the economic rise of China and India was nothing less than a fundamental realignment of the global order (1). Rapid economic progress will likely continue in these two countries and in most parts of Asia. Concurrently, Asia is undergoing a rapid demographic and epidemiological transition. Aging and the rise of chronic diseases such as heart attack, stroke, diabetes, respiratory diseases and cancer do not have just major health and social implications, but also economic and financial costs. Chronic diseases could result in some national income losses of $550 billion in China and $225 billion in Indiaⁱ between 2005 and 2015, according to a study for the World Economic Forum (2). The interaction of economic growth with health outcomes is complex. Rapid economic growth in Asia does not, per se, guarantee rapid improvements in health outcomes but it does, however, raise more resources which can be used for public finance of essential services (be they delivered by the public or private sector; 3).

In this essay, we argue that the control of a handful of chronic diseases is central to ongoing improvements in health in Asia and to containing major cost burdens on governments and households. We begin by examining the mortality risksⁱⁱ among adults in South Asia and East Asia.ⁱⁱⁱ We then examine priorities for prevention and treatment. We conclude that generating knowledge on the causes, consequences and control of chronic diseases is a priority for investment by Asian governments and development partners.

Avoidable adult mortality in Asia

Nearly 200 years of epidemiology and demography tell an important story: Death at young ages (below age 30 years) has fallen dramatically and could become a rare occurrence, and death in middle ages (ages 30 to 69 years) need no longer be common (4,5). Currently, each year, about 27 million deaths occur in South and East Asia: 7 million before age 30, 10 million between ages 30 and 69 years and another 10 million at 70 and above (6). The individual years of life lost are greatest for those at young ages, averaging about 60-65 years versus non-smoking life expectancy. But even among the middle aged, a premature death means 20 to 25 years of productive life lost—often as the head of a household.

Rapid reductions in child mortality in China and India over the last few decades have meant that the vast majority of those born in these countries in the 1980s onward can expect to reach middle age. Today, there are an estimated 1.3 billion adults ages 30-69 (see Table 1) in South Asia and East Asia. As of 2001, nearly 70 percent of deaths during these ages in these two regions were from the “non-communicable diseases.” Communicable, maternal, and nutritional conditions account for 20 percent of deaths. Injuries—including traffic accidents—account for another 10 percent.

 

Table 1: Population and Deaths in South and East Asia by Cause at Ages 30-69, 2001 (in millions)
	Men	Women	Persons
Total population	6,621	6,363	12,984
All causes	6.1	4.2	10.3
Communicable, maternal and nutritional conditions	1.2	0.8	2.0
Non-communicable diseases	4.1	2.9	7.0
Injuries	0.8	0.5	1.3
Source: A.D. Lopez et al., Global Burden of Disease and Risk Factors (6).

 

Most deaths in middle age worldwide involve vascular disease, respiratory disease, or cancers. These diseases are costly to treat. But there are proven, feasible, affordable, and cost-effective preventive measures that can avert such problems. These include control of tobacco (7), blood pressure and elevated lipids (8-10), selected cancers (11-12), and provision of low-cost highly accessible secondary prevention for vascular disease (10). Moreover, a significant minority of adult deaths involves tuberculosis and AIDS, so that effective tuberculosis treatment and HIV-1 avoidance are also important at these ages (see Table 2). Comments follow in more detail about specific conditions.

 

Table 2: Mortality in South and East Asia from Selected Causes, at Ages 30-69 Years, 2001 (in millions)
	Men	Women	Persons
Cancer	1.1	0.8	1.9
Ischemic heart disease	0.9	0.6	1.5
Stroke	0.6	0.4	1.0
Respiratory diseases	0.5	0.4	0.9
Tuberculosis	0.5	0.4	0.9
AIDS*	0.2	0.05	0.3
Sub-total	3.8	4.0	7.8
Source: A.D. Lopez et al., Global Burden of Disease and Risk Factors (GBD, 6). * Note: Newer data from direct epidemiological studies suggest that AIDS deaths may be a magnitude lower than the indirect GBD estimates.

