Ageing And The Challenge Of Noncommunicable Diseases In Low

ageing and the challenge of non-communicable diseases in low and middle-income countries a position paper we are living in the

Ageing and the challenge of non-communicable diseases in low and
middle-income countries
a position paper
We are living in the century of global ageing. Global investment in
public health and wellness has resulted in the triumph of longevity,
which is a worldwide phenomenon. By 2030, for the first time in
history those over 60 will outnumber those under 15, with the fastest
growth in the developing world.
This triumph for humanity also presents great challenges, among them
the need for urgent action to address the rising burden of
non-communicable diseases (NCDs) for older people worldwide.
“Health is a fundamental human right, indispensable for the exercise
of many other rights, and necessary for living a life in
dignity…Nevertheless, for millions of people around the world, the
full enjoyment of the right to health remains an elusive goal. This is
especially true for older persons, who are particularly vulnerable to
infringements of their right to health”1.
Healthy and active ageing requires investment in age-friendly and
affordable health services. This approach will drastically improve the
well- being of people over 60.
A whole life course approach to NCDs, which is inclusive of all ages,
should be adopted for any recommendations on detection and diagnosis,
and strategies for prevention, management and treatment as well as
more effective care. Just as it is never too early to start prevention
and promotion efforts counteracting NCDs, so it is never too late.
We challenge the use of discriminatory language and concepts relating
to older age in the NCDs debate. The criteria for setting an
age-specific point for ‘prevention of premature death’ should be
subject to review.
Demographic transition - the ageing of humanity
During the 21st century the world will make a historic transition. For
the first time in history humanity will no longer be young, as the
number of people over 60 will outnumber those under 15 by 2030. The
enormous gains in health, economic and human development of the past
one hundred years have produced the triumph of ageing in this century.
This triumph is accompanied by many challenges. Population ageing is
no longer the domain only of the “developed” world, but is occurring
most rapidly in low and middle-income countries, where the global
pattern of falling birth rates and rising life expectancy is most
rapid. Already the majority of people over the age of 60 live in
developing countries, a proportion which is projected to rise to over
80% by mid-century. Population ageing in developing countries is
leaving them less time to adapt to its consequences. The older
population is itself ageing, and again this is happening most quickly
in developing countries, where the size of the over-80 population is
growing faster than that of any other cohort2.
Progress in global health has benefitted older people, many of whom
live longer and healthier lives. However, for older people as for
other age groups, progress in health has been deeply unequal. In
developing countries, health priorities reflect those prioritised by
the Millennium Development Goals, with a focus on communicable
diseases, primary health care for children and mothers and
reproductive health. Despite the demographic and epidemiological
transition increasing the greatest burden of disease on
non-communicable conditions more associated with older age, addressing
older people’s health needs have low (or no) priority in health
policies and programme financing.
Epidemiological transition – the rise of NCDs
The global demographic transition has been accompanied by an
epidemiological transition, shifting from the predominance of
infectious, acute diseases to non-communicable or chronic disease.
NCDs include a wide range of chronic conditions, including cancer,
diabetes, cardiovascular disease, hypertension and also Alzheimer’s
and other dementias. While NCDs have been seen as “diseases of
affluence” the evidence is that risks are often greatest in poor and
deprived communities, worsened by exposure to health hazards over the
whole life-course.
NCDs and older people
Ageing brings an increased risk of developing chronic disease and
disability. Non-communicable diseases (NCDs) are already the single
largest cause of both mortality and morbidity in most developing
countries3. NCDs account for nearly 90% of the disease burden for the
over-60s in low-, middle and high income countries, and people over 60
accounted for 75% of the 35 million deaths from NCDs worldwide in
2004, with the majority in low and middle-income countries4. This was
recognised in the UN Secretary-General’s note of September 2010
transmitting the World Health Organization’s global status report on
NCDs, which refers to ageing as the first of four drivers of NCD
predominance in developing countries5.
The links between ageing and NCDs are increasingly visible in low- and
middle-income countries. Two-thirds of the 177 million people with
type-2 Diabetes are estimated to live in the developing world6, and
the greatest increase in prevalence of Type-2 Diabetes in older people
is expected to occur in Asia and Africa, where most patients will
probably be found by 20307. Large numbers of older people suffering
from cardio-vascular disease, stroke and diabetes are living in
developing countries. Hypertension, often undetected, is widespread in
older populations of low- and middle-income countries. In countries
such as Cuba (73%) urban China (63%) and urban India (60%)
hypertension prevalence rates approach the levels found in Europe and
north America. Half of China’s older rural population and nearly
one-third of older rural dwellers in India suffer from hypertension8.
