Srinath Reddy

Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Harvard School of Public Health, Boston, MA, USA (Prof J Frenk MD); China Medical Board, Cambridge, MA, USA (L Chen MD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD); George Washington University Medical Center, Washington, DC, USA (Prof J Cohen MD); Independent member of House of Lords, London, UK (N Crisp KCB); James P Grant School of Public Health, Dhaka, Bangladesh (Prof T Evans MD); US Institute of Medicine, Washington, DC, USA (H Fineberg MD, P Kelley MD); School of Public Health Universidad Peruana Cayetano, Heredia, Lima, Peru (Prof P Garcia MD); Peking University Health Science Centre, Beijing, China (Prof Y Ke MD); National Health Laboratory Service, Johannesburg, South Africa (B Kistnasamy MD); School of Nursing, University of Pennsylvania, Philadelphia, PA, USA (Prof A Meleis PhD); University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); The Rockefeller Foundation, New York, NY, USA (A Pablos-Mendez MD); Public Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Prevention of chronic diseases: a call to action

Chronic (non-communicable) diseases--principally cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes--are leading causes of death and disability but are surprisingly neglected elements of the global-health agenda. They are underappreciated as development issues and underestimated as diseases with profound economic effects. Achievement of the global goal for prevention and control of chronic diseases would avert 36 million deaths by 2015 and would have major economic benefits. The main challenge for achievement of the global goal is to show that it can be reached in a cost-effective manner with existing interventions. This series of papers in The Lancet provides evidence that this goal is not only possible but also realistic with a small set of interventions directed towards whole populations and individuals who are at high risk. The total yearly cost of the interventions in 23 low-income and middle-income countries is about US

An international randomised placebo-controlled trial of a four-component combination pill ("polypill") in people with raised cardiovascular risk

5.8 billion (as of 2005). In this final paper in the Series we call for a serious and sustained worldwide effort to prevent and control chronic diseases in the context of a general strengthening of health systems. Urgent action is needed by WHO, the World Bank, regional banks and development agencies, foundations, national governments, civil society, non-governmental organisations, the private sector including the pharmaceutical industry, and academics. We have established the Chronic Disease Action Group to encourage, support, and monitor action on the implementation of evidence-based efforts to promote global, regional, and national action to prevent and control chronic diseases.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS)

Background There has been widespread interest in the potential of combination cardiovascular medications containing aspirin and agents to lower blood pressure and cholesterol (‘polypills’) to reduce cardiovascular disease. However, no reliable placebo-controlled data are available on both efficacy and tolerability. Methods We conducted a randomised, double-blind placebo-controlled trial of a polypill (containing aspirin 75 mg, lisinopril 10 mg, hydrochlorothiazide 12.5 mg and simvastatin 20 mg) in 378 individuals without an indication for any component of the polypill, but who had an estimated 5-year cardiovascular disease risk over 7.5%. The primary outcomes were systolic blood pressure (SBP), LDL-cholesterol and tolerability (proportion discontinued randomised therapy) at 12 weeks follow-up. Findings At baseline, mean BP was 134/81 mmHg and mean LDL-cholesterol was 3.7 mmol/L. Over 12 weeks, polypill treatment reduced SBP by 9.9 (95% CI: 7.7 to 12.1) mmHg and LDL-cholesterol by 0.8 (95% CI 0.6 to 0.9) mmol/L. The discontinuation rates in the polypill group compared to placebo were 23% vs 18% (RR 1.33, 95% CI 0.89 to 2.00, p = 0.2). There was an excess of side effects known to the component medicines (58% vs 42%, p = 0.001), which was mostly apparent within a few weeks, and usually did not warrant cessation of trial treatment. Conclusions This polypill achieved sizeable reductions in SBP and LDL-cholesterol but caused side effects in about 1 in 6 people. The halving in predicted cardiovascular risk is moderately lower than previous estimates and the side effect rate is moderately higher. Nonetheless, substantial net benefits would be expected among patients at high risk. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12607000099426

Poverty and Human Development The Global Implications of Cardiovascular Disease

Summary Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the worlds population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by Chinas rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Verbal autopsy coding: are multiple coders better than one?

