A new product/service to improve medications for chronic diseases

A new

product/service

to improve

medications for

chronic diseases

—

Arch. Giulio Ceppi

Contro-relatore

—

Ing. Marco Gribaudo

Paolo Quattrocolo

Tesi di laurea Magistrale in

Design del Prodotto per l’Innovazione

Content

Chronic diseases - p.7 Worldwide situation -p. 9 Chinese situation - p. 19 Economic impact - p.31

Possible causes and prevention - p.43 Consideration - p.77 03. Problems identification . p.79

00.

Working for Chronic diseases

The future of medications

The research and the development of my master‘s degree thesis project investigate the world of health care. The intent is to understand and analyze the problem of chronic diseases, now considered to all effects a social and economic plague on a global level. The carried-out research seeks to understand what the extent of this problem is nowadays, and what could be the envisaged scenario as a consequence in the years to come. The research is intended as a starting point for reflection about everything that someway can be considered connected to the case of chronic diseases. This meant a particular attention on understanding the most diverse causes that lead to these health problems; the goal, where possible, was to get to understand the origin of the cause, and why people do not or do not want to understand the effect that some „habits“ may have on their clinical status. To succeed in all this, it was essential to create a wide range of basic knowledge about the health sector and to study who seems to be the most affected by this problem and the extent of the phenomenon worldwide. After collecting these information, I went to investigate what all this meant specifically for China, because the project that I aim to develop is primarily designed for the Chinese context. The further step that follows this first phase of analysis, that can be defined as cognitive, was the direct contact and investigation of those that are the main actors in the scene of this problem.

I have done interviews with patients and professionals in the medical field. This phase of my research was essential to define the specific detail of this broad problem to focus on. So, I decided to investigate the problem of drug adherence from patients with chronic diseases even more closely. A lot has already been done in this area but seems that there are not any standard for treatments and monitoring that could be able to allow a significant mitigation of the problem. Therefore, I explored which were the main causes that push Chinese patients not to take their medications accurately. Once this question has been clarified, I have taken stock of the situation regarding how we are trying to solve this problem, looking for virtuous case studies that have shown to have a significant positive effect on the medication adherence of chronic patients. At this point, having a sufficiently large picture of the situation, I developed a system based on the use of a digital platform combined with a smart pill box, able to manage the interactions between patient-doctor-pharmacist, and to improve the adherence of the patient through a system of warning and information, designed to avoid all the unpleasant problems that may occur when a patient is unable to accept his health condition.

01.

01.1—My point of view

Why Health Care?!

I would like to introduce the paper of my master‘s thesis explaining the reasons why I focused on such a topic and which are the connections with my studies, making clarity about my idea of design.

Make Design

As already mentioned, my thesis aims at researching and designing a service that allows a better adherence to medicines by patients with chronic diseases. This choice for my thesis project surprised many people who know me, like family, friends and university colleagues, because most of them did not see any relation with the world of design, discipline that I deal with as a design student of the Politecnico di Milano. So I will briefly explain what it is for me „To do Design“ and why such a theme. When I started my university studies 5 years ago, I also interpreted design as the study and realization of „forms“, simply linked to the ability to transmit with manual or artistic skills aesthetic values associated with products or graphic elements. In practice, I believed that a designer was able to create beautiful products, intended in a material or digital sense. Fortunately, I have discovered over the years that it was not like this, I say “fortunately” because if it was as I imagined, I probably would not have had great success in this sector. I learned that „To do Design“ is an approach to the planning world,

based on an extremely careful and accurate analysis of all the factors that surround or are part of a specific area of interest.

Human centred

Design is to find intelligent solutions to complex problems that can sweep in any area and sector, based on a research that always puts the people who will benefit from the final „product“ at the center.

Ethical and social value

In my university career and in the study experiences that I have done during the years abroad, I have always found greater interest in developing projects focused on solving problems with an ethical and social value compared to those that are mainly focused on the aesthetic value that comes from a world of production and market trends. In particular, I have chosen to deal with this issue because I would like to be able to do something mportant for our planet and for the people who live there: I believe that raising people‘s awareness about their health can make them more responsible and aware of themselves. Translated into simple words, I would like people, in this case patients, to have greater respect for themselves and their clinical condition, so that in the future they will have greater respect for others and for our planet.

02.

General Context

The first phase for the development of my thesis was the exploration of what was, in the

medical field, an illness considered to be chronic and which were the differences with other

diseases.

A condition of chronic health is a condition of

persistent

negative health, lasting in its effects and that, despite

therapeutic interventions, will hardly fade over time.