Preventable risk factors for NCDs continue into old age. For example,
an average of 66% of older people in seven Latin American cities were
found to be overweight in a 2000 study9. Some non-modifiable risk
factors will also grow exponentially with ageing. By 2050 115 million
people worldwide will have Alzheimer’s disease or other dementias, 71%
of whom will be living in low- and middle-income countries10.
Chronic Disease, ageing and disability
Chronic diseases are thus the main cause not only of death but also of
disability in most developing countries. Disability is strongly
associated with age, especially in poor countries. Poverty and
exposure to harsh, hazardous living conditions over the life course,
as well as chronic illness acquired during the life-course, contribute
significantly to disability in old age.
Disability is predominantly concentrated in older populations. For
example blindness and visual impairment rise exponentially with age.
Over 80% of all people who are visually impaired are aged 50 and older
(although they represent only 19% of the world's population) and again
the great majority (well over 80%) live in the developing world11.
Evidence is also growing of the cost and social implications of the
impact of Alzheimer’s disease and other dementias. In 2010, the global
cost of dementia was an estimated $604 billion or 1% of global GDP.
The costs of informal care are borne especially heavily by poor
communities worldwide and therefore associated with poverty12.
Links between communicable and non-communicable diseases and ageing
also need to be addressed. For example, with increased access to
antiretroviral therapy for HIV, and the growth of new infections
amongst older people, an “ageing” of the epidemic is now occurring. It
is estimated that 14.3% of people living with HIV in sub-Saharan
Africa are 50 and over13 and this figure is rising14. This is a
reflection of a pattern that has emerged in high-income countries,
where research has also shown that older people living with HIV are
likely to have other health conditions (such as hypertension,
arthritis, heart disease and diabetes).
Women, NCDs and ageing
The rapid increase of the oldest-old populations and the feminization
of ageing will mean even greater risks of long-term physical and
mental frailty especially amongst women. Worldwide older women
represent the majority of older people, a proportion which increases
with age. The oldest old (80 plus) age group is growing
proportionately the fastest of all age groups. Women’s greater
longevity also carries a burden of ill health, and we are already
seeing the concentration of chronic disease in older women. For women
in developing countries who survive beyond middle age, life expectancy
is close to that of women in the developed world15; at age 65 for
example, women in developing countries now have about three-quarters
of the remaining life expectancy of their counterparts in the
developed world.
Older women are at risk of “multiple jeopardy” where social
disadvantages (such as widowhood and reduced family support) combine
to exacerbate age related disabling conditions. Older women are
prominent among sufferers from Alzheimer’s Disease and other
dementias, 58% of whom are already living in developing countries, and
these numbers are growing rapidly16. Again there are significant
gender differences in disability. Women are more likely than men to
have a longer duration of life lived with disability.
Responses to NCDs and ageing in the international development agenda
Combatting NCDs in developing countries makes sense from both a public
health and a development perspective. Since NCDs are both a cause and
outcome of poverty at all ages, combating them is also essential for
the achievement of the Millennium Development Goals (MDGs).
Recognition of the shift in disease profiles from infectious to
non-communicable diseases in disaster settings due to population
ageing and increased life expectancy has led to the inclusion of
minimum essential standards and indicators for response to NCDs in the
revised 2011 Sphere Minimum Standards for Humanitarian Response.17
However, so far progress in introducing NCDs onto the development
agenda has been slow. The Millennium Development Goals do not address
NCDs, while the focus of both donor and national government funding in
the developing world remains on infectious and acute diseases18.
Although action on health and poverty are key objectives in the 2002
Madrid International Plan of Action on Ageing, and ‘Advancing health
and wellbeing in old age’ is the second “priority direction” of the
Plan19, there has been little or no implementation of these objectives
by Member States. Likewise, WHO’s “Age Friendly Primary Health Care”
programme has had limited response in national health priorities20.
There are signs of welcome changes. In most WHO regions action plans
on NCDs are being developed (though the priority given to these plans
is often low, as is the visibility of older people within them). The
commitment of 130 UN member states in 2009 to hold a High-Level Summit
on NCDs in September, 2011 “provides an unrivalled opportunity to
create a sustained rights-based global movement to tackle NCDs,
analogous to the UN General Assembly Special Session on HIV infection
and AIDS a decade ago, which concluded that dealing with the disease
was central to the development agenda…A successful meeting will ensure
that NCDs become central to the long-term global development agenda”21.