Cardiovascular disease (CVD) is absent from the global development agenda. This absence is striking, because CVD is a major impediment to human development, imposing large health and economic burdens in low- and middle-income countries. These burdens have a reciprocal relationship in that poverty is a potent cause of CVD, whereas CVD contributes to poverty. The present editorial explores and seeks to explain the global neglect of CVD in pursuit of a strategy for its prevention and control worldwide. Chronic (noncommunicable) disease, principally CVD, cancer, chronic respiratory disease, and diabetes mellitus, caused 35 million deaths (60% of all deaths) in 2005. CVD (mainly heart disease and stroke) is the leading chronic disease, with 17 million deaths. The contribution of diabetes mellitus is underestimated; deaths due to diabetes are usually recorded as being due to heart disease or renal failure. CVD is also responsible for much disability, often for decades of a person’s life. Nearly half of the global burden of disease is caused by chronic diseases, and CVD is the leading contributor among these.1 Although the CVD burden and trends vary from country to country,2,3 from a human development perspective, 4 aspects of the burden of CVD are critical. First, the number of CVD deaths is similar in men and women, although the average age of onset is older in women than in men, so no gender bias exists in the burden of CVD that might remove it from development agendas.4 Second, the poorest countries are often deeply affected. CVD deaths are spread evenly among the developed and developing world; this is not a disease specific to wealthy nations. Of the world’s population, 80% of people live in developing nations, and 80% of all CVD deaths, occur in countries with a per capita income in 2001 of less …

Assessment of physical activity using accelerometry, an activity diary, the heart rate method and the Indian Migration Study questionnaire in South Indian adults.

OBJECTIVE To assess the impact on the reported cause-of-death patterns of a verbal autopsy coding strategy based on a review of every death by multiple coders versus a single coder. METHODS Deaths in 45 villages (total population 180,162) in southern India were documented during 12 months in 2003-2004, and a standard verbal autopsy questionnaire was completed for each death. Two physician coders, each unaware of the others decisions, assigned an underlying cause of death in accordance with the causes listed in the chapter headings of the International classification of diseases and related health problems, 10th revision (ICD-10). For the three chapter headings that applied to more than 100 of the deaths, agreement for subsets of causes of death within the chapter was also analysed. In the event of discrepancies, a third coder was used to finalize a cause of death. Cohens kappa statistic (Kappa) was used to measure levels of agreement between the two physician coders. FINDINGS In total, 1354 deaths were documented, and a verbal autopsy was completed for 1329 (98%) of them. At the chapter heading level of the ICD-10, physician coders assigned the same cause to 1255 deaths (94%) (Kappa = 0.93; 95% confidence interval: 0.92-0.94). The patterns of death derived from the causes assigned by each physician were all very similar to the patterns obtained through the consensus process, with the rank order of the 10 leading causes of death being the same for all three coding methods. CONCLUSION Duplicate coding of verbal autopsy results has little advantage over a single-coder system for mortality surveillance or for identifying population patterns of death. Resources could be better diverted to other parts of the mortality surveillance process, such as validation.

Regional Case Studies – India

OBJECTIVE To validate questionnaire-based physical activity level (PAL) against accelerometry and a 24 h physical activity diary (24 h AD) as reference methods (Protocol 2), after validating these reference methods against the heart rate-oxygen consumption (HRVO2) method (Protocol 1). DESIGN Cross-sectional study. SETTING Two villages in Andhra Pradesh state and Bangalore city, South India. SUBJECTS Ninety-four participants (fifty males, forty-four females) for Protocol 2; thirteen males for Protocol 1. RESULTS In Protocol 2, mean PAL derived from the questionnaire (1.72 (sd 0.20)) was comparable to that from the 24 h AD (1.78 (sd 0.20)) but significantly higher than the mean PAL derived from accelerometry (1.36 (sd 0.20); P < 0.001). Mean bias of PAL from the questionnaire was larger against the accelerometer (0.36) than against the 24 h AD (-0.06), but with large limits of agreement against both. Correlations of PAL from the questionnaire with that of the accelerometer (r = 0.28; P = 0.01) and the 24 h AD (r = 0.30; P = 0.006) were modest. In Protocol 1, mean PAL from the 24 h AD (1.65 (sd 0.18)) was comparable, while that from the accelerometer (1.51 (sd 0.23)) was significantly lower (P < 0.001), than mean PAL obtained from the HRVO2 method (1.69 (sd 0.21)). CONCLUSIONS The questionnaire showed acceptable validity with the reference methods in a group with a wide range of physical activity levels. The accelerometer underestimated PAL in comparison with the HRVO2 method.

