Cherian Varghese

Priority actions for the non-communicable disease crisis

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US

Responding to the threat of chronic diseases in India

9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

The rise of chronic non-communicable diseases in southeast Asia: time for action

At the present stage of Indias health transition, chronic diseases contribute to an estimated 53% of deaths and 44% of disability-adjusted life-years lost. Cardiovascular diseases and diabetes are highly prevalent in urban areas. Tobacco-related cancers account for a large proportion of all cancers. Tobacco consumption, in diverse smoked and smokeless forms, is common, especially among the poor and rural population segments. Hypertension and dyslipidaemia, although common, are inadequately detected and treated. Demographic and socioeconomic factors are hastening the health transition, with sharp escalation of chronic disease burdens expected over the next 20 years. A national cancer control programme, initiated in 1975, has established 13 registries and increased the capacity for treatment. A comprehensive law for tobacco control was enacted in 2003. An integrated national programme for the prevention and control of cardiovascular diseases and diabetes is under development. There is a need to increase resource allocation, coordinate multisectoral policy interventions, and enhance the engagement of the health system in activities related to chronic disease prevention and control.

Evaluation of chemoprevention of oral cancer with spirulina fusiformis

Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a countrys gross national income. Families shoulder the financial burden, but entire economies suffer as well. Although attempts to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and to study the effects of interventions. All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. The Association of Southeast Asian Nations is in a unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect millions of lives-often, the lives of those who have the least.

Radiotherapy in the treatment of verrucous carcinoma of the oral cavity

The blue-green microalgae Spirulina, used in daily diets of natives in Africa and America, have been found to be a rich natural source of proteins, carotenoids, and other micronutrients. Experimental studies in animal models have demonstrated an inhibitory effect of Spirulina algae on oral carcinogenesis. Studies among preschool children in India have demonstrated Spirulina fusiformis (SF) to be an effective source of dietary vitamin A. We evaluated the chemopreventive activity of SF (1 g/day for 12 mos) in reversing oral leukoplakia in pan tobacco chewers in Kerala, India. Complete regression of lesions was observed in 20 of 44 (45%) evaluable subjects supplemented with SF, as opposed to 3 of 43 (7%) in the placebo arm (p < 0.0001). When stratified by type of leukoplakia, the response was more pronounced in homogeneous lesions: complete regression was seen in 16 of 28 (57%) subjects with homogeneous leukoplakia, 2 of 8 with erythroplakia, 2 of 4 with verrucous leukoplakia, and 0 of 4 with ulcerated and nodular lesions. Within one year of discontinuing supplements, 9 of 20 (45%) complete responders with SF developed recurrent lesions. Supplementation with SF did not result in increased serum concentration of retinol or beta-carotene, nor was it associated with toxicity. This is the first human study evaluating the chemopreventive potential of SF. More studies in different settings and different populations are needed for further evaluation.

Overall survival from breast cancer in Kerala, India, in relation to menstrual, reproductive, and clinical factors

Verrucous carcinomas are considered to have poor radioresponsiveness and radiotherapy has been reported to induce anaplastic transformation. Surgery has been considered to be the primary mode of treatment for these tumours. The clinical features, response to radiotherapy, survival and prognostic factors of a group of 53 patients with oral verrucous cancers, were studied and compared to patients with oral well-differentiated, squamous cancers, treated during the same time period. The buccal mucosa was the commonest primary site in both groups. 42 patients with verrucous cancer underwent primary radiotherapy and 11 underwent primary surgery. Complete response to radiotherapy was achieved in 76% of patients with verrucous cancer and partial response in 24%. Patients with verrucous cancer had a five year actuarial disease-free survival of 66% and overall survival of 86%. The corresponding survival figures were 43% and 56% in well-differentiated squamous cancers (P = 0.004). Composite stage of disease was a significant predictor of disease-free survival in both groups. None of the 16 patients with verrucous cancers that recurred after radiotherapy, had features of anaplastic transformation. Oral verrucous carcinoma appears to have similar radioresponsiveness and improved disease-free survival, compared to well-differentiated squamous cancers. The treatment policies for other oral squamous cancers are applicable to these tumours.

Stroke Prevention Worldwide--What Could Make It Work?

Background. Breast cancer accounts for one‐fourth of cancer cases seen in female patients in Kerala, India. Results of a retrospective analysis of breast cancer in Kerala are presented in this article.

