Living to the end: Palliative care for an ageing population.

The theme above is about a goal that concerns every one of us.  

On the occasion of this World Hospice and Palliative Care Day (13 October 2012), this blog ‘Stop-NCDs Network’, joins the international fraternity in issuing a warning and drawing attention of all concerned to an urgent need. 

The objective is not an ordinary one, but of a global dimension: necessity to respond to improved palliative care for the world’s ageing populations. 

In this context, the global trend is alarming. Within the next five years, the number of adults aged 65 and over will outnumber children under the age of five. And the older people are at higher risk of multiple, chronic debilitating conditions such as cardiovascular disease, diabetes, cancer, dementia and HIV/AIDS. 

Many older people are at a higher risk of living in agony and pain, and die in pain and distress as they are unable to access the care they need, including the appropriate medications to address their suffering. 

Given the  estimates for NCDs by the World Health Organization (WHO) in near future, millions of adults will require palliative care at the end of life each year: 66% of these are over 60 years old. Older people at the end of life are missing out on vital care and support because of a lack of access to palliative care services in most parts of the world.  

As compared to increasing need, 42% of countries still have no identified hospice and palliative care service, while 80% of people globally lack adequate access to medication for treatment of moderate to severe pain.  

This means millions of older people, especially in the developing world, are living and dying in unnecessary pain and distress.  

This World Hospice and Palliative Care Day, the Worldwide Palliative Care Alliance (WPCA) is warning that an urgent response is needed to improve palliative care for older people and meet the growing needs of the world’s ageing populations.  

To ensure all older people with life-limiting conditions are cared for with dignity and according to their wishes, the WPCA is today calling for palliative care to be integrated into national and community health systems around the world. 

Dr John Beard, Director of the Department of Ageing and Life Course at WHO, says “The main focus of health services is generally on preventing, curing or managing disease. But one of the things that is often neglected is providing quality care at the end of life.  

Dr. Beard says, “Millions of people today die in needless suffering simply because they are denied access to appropriate pain relief and social support. This care is not expensive, and everyone has a right to it.”  

There is often a misconception that palliative care is primarily for people with cancer. This is not true. The latest estimates from WHO show that older people with a range of conditions require palliative care and that in many disease groups those over 60s are the largest group in need.  

Globally, those in need of palliative care are dying from Alzheimer,  dementias, Parkinson disease, chronic obstructive pulmonary diseases, cardiovascular diseases, diabetes, rheumatoid arthritis, nephritis and nephrosis and cancer, predominantly affecting those in over 60s age group.  

Older people must have access to appropriate care, support and treatment, which recognises their contribution to society and is tailored to their individual needs through the course of illness, including at the end of life. Unfortunately, palliative care is very rarely available. 

To ensure all older people with life-limiting conditions are cared for with dignity and according to their wishes, ‘Stop-NCDs Network’ is today calling for palliative care to be integrated into national and community health systems around the world. 

Through this blog, I therefore share and reiterate the common global concern, “While our ageing population is a cause of celebration, this also brings great challenges, not least in the delivery of health care. Despite progress in the development of hospice and palliative care, which has improved the quality of life for millions, it is far from adequately available for all those who need it. 

“Shockingly 42% of countries do not have any identified hospice and palliative care services and 80% of people globally lack adequate access to medication for treatment of moderate to severe pain. This means millions of older people, especially in the developing world, are living and dying in unnecessary pain and distress.” 

Therefore, it is called upon the national international agencies, our governments, the private sector and civil society to work for improvement of access to palliative care for older people with life-limiting conditions by integrating palliative care into existing services. 

Sharon Baxter from the Worldwide Palliative Care Alliance and Executive Director of the Canadian Hospice Palliative Care Association has issued a special focus on reducing pain and suffering among neglected or marginalised groups that are unable to get the care that they require. 

He says, “It is totally unacceptable that older people, wherever they are based, are unable to access the care that they need to live and die with dignity and respect. With the rising incidence of non-communicable diseases and the ageing of the HIV pandemic, it is even more pressing that urgent action is taken.”  

For integration of palliative care within existing services, however, it is necessary that initiatives be taken on measures like: 

· Training of greater number of health professionals and carers 

· Making available improved access to pain medications  

· Inclusion of palliative care in existing health policies  

· Engagement of older people in decisions concerning their care  

This World Hospice and Palliative Care Day 2012 assumes importance as thousands of people in around 60 countries are coming together at more than 1,000 events to celebrate, support and speak up about hospice and palliative care.

