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Non-Communicable Diseases

The world today is seeing a new epidemic of NCD that would have a devastating affect unless it is stopped. Worldwide cardiovascular diseases cause 17.5 million deaths every year and one in three deaths in the world are caused by cardiovascular diseases such as stroke, heart attack or heart failure. CVD would be the cause of more than half the deaths worldwide by the year 2010.  

In addition every year not less than 20 million people have an acute myocardial infarction (MI) or stroke but survive. CVD is not only the problem of the West. Eighty percent of the deaths due to CVD and 86 percent of the global burden of CVD are in the developing countries. Despite the high death rates due to non-communicable diseases, by 2010 the leading cause of death in the developing countries including Pakistan would be CVD. 

There are at least 600 million hypertension sufferers worldwide, which is 4.4 percent of the total global disease burden. Hypertension causes 7.1 million deaths annually i.e. 13 percent of the total deaths. In Pakistan too the prevalence of hypertension is quite high. It is estimated that over 50 percent of the population over the age of 50 is hypertensive. 

About 56 percent of heart diseases and 18 percent of strokes are attributed to total serum cholesterol levels >5.2 mmol/l (200 mg/dl). Dyslipidemias account for 4.4 million deaths annually, which is 7.9 percent of the total global deaths and 2.8 percent of the total global disease burden. 

Cigarette consumption constitutes the single most important modifiable risk factor for coronary artery disease and the leading preventable cause of death. Nearly 1 billion individuals now smoke worldwide. Smoking has a particularly staggering impact in the Third World: almost one-half billion individuals worldwide will eventually die of smoking-related complications. Even among nonsmokers, we now recognize that inhaled smoke, whether from passive exposure or from cigar and pipe consumption, also greatly increases coronary risk.  

Diabetes is the fourth leading cause of death by disease globally; diabetes is the leading cause of blindness and visual impairment in adults in developed countries. People with diabetes are 15 to 40 times more likely to require a lower limb amputation and are two to four times more likely to develop cardiovascular disease than people without diabetes.  

Other devastating complications of diabetes, such as blindness, kidney failure and heart disease, are imposing a huge burden on health care services. 

This is expected to rise to 16 million in another 5 years. Pakistan is one of the 10 countries in the world with the highest prevalence of diabetes and has one of the fastest increase in the number of diabetics. 

There are over 30 million people in the world who are obese (BMI > 30/kg/m2) and another 1 billion who are overweight (BMI 25-30 kg/m2). In Pakistan, where there is also a problem of under nutrition, in 1994 11.6 percent males and 18.93 percent females were obese or overweight (WHO global database on BMI). 

Lack of adequate physical activity is directly responsible for 2 million deaths globally every year and is responsible for 3-4 percent of global disease burden. Physical inactivity contributes to 22 percent of IHD, 11 percent of ischemic strokes, 14 percent of type 2 diabetes, 10 percent of breast cancer and 16 percent of colon cancer. Physical inactivity also causes obesity, osteoporosis, falls, low back pain, depression and anxiety. 

In Pakistan there is a lack of adequate data on the disease burden of cardiovascular disease as well as the risk factors involved. Many primary care physicians do not have current knowledge about the management of CVD. The public also is largely unaware about the prevention of CVD. There is no consensus amongst the specialists in the management of hypertension in Pakistan.NCDs and injuries are considered as one of the top ten causes of mortality and morbidity in Pakistan; estimates indicate that they account for approximately 25% of the total deaths within the country. NCDs contribute significantly to adult mortality and morbidity and impose a heavy economic burden on individuals, societies and health systems. In most cases, it is the economically productive workforce, which bears the brunt of these diseases. Existing population-based morbidity data on NCDs in Pakistan show that one in three adults over the age of 45 years suffers from high blood pressure. 

Cardio-vascular diseases

Among non-communicable diseases, cardio-vascular diseases (CVD) are an important public health problem. Although no accurate data is yet available, the burden of CVDs is expected to be high in view of behavioral and lifestyle changes in Pakistan. Moreover, many primary care physicians and the majority of citizens do not possess adequate knowledge concerning the prevention and management of cardio-vascular diseases. There is also no clear consensus among the specialists with regard to the management of hypertension. 

The Ministry of Health addresses the non-communicable disease control through the public-private collaborative arrangement involving a NGO. A tripartite partnership of the MoH, NGO (Heartfile) and WHO was launched in April 2003 mandated with the task of developing and implementing a national strategy for achieving national goals for the prevention and control of NCDs. The partnership released a strategic framework for action: the National Action Plan for Non-Communicable Disease Prevention, Control and Health Promotion (NAP-NCD) – an integrated approach to address the multi-disciplinary range of issues within a prevention and control framework across the broad range of NCDs in 2004. It is set within a long-term and life course perspective and calls for an institutional, community and public policy level change. 

The Action Plan delivers an Integrated Framework for Action (IFA) that has been developed through a concerted approach to address the complex multidimensional issues within a prevention, control and health promotion framework across the broad range of NCDs. It is modeled to impact a set of indicators through the combination of a range of actions in tandem with rigorous formative research. This initiative created a mechanism for the visible involvement and participation of the relevant sectors, educational institutions, and NGOs.

Cancer control

Cancer is also an important public health problem. The Ministry of Health has started cancer registration in pilot districts. According to the registry, the top 10 ranking cancers are as follows (n=1110): Breast (15%), Lung (8%), Leukemia (CLL) (8%), Stomach (7%), Esophagus (6%), Bronchus (5%), Leukemia-ALL (5%), Leukemia - AML (4%), Pancreas (4%), Rectum (4%). the age group of these cases in order of prevalence is age group 51-60 years (25%), followed by f 61-70 years (20%) and age group of (18%). The cancer registries clearly indicate the social and economic burden of cancer in the country.

Preventable blindness

According to National survey of Blindness and Low Vision 2002-2004, the prevalence of blindness in Pakistan is 1% with 1.5 million people blind in the country. The Government of Pakistan launched National Plan for Prevention and Control of Blindness for the year 2005 to 2010 and has allocated PKR 2.74 billion for the Plan. There are three areas that the Ministry of Health has to work to reduce blindness burden from Pakistan:

• Infrastructure and Technology Development

• Human Resource Development: train PHC workers in PEC, Ophthalmic Technicians, Refractionists, Optometrists, Orthoptists, Ophthalmic Nursing,

• Disease Control (Trachoma , Childhood Blindness and Diabetes Related Blindness)

Objectives

1. Prevention and control of important types of cancer.

2. To reduce mortality and morbidity due to CVDs.

3. To strengthen the tripartite partnership with a mandate to develop and implement a national plan of action for prevention and control of NCDs.

4. To reduce cataract backlog.

5. Reduce other causes of blindness.

6. To strengthen the infrastructures of eye care.