The main causes of death and disability in a country can change dramatically over time because of a range of factors including lifestyle.
The paper looks at health issues in a number of countries including PNG, Vanuatu and Fiji.
Geraldine Coutts spoke to the author of the blog version of the study, Ian Anderson, research associate at ANU's Development Policy Centre.
Presenter: Geraldine Coutts
Speaker: Ian Anderson, researcher at the Development Policy Centre
ANDERSON: There really is a lack of data and that was the cause of this big group to try and work out through modelling and statistics and a very wide range of assumptions as to what is going on behind it. So we do have to sort of use a fair bit of caution as to sort of try and explain this. But behind the general sense, I mean there is a general sense that a lot of countries, particularly development countries are seeing this change from what we would call communicable diseases as a cause of death; things like measles and malaria etc., etc., through to non-communicable diseases, and particularly things like heart attacks, stroke, diabetes, etc., etc. Now what are the causes of that and that's really what you're asking. Some people and particularly with the World Health Organisation say that there's a little acronym called SNAP, and the S stands for smoking, the N stands for nutrition, the A stands for alcohol, and P stands for physical inactivity. And that's not a bad way of trying to sort of understand why there is the rise of the non-communicable diseases, such as diabetes and heart attacks. And that's particularly true in the Pacific, we see a lot of lifestyle changes. The early explorers in the Pacific noticed how lean and fit people were in the Pacific, that's not the case really now. I mean in Nauru for example in 1933 there was a study that showed the health situation, diabetes was not mentioned, and now these days diabetes in Nauru is one of the leading causes of death, and not only that, Nauru has one of the highest levels of diabetes in the world. What's causing this and part of it is the lifestyle changes, people are eating more but they're changing the nature of their diet, so it's more processed food, including sugary drinks, salt laden food, etc., etc., highly processed food. Inactivity, so large numbers of people are just not getting the exercise that they used to have, smoking and poor nutrition. So the result is people are becoming overweight and obese, the study that we did showed that 60 per cent of the countries where information is available in the Pacific are overweight, and in four countries of the Pacific over 50 per cent of the adult population is obese. So you put all these things together and then you recognise of course that the health system in these countries doesn't necessarily focus a lot on promotion or prevention of these lifestyle diseases, and that seems to be the best explanation. But I come back to the starting point, we really do not know enough about the causes and trends and levels of these diseases to give a very accurate answer to your question.
COUTTS: So principally there the changes then since the 1990s to today, diabetes appears and looms large on the health horizon as distinct from in the 1990s, but you're saying it's because even though we don't have better records, we know a bit more about it now than we did then?
ANDERSON: That's exactly right, yes, that's right.
COUTTS: And is that the case for … well there were two studies here, you've done a second study on the economic costs of non-communicable diseases in the Pacific, which we'll get to in a moment, but the first one is this one from the health in Papua New Guinea and Indonesia, the changes since 1990. The three countries that I note in that as I said were Papua New Guinea, Vanuatu and Fiji. So that's the situation for all three countries?
ANDERSON: No they do vary. Diabetes has increased quite a lot in Papua New Guinea. It is now the second leading cause of premature deaths in Papua New Guinea. But for the other countries it's even clearer that the non-communicable diseases are becoming much more important. So this thinking again about Papua New Guinea, three of the top ten causes of early death are these non-communicable diseases. But for many of the other countries there's even higher levels of these non-communicable diseases, including heart attacks and stroke. And it's not just the premature deaths that's important, but also the long-term disability. I mean once people start getting diabetes it can lead to blindness, amputations and all these other factors that mean that they can't work or can't live productive lives.
COUTTS: Now onto your study about the economic costs of non-communicable diseases, again I'm guessing they're huge because of the higher rates of kidney disease because of diabetes, the costs of renal and dialysis and all the rest of it is rising, and I'm guessing that the health authorities can't keep pace with that?