An immediate opportunity for integration is provided by the UN member
states meeting in June 2011, three months ahead of the NCDs summit, to
review progress in response to the HIV epidemic. As the UN
Secretary-General notes in his report on the implementation of UN
declarations on HIV, ‘since people with HIV live longer as a result of
treatment advances, cancers and other disorders associated with ageing
are likely to become more prominent…underscoring the need…to provide
holistic care and support’22. Furthermore, the draft declaration for
the UN Summit on HIV and AIDS in June 2011 makes a direct link between
HIV, NCDs and ageing. It commits ‘to review models of service delivery
to take account of new evidence about the effects of long-term living
with HIV…including increased risks of cancer, disorders associated
with aging such as diabetes, cardiovascular disease and cognitive
impacts…and ensure access to holistic comprehensive care and support
services’23.
Action on ageing in the MDG debate is still a challenge, despite
commitments under MIPAA and the global drive towards ‘health for all.’
Given longevity and the family care associated with NCDs, the
financial implications of care responsibilities on already
impoverished families and caregivers need special recognition if the
Millennium Development Goals are to be realised.
Ageing and older people in the NCD debate
The increased focus on NCDs linked to the development agenda is
welcome, and a tribute to those who have successfully positioned the
issue in recent years. However, it is a concern that the challenge of
NCDs for older people in the developing world remains marginal. This
is particularly surprising given that population ageing is frequently
referred to as a key driver of the global growth in NCDs (for example,
in the preparation documents for the UN High-Level Meeting24).
Nor is this focus new. In 2002 the UN Madrid International Plan of
Action on Ageing recognised the growth in NCDs “in all regions of the
world”, and called for actions to reduce “the cumulative effects of
factors that increase the risk of disease and…potential dependence in
older age”25. As we have seen, the NCD burden is strongly associated
with old age, increasing the risk of long-term disability and
dependency.
It is also clear that ageing, associated with poverty, contributes to
a continued growth of the NCD burden in the developing world. A World
Bank report on NCDs in South Asia notes: “Aging is occurring rapidly
but often without the social changes…that accompanied aging in most
developed countries decades ago. Aging due to this transition will,
alone, increase NCDs because they are more common with increasing age.
However, population aging… is associated with a rapid increase in
health problems such as heart diseases, cancers, diabetes, and
obesity—in other
words, unhealthy aging—putting new pressure on health systems”26.
Nevertheless, despite broadly inclusive language about tackling “key
determinants of global health to strengthen chronic disease prevention
and promote improved health for all,”27 mention of the
disproportionate impact of NCDs on older people is strikingly absent
from much of the current dialogue. In citing the burden of disease,
some articles explicitly exclude those over 6028. References to older
people are often incidental to discussion of global population ageing
as a contributory factor to the overall burden of NCDs29. Data on NCDs
focuses on early onset and emphasises the need to prevent “premature”
death (i.e. death below the age of 60). For example a recent WHO paper
says:
“Sixty percent of all deaths in the world are caused by NCDs. Eighty
percent, or 38 million, of these deaths are in people from low- and
middle-income countries. Nine million people die from NCDs every year
before they reach their sixtieth birthday. And most of these
‘premature deaths’ occur in low- and lower middle-income countries. In
these countries, 47% of all NCD deaths occur in those under 60 years
old”30. There are frequent references to the concentration of NCDs in
the “economically productive” populations in developing countries but
almost none to the burden of NCDs in old age31.
The neglect of ageing and older people in dialogues on NCDs is so
prevalent as to suggest a possible strategy among those leading the
debate, perhaps as a means to motivate decision makers to take action
on NCDs by a focus on people at “productive ages”32. It has been
suggested for example that conceiving NCDs as diseases of old age is a
“negative myth” hindering intervention33. Just the opposite is the
case, as we have seen, but it may be thought necessary to focus
attention on younger, “productive” generations in order to emphasise
high-priority issues for the development agenda such as economic
impact of NCDs . This is both a denial of the rights of older people
and ignores the fact that many poor people in developing countries
continue to work productively well into old age.