Prevention priorities

1. Tobacco control

In China and India, as in most low-income countries, death in middle age is increasing in relative importance as the effects of smoking increase. Tobacco kills differently in different parts of Asia. In China, the leading causes of death from smoking are chronic lung disease and lung cancer, with a noted excess also of tuberculosis deaths, but much lower heart disease (13). In India, the leading causes of death from smoking are tuberculosis and heart disease, with relatively less lung cancer (14). Unless there is a widespread cessation of smoking in China, one-third of the approximately 300 million male smokers alive today will eventually die from tobacco-related causes. India may well see 40 percent of the estimated 100 million male smokers alive today die from smoking, unless many men quit smoking. Household tobacco use in India is associated with low birth-weight and premature babies as well as economic hardship arising from increased hospitalizations (15-16). In both India and China, a substantial amount of the excess risk of death from smoking occurs in middle age. Indeed, in India, smokers appear to have lost about a decade of life versus nonsmokers as young as age 50.

Rapid and sustained reductions in smoking can occur. The Organization for Economic Cooperation and Development (OECD) countries have shown substantial declines in smoking deaths in middle-age in the last two decades: Lung cancer deaths among young men ages 30-44 years fell by nearly 80 percent in the United Kingdom (7,16), with much of the decline due to marked increases in cessation. In OECD countries, over 30 percent of the adult population are ex-smokers, in contrast to only 2 percent in India, 9 percent in China and 15 percent in Thailand (5, 17-18). Thailand is far ahead of China and India as it has had the most comprehensive tobacco control strategy. The increased cessation in China has only occurred since about 1998, when the first scientific reports that smoking was killing Chinese in large numbers appeared in the popular press (13). A considerable number of tobacco deaths over the next half century could be prevented by encouraging current smokers to quit smoking. Reducing the number of children who start smoking now will chiefly yield benefits only in the second half of the 21st century (7). Cost-effective measures to encourage cessation and reduce uptake include higher taxes, which are vastly under-used in Asia. Bidis, the most commonly smoked tobacco in India, have historically had low taxation rates, for example. Effective measures also include restrictions on public smoking; government support for quit smoking clinics; better public information on smoking hazards, and prominent warning labels on cigarette and bidi packs and packaging. Some of these warning labels could tell users that smoking is an important risk factor for tuberculosis and of heart disease (14).

2. Hepatitis B vaccination

There are an estimated 0.4 million deaths a year from liver cancer in East and South Asia (6). Many are due to chronic infection from hepatitis B. Universal immunization with hepatitis B vaccine is highly cost-effective, and could avert up to 90 percent of the estimated 1.5 million deaths from liver cancer that will occur in those born in the region in 2000 (11, 19). For those who are already infected, however, vaccination will not help. Strategies to reduce co-factors such as exposure to aflatoxins, toxic compounds produced by certain strains of fungi that can damage the liver, and alcohol are required.

3. Cervical cancer vaccines and screening

Nearly 150,000 women die from cervical cancer a year in the region—almost all from infection by human papillomavirus (HPV). New HPV vaccines have been introduced in western countries. Making these widely accessible at reasonable cost to adolescent girls would avert a very large proportion of the future deaths from cervical cancer among women who are just beginning adult life. Ensuring that all adult women have at least one screening—with referral if positive—for early cervical cancer would be an effective way to reach the older women who would not benefit from current HPV vaccines (11-12).

4. Prevention of obesity and diabetes

Obesity and lack of physical activity are clear risk factors for development of a range of diseases, including expensive-to-treat diabetes. These problems are further compounded by raised blood pressure and lipid imbalances, such as elevated “bad” cholesterol (20). These factors work together, so only careful epidemiological studies can tease out the contributions that each make to eventual mortality. Urbanization is a good marker for the acquisition of higher fat and reduction in physical activity, and diabetes prevalence among urban adults in China and India is already about 10 times that of their rural counterparts (21-22).

The contribution of body mass to premature mortality in developing countries such as India and China appears to be different from the OECD experience, and this raises some important research and policy issues. For example, a 10-year prospective study of 220,000 men in urban China found higher risks of vascular deaths among those with elevated body mass index but also higher risks for respiratory disease at low body mass. Indeed, the excess risk at lower body mass persisted after adjusting for smoking or blood pressure (23). Better public information on risks, including more widespread communication of emerging scientific findings for large, reliable studies, can influence individual adult behaviour, and lead to further public demand for control of risk factors, as has occurred in the United States (24). A specific challenge is to convert scientific findings into behavioral change, including better understanding what humans respond to in information and regulation—for example the regulation of saturated fat in diets in the manufacturing process can be cost-effective (25).

