Richard Smith on countering the “wicked problem” of the chronic disease pandemic

Richard SmithI spent two days last week in the seductive grandeur of Trinity College, Oxford, fretting about the global pandemic of chronic disease, but I left feeling optimistic—despite the pandemic raging as fiercely as ever.

For doctors chronic disease means any disease that keeps going, including AIDS, TB, and other chronic infections together with neurological, rheumatological, and mental health problems. But those of us in what might be called “the chronic disease movement” mean cardiovascular disease, diabetes, chronic respiratory disease, and some cancers. These four diseases are caused by three main risk factors—smoking, poor diet, and physical inactivity—and cause more than 50% of world deaths. Hence the naming of the 3:four:50 website that is a Web 2.0 creation to counter chronic disease where I have placed more blogs on the Oxford conference.

Most BMJ readers are probably aware that although deaths from heart disease and stroke are coming down in developed countries they are shooting up in low and middle income countries. So far very few resources have been devoted to countering the problem, although last year’s World Health Assembly did adopt an action plan. Trying to slow the progress of the pandemic of chronic disease sweeping through the developing world is, a “wicked problem” said David Mathews of the Oxford Health Alliance at the conference. A wicked problem is highly complex, perhaps ultimately insoluble, has no obvious solution and is full of contradictory data; every step forward is possibly a step backwards. Such problems can be tackled only by partnerships devising multiple options for responding and being content with “constructive ambiguity,” whereby partners who may feel uncomfortable with each — like public health practitioners and food companies — concentrate on where they agree and park their disagreements.

One good way to approach wicked problems is to “think big, act small, move fast, and leverage like hell.”  The big thinking is to maintain faith that we can make a difference and to continue to work on a global scale.

Some of the small actions are community interventions for health, where an attempt is made to redesign neighbourhoods so that “healthy choices are the easy choices.” The North Karelia programme that brought down deaths rates from heart disease in that part of Finland can be considered one of the first of the community interventions for health.

The interventions are made in schools, workplaces, health centres, and the whole environment, and ideally the interventions operate not by persuading individuals but by making structural changes like banning smoking in public places, making stairs more accessible, improving public transport, reducing the amount of sugar in drinks, or a hundred other possible changes. Some are large and might require legislative actions, while others are small and easily implemented—like putting notes beside lifts encouraging people to use the stairs.

These interventions require political support and agreement from all the different stakeholders in a community. Indeed, the very act of bringing people together to think how they can redesign their environment is in itself an important intervention. Ideas for change will begin to flow.

These programmes are underway in Kerala, Hangzhou, and Mexico City and are being planned for Leicester, New Haven, Andover, Delhi, and Sousse in Tunisia. Most of the programmes will be rigorously evaluated, although evaluating such programmes is itself close to being a wicked problem.

Another way to prevent heart disease and stroke—but not other chronic diseases–is through the polypill, a pill that combines a statins, antihypertensives, and aspirin. These drugs work in different ways, and so their benefits can be added together. Nick Wald, who spoke at the conference, proposed in the BMJ in 2003 together with Malcolm Law that such a pill could reduce heart attacks and strokes by about three quarters.

Now Denis Xavier, who was also at conference, and colleagues have begun to test the idea, conducting a trial in over 2000 people in India. They have shown that people will take the pill, it is safe, and it does have the expected effects on reducing blood lipids, blood pressure, and platelet stickiness—although the effects were not quite as dramatic as Wald and Law hypothesised. Still, however, one pill that might be available for as little as a dollar a month could prevent more than half heart attacks and strokes.

Tom Marshall, also at the conference, is conducting a trial in Iran and has results similar to those from India.

There seem to be five polypills in the world (three from India, on from Iran, and one from Spain), and all but the Spanish one were represented at the conference—making this an historic occasion.

Anthony Rodgers from Australia has helped Dr Reddy’s Laboratories from India make one of the first pills, but in his talk he regretted the slowness of progress. He attributes the slowness to professional conservatism, regulatory hurdles, and lack of market pull. Nevertheless, I was left with a feeling that we are at last gathering momentum, and polypills may be on the market in Europe and the US within a couple of years. (I’m taking the components already, but it means taking five pills every night.)

Innovation will be essential for tackling chronic disease, but it’s probably less scientific innovation and more innovation in making change happen, getting things done. An example came from Tal Gilbert, head of research and development at PruHealth, a joint venture between the venerable Prudential and the South African company Discovery.

The company offers heavy incentives to people to adopt healthy life styles. Those covered by its policies are given detailed information on what they could do to live healthier lives, guided to companies who can help them by providing healthy foods or access to gyms, and then given “vitality points” for eating healthy foods and exercising. The points become cash benefits.

Academic analysis soon to be published suggests that those who collect many points have much lower claims; interestingly and surprisingly the big reductions are in cancer and mental health. (There is the obvious problem of causation, but Gilbert said that those conducting the analysis were well aware of all the methodological problems.)

“Leveraging like hell” was in many ways the major theme of the conference. Building a jumbo jet was a complex problem but not a wicked one in that there was a clear blueprint. Yet no individual knows how to build a jumbo jet. It depends on many different groups of people with different knowledge and skills, and we are likely to make progress with chronic disease only by bringing together many different stakeholders—politicians, academics, patients, health workers, social scientists, private companies, non-governmental organizations, and many others.

Jonathan Horrell from Kraft Foods UK described the experience in Britain of bringing together government, business, charities, and community organisations in the Department of Health’s Change for Life programme. He is part of Business for Life, and the government’s hope is that industry will contribute some £200m in kind through marketing and creativity. The media and some of the other partners are understandably suspicious that food companies are part of the problem rather than the solution, and building trust among the different groups is proving difficult. “Bilateral trust” among just two groups is not so hard but it’s trust among all that is hard to achieve.

Partnership, ideas, and innovation can achieve little without resources, and lack of resources has always so far been a problem for those trying to counter chronic disease in the developing world. Rajaie Batniji from Oxford University pointed out that about $3 in aid is spent for every death from chronic disease compared with $1030 for every death from AIDS.

Rachel Nugent, an economist from the Centre for Global Development in Washington, described how data from the OECD showed that only around $2m of aid was spent on chronic disease in 1996, but the figure was $56m in 2007, although $31m of that was on “mental health”—in fact, conflict resolution.  In the same year $1346m was spent on infectious disease. Nugent’s survey of donors did, however, suggest that total funding has increased to over $600m by 2008 with about half of it coming from private donors.

Stig Pramming of the Oxford Health Alliance led the conference towards an upbeat conclusion by announcing that June will see the launching of a Global Alliance for Chronic Disease that will include the government research bodies from the US, Canada, UK, India, China, and Australia. It will initially have some $45m to invest in research.

Competing interest: RS is heading UnitedHealth’s Chronic Disease Initiative, which funds eight centres in low and middle income countries to counter chronic disease. The initiative partners with the Oxford Health Alliance, which organized the conference, and helped sponsor the conference.