La transición epidemiológica y su impacto en la salud global A new

La transición epidemiológica y su impacto en la
salud global
A new paradigm in Global Health: Non
Communicable Diseases and the urgent need for
palliative care
Dr Liz Grant
Deputy Director, Global Health Academy
University of Edinburgh
Unforgettable journeys
Though we are all born
equal we are born
into, and we die in,
very unequal
circumstances.
We cannot change the
inevitability of death
but we can change
these unequal
circumstances
Through the keyhole - by Jo Spiller
There is no hierarchy
of humanity
• Neither within the
human race
• Nor in the life of a
person
• Yet our world is constructed to encourage
division, inequity has become ingrained,
and life is valued for economic gain and
not for the soul of the person
A perfect storm
So many diseases are the products and the by-products of
the storms created as the forces of globalisation clash
together.
Global Causes of Death (2006)
Chronic diseases:
Infectious diseases:
HIV/AIDS 4.9%
Tuberculosis 2.4%
Heart disease
30.2%
Malaria 1.5%
Total:
58.0M
Cancer
15.7%
Diabetes
1.9%
Other chronic diseases
15.7%
Other
Infectious
Diseases
20.9%
Injuries 9.3%
The total number of people
dying from chronic diseases is
double that of all infectious
diseases including HIV/AIDS,
tuberculosis and malaria
(Nature, 2007).
Lancet Global Burden of
Disease study 2010
A data audit which showed
• 8 million died from cancer ( 1/3 more than
in 1990)
• 1 in 4 deaths form heart disease or stroke
• 1.3 million due to diabetes
• And young adults are dying in far greater
numbers than appreciated
But what lies under this picture
The new 21st C diseases: disorders of
maladapted modernity
Disease burdens
that are different
A disease vortex of
Infectious and NCDs
interplaying off each
other to create a
perfect storm
Co-morbidity and
multi-morbidity
Chronicity
Most importantly Drivers of Diseases are
different: disease transitions and diseases
caused by many winds of change
•
•
•
•
•
•
•
•
Nutritional
Demographic
Epidemiological
Technological
Social
Economic
Political
Educational
The irony of 21st century
health – the drivers of
economic prosperity are
also the drivers of illness
double and triple
burdens and the hidden
unspoken burden of
emptiness, longing,
regret, soulessness - a
driver we ignore to our
peril
Social/environmental
determinants
Actions/Choices
Biomarkers
Cardiovascular
disease
Sedentary work
Motorised transport
Availability of cheap
convenience foods
Diet high in
salt, fat, sugar
High alcohol
intake
Disposable income
Raised blood
pressure
Raised blood
glucose
Tobacco use
Weakening of traditional
social and family structures
Outdoor environmental
pollution
Indoor pollution from
cooking smoke
Limited time
Low fruit/vegetable
intake
Disease
Type 2 diabetes
Breast cancer
Colon cancer
Raised
cholesterol
Prostate cancer
Lung cancer
Physical inactivity
Overweight/
obesity
Use of illicit drugs
Marketing and advertising
Chronic
respiratory
disease
Depression/
mental disorders
Work stress
Modifiable Risk Factors
McQuillan and Grant 2011
Infectious
Life
style
choices
Non
Communicable
Unnamed
burden
Real life
Social Determinants of
Health
Current systems: we know what to
do but don’t know how
We know the
drivers/
vectors but
we have
forgotten
how nimble
they are
Weak health systems
Infrastructure,
governance
technology
HR, financing
Separate systems
Concomitant burdens
Infectious, NCD, new ENID
maternal and child health,
Famine, war, climate change,
Economic collapse, food security
Health inequalities
Urban- rural; gender,
income, education,
What are the
Lessons from
past and the
shared lessons?
Recognising the Choice makers and recognising the
Change makers – united efforts,
whole system change , not just health system change
Searching: Eos and Tithonus
A world craving Immortal life - but
meaning immortal youth
Increasingly complex mix of
polypathologies
consequential, random, age related
Growing old decades younger in
many countries, while in others
constantly paying money to appear
younger
And in all taking risks that destroy
health
• Despite best practice and new interventions world
mortality rates just don’t change - 7 billion people will die
Palliative care: not a niche market
but a new global priority
A justice development goal
• An urgent humanitarian responsibility – “a basic
human right” WHO 2005
• Yet palliative care is missing from the
international development agenda – the MDGs
and their successors, the Sustainable
development goals (SDGs) - not a poverty
alleviation measure, contributing to an
economically viable society.