Treatment priorities^iv

Low-cost generic risk pills for vascular disease

There is considerable evidence that simple combinations of cheap drugs can be highly effective in reducing mortality among the millions of adults in South and East Asia with some existing vascular disease or diabetes (8, 10, 26). Consider the following: in the absence of any drug therapy, adults with previous stroke, heart attack, diabetes or any other evidence of some serious vascular disease have about a 7 percent annual risk of either dying or being re-hospitalized with a recurrence. If they take an aspirin a day, that risk drops to 5 percent; if they add two more drugs to reduce blood pressure and blood lipids, it drops further to 2 percent. The exact sequence of drugs matters little, but an untreated patient faces a 10-year risk of death or re-hospitalization of about 50 percent as against 16 percent when he or she takes three to four drugs a day. All these drugs are low-cost, and thus could be easily packaged into “polypills” or generic risk pills for widespread use (26). Indeed, China’s success in ensuring widely-accessible tuberculosis therapy with several drugs serves (29) as a model of how simple drug therapy for vascular disease could be introduced in the region.

Can it be done?

Good decisions by governments and households now will save lives and reduce economic (and possibly financial) costs. A set of highly practical, available, proven, and affordable tools exist to reduce premature chronic disease mortality in Asia. But will this happen in time and be scaled up enough to make a difference? There are three important constraints.

First, political opposition to tobacco control will persist in some quarters. But much has been done to counter such opposition in OECD countries. Good analytical studies demonstrating that higher tobacco taxes increase – rather than reduce – government revenue in the medium term, is key, as are studies that demonstrate the health, financial and economic benefits of tobacco control (7). In China, an earlier report suggested that a 10 percent higher price could cut consumption by about 5 percent and generate enough revenue to finance a basic package of health services for about 33 million poor rural Chinese (30).

Second, chronic diseases place major challenges on health systems, many of which are not working effectively, efficiently, or equitably. While control of tobacco involves tax and regulation measures largely outside clinical health services, the control of most other chronic diseases will require important improvements in health systems. Improvements include better incentives; increased accountability; human resource management; public finances and resource allocation; the role of the private sector; drug procurement and distribution; and ways to create demand for health promotion by the public (31). Health systems need to scale up some of these cost-effective programs to universal access. And as argued eloquently by Julio Frenk (32), it would help to make explicit, evidence-based interventions an “entitlement.” Similar approaches were used in Mexico to expand coverage of adult clinical services and to ensure that people demanded such services. Development partners are increasingly committed to working through—and building up—national health systems, rather than bypassing those structures with stand-alone health projects or vertical programs and their role is changing from financiers of programs to architects of knowledge. Thus for governments and partners, intervention decisions and spending money wisely within competing priorities of a national health system become even more relevant.

The third constraint takes us back to where we began: evidence and information. A powerful and often vastly underestimated tool for chronic disease control in Asia is the generation of reliable information on the causes, consequences, and control of chronic diseases. Generating knowledge on levels and trends of major diseases and their risk factors and insights into “what works” in the highly diverse social and epidemiological landscape of Asia is a major investment with large payoffs because it sharpens priorities, informs resource allocation, and helps to make health systems more effective, efficient, equitable, and sustainable. Specific research is needed to measure program performance (including how much health is bought with taxpayers’ money); thus evaluation and cost-effectiveness analyses are of particular importance.

A reasonable analogy for chronic disease research today would be the status of diarrhea research about 40 years ago when it was fragmented and low impact. Led by efforts of Bangladeshi institutions and support from the World Health Organization and others, oral rehydration and related efforts were initiated worldwide that have markedly reduced childhood deaths from diarrhea (33-34). There is every reason to believe that a major Asian-led effort, with support from global research and development partners, to improve health research and development for the control of chronic disease could be as effective at saving lives and resources in the 21st century.

 

Professor Prabhat Jha is the Canada Research Chair of Health and Development at the University of Toronto and director of the Centre for Global Health Research at St. Michael's Hospital. He can be reached at prabhat.jha@utoronto.ca.

Ian Anderson is an advisor for the Asian Development Bank in Manila, Philippines. He can be reached at ianderson@adb.org.

 

ⁱ The literature is ambiguous if chronic disease control saves financial costs over the lifetime of any one person, as people consume resources sooner or later. Here, our definition of economic costs is broader, encompassing the costs of foregone good years of life, household effects from dead adults, slowing of economic productivity and other economic costs (see Jamison et al in DCP2, reference 2, for a review).

