1. The challenge of non-communicable disease in our near neighbours: a disease burden perspective Professor Alan Lopez School of Population Health The University of Queensland

2. Measuring Disease Burden: Some Commonsense Notions Mortality, including age at death -lost years of life (ie. age at death matters) Ill-health (Morbidity, Disability), including: -incidence of major sequelae of disease -duration of sequelae -severity (disability weight) of sequelae

3. A: very low child and adult mortality B: low child and adult mortality C: low child, high adult D: high child, high adult E: high child, very high adult 14 WHO mortality subregions

4. Who dies of what? What do we know? WHO Region No. of countries with: Complete VR Incomplete VR Sample Surveillance Child but no adult data SEAR B1101 SEAR D0124 WPR A4100 WPR B21118 Total714313

5. China India Indonesia Pakistan Trends in Child mortality (5q0), selected countries

6. Adult Mortality Success of child health programmes greatly increased survival chances to adulthood Enormous lack of interest in measuring levels and trends of adult mortality, let alone causes Concept of “premature deaths” equally valid for adults as for children - focus on “young” adults 15-60 years As for children, vast differences in risk of adult death across Region

7. Subregional Age Patterns of Mortality, 2002 WPR AWPR B

8. Leading Causes of Death, WHO Western Pacific B Region (largely China), 2002

9. Leading Causes of Death, WHO South East Asia Region (largely India), 2002

10. Leading Causes of DALYs, Asia-Pacific Region, 2002

11. Asia-Pacific Disease Burden: Summary Clear evidence of advancing epidemiological transition Major vascular diseases (stroke, IHD) already leading causes of death Specific causes of major importance in different regions (e.g. COPD in China, stomach cancer in Japan, TB and traffic accidents in Thailand/Indonesia) Major childhood diseases of poverty (pneumonia, diarrhoea, perinatal causes, TB) still major causes of death in India and neighbours No real evidence yet of HIV/AIDS as major cause of death in Region, except South Asia (300,000-400,000 deaths) Mental disorders/injuries major cause of non-fatal outcomes Considerable UNCERTAINTY around estimates

12. Comparative Risk Assessment: The Impact of Risk Factors on the Health of Populations

13. Three Key Perspectives on Health Risks -Individual: what does the risk from exposure mean for me? -Population: what does the population distribution of exposure mean for overall population health -Intervention: do we know enough to (cost- effectively) modify individual and population exposure?

14. Basic CRA framework and goals All by 224 age, sex and region subgroups and by levels of poverty Risk factor levels current distribution counterfactual distribution(s) Disease burden Risk factor-disease relationships risk accumulation risk reversal Attributable burden in 2000 Avoidable burden in 2010 & 2020

15. Number of deaths (000s) SOUTH-EAST ASIA Deaths in 2002 attributable to selected leading risk factors

16. Number of deaths (000s) WESTERN PACIFIC Deaths in 2002 attributable to selected leading risk factors

17. Leading risk factors for disease/injury, Asia-Pacific, 2002 (% of disease burden in each category) Industrialized countries Tobacco 8.1 Blood pressure7.5 Alcohol4.6 BMI3.8 Cholesterol3.7 Low-mortality developing Alcohol5.8 Blood pressure5.3 Tobacco4.0 Malnutrition3.3 Indoor air pollution2.5 High-mortality developing Malnutrition 12.4 Unsafe water/hygiene 5.2 Indoor air pollution 4.0 Unsafe sex 3.8 Iron deficiency 3.5 Blood pressure 3.5

18. The next 20 years Projected changes:

19. Ratio of Non-Communicable/ Communicable Deaths, India, China, Other Asia-Pacific, 1990-2020

20. Change in Leading Causes of DALYs, India, China & OAP, 1990-2020

21. Estimated smoking prevalence by gender and number of smokers in population aged 15 or more, 1995 Note: numbers have been rounded Source. Author’s calculations based on World Health Organization 1997. Tobacco or health: A Global Status Report, Geneva, Switzerland.

22. Individual risk of premature death (Male smoker versus non-smoker, US Cancer Prevention Study, 1984-88)

23. DALYs attributable to diarrhoea, HIV and tobacco, 1990-2020 (baseline scenario)

24. Conclusions I Region with vast differences in health status and epidemiological patterns Much is known about child mortality levels and trends, MUCH LESS about adult mortality Significant progress in reducing child mortality in most countries (primarily vaccine programmes and ORS for diarrhoea) Little can be reliably said about trends in adult mortality Leading causes of death mixture of “old” and “new” diseases

25. Conclusions II Depression appears by far the leading cause of disability - Other mental health/musculoskeletal conditions also significant Vast uncertainty about causes of death patterns and disability due to poor quality of epidemiological data in most countries in Region Injuries, especially traffic accidents, significant in all countries (typically 10% of deaths) Tobacco already major cause of death in India and China (0.8 million deaths annually in each country) and likely to INCREASE rapidly Substantial UNCERTAINTY around HIV/AIDS - May be major cause of disease burden in future?

26. Conclusions III Reduction in large causes of disease burden (tobacco, blood pressure, cholesterol, under- nutrition) will yield largest gains in population health Need appropriate policy focus: large, avoidable causes vs possible, but improbable causes Urgent research agenda to establish causes of disease burden with greater reliability – implications for cost-effective data collection systems More strategic health investments: optimal intervention packages to accelerate health development – much is known, too little is applied