The quality signatures of a
nation – how it deals with
birth and death
Palliative Care….
“ is an approach that
improves the quality of
life of patients and their
families facing the
problems associated with
life-threatening illness,
through the prevention
and relief of suffering by
means of early
identification and
impeccable assessment
and treatment of pain and
other problems, physical,
psychosocial and
spiritual” (WHO 2002)
A new palliative care concept - integrated care, with curative
and palliative care earlier rather than later.
Murray SA, Kendall M, Boyd K, Sheikh A.
Illness trajectories and palliative care.
BMJ. 2005; 330:1007-1011.
Copyright ©2005 BMJ Publishing Group Ltd.
Living with dying
80%
Patients on the
palliative care
register (%)
generalist
80%%
specialist
20%
5%
Palliative Care
159
2.4
Diagnosis
No. of weeks before
death (median)
)
2wks
Time
Mapping diseases trajectories
Multi-morbidities normal
Copyright ©2008 BMJ Publishing Group Ltd.
Recognising multi morbidity disease trajectories
Function
High
Stage 1
Living with
long term
conditions
Stage 2 Add supportive and
palliative care
Stage3
Terminal care,
bereavement,
support
Death
Low
Self
managementTrigger 1
Time
Case management –by
patient, informal or
professional carer
Trigger 2
Professional
care
Mapping multi-dimensional needs
Physical
Information
Social
Spiritual
Psychological
Grant E, Murray SA, Sheikh A. Spiritual dimensions of dying
in different cultures. BMJ 2010;341:4859.
Fig 1 Unmet spiritual need cycle may result in increased demand and service use3.
Grant L et al. BMJ 2010;341:bmj.c4859
©2010 by British Medical Journal Publishing Group
Fluctuations of physical, social, psychological and spiritual
wellbeing in family carers of patients with lung cancer
Murray, Grant, et al. BMJ 2010;340:c2581
Copyright ©2010 BMJ Publishing Group Ltd.
Consequences of a lack of
palliative care
• Aggressive expensive treatments that are
focussed on cure
• Anxiety among patients, families carers
and practitioners
• Spiralling poverty
• A failure to say goodbye and a failure to let
go
• PAIN ( in all dimensions)
•
The costliness of no palliative care
sharing from another continent
• Health staff who feared to
break bad news –
cultural, social, emotional,
and time reasons.
• Families and patients
understanding illness in
the context of infection
• “Always searching for
cures and never finding
them”
• “I spent over a million
shillings on care that
failed to heal him. I took
my own children out of
school and sold their
inheritance. I sold land,
cows, goats, chicken”
(Uganda: Aunt of pt)
• There is no money in the
family because of the
many times I attended
dispensaries and did not
get well ( Kenyan cancer
pt)
Lack of timely and adequate
pain relief
• “I would like to go
to sleep and wake
up dead” Kenyan
woman with breast
cancer
Caring in the moment – social,
emotional and spiritual care
“I
must say the word ‘touch’.
We make these people
smile…. There was a
patient who had a wound
that smelled very bad. The
patient said, ‘Nurse, you
don’t want to touch it.’ But
we do touch and treat their
wounds….This touching
helps put a smile on
people’s faces
“we instil a sense of hope
before hope was lost in
pain” (Uganda nurse)
Primary Palliative Care
Research Group
INTEGRATE
Strengthening and integrating palliative care
into national health systems through a
public health primary care approach
Palliative care
Approach
1. All illnesses
3. All
dimensions
2. All times
5. All
nations
4. All settings
Unforgettable journeys
Though we are all
born equal we are
born into, and we
die in, very unequal
circumstances.
We cannot change
the inevitability of
death but we can
change these
unequal
circumstances
Being Change makers on this journey
Little Gidding T.S. Elliot
We die with the dying:
See, they depart, and we
go with them.
We are born with the
dead:
See, they return, and
bring us with them
With the drawing of this
Love and the voice of this
Calling
We shall not cease from
exploration
And the end of all our
exploring
Will be to arrive where
we started
And know the place for
the first time.
Through the unknown,
remembered
….
And all shall be well and
All manner of things shall
be well