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Third Copenhagen Consensus: Chronic Disease Assessment, Jha Nugent Verguet Bloom Hum

By Prabhat Jha, Rachel Nugent, Stéphane Verguet, David Bloom and Ryan Hum and released by the Copenhagen Consensus Center.

The working paper used by the Expert Panel is available for download here, the finalized paper has been published in Global Problems, Smart Solutions - Costs and Benefits by Cambridge University Press.

Eighty percent of global deaths from heart disease, stroke, cancer, and other chronic diseases occur in low-income and middle-income countries. 

But according to a recent review of donor health funding, chronic disease receives the smallest amount of donor assistance of all health conditions, having lost ground since 1990 relative to infectious diseases. Donor assistance for health was estimated at almost $26 billion in 2009. The amount allocated to chronic disease was $270 million, or about 1% of the total. Yet cardiovascular disease in low- and middle-income countries killed over twice as many people in 2001 as did AIDS, malaria, and TB combined. 

In a research paper for Copenhagen Consensus 2012, Prabhat Jha and a team of researchers argue that chronic diseases already pose a substantial economic burden, and this burden will evolve into a staggering one over the next two decades. 

Although high-income countries currently bear the biggest economic burden of chronic diseases, developing countries, especially those that are middle-income, will assume an increasing share as their populations grow and the effects of the tobacco epidemic take greater hold. 

And the costs for governments of achieving maximal adult survival are rising, in contrast to declines in the costs of achieving child survival. This divergence is a consequence chiefly of the lack of tobacco control in most low and middle-income countries, the lack of sustained investments in new drugs, and gaps in the strategies and in the program implementation for chronic diseases. 

Jha and his team argue that addressing chronic disease in poor countries requires a rethinking of developmental assistance and possibly new delivery approaches.

They identify five key priority interventions where the costs are relatively low compared to the benefits.

The most important action is tobacco taxation. Conservatively estimating that tobacco is a cause of about one-third of the vascular disease, half the cancers and 60% of chronic respiratory diseases, the researchers estimate a total economic loss from tobacco of about 12.7 trillion dollars over the next 20 years – or about 1.3% of GDP annually. Already, tobacco kills about 5-6 million people a year, including about 1million each in China and India. Without increases in cessation, tobacco use may account for some 10 million deaths per year by 2030, with most of these occurring in low- and middle-income countries. On current smoking and cessation patterns, some 1 billion tobacco deaths might occur this century in contrast to 100 million in the 20th century.

Reducing tobacco deaths in the next few decades requires current smokers to quit, and tobacco taxation is particularly effective at raising cessation rates-- a 10% increase in price leads to a 4 to 8% drop in consumption. France, for example, tripled the price of cigarettes quickly (over a decade or so), and this cut consumption per adult in half, while more than doubling tax revenue in real terms. Lung cancer rates in France in young men fallen sharply since. Tax hikes need not cost anything- except the political will to overcome vested interests. Generously estimating a comprehensive tobacco control program including a tobacco tax rise to cost $500 million annually, such a program would avert more than 1 million deaths each year. Put into economic terms, the benefits would be 40 times higher than the costs.

The second initiative is using low-cost drugs to avert heart attacks. Jha argues that system-wide efforts to achieve high rates of appropriate drug use given within hours of an acute heart disease should be a high priority, with $200 million in annual expenditure saving 300,000 heart attack deaths each year. Jha calculates that, in economic terms, each dollar spent would generate $25 of benefits.

Another approach to the same problem is to create a ‘generic risk pill’. In the absence of any drug therapy, adults with previous stroke, heart attack, diabetes or any other evidence of some serious vascular disease have about a 7% annual risk of either dying or being re-hospitalized with a recurrence. If they take an aspirin a day, that risk drops to 5%; if they add two more drugs to reduce blood pressure and blood lipids, it drops to 2%. The exact sequence of drugs matters little, but being on 3 or 4 drugs (aspirin, a blood pressure pill or two, and a statin drug to lower cholesterol) daily versus none means a 10-year risk of death or re-hospitalization of about 50% for untreated versus 16% if on treatment. All these drugs are low-cost, and thus could be easily packaged into “polypills” or generic risk pills for widespread use, similar to the way many countries treat tuberculosis with several drugs. This generic risk pill would avert a total of 1.6 million deaths annually. If the cost per adult patient per year were $100, the total cost would then be $32 billion per year. The higher cost is reflected in a lower ‘benefit-cost ratio’: each dollar spent on this initiative would see about $4 worth of benefits – still, this remains an attractive investment. 

Next, Jha examines efforts to reduce salt consumption, which is a significant cause of heart diseases and strokes. This can be done in food processing or at the cooking or eating stages. The former approach is being tried in Latin America where Brazil, Argentina and Chile are among the countries with industry agreements to reduce salt in processing. 

Experience in the USA and other developed countries suggest that substantial reduction from current levels is feasible with only some consumer resistance. Argentina and South Africa are focusing on salt reduction in bread. The main limitation in salt reduction strategies is the unproven impact on changing behavior when salt is mostly added at the table as a condiment. The researchers propose a population-level intervention to reduce salt intake through voluntary manufacturing changes, behavior change using mass media and other awareness raising campaigns. An annual cost of $1 billion would save more than 1.3 million lives a year from heart disease and strokes – in economic terms, the benefits are 20 times higher than the costs. 

Hepatitis B is a viral infection which attacks the liver and is the major cause of liver cancer worldwide. Yet vaccines can avert over 90% of the liver cancer deaths, and the Hepatitis B vaccine is a safe and very effective when given at birth or in early childhood. The vaccine could cost as little as $3.60 per child vaccinated. Spending a total of $122 million to increase vaccine coverage by a quarter would avert about 25% of the 600,000 annual deaths from the disease, 40 years into the future. Each dollar spent generates $10 of benefits.