1. Gopal Sankaran*, MD, DrPH & Monika Sawhney**, PhD *Interim Assistant Vice President for International Programs and Professor of Public Health, West Chester University, PA **Assistant Professor in Global Health, Mercer University, Macon, GA 138 th Annual Meeting of American Public Health Association Denver, CO November 8, 2010

2. Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Gopal Sankaran and Monika Sawhney “No relationships to disclose”

3. Session Objectives 1.Discuss the increasing burden of chronic non-communicable diseases (CNCDs) in Costa Rica (CR) and the United States (US). 2.Specify the parallels in the impact of CNCDs on select health status indicators and the health care costs in the two nations. 3.Explain the commonality and differences in the occurrence of risk factors for CNCDs in both nations. 4.Identify opportunities for collaboration in research and training of health workforce in prevention and control of CNCDs in CR and the US. November 8, 2010 Gopal Sankaran & Monika Sawhney 3

4. Change in disease management paradigm 20 th Century Acute conditions Infectious diseases Single agent model Focus on cure (Antimicrobials) Prevention through vaccines 21 st Century Chronic conditions Non-communicable diseases Multi-factorial causal model Focus on treatment Prevention through risk factor reduction or elimination November 8, 2010Gopal Sankaran & Monika Sawhney4

5. Major Chronic Non- Communicable Diseases Affect individuals over an extensive period of time; and No known causative agents that are transmitted from one affected person to another Major CNCDs Cardiovascular diseases (heart disease & stroke) Some Cancers Chronic Respiratory Conditions Type 2 Diabetes November 8, 2010 Gopal Sankaran & Monika Sawhney 5

6. Global Burden of Chronic Diseases— Deaths (WHO, 2005, pp. 2-3) November 8, 2010 Gopal Sankaran & Monika Sawhney 6

7. Chronic Diseases—Deaths by Age and Sex (WHO, 2005, p. 39) November 8, 2010 Gopal Sankaran & Monika Sawhney 7 45% of deaths occur prematurely before 70 years.

8. Chronic Diseases—DALYs by Age and Sex (WHO, 2005, p. 40) November 8, 2010 Gopal Sankaran & Monika Sawhney 8 86% of burden of chronic diseases occurs under the age of 70.

9. Deaths by Major Cause and World Bank Income Group (WHO, 2005, p. 4) November 8, 2010Gopal Sankaran & Monika Sawhney9

10. Costa Rica and the United States— Select Indicators (CIA, on-line, n.d.) IndicatorCosta RicaUnited States Population (millions) (07/2009)4.3307.2 Age structure (2009) 0-14 years 15-64 years 65 & + years 26.7% 67.1% 6.2% 20.2% 67.0% 12.8% Birth rate (births/1,000 people)17.4313.82 Death rate (deaths/1,000 people)4.348.38 Life expectancy at birth (years)77.5878.11 Literacy (15 & > read & write)94.9%99% GDP per capita (PPP) (2008)$11,600$47,500 November 8, 2010Gopal Sankaran & Monika Sawhney10

11. Deaths due to all causes— Costa Rica and the US (WHO Global InfoBase, 2002) November 8, 2010Gopal Sankaran & Monika Sawhney11

12. Comparative Burden of CNCDs—Costa Rica & the US (WHO InfoBase, n.d.) Disease ConditionCosta Rica*United States* Cardiovascular diseases185188 Diabetes mellitus2118 Respiratory diseases3839 Malignant neoplasms (cancers) 125134 Digestive diseases4321 Neuropsychiatric conditions 1530 November 8, 2010Gopal Sankaran & Monika Sawhney12 *Age standardized cause-specific death rates per 100,000 population

13. Obesity among Males and Females in Costa Rica & US (WHO Global InfoBase, 2005) November 8, 2010 Gopal Sankaran & Monika Sawhney 13

14. Mean Total Cholesterol level among Males and Females in Costa Rica and US November 8, 2010Gopal Sankaran & Monika Sawhney14

15. Mean SBP among Males and Females in Costa Rica and US November 8, 2010Gopal Sankaran & Monika Sawhney15

16. Smoking among Males and Females in Costa Rica and US (American Cancer Society Database, 2001) Smoking prevalenceCosta RicaUnited States Males (20-49 years)29.0%25.7% Females (20-49 years)9.7%21.0% November 8, 2010Gopal Sankaran & Monika Sawhney16

17. Human and Fiscal Impact of CNCDs Years of Life Lost to CNCDs Costa Rica57% United States 75% (WHO Statistical System, n.d.) Fiscal Impact Chronic diseases consumed 75% of the nation’s 2.2 trillion dollars spent on health care (NCHS, 2008) November 8, 2010Gopal Sankaran & Monika Sawhney17

18. The Urgency to Combat CNCDs in Costa Rica & US Very high impact in both nations Greater than half of premature deaths Underlying risk factors can be effectively addressed with primary prevention (WHO, 2005, p. 15) November 8, 2010 Gopal Sankaran & Monika Sawhney 18

19. Possibilities for Transnational Collaboration Developing collaborative teaching modules in primary prevention of CNCDs Training healthcare workers in prevention and control of CNCDs Collaborative research to effectively reduce and eliminate the occurrence and impact of risk factors for CNCDs Others? November 8, 2010 Gopal Sankaran & Monika Sawhney 19

20. Contact Information Gopal Sankaran, MD, DrPH Interim Assistant Vice President for International Programs and Professor of Public Health Center for International Programs 310 McKelvie Hall West Chester University West Chester, PA 19383 P: 610-738-0536 F: 610-436-3426 E: gsankaran@wcupa.edugsankaran@wcupa.edu Monika Sawhney, Ph.D. Assistant Professor in Global Health Department of Interdisciplinary Studies 107 Groover Hall Mercer University Macon, GA 31207 P: 478-301-2353 E: sawhney_m@mercer.edusawhney_m@mercer.edu November 8, 2010Gopal Sankaran & Monika Sawhney 20