Tobacco Control in Africa: Advocating Through Videos

In 2007, IDRC, Canada, analysed tobacco situation in Africa. Evidence indicated that the majority of countries in sub-Saharan Africa were in the early stages of the tobacco epidemic. In recent years tobacco consumption in Africa has increased faster than in the developing world as a whole. 

Between 1995 and 2000, tobacco consumption was estimated to have risen by 2.7% in the developing world as a whole, but in Africa by 3.2%, during the same period. The majority of governments in the region were aware of the looming epidemic and its potential for thwarting the development process. 

Under a research project ‘Research for International Tobacco Control (RITC)’ funded by IDRC, Canada, in partnership with the Bill & Melinda Gates Foundation, the initiative aimed at understanding the critical determinants of success for tobacco control in Africa. The initiative aimed at a situation analysis to assess tobacco use, the dynamics of tobacco farming and tobacco control policies (including their level of implementation) in 10 to 14 sub-Saharan African countries. 

The project also aimed to build the technical capacity of African researchers to gather, synthesize and analyze data at the country and the regional level, and the result was used for weighing opportunities and obstacles to tobacco control, assess country readiness and capacity for action, and guide action for tobacco control in Africa. A key element was to ensure the engagement of African stakeholders and global partners in the effort.

WHO’s tobacco control efforts in Africa

 

The World Health Organization (WHO) increased its attention to tobacco control in Africa in 2009, with the overall goal of preventing tobacco use from becoming as prevalent there as it is in other parts of the world.

 

The focus of the programme was on strengthening countries' ability to implement the WHO Framework Convention on Tobacco Control (WHO-FCTC), the international health treaty that guides national efforts to counter the tobacco epidemic, and the establishment of a regional centre of excellence to support the development of countries' capacity to resist the spread of tobacco use. 

Tobacco use is the most preventable cause of illness and death. It is now common knowledge that if unchecked, it will kill several million people per year by 2030, with more than 80% of those deaths occurring in developing countries. Tobacco use is a risk factor for the major non-communicable diseases – heart attacks, strokes, cancers, diabetes and asthma and other chronic diseases – which together account for 60% of all deaths in the world. In the 46 countries of WHO's Africa region (AFRO), non-communicable diseases are expected to account for 46% of deaths by 2030, up from 25% in 2004.

For the African region, tobacco use is more than a health problem, because of its effect on countries' development. Tobacco breeds poverty, killing people in their most productive years. It consumes family and health-care budgets. The money spent on tobacco products is equal to money not spent on essentials like education, food and medicine, according to experts in the area.

The importance of tobacco lies in its association as the leading preventable cause of death in the world. Actions for tobacco control will prevent young people from starting its use and help current tobacco users to quit, and protect unwilling non-smokers from exposure to second-hand smoke or passive smoking.

Strengthening the implementation of the WHO Framework Convention on Tobacco Control (WHO-FCTC) is ratified by about 40 out of the 46 countries in the African region, and its implementation through comprehensive tobacco control legislation and capacity building for its effective enforcement is a major challenge for the member states in the African region.

The fast growth of the population in Sub-Saharan Africa is leading to larger and more accessible markets and an increase in purchasing power of the African consumers. Intensive efforts by the tobacco industry to expand African markets has had an effect on tobacco consumption. According to reports, countries in the African region are experiencing an increasing rate of tobacco use. The prevalence of tobacco use in African countries is between 8 to 43% for boys and 5 to 30% for girls. 

Observance of No-Tobacco Day in the African Region

Prevention of diseases is clearly the most cost-effective measure. The world over ' World No-tobacco Day' is observed on 31st May to develop mass awareness about tobacco, its harmful effects and necessity to control it. The last year theme for the event was 'The WHO Framework Convention on Tobacco Control' held around the world on 31 May 2011. In the African Region, the event was organised in several countries; reports on events organised in thirteen countries (Benin, Burkina Faso, Burundi, Cape Verde, Gambia, Kenya, Mali, Mauritania, Mozambique, Niger, Senegal, Sierra Leone, Tanzania) are enlisted in the WHO site.