ⁱⁱ Avoidance of disability is also important. Mortality does not capture all illnesses, specifically neuropsychiatric and musculoskeletal diseases. However, the correlation of mortality with morbidity for most major diseases is quite strong. Moreover, it is important to note that measurement error in disability estimates is much greater than for mortality, and often can exceed the desired change in health outcomes. For example, a health policy planner may desire a 10% improvement in diabetes outcomes, but if measurement error exceeds 10% in the health outcome measure, she or he will not know if the intervention worked. Since it is usually possible to tell the difference between a dead person and a living one, restricting analyses to mortality should reduce measurement error in health policy-making. For more details, including estimates of disability-adjusted life years (DALY) in the region, see Lopez et al, reference 6 for more details.

ⁱⁱⁱ We refer chiefly to the World Bank regional classifications of South Asia and East Asia and Pacific; China and India comprise over 70% of the total population in these regions.

^iv There are other interventions that are highly practicable and cost-effective. These include markedly liberalizing access to opiates for those suffering from cancer, AIDS or other chronic ailments (see Foley et al, DCP2 reference 27) and low-cost epilepsy treatment (see reference 28).

 

References:

1. Wolf, M. 2006. “What India Must Do to Outpace China.” Financial Times, Feb 14, 2006.

2. Asian Development Bank. 2006, Attaining MDGs in Health: Isn't Economic Growth Enough? Accessed online at www.adb.org/Documents/EDRC/Policy_Briefs/PB035.pdf on June 29, 2007.

3. Jamison, D.T. 2006. “Investing in Health.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 3-34. New York: Oxford University Press.

4. Jha, P. “Avoidable Mortality in India: Past Progress and Future Prospects.” National Medical Journal of India 2002; 15 (suppl 1): 32–6.

5. Peto, R. “Statistics of Chronic Disease Control.” Nature. 1992 Apr 16; 356(6370):557-8.

6. Lopez, A.D., C.D. Mathers, M. Ezzati, D.T. Jamison, and C.J.L. Murray. 2006. Global Burden of Disease and Risk Factors, New York and Washington: Oxford University Press.

7. Jha, P., F.J. Chaloupka, J. Moore et al. 2006. “Tobacco Addiction.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 869-886. New York: Oxford University Press. Accessed online at http://files.dcp2.org/pdf/DCP/DCP46.pdf on May 22, 2007.

8. Rodgers, A., C.M.M. Lawes, T. Gaziano, and T. Vos. 2006. “The Growing Burden of Risk from High Blood Pressure, Cholesterol, and Bodyweight.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 851-868. New York: Oxford University Press.

9. Teo, K.K., S. Ounpuu, S. Hawken, M.R. Pandey, V. Valentin, D. Hunt, R. Diaz, W. Rashed, R. Freeman, L. Jiang, X. Zhang, and S. Yusuf, on behalf of the INTERHEART Study Investigators. “Tobacco Use and Risk of Myocardial Infarction in 52 countries in the INTERHEART Study: a Case-Control Study.” The Lancet. 2006; 368: 647–58.

10. Gaziano, T.A., K.S. Reddy, F. Paccaud et al. 2006. “Cardiovascular Disease.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 645-662. New York: Oxford University Press.

11. Brown, M.L., S.J. Goldie, G. Draisma et al. 2006. “Health Service Interventions for Cancer Control in Developing Countries.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 569-589. New York: Oxford University Press.

12. Institute of Medicine, 2007. Cancer Control Priorities in Low and Middle-Income Countries. Washington, DC: National Academy of Sciences.

13. Liu, B.Q., R. Peto, Z.M. Chen, J. Boreham, Y.P. Wu, J.Y. Li, T.C. Campbell, and J.S. Chen. “Emerging Tobacco Hazards in China: 1. Retrospective Proportional Mortality Study of One Million Deaths.” BMJ (British Medical Journal) 1998; 317: 1411–22.

14. Jha, P., B. Jacob, V. Gajalakshmi, P.C. Gupta, R. Kumar, N. Dhingra et al. “Male Mortality From Tuberculosis and Other Diseases in India: Case-Control Study of 32 000 Deaths and 30 000 Controls. Submitted to New England Journal of Medicine.

15. Bonu, S., M. Rani, P. Jha, D.H. Peters, and S.N. Nguyen. “Household Tobacco and Alcohol Use, and Child Health: An Exploratory Study from India.” Health Policy. 2004; 70(1):67-83.