ANDERSON: That's exactly right, that's exactly right. And if you think about it, I mean these financial and economic costs occur at three levels; they occur at the individual and the household level. This means that people can't work, particularly if they've got diabetes and they can't walk or they can't see and these sort of issues. So they can no longer work, that affects their family. It certainly affects the ministries of health. So for example, the study showed that in Tonga one in ten of the admissions to the hospital were related to one of these NCDs and often diabetes, one in ten. However it was also these diseases attributed to one in five dollars actually spent at the hospital. So you can see it has a disproportionate impact on the costs. In Samoa the dialysis where it could be used was twelve times what the gross national income was for an individual. So this is very, very expensive. And in the case of Vanuatu, even something quite as small and cheap as the glucose testing strips to test for diabetes, when you use it once every day to test for blood sugars for diabetes as you should, that still comes out to around about 164 dollars per person per year, which is much more than the government is able to spend already on healthcare. And the other part that's important about this is that these ministries of health who are trying to struggle with these budgets also have these unfinished agendas of communicable diseases, such as measles and malaria, have a big program to do with maternal health, so they're still trying to catch up with all of those issues. And the trouble then becomes when they're increasing these big costs for these very widespread and expensive treatments to treat diseases, it absorbs quite a lot of their national budgets, not just a ministry of health issue, this is something that affects the national economy. In Samoa the ministry of health absorbs something like about 23 per cent of all government expenditure. In some ways that's a good thing because it's showing the government's commitment to health. But 23 per cent is a lot of money to be spending on your national budget for countries that often don't have the strong sustained economic growth that some of the countries in Asia have. So it has an impact on the whole of the national economy, these are really important sort of economic issue.
COUTTS: Another crisis that's looming within the crisis I guess is that I have been told on previous occasions that the younger and younger, the diagnosis for kids now getting diabetes, so they're much younger. It used to be juvenile except it's much younger, sometimes five and six. So what's actually happening in the renal dialysis area is that the existing people on dialysis already are being pushed by the people who are about to be ready for it, and then the young ones are going to be needing it much earlier than was previously shown, and so there's going to be a real rush and demand on dialysis machines that again the health departments can't meet?
ANDERSON: That's exactly right and what the study showed was that for lower middle income countries across the world something like about 30 per cent, the NCDs normally contribute about 30 per cent of all premature deaths. However in the case of the Pacific 11 countries of the Pacific have even higher levels than the average income for them when you compare them across the world. In the case of Nauru over 50 per cent of all of the premature deaths are caused by NCDs. In case of Tonga the life expectancy of the country is actually going down, and it's exactly the cause of what you're saying there, that these NCDs, including diabetes is strike people quite early. And part of the reason for that is the risk factors that could create all these sort of difficulties are there at quite young levels. The statistics show that for a lot of these countries, even school age children are obese or overweight, not getting the physical activity, or perhaps they're not doing the prevention and promotion of their health that they need to be. So if you've got a young population that is obese, overweight, etc., etc., it's certainly then going to be shown in the young adult population that they're starting to hit these diseases.
COUTTS: Is there an answer, what can be done?
ANDERSON: Well again a very good question and I think a lot of the countries are struggling to get the right information to work out these root causes so that they can respond appropriately. But at the end of the day quite a lot is being done, the Pacific Island Forum leaders themselves have recognised formally, at least in 2011 that NCDs, these non-communicable diseases is a crisis in the Pacific, so that suggests that there's a political commitment, which is a starting point for a lot of these things. I think within the health sector governments need to support individuals and families to actually adopt these lifestyles that are going to if not prevent at least delay the onset of a lot of these problems. I guess it's pretty clear we're all going to have die of something, but the trick is to try and ensure that we've got lifestyles that avoid these premature things, which can cause so much sort of difficulty and harm. A lot of this comes back to prevention, is the health system setup so that it can really advocate for better health, promote better health, is the tax system setup so that it's made it clear that tobacco for example very important, easily preventable cause of death is taxed at a level that discourages uptake amongst young people, and incidentally provides quite a lot of additional money for the health system. Cook Islands has done a very sensible thing I think which is to tax and increase the excise duty on sugary drinks. The average soft drink that people consume has something like eight to nine teaspoons of sugar in every single drink, and that's obviously going to be a difficulty for people who are on the cusp of getting diabetes. Some countries have looked at school canteens to try and ensure that people eating their local produce in food, rather than these highly processed foods. So things are being done but I think it's very clear that the governments in the region themselves know much more has to be done. It's got to be better targeted, these countries don't have enough money to spend in ways that are wasteful, it's got to be targeted on prevention to make sure that these things don't arise. I think those are some of the key issues.