Tobacco in Africa Video Series 

The African region is a new frontier for tobacco companies and the region is witnessing a smoking epidemic. However there is a major effort to promote harmful effects of smoking and tobacco control, and counter tobacco companies’ promotional efforts through videos. These short videos provide an introduction to tobacco use in Africa, some of the successes in addressing the devastating effects of tobacco use, and the challenges to progress, including tobacco industry influence.

The videos have been made in conjunction with the African Tobacco Situation Analysis Project (ATSA), an initiative supported by IDRC in partnership with the Bill and Melinda Gates Foundation. The project helped African advocates and researchers identify barriers and opportunities to tobacco control in their countries. They achieved groundbreaking success by focusing their efforts on key advocacy, policy, and legislative strategies.

These short videos provide an introduction to tobacco use in Africa, successes in addressing the devastating effects of tobacco use, and the challenges to progress, including tobacco industry influence. African advocates and researchers describe the tactics used by tobacco companies to undermine tobacco control efforts.

The African example to promote issues associated with tobacco through videos is a creative mass awareness and education campaign, leading to pressuring the tobacco industry and engaging governments to strengthen legislation. Thus African tobacco control advocates are protecting people from the harmful effects of tobacco use, and having their influence on future of NCDs in Africa.

India Pilots Resolution on Mental Disorders at WHO Meeting

The 130th Session of the Executive Board of the World Health Organization (WHO) has adopted a Resolution on ‘Global Burden of Mental Disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level’.

This marks the first time in over a decade that WHO has, at its highest levels, taken note of this very major public health concern. The draft Resolution in the matter was moved on Friday, 20th January, 2012 by India.

The Indian delegation led by P.K. Pradhan, Secretary, Ministry of Health and Family Welfare, were primarily responsible for piloting the matter.

Mental disorders account for 13% of the global burden of the diseases and, in keeping with latest thinking, the resolution recognizes the importance of early identification, care and recovery.

An important aspect of persons suffering from mental disorders  is the problem of stigma, poverty and homelessness, and the need for community based interventions including deinstitutionalised care.

It is clearly recognized that all countries must take steps to promote mental health and empower persons with mental disorders to lead a full and productive life in the community.  (Source: PIB.23.01.12)

Gulf states adopt strategy to address NCDs

The Gulf Cooperation Council (GCC), whose Ministers of Health met in Muscat, Oman early this month, is the first regional entity to respond, at a heads of state level, to the UN General Assembly Political Declaration on the Prevention and Control of Noncommunicable Diseases (NCDs) by developing a regional strategy to address diseases, such as diabetes, cardiovascular disease, cancer and chronic respiratory disease.

Putting commitments into action

The strategy outlines a plan to put into action the commitments agreed upon in September in the UN General Assembly's Political Declaration on NCDs. NCDs cause more than 60% of all deaths in GCC countries, and are caused by shared risk factors like tobacco use, unhealthy diet and physical inactivity.

"The regional strategy details what the six countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates) will be doing to tackle NCDs during the next years in terms of reducing people’s exposure to causative risk factors and improving services to prevent and treat these leading health problems," said Dr Ahmed Al Saidi, Omani Minister of Health who chaired the meeting. "It also highlights what the six countries will do to set targets and measure results, advance multisectoral action, and strengthen national capacity."

Reducing premature deaths

The Oman meeting followed a two-day summit in December where heads of state of the Cooperation Council for the Arab States of the Gulf endorsed a regional approach to reduce premature deaths from noncommunicable diseases.

Welcoming the announcement, WHO Regional Director-Elect of WHO's Eastern Mediterranean Region Dr Ala Alwan said, "We have the knowledge of what works to prevent and treat NCDs, a global public health and development problem of increasing significance to many countries. We are pleased to see the Gulf Cooperation Council countries taking concrete action to implement affordable best practices (called 'best buys') to curb NCDs and we hope other regions will take similar action.”

"Up to 50% of people dying from these diseases in some of the Gulf countries, die prematurely, before the age of 60 years. This initiative by the GCC should be a major landmark in stopping these premature deaths," said Alwan. (Courtesy: WHO.06.01.2012)

 

Low-cost solutions for NCDs

The good news is that if the UN special summit on 19-20 September 2011 discussed the challenge of global upsurge in the incidence of NCDs, the World Health Organization (WHO) beforehand had worked out low-cost prevention and control strategies for adoption by the low and middle income countries. 

