[MUSIC] My name is Ib Bygbjerg. I'm a specialist in tropical medicine and infectious diseases. But also Professor of International Health and running a course in Global Health. Meaning that I should know about both communicable and non-communicable diseases. And this is what this presentation is about. We have on the one side the non-communicable diseases and on the other side the communicable. Do they have anything to do with each other? The answer is yes. They have a lot because they're hitting the same populations and the same people. But before discussing how much they are interacting and interlinked, and whether they're burdening each other doubling or tripling. We'll have to look into an analysis that was recently made by Murray and. He's looking into the disability adjusted life years that you've also heard about. And that's for no less than 291 diseases and injuries in 21 regions. And what did he find? Well, he found what we probably would have expected. That the global disease burden has continued to shift away from communicable towards non-communicable diseases and from premature death to long life or old age diseases. But that's not the whole truth, it varies. In the Sub-Saharan Africa, particularly many of the communicable and the maternal and neonatal deaths, and nutritional disorders they're still there. But they're also getting an emerging burden of non-communicable diseases. The regional heterogeneity is there. We have to understand what is the local burden and not only the global burden. So, how can we make the goals and the targets post 2015? So on this slide, you'll see the distribution of disability adjusted life-years in the world, in the high income countries, and the low income countries. You'll see them by 2002 and by 2030. And the world is divided into infectious diseases, which is dark blue, accidents in a light blue, and non-communicable diseases that are gray. And you'll see that the gray area is getting bigger and bigger but there are still the blue area. And if you go into particularly Sub Saharan Africa you will see that they still have their burden of non-communicable diseases. Some of these, the so called neglected diseases, they may be common in developing countries or low income countries. Whereas they are rare in the rich countries, and therefore they are simply neglected. Neglected by the industry, there is no market for them. And what can we do to get them on board? Make a new vertical program, that has been the way forward for many years. But, it could also be that, they should perhaps be adopted, or adapted to some of the other health problems. And this leads me to the next definition Orphan Disease. Sometimes it's the same as a Neglected Disease. It is alone in the world. Nobody cares for it. It could be because it's a very rare disease, but it could also be that it is frequent in an area where there is no money. So, often diseases and neglect diseases are linked and now come some of the questions. Could you think of some common diseases that has been ignored, neglected? And it's more prevalent in the low income countries than in the developed countries. But the next question is, what about some of these diseases that are actually prevalent in Africa but they have nothing to do with what we thought tropical medicine. Let's take hypertension. Hypertension a neglected disease in Africa? Yes it is. People are not prioritizing, there is no interventions against it. The same for diabetes in Asia until recently. So, are they orphan diseases or what are they? We could also ask whether we should leave it to the pharmaceutical industry to decide or classify the various diseases and how they're prioritized. And should we address them with a new vertical programme or should we try to do it more horizontally and jointly? So, I have a burning question and so has the ministers of health in developing countries. What should a poor government prioritize if there’s an increasing burden of non-communicable disease, and at the same time a remaining burden of neglected and orphan diseases? Well, maybe you should start looking for the joint risk factors and also if some of them could be managed together. So you'll have to adapt the control and the management and you'll have to do it in the existing primary health care system, because there won't be money for a new vertical approach. And besides adapting, you could start talking about adopting. Like an orphan, who adopted, or you link it. So take one of the neglected diseases and connect it with some other diseases which are not neglected. If they have the same manifestations, if they have the same complications, why don't you integrate the control and the management? So on this slide, one of my colleagues Olesen and Parker, made a very interesting study in Africa, and they looked to see are there any disease risk factors that are co-localized. And they divided into various categories, and as you can see from this slide, they found out that in big parts of Africa, there are three risk factors that are co-localized. One of them is high HIV prevalence. The other one is high overweight prevalence, particularly in women. And then there's also a high prevalence of neglected infectious diseases. So what should you prioritize? So let us do a little experiment or a little questionnaire. Here is two neglected diseases. They are both taking place in a low income country. [COUGH] They are both having the same symptoms, from the eyes, from the musculoskeletal system, the hand, the feet. They are also involving your eyes. And they also need long time, or life-long care. So they connected, could they be adopted, could they be managed jointly? Could you give one