1

As reported by the U.S. National Center for Health Statistics,

a chronic illness in order to be considered this way, should

last 3 months or more.

2

1 Costantino Cipolla, Manuale di sociologia della salute, Franco Angeli, 2005 2 Medicinenet, Medical definition of Chronic diseases, 2016

02.1—Chronic diseases

What are they?

These kinds of diseases are becoming increasingly important within the medical health sector. The symptoms of chronic situations are in fact a new challenge for all those who work in the medical sector, as up to 50 years ago they had a role in non-existent or marginal within the wide range of known diseases, treatable or not. To be able to make an accurate analysis of this phenomenon and to better understand what are the diseases that lead to chronic health situations, there is no better way than trying to analyze some data, now traceable from different sources, as since 25 years ago the study of this kind of diseases has become a priority for all those involved in health.

World Health Organization

In 2005 the WHO (World Health Organization) drew up a comprehensive report on chronic diseases; explaining what they are, which are the causes, the current situation, the possible developments and costs. In order to have a global overview of this issue, I have carefully studied this document. It made me understand the importance and the need for concrete action to limit and

constantly lower the negative tendency of deaths caused by chronic diseases.

Numbers

To speak are the numbers reported by this research, which leave space to many reflections and ideas to understand and interpret the problem. I think it is important to name a few of them, in order to quickly explain what the current situation of contemporary society is, towards a scourge of this kind. The data show that since 2005 there has been an average of about 58 million people dead every year for reasons of any kind; it is estimated that at least 35 million of them were caused by chronic diseases, a value greater than twice the number of deaths caused by the set of all the other factors that can cause death, including deaths from wars, infections, accidents , childbirth and poor nutrition. Of these 35 million deaths from chronic diseases, 17 million and more are attributable to cardiovascular problems, 7 and a half million to cancer, 4 million to diseases that cause chronic respiratory difficulties, and one million and a half to diabet. 3

Developing Countries

The research conducted by the WHO has also shown that the developing countries are the most affected, despite what could be expected. Numbers say that the 80% of people with chronic situations live in poor or in developing countries. The situation regarding the number of deaths per year is critical particularly for those countries classified as poor, as in addition to having such a high number of deaths as a result of chronic diseases, they are also those most affected by deaths from wars, treatable diseases, childbirth and poor nutrition. However, we must consider that it is in these states that the greatest number of inhabitants of the earth resides.4 _{The trend}

with respect to the increase in deaths per

year caused by chronic diseases is currently negative. It has been estimated that if, in the coming years, the number of deaths due to infectious diseases, childbirth and bad nutrition will decrease even with peaks of 3% per year, the percentages of deaths per year for chronic causes could have a completely different trend.

Projection

In 2005 it was estimated that an increase of 17% would have been achieved in the next 10 years: these numbers still seem to be confirmed in the estimates for the next 10 years. In these 10 years and little more, about 338 million people on earth are expected to be dead due to causes attributable to chronic diseases.5

4 Catherine Le Galès-Camus, Robert Beaglehole, JoAnne Epping-Jordan, Preventing Chronic Diseases, a vital investment. Poorest country are the worst affected, WHO 2005

5 Catherine Le Galès-Camus, Robert Beaglehole, JoAnne Epping-Jordan, Preventing Chronic Diseases, a vital investment. The threat is growing, WHO 2005

02.2—Worldwide situation

A new plague

So, there are some questions to ask about such a negatively important factor: how was it possible to get to this situation? The WHO highlights some of what might be the answers to this question, not really trying to explain why people are affected by these diseases, but mostly analyzing the reasons why little or nothing has been done globally to avoid such diffusion.

False myths

IFirst, it is unjustifiably believed that these kinds of diseases spread more easily in those countries that are recognized as rich and

is a completely unfounded belief, indeed, as the data show, the number of deaths due to chronic symptoms occur in third world countries such as Nigeria and Tanzania. The answer to why there is such a diffusion in poor countries is certainly not simple: as previously mentioned, a motivation could undoubtedly be the number of people residing in these countries, but not only, in third world countries, in fact, priority is given to the treatment of infectious diseases, considering them to be more lethal and more rapid in diffusion, thus allowing chronic diseases to pass as a secondary and minor problem.

It is evident that for countries like these, in the future, the health challenge could become unsustainable. Another disbelief is that to be affected by these health problems are mainly rich people, because they are used to a more exuberant lifestyle and with the possibility of enjoying all the pleasures that life can offer. Even in this case, however, the truth is at the opposite. First of all, the number of rich people on the planet is enormously lower than that of poor people, but even more because many poor people fall into those vices that most of all can create chronic health situations, such as alcohol and smoking. Another mistake that is often committed is to consider chronic diseases as prevalently diffused among elderly people. Once again, the numbers confirm this: the 50% of the deaths due to chronic clinical situations are under 65. It has been found that the people most affected by such disorders are middle-aged adults, especially in developing countries.