NCDs are a major killer worldwide; 80% of deaths occur in low and middle income countries. The impact of NCDS is tremendous, not only in morbidity and mortality terms but also in socioeconomic terms. The cost of delayed action against NCDs is severe and can even increase over time. NCDs are leading threat to global economic growth and development.

Over the next 15 years, NCDs will cost low and middle income countries more than US $ 7 trillion, according to Jean Pierre Rosso, Chairman, World Economic Forum (WEF), based on a joint study of WEF and Harvard School of Public Health.

When large workforce is affected by NCDs and fall sick and dies from those diseases in their productive years, national economies will lose millions of dollars in output, and millions of families are pushed into poverty.

The WHO study set out to identify low-cost interventions that could prevent NCDs and their effect. The criteria were availability of strong evidence that such a strategy prevented disease and saved life. The strategies were for adoption separately at Population level and Individuals focused.

The strategies for implementation at population level include: Excise taxes on tobacco and alcohol, smoke-free indoor  and public places, health information and warnings, campaigns to reduce salt content, replacement of trans fats by polyunsaturated fats, public awareness programme, physical activity.

The individual level strategy include: screening, counseling, drug therapy in case of high risk cardiovascular disease, screening for cervical cancer, hepatitis B immunization to prevent liver cancer.

Several countries which had adopted such measures at population and individual levels against CVS disease, on monitoring by WHO over a period of ten years have found marked reduction in risks, disease incidence and deaths.

Total cost of adopting these strategies in all low and middle income countries is estimated to be  US$ 11.4 billion per year. Implementation per person per year is low, US$1.20. These strategies are easy measures, and can be easily adopted by low and middle income countries.

This report is to be noticed by all concerned, and the targeted countries serious to tackle the onslaught of NCDs must take immediate steps to implement these, and other strategies more specific to respective countries.

Report maps NCDs trend

A World Health Organization (WHO) report released earlier (September 2011) gives baseline data on all NCDs in 193 countries in order to monitor their epidemiological trends and assess the progress made by these diseases in their countries. This report indicates where each government needs to focus in order to prevent and treat the four major killers: cancer, heart disease and stroke, lung disease and diabetes. Updated report is expected in 2013.

The report includes details of what proportion of each country’s deaths is due to NCDs. In a single page per country presentation format, the report provides information on prevalence, trends in metabolic risk factors (cholesterol, blood pressure, body mass index and blood sugar) alongside data on the country's capacity to tackle the diseases.

NCDs are the top cause of death worldwide, killing more than 36 million people in 2008: Cardiovascular diseases were responsible for 48% of these deaths, cancers 21%, chronic respiratory diseases 12%, and diabetes 3%.More than nine million of all deaths attributed to NCDs occurred before the age of 60; 90% of these "premature" deaths occurred in low- and middle-income countries.

One of the findings shows that men and women in low-income countries are around three times more likely to die of NCDs before the age of sixty than in high-income countries. According to these estimates, the proportion of men dying under the age of 60 from NCDs can be as high as 67%. Among women under 60, the highest proportion was 58%.The lowest rates of mortality from NCDs for men under 60 were 8% and for women under 60, it was 6%.

High risk factors like smoking and exercise are important. The profiles report on the proportion of people who smoke and are physically inactive. They also indicate trends for four factors that increase people's risk of developing these diseases, blood pressure, cholesterol, body mass index and blood sugar over the past 30 years.

In the United States of America, for example, 87% of all deaths are due to NCDs. 16% of the population smokes and 43% are physically inactive. On average, blood pressure has decreased since 1980; body mass index has increased; and glucose levels have risen.

Overall, the trends indicate that in many high income countries, action to reduce blood pressure and cholesterol is having an impact, but there is a need to do more on body mass index and managing diabetes.

Based on data from the report, India’s capacity to address and respond to NCDs  need  concerted action in order  to contain impact of NCDs . A national Cancer Registry, specific policy framework for chronic respiratory diseases, and implementation of tobacco Power Measures are areas that need greater focus. In India, NCDs account for 53% of all deaths:  Cardiovascular diseases, 24%; Cancers 6%; Respiratory Diseases 11%; diabetes 2%, other NCDs 10%.

(Source: WHO-Country profile, 2011)