example? Most people wouldn't think about it. And when I've made this presentation recently in London, there was no good answer to this even if it was in a forum of neglected diseases. But the answer is leprosy, a communicable disease and diabetes a non-communicable disease. They both have problems with peripheral neuropathy. You can't feel your hands and your feet. You have problems with ulcers and superinfection. You may have cataracts. You may get blind, you may have deformities and you need special foot-wear. And I want to show you a concrete example of this from a previous leprosarium in India. Here's an old gentleman who was diagnosed with leprosy, neuropathy, food ulcers 30 years ago. But this picture is a recent picture where he came back to the old leprosarium. Now looking after other diseases as well. Again, he got lack of feeling in his feet. That was permanent, but now we've got new ulcers on his souls. He was investigated for leprosy by skin biopsies, there were no leprosy pests alive, but there was no sensitivity in his palms, as you can see here with this bone filament. If you can't feel that then there's something wrong. It could be leprosy, it could be diabetes. But they took a blood sugar and it was elevated so he has got Type 2 diabetes, neuropathy and ulcers whereas in the old days he had neuropathy from leprosy. Now he's managed in the same hospital as before. We'll take another example. Un-prioritized, non-communicable disease plus very much prioritized communicable disease in poor or developing country in the tropics. And that cover would benefit from integrated management and control because they have joint-risk factors and they interact. So what were you think of? Well, most people don't know but it's actually tuberculosis and diabetes. Rarely, yes. Smoking increases the risk for both. Alcohol, for both. Tuberculosis increases the risk for diabetes two fold. And diabetes increases the risk for tuberculosis three fold. And in and other places there are now clinics where people are being treated primarily for their tuberculosis but also from their diabetes by the same people and visa versa. So it is actually possible. Third example we take two un-prioritized, non-communicable diseases this time. The poor, developing country. And one is having a prevalence of 5%, sometimes more, and the other one is having a prevalence of 30%. What am I talking about? They would both benefit from integrated management and control, and they also have factors, and they interact. What am I talking about? Well, again, diabetes, 5%. Hypertension, 30%. What are the factors, smoking, obesity, westernized food increase the risk for both. Diabetes is that connected with hypertension at 60% of all diabetics have got hypertension. And both may end with a stroke or cardiovascular complication. So why should you have separate clinics for diabetes and for hypertension. It starts and they have seen the light. Now they have integrated clinics for diabetes and hypertension. Most people think, when they go to the tropics, and I have to admit, I'm a tropical medical expert myself. And I like malaria and trichomoniasis, but when I go to a rural hospital in Tanzania nowadays. I will see that it's not necessary being a tropical specialist that will do a major change. There is a ward in a so-called district hospital in Tanzania, and what will you see? You will not see tropical diseases and it infectious decisions alone. Here's a top ten list. Malaria is still there but after malaria comes a non communicable hypertension, non communicable heart disease, communicable pneumonia, tuberculosis, non communicable anemia, asthma, bronchitis, diabetes, and last meningitis, another infection. So it's about half and half, even in rural Tanzania, and this is by 2010. So one could ask, as I did in a recent publication, in Science, [COUGH] is at a time where there's a global financial crisis and a shrinking health budget, is that sharp demarcation between communicable and noncommunicable diseases justified when it's hitting maybe the same individual and even the same populations? So what are we talking about? Well, I could take an example from the nature. And here you'll see that there are one tree and another tree. One is a birch tree, and the other one is a beech tree. Are they antagonizing each other, or are they supporting one another, are they adapting and so on. If trees can find out, why can't the health system find out? Maybe we are getting too specialized. As I said before, I made this presentation recently, in London. And there was the editor from, The Atlantic, present and he said, that's interesting. And later he wrote this leading article, where he was writing, you will have two birds with one stone. So, maybe, the messages is about to be taken. One of our heroes, the previous Director General and of the World Health Organization, Halfdan Mahler who was the father of the Alma Ata Declaration of Primarily Healthcare was a very clever man because he was promoting, at the same time, primary healthcare, integrated healthcare, management, etc. But he was also aware that the medical profession would not necessarily like this. He was also aware that if you're not getting the specialties on board then you have a problem. So the of disease requires integrated balanced control strategies that should begin with the primary health care, yes. But as you said quote, it should not be forgotten that integration far from being a laissez-faire approach requires maximum involvement of all specialized personnel, not just the primary health care sector. So with these warnings and with these hopes I think I'll end this presentation and thank you for your attention.
