Tag Archives: cardiovascular disease

Health service or sickness service?

I don’t often manage to make the time to watch the daily Ted Talks, but I inevitably enjoy them when I do and they have always left me with something to think about.

In June, I watched a talk by Rebecca Onie, co-founder and CEO of an American organisation called Health Leads, which really got me thinking – so much so that I’ve been back and watched the video several times since.

Ms Onie talked about how and why Health Leads was established and the work that it does among disadvantaged citizens of the USA. This is inspiring stuff and I encourage you to watch her Ted Talk, but it was one line that really got to me. Rebecca described the frustration of physicians writing prescriptions for medications whose root cause was the conditions in which the patients were living: in essence doctors were dealing with their patients’ sickness without really focussing on their health – was this a health service or a sickness service, she wondered.

The UK Department of Health seems to have been asking itself similar questions. In 2009, it introduced the NHS Health Check – a voluntary screening programme for people aged ≥40 not being treated for cardiovascular disease, diabetes and kidney disease, which is just completing its roll-out phase. The health check uses simple screening tests (blood tests, blood pressure, BMI and patient histories) to identify extant disease or to assess risk factors for developing disease. Follow-up screening visits will occur at 5-yearly intervals.

In the fight against non-communicable diseases (NCDs) I think that this is a worthy programme – I’ve had a health check: it was over in ~15 minutes, the nurse who conducted the test was friendly and reassuring and offered me advice and encouragement when discussing the results of the tests.

It was rather a shame then, to see a review from the Nordic Cochrane Centre in Denmark published this week, which concluded that such programmes do not result in reductions in overall or disease-specific mortality and which recommended that ‘systematically offering general health checks should be resisted’. I was surprised at both the finding and the recommendation. When I had a look at the paper though, I noticed that many of the studies were initiated in the 1960s and 1970s and included subjects who had been born before 1940 – in fact in two studies the subjects had been born before 1920.

Although I’m no statistician and I’m conscious that this is a Cochrane Centre analysis, I’m not sure how helpful it is to make recommendations for today’s patients based on a population whose lifestyle will have been so very different to that of people born after 1960. And although the measurements taken at the screening visits are essentially the same, their accuracy and their meaning in the context of a much wider understanding of NCDs also must be very different. Moreover, the range and efficacy of available therapeutic interventions has changed beyond recognition, which will likely have a greater effect on morbidity and mortality rates in present-day subjects who undergo screening and are found to have disease.

One of the explanations that the Cochrane authors gave for their findings is that the people most likely to volunteer for screening are generally healthier than those who do not. They also voiced concerns that routine testing may lead to over-diagnosis and unnecessary treatment and they quote convincing (and more recent) examples of this.

If the DoH is to continue to offer health checks – and its response to a BBC article on the Cochrane findings implies that it has no plans to even consider stopping – these last two points deserve some attention. It is inconceivable that the NHS would mandate screening checks, so other ways to encourage people to attend need to be sought.

The NHS Future Forum has recommended that every healthcare professional (HCP) should: ‘… use every contact with an individual to maintain or improve their mental and physical health and wellbeing where possible, in particular targeting the four main lifestyle risk factors: diet, physical activity, alcohol and tobacco – whatever their specialty or the purpose of the contact [my emphasis].’ The Forum’s report, The NHS’s Role in the Public’s Health, gives as an example a dental surgery in Manchester which offers smoking cessation studies, BMI and blood pressure checks and even screening for STIs to its mainly young patients, who otherwise have little contact with the rest of the NHS. Also, GPs see women at regular intervals to prescribe contraception, and those consultations could, once every 5 years, be extended to include screening for NCDs.

And with regard to over-diagnosis and unnecessary treatment – well, to my mind, a disease prevention strategy should start with a presumption of no diagnosis and no necessary treatment. However, if you only start to screen at age 40, then this is perhaps a forlorn hope.

In order to prevent NCDs (ie to promote healthiness), I would suggest initiating screening in a much younger population, (perhaps even starting just as people leave school at 18) who can (probably rightly) assume that they are reasonably healthy and who should have fewer anxieties about volunteering to be tested. Over time, such a scheme would allow trends in indicators of healthiness to be monitored and changes addressed before disease sets in and the person has to begin a possibly life-long course of treatment, with all that means for his or her quality of life and for the NHS.

To find out more about me and my medical writing work, please visit my website at www.freelancemedicalwriting.co.uk .

17 October 2012

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Communicating on non-communicable diseases

Last week, the World Health Organization (WHO) held its annual World Health Assembly (#WHA65) in Geneva, Switzerland. I was particularly interested to read the outcomes of the session on the prevention and control of non-communicable diseases (NCDs) – cardiovascular disease (CVD), cancers, chronic respiratory diseases (eg asthma and chronic obstructive pulmonary disease [COPD]) and diabetes mellitus (especially type 2 diabetes [T2DM] – which took place on 22nd May 2012. Most medical writers will work on one or more of these conditions at some point during their career because of their high prevalence and their correspondingly high levels of interest to the pharmaceutical and medical devices industries.

The background to the session is interesting.