Sugar, tobacco, and alcohol taxes to achieve the SDGs

As a proportion of all deaths in India, cardiovascular disease (CVD) will be the largest cause of disability and death, by the year 2020. At the present stage of Indias health transition, an estimated 53% of deaths and 44% of disability-adjusted life-years lost are contributed to chronic diseases. India also has the largest number of people with diabetes in the world, with an estimated 19.3 million in 1995 and projected 57.2 million in 2025. The prevalence of hypertension has been reported to range from 20 to 40% in urban adults and 12-17% among rural adults. The number of people with hypertension is expected to increase from 118.2 million in 2000 to 213.5 million in 2025, with nearly equal numbers of men and women. Over the coming decade, until 2015, CVD and diabetes will contribute to a cumulative loss of USD237 billion for the Indian economy. Much of this enormous burden is already evident in urban as well as semi-urban and slum dwellings across India, where increasing lifespan and rapid acquisition of adverse lifestyles related to the demographic transition contribute to the rising prevalence of CVDs and its risk factors such as obesity, hypertension, and type 2 diabetes. The underlying determinants are sociobehavioral factors such as smoking, physical inactivity, improper diet and stress. The changes in diet and physical activity have resulted largely from the epidemiological transition that is underway in most low income countries including India. The main driving forces of these epidemiological shifts are the globalized world, rapid and uneven urbanization, demographic shifts and inter- and intra-country migrations--all of which result in alterations in dietary practices and decreased physical activity. While these changes are global, India has several unique features. The transitions in India are uneven with several states in India still battling the ill effects of undernutrition and infectious diseases, while in other states with better indices of development, chronic diseases including diabetes are emerging as a major area of concern. Regional and urban-rural differences in the occurrence of CVD are the hallmark. All these differences result in a differing prevalence of CVD and its risk factors. Therefore while studying nutrition and physical activity shifts in India, the marked heterogeneity and secular changes in dietary and physical activity practices should be taken into account. This principle should also apply to strategies, policies and nutrition and physical activity guidelines so that they take the regional differences into account.

Recommendations for the implementation of WHO Framework Convention on Tobacco Control Article 14 on tobacco cessation support

More than a decade after the adoption of the WHO Framework Convention on Tobacco Control, there is compelling evidence that raising tobacco prices substantially through taxation is the single most effective way to reduce tobacco use and save lives. Similarly, alcohol taxation is a cost-effective way to reduce alcohol consumption and harm. With growing evidence, sugar taxes are another fiscal tool to promote health and nutrition. Mexico’s sugar tax reduced sugarsweetened beverage sales by 5% in the first year, with an almost 10% further reduction in the second year. Tobacco taxes in South Africa contributed to tobacco consumption decreases of about 40% between 1993 and 2003. When Finland reduced taxes on alcohol in 2003, alcohol-related mortality increased by 16% among men and by 31% among women. As part of a broader public health approach to promote a life-course approach to prevention and to address commercial determinants of health, it is now time for governments to adopt sugar, tobacco, and alcohol taxes (STAX). Despite their potential, taxes on sugar, tobacco, and alcohol are underused by policy makers. The 2017 WHO Report on the Global Tobacco Epidemic showed that only 10% of the world’s population is covered by sufficiently high levels of tobacco taxation. According to this report, the tobacco industry undermines taxation efforts by lobbying policy makers and exaggerating their industry’s economic value and the risk of illicit trade. The alcohol and food industries are now deploying similar tactics—one example is successful efforts to erase language on alcohol and sugar taxes in the Montevideo Roadmap on non-communicable diseases (NCDs). Despite industry efforts, taxation is gaining more attention from policy makers as a win–win–win policy measure for public health, domestic resource mobilisation, and equity. Taxes on sugar, tobacco, and alcohol have been, or are now being, introduced in diverse contexts, including Botswana, Chile, Ecuador, India, Mexico, Nigeria, Peru, Saudi Arabia, South Africa, the United Arab Emirates, and the UK. Tobacco and alcohol taxes are recognised by WHO as “Best Buys” to prevent and control NCDs; taxes more broadly are a focus of the Bloomberg Task Force on Fiscal Policy for Health in advance of this year’s UN High-Level Meeting (HLM) on NCDs. NCDs are estimated to account for 72% of all deaths globally and this proportion is growing. Worldwide, tobacco is estimated to kill more than 7 million people and alcohol more than 3 million people each year. The global number of young people aged 5–19 years who are overweight and/or obese has increased from 11 million in 1975 to 124 million in 2016. Sugar consumption is a major contributor. High body-mass index is estimated to claim at least 4 million lives each year. The consumption of tobacco, alcohol, and sugar are risk factors for health and NCDs that disproportionately affect people with low socioeconomic status and low-income countries, which are the least prepared. STAX could help mitigate these risk factors. Yet existing efforts are inconsistently applied. Scaled-up country support is needed to accelerate and implement STAX as a cost-effective fiscal policy to contribute to the Sustainable Development Goals (SDGs). STAX not only contribute to improving health and saving lives, but they can also raise resources. For example, Thailand’s Health Promotion Act of 2001 established a tax on tobacco and alcohol, which now contributes about US