Cervical cancer in Kerala: a hospital registry-based study on survival and prognostic factors.

The global burden of stroke is of continual major importance for global health. The present report addresses some of the core principles that could make stroke prevention work. The prevention of stroke shares many common features with other non-communicable diseases (NCDs); stroke prevention should therefore be part of the joint actions on NCD led by the WHO and member states. Stroke prevention is an integral part of both the 2011 UN declaration on actions on NCDs and the UN Post-2015 Sustainable Developmental Goals. Stroke prevention requires an intersectoral approach, with important responsibilities on the part of governmental bodies, non-government organizations and the health sector as well as communities, industries and individuals. Although official development assistance will need to be provided for the lowest income countries, financing will need to be raised for most countries by reallocation of resources within the country. Stroke is a prototype NCD in that there is overwhelming scientific evidence that with actions taken to reduce risk factors, the risk of stroke can be substantially reduced. Prevention of stroke will also have beneficial effects on cognitive decline and dementia. As most strokes do not lead to death, stroke statistics should not only focus on mortality, but also on disability and quality of life. All preventive actions should start early in life and continue during the life cycle. Prevention of stroke is a complex medical and a political issue with many challenges. Upscaling of efforts to prevent stroke are urgently needed in all regions, and the opportunity to act is now.

Care of non-communicable diseases in emergencies

The survival experience of 452 cervical cancer patients registered during 1984 by the hospital registry of the Regional Cancer Centre, Trivandrum, Kerala, India, is described in this paper. Eighty per cent of the patients completed the prescribed treatment, which was predominantly radiotherapy. The vital status of each patient was established by scrutiny of case records and by reply-paid postal enquiries. The observed survival rates were estimated by the Kaplan-Meier method and prognostic factors were assessed using Coxs proportional hazards regression analysis. The overall 5 year observed survival rate was 47.4% (95% CI, 41.6-52.9%). Socioeconomic status, performance status and the clinical stage of disease emerged as independent predictors of survival. Low survival was associated with advanced stages of disease, low socioeconomic status and poor performance status. The problems in studying survival from cancer in developing countries and the strategies used to improve follow-up rates in India are discussed. It is stressed that trends in survival rates may be used to evaluate cancer control programmes in developing countries in the absence of reliable mortality statistics and, even when mortality data are available, survival rates are valuable comparative statistics. Earlier detection by improving the awareness of the population and the physicians will improve survival rates, but a more effective and prudent approach would be to prevent invasive cervical cancer, and thereby reduce mortality, by implementing feasible and effective screening programmes in India.

Prevention of infection-related cancers in the WHO Western Pacific Region

Introduction Emergencies include natural disasters such as earthquakes and severe meteorological events, but also armed confl ict and its consequences, such as civil disruption and refugee crises (sometimes termed chronic emergencies). The health component of the humanitarian response to emergencies has traditionally focused on management of acute conditions such as trauma and infectious illnesses. However, noncommunicable diseases (NCDs) such as diabetes, hypertension, cardiovascular disease, cancer, and chronic lung disease are now leading causes of disability and death in low-income and middle-income countries (LMICs) and disaster-prone areas. NCDs require ongoing management for optimal outcomes, which is challenging in emergency settings because natural disasters or confl icts increase the risk of acute NCD exacerbations and decrease the ability of health systems to respond. Also, complex emergencies compromise NCD prevention and control over a prolonged period; limited access to timely treatment can lead to poor outcomes for patients and impose the high costs of managing complications on humanitarian agencies. Therefore, a more comprehensive approach to NCD management in emergencies is an important but neglected aspect of humanitarian response. Management of NCDs in emergencies requires inclusion of NCD care into standard operating procedures, which would facilitate horizontal and vertical integration with other aspects of relief eff orts. Humanitarian response in emergencies can be divided into three phases: mitigation and preparedness, emergency response, and post-emergency phase. Existing guidance for humanitarian response identifi es certain NCD-relevant considerations, but these chiefl y refer to the emergency response phase and are limited in scope. Here we propose the content of a minimally adequate response to NCDs in emergencies. This Viewpoint proposes specifi c actions organised by phase of the humanitarian response (fi gure), as well as some potential indicators for assessment of progress. We selected actions for inclusion based on their potential to reduce morbidity and mortality while minimising administrative and logistical burden for humanitarian responders. Where possible, we have prioritised actions that align with existing eff orts to strengthen NCD care.