In 2009, the leaders of the International Diabetes Foundation (IDF), World Heart Federation and the International Union Against Cancer (UICC) came together at WHO’s 62nd World Health Assembly to launch a campaign for a UN summit on NCDs to address the demographic-shifting levels of deaths from NCDs in low- and middle-income countries.1 This group highlighted the futility of spending millions of dollars every year to save people from infectious diseases only to lose them at a relatively early age to NCDs, particularly when efficacious drugs to address these conditions are readily available and cheap. In 2010, this group of three founded the NCD Alliance (www.ncdalliance.org), bringing together a network of 880 member organisations in 170 countries to continue to advocate for action against NCDs.

The UN duly held a high level Global Assembly Meeting in September 2011, to which >30 heads of state and government and ≥100 other senior ministers and experts were invited and which upheld the NCD Alliance’s call for NCDs to be added to the development agenda. As a result, the UN charged WHO with setting up a global surveillance programme and making recommendations for voluntary global targets for reducing deaths due to NCDs before the end of 2012.2 Perhaps surprisingly (and underlining the seriousness with which the UN regards these goals), this is only the second health-related campaign promoted by the UN – the first being the campaign to control the spread of HIV/AIDS.

The statistics3 that prompted the UN to act are shocking. NCDs account for 57 million deaths annually (63% of all deaths). Approximately 16% of all deaths due to NCDs occur in the under-60s. A disproportionate number of these occur in developing nations, where widespread death and debilitation among adults of working age could retard industrial development and where in any case the loss of a wage earner throws families back into poverty from where they are more susceptible to the effects of NCDs. Worse, WHO estimates that the proportion of deaths attributable to NCDs will increase by 17% worldwide in the next decade. The key messages to take from this are that NCDs are not conditions only associated with the developed world and not only associated with aging.

The burden of caring for people with NCDs is no less daunting. One in three people has raised blood pressure (a risk factor for CVD), rising to almost one in two in Africa, and one in ten people has diabetes mellitus.4 Moreover, in every region of the world the prevalence of obesity – which is a risk factor in T2DM, CVD and some cancers – doubled between 1980 and 2008.3 Today, half a billion people (12% of the world’s population) are considered obese. Worryingly, it is thought that there are hundreds of millions of people worldwide who are unaware that they have a NCD and whose first contact with the health service will only come when they develop complications associated with advanced disease. No wonder, then, that Margaret Chan – Director-General of WHO – referred to NCDs as ‘the diseases that break the bank’ at last week’s meeting.

It is generally recognised that the slowly progressive nature of most NCDs requires a quite different mindset at government/NGO level to that necessary for promoting control of infectious disease outbreaks. The NCD programme must be goal orientated and focussed on prevention (ie reducing exposure to risk factors such as tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity) and universal access to treatment.1  WHO has announced its aim to work with its existing stakeholders in the education, agriculture, sports, transport, communications, urban planning, industry, employment and finance sectors, in addition to the health sector, to develop a global framework for the prevention and control of NCDs.5

De Maeseneer et al, in their commentary on the aims of the NCD Alliance, agree that a fundamentally different approach is required for preventing and controlling NCDs but disagree that the vertical, disease-orientated approach advocated by the Alliance is the best way to approach the problem.6 They note that altering patient perceptions and behaviours are key aims in preventing and treating NCDs and that this process requires more than just access to medicines. They believe that it is necessary to empower patients, reduce barriers to healthy lifestyles and care that reflects the needs of individual patients and that this is best achieved by global investment in local primary healthcare.

And the outcome of the session at the WHA65? A target to reduce premature deaths due to NCDs by 25% by 2025 – this is a massive target (and an incredible achievement for the NCD Alliance).

Speaking personally, though, I was struck by the lack of any reference to the need for innovation in the approach to the prevention and control of NCDs. We know what the causes are, we know how to prevent NCDs and, as the Alliance has pointed out, medicines are available – but still their prevalence is increasing in countries with well-funded healthcare services and in countries without.

De Maeseneer et al, whose paper was published before WHO assembly, say that: ‘We must fundamentally rethink the way that we address complexity in health problems, in both developed and developing countries.’ And I agree with them.

References

1. IDF, UICC, International Heart Federation. Time to act: The global emergency of non-communicable diseases (2009). Available at: http://www.world-heart-federation.org/fileadmin/user_upload/documents/Publications/Time%20to%20Act%20-%20High%20Res.pdf

2. UN News Center. UN launches global campaign to curb death toll from non-communicable diseases (19 September 2011). Available at: http://www.un.org/apps/news/story.asp?NewsID=39600&Cr=non+communicable+diseases

3. World Health Organization. World health statistics 2010 (2011). Available at: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf

4. World Health Organization. World health statistics 2012 (May 2012). Available at: http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Brochure.pdf

5. World Health Organization. Sixty-fifth World Health Assembly: daily notes on proceedings. (Tuesday 22nd May, 2012). Available at: http://www.who.int/mediacentre/events/2012/wha65/journal/en/index4.html

6. De Maeseneer J, Roberts RG, Demarzo M et al. Tackling NCDs: a different approach is needed. Lancet 2012;379:1860–1. (Free registration.)

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