The invisibility of older persons in the NCD debate is an example of
how ageing populations continue to have a marginal place in
development. Conversely a focus on a whole life course approach to
NCDs which is inclusive of older people presents opportunities for
innovative solutions which both keep people healthy and active longer,
and have beneficial social and economic impacts. For example, a
strategy “with greatest and most immediate impact is to address risk
factors in adulthood, and increasingly the elderly. Risk factor
behaviours can be modified in these groups and changes seen within 3-5
years. With all populations ageing, the sheer numbers and potential
cost savings are enormous and realizable”34.
Why prevention and management of NCDs in old age makes sense
Global demographic change and population ageing are a call to action.
“Population aging does raise some formidable challenges, but…also
bring some new opportunities, because people…have different capacities
and needs. The key is adaptation on all levels”35. Including older
people in programmes combating NCDs – both management and prevention –
makes sense for individuals, but also for families, societies and
economies. People who age in better health can remain productive for
longer, continuing to make significant contributions to their families
and communities. There will be reduced need for family support, and
particularly for the emergency care which often causes financial as
well as health crises in poor households. There will be an increasing
need for long-term care, especially for people entering later old age
with chronic illness. However, effective support to both formal and
informal carers will ensure the continuity of this vital assistance to
frail older people, with all its societal and economic benefits. In
the era of global ageing, helping people to age as well as possible
will not just be sensible policy, it will be indispensable.
HelpAge International’s position – key messages
Investment in public health has resulted in the triumph of longevity,
which is now a global phenomenon. However, progress in health
provision for older people has been deeply unequal across the world.
Increased longevity also leads to challenges – global ageing is one of
the key drivers of the exponential growth of NCDs.
*
A whole life course approach to NCDs, which is inclusive of all
ages, should be adopted for Summit recommendations on detection
and diagnosis, and strategies for prevention, management and
treatment as well as more effective care.
*
Diseases particularly prevalent in old age, ranging from blindness
to Alzheimer’s disease and other dementias need to be addressed
with urgency.
*
Governments should ensure the right of older people to
age-friendly prevention, diagnosis and treatment, as well as home
and institutional care services.
*
Health systems should recognise the strong interconnections of
NCDs and communicable diseases, working towards an integrated
health approach which addresses the spectrum of people’s health
needs and the interactions between them.
*
The explicit objectives on ageing, poverty and improved health (in
line with MDG goals) contained in the 2002 Madrid International
Plan of Action on Ageing shoul be implemented by the Member
States.
*
Action on the health consequences of rapid demographic change
should be a key element of international development targets after
2015.
*
The use of discriminatory language and concepts relating to older
age in the NCDs debate must be challenged. We call for a review of
the criteria for setting an age-specific point for ‘prevention of
premature death’.
*
Strategies against NCDs should recognise that inclusion of older
people in prevention, promotion and management strategies will
substantially reduce the health costs arising from rapidly ageing
populations
*
The economic and social contributions of older people should be
recognised, and “productive ageing” should be enabled by
strategies supporting the health of older populations
*
The following specific and measurable strategies to reach older
people should be considered:
*
Use WHO’s age friendly primary health care guidelines as a key
tool in all programmes combating NCDs
*
Include modules on older people’s health in health professional
training
*
Develop primary prevention, screening and treatment programmes
which are inclusive of older people
*
Develop social networks for community-based support of older
people, both as recipients and providers of care
*
Implement the NCD Alliance/Lancet recommendation to ensure
access to affordable essential drugs to treat NCDs as part of
primary health care programmes
*
Ensure continuity of treatment for older people with NCDs in
emergency responses
1 Office of the United Nations High Commission for Human Rights:
Expert consultation on older persons and the right to health.