16. Bonu, S, M. Rani, D.H. Peters, P. Jha, and S.N. Nguyen. “Does Use of Tobacco or Alcohol Contribute to Impoverishment from Hospitalization Costs in India?” Health Policy Plan. 2005; 20(1): 41-9; and Peto, R., A.D. Lopez, J. Boreham, and M. Thun. Mortality from Smoking in Developed Countries, 1950–2000. 2d ed. Accessed online at www.deathsfromsmoking.net/ and www.ctsu.ox.ac.uk/~tobacco/ ,on May 22, 2007.

17. Runlin Gao and Yangfeng Wu, “Current Status of Cardiovascular Diseases in China.” (paper delivered at Disease Control Priorities Project Launch and 2nd Global Meeting of the Inter-Academy Medical Panel, Beijing, March 5, 2006).

18. Vateesatokit, P., B. Hughes, B. Ritthphakdee. “Thailand: Winning Battles, But the War's Far From Over.” Tobacco Control. 2000 June; 9(2):122-27.

19. Goldstein, S.T., F. Zhou, S.C. Hadler, B.P. Bell, E.E. Mast, and H.S. Margolis. “A Mathematical Model to Estimate Global Hepatitis B Disease Burden and Vaccination Impact.” International Journal of Epidemiology. 2005 December; 34(6):1329-39. Epub 2005 Oct 25.

20. PSC Collaborators. “Cholesterol, Diastolic Blood Pressure, and Stroke: 13,000 Strokes in 450,000 People in 45 Prospective Cohorts.” Prospective Studies Collaboration. The Lancet. 1995; 346:1647-53.

21. Rajesh Kumar, personal e-mail communication on May 21, 2007.

22. Zhengming Chen, personal communication 2007.

23. Chen, Z., G. Yang, M. Zhou, M. Smith, A. Offer, J. Ma, L. Wang, H. Pan, G. Whitlock, R. Collins, S. Niu, and R. Peto. “Body Mass Index and Mortality From Ischaemic Heart Disease in a Lean Population: 10-Year Prospective Study of 220,000 Adult Men.” International Journal of Epidemiology. 2006 Feb;35(1):141-50. Epub 2005 Oct 28

24. Cutler, D.M. and S. Kadiyala.“The Return to Biomedical Research: Treatment and Behavioral Effects.” In Measuring the Gains of Medical Research: An Economic Approach, ed. K.M. Murphy and R.H. Topel. Chicago: University of Chicago.

25. Savedoff, W.D. and A-M Smith. 2006. “Cost Effective Strategies for Noncommunicable Diseases, Risk Factors, and Behaviours.” In Priorities in Health., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 97-128. New York: Oxford University Press.

26. Peto, R., “Noncommunicable Diseases.” (paper delivered at Disease Control Priorities Project Launch and 2nd Global Meeting of the Inter-Academy Medical Panel, Beijing, March 5, 2006.)

27. Foley, K.M., J.L. Wagner, D.E. Joranson, and H. Gelband. 2006. “Pain Control for People with Cancer and AIDS.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 981-993. New York: Oxford University Press.

28. Chandra V., R. Pandav, R. Laxminarayan et al. 2006. “Neurological Disorders.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 627-643. New York: Oxford University Press.

29. Dye, C., K. Floyd. 2006. “Tuberculosis.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 289-309. New York: Oxford University Press.

30. Hu, T.W. and Z. Mao. “Effects of Cigarette Tax on Cigarette Consumption and the Chinese Economy.” Tobacco Control. 2002 June; 11(2):105-8.

31. Mills, A., F. Rasheed, and S. Tollman. 2006. “Strengthening Health Systems.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 87-102. New York: Oxford University Press.

32. Frenk, J., E. Gonzalez-Pier, O. Gomez-Dantes, M.A. Lezana and F.M. Knaul. “Comprehensive Reform to Improve Health System Performance in Mexico.” The Lancet. 2006 October 28; 368(9546):1524-34.

33. Keusch, G.T., O. Fontaine, A. Bhargava et al. 2006. “Diarrheal Diseases.” In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, A.R. Measham, J.B. Breman et al., 371-387. New York: Oxford University Press.

34. Jha, P., D. Brown, A.S. Slutsky et al. for Global IDEA Scientific Advisory Committee. “Health and Economic Benefits of an Accelerated Program of Research to Combat Global Infectious Diseases.” Canadian Medical Association Journal, 2004; 172 (12): 1538-39.