Background paper. UN, Geneva April 2011
2 UN Department of Economic and Social Affairs: “World Population
Ageing 2009”. United Nations, New York 2010
3 Sub-Saharan Africa remains the exception, though even here NCDs are
accounting for a rapidly increasing share of mortality and morbidity
4 World Health Organisation: “Raising the priority of non-communicable
diseases in development work at global and national levels”. WHO
Presentation 2010
5UN General Assembly sixty-fifth session 13th September 2010: Note by
the Secretary-General transmitting the report by the Director-General
of the World Health Organization on the global status of
non-communicable diseases, with a particular focus on the development
challenges faced by developing countries
6 World Health Organisation: “Facts related to chronic disease”.
www.who.int
7 Wild S, Roglic G, Green A, Sicree R, King H: "Global prevalence of
diabetes: estimates for 2000 and projections for 2030". Diabetes Care
27 (5): 1047–53 (May 2004)
8 http://www.alz.co.uk/1066/1066 presentations
9 ECLAC/CELADE: “La situacion de las personas mayores”. Document
presented at Inter-Governmental Conference on Ageing, Santiago 2003
10 Alzheimer’s Disease International Annual Report 2010 p15
11 World Health Organisation: Visual impairment and blindness. Fact
sheet www.who.int ND
12 http://www.alz.co.uk/worldreport
13 Those aged 50 and overare considered as older people in the HIV
response. This is due to the fact that data on the epidemic is often
exclusively focussed on those aged 15-49 years
14 Negin J and Cumming R G 2010 HIV infection in older adults in
sub-Saharan Africa: extrapolating prevalence from existing data,
Bulletin of the World Health Organisation 2010;88:847-853
15 World Health Organisation: “Women, Ageing and Health” WHO Fact
Sheet no 252, June 2000.
16 Alzheimer’s Disease International: World Alzheimer’s Report 2009 p8
17 The Sphere Project Handbook, 2011, page 336
18 Geneau, R. et al: “Raising the priority of preventing chronic
diseases: a political process” The Lancet vol 376 issue 9753 pp
1689-98 13 November 2010
19 United Nations, ‘Madrid International Plan of Action on Ageing’
paras 48 (a) and (b), NY 2002/3
20 World Health Organisation: Towards Age-friendly Primary Health
Care. WHO, Geneva 2004.
21 Beaglehole, R. et al: “Priority actions for the non-communicable
disease crisis”. www.thelancet.com Published online April 6, 2011
22 UN General Assembly 2011 Implementation of the declaration of
commitment on HIV/AIDS and the political declaration on HIV/AIDS:
uniting for universal access: towards zero new HIV infections, zero
discrimination and zero AIDS –related deaths, Report of the Secretary
General 28 March 2011
23 United Nations: Draft declaration on HIV/AIDS “Zero New Infections
– Zero Discrimination – Zero AIDS Related Deaths” April 2011
24 UN General Assembly sixty-fifth session 13th September 2010: Note
by the Secretary-General transmitting the report by the
Director-General of the World Health Organization on the global status
of non-communicable diseases, with a particular focus on the
development challenges faced by developing countries
25 Report of the Second World Assembly on Ageing Madrid, 8-12 April
2002 United Nations
New York, 2002
26 Engelgau, M. et al: Capitalizing on the Demographic Transition:
Tackling Noncommunicable Diseases in South Asia” World Bank February
2011 p X
27 Geneau, R. et al: Raising the Priority of Preventing Chronic
Diseases: a Political Process, The Lancet (2010) 376: 1696
28 Mbanya, et. Al: “Mobilising the World for Chronic NCDs”, The
Lancet, 377 February 12, 2011, p. 536 (“The 9 million deaths such
diseases cause in people younger than 60 years of age each
year…represent nothing less than a development emergency in slow
motion”)
29 Alwan, et. Al: “Monitoring and Surveillance of Chronic
Non-communicable Diseases: Progress and Capacity in High-Burden
Countries” The Lancet November 11, 2010, p. 53 (‘the ageing of the
populations of these countries will lead to a substantially increased
overall number of deaths”); WHO: Preventing Chronic diseases, a Vital
Investment (2005) p. 51
30 World Health Organisation: MDG side-event on NCDs (New York, 20
September 2010) background paper
31 See for example Information Note on a Joint WHO/FAO Expert
Consultation on Diet, Nutrition and the Prevention of Chronic
Diseases: “the growing epidemic of NCDs, which contributes to the
increasing loss of economically productive life years, affects
economic growth and places an increasing burden on the healthcare
sector”. FAO Rome April 2003
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32 See for example WHO: Preventing Chronic Diseases, a Vital
Investment (2005), p.37 (“It is often assumed that chronic disease
deaths are restricted to older people, but this is not the case”).
33 Geneau, et al op.cit.
34 Darnton-Hill, I. et al: “A life course approach to diet, nutrition
and the prevention of chronic diseases” Public Health Nutrition: 7
(1A) 2004 pp101-121
35 Bloom, D. et al: Population Aging: facts, Challenges and Responses.
Harvard University Program on the Global Demography of Aging Working
Paper 71 May 2011
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