These people tend to get sick at a young age, then suffer from these health problems for a long time, and then die prematurely. A worrying trend is that it shows a steady increase in the spread of type 2 diabetes among children under 10 years of age. From this data many scenarios could be opened, which certainly do not offer a happy future for future generations. Especially in the case of children suffering from weight disorders that result in diabetes, it seems that their parents are the least worried about the situation. They often believe that it is a temporary problem, something that is simply due to the growth and will therefore be resolved over time. In this regard it is necessary once again to distinguish between well-off and non-wealthy countries, this because it is mainly in those countries where the level of education is still very backward that the percentage of children with diabetes 2 is higher.

Parents role

Numerous interviews collected by WHO researchers show that, especially in third world countries, parents, especially mothers, do not realize the importance of a healthy lifestyle for their children, believing that time is sufficient to fix disturbances which in their eyes are only temporary and caused by age. In some cases, it seems almost incomprehensible how these people can think such things, considering that these parents, often, are affected by the same illnesses as their children.

The guilty

Another common mistake is to recognize the people who are affected as the only ones guilty of their own illness. This is true only in cases where people have complete access to a healthy lifestyle, and where they are free to make informed choices. It is therefore evident that governments and institutions play a predominant role in this scenario, they have to be able to make their knowledge and „raw materials“ available to their citizens, making “informed choices” possible. In addition, they must be able to help and give special protection to groups that are deemed vulnerable. This consideration is especially true for children, who can not choose the place to live, what to eat and their exposure to cigarette smoke, that is exposure to secondhand smoke. For this category of people, it is also difficult to understand what the consequences of wrong habits and lifestyles may be, as their education and life experience are still insufficient to prepare

Besides children, there are poor people that are particularly exposed to these risks as they often do not have the possibility to choose what to eat and where to live, but primarily they do not have the financial means to receive an adequate or even minimal education and efficient medical care.

Prevention

Another aspect that is a little or not at all considered when it comes to chronic diseases, is the prevention. In general, people believe that against chronic diseases there is nothing to do, it is something that can happen to anyone at any time and there is no way to prevent or treat them. This state of resignation is more pronounced with some diseases than others, one of them is certainly cancer. I will talk later about the importance of the preventive aspect, but for now it is enough to underline that according to studies and researches in the medical field and health education, it was discovered that 40% or

The Half Truths

Other equivocal statements that are associated with chronic diseases are the „half-truths“. The half-truths are event that really happened, which are reinterpreted in an improper way and adopted as absolute truths, rather than as fortuity. A famous example could be the typical phrase: „My grandfather smoked and was overweight and lived up to 95 years“. This kind of people actually exists, but they can be considered as an exception to the rule. In every community, in fact, there are rare cases of two particular

types of people: people who lead a life with many factors that could lead to chronic diseases, but that will inexplicably lead a long life without health problems; and people who instead follow the canons of a healthy life and keep themselves away from the risks that can cause a chronic situation, and that at the end are equally affected by one of these pathologies. But we must be able not to rely on these particular cases, as they are impossible to analyze in a scientific way, and therefore should be considered unreliable.

Social impact

Family role

the economic and social fallout of a chronic disease falls primarily on families

Chronic diseases

Sooner or later...

Another consideration that is made by many of those who abandon themselves to ephemeral pleasures, which lead to unhealthy lifestyles, is that sooner or later somehow one must die. This sad affirmation is unfortunately true, but the people who say this do not imagine what the difference is in dying serenely because of age, or dying after a long and painful ordeal, which for years and years may not allow them to conduct a life considered at least normal. Besides the aspect linked to the physical pain that this choice may entail, there is also the economic and social fallout that such a statement, or even worse, this kind of life choice can cause on the whole society and in particular on their loved ones and family.6

Stroke

8 Leading Causes of Death in 1900 and 1990

0-5% 6-10% 11-15% 16-20% 21-30% 31-40%

Pneumonia & Influenza

Tuberculosis

Gastroenteritis

Heart Diseases

Cancer

Chronic Lung Diseases

Change in causes of death

Important deductions, referring to what is the current global situation in the spread of chronic diseases and their impact on the general trend of our society, can be made based on the numbers that show what were the changes in the causes of death in the last 50 -60 years. To get a more complete picture, I used data that show changes in trends with respect to possible causes of death in the United States from 1900 to 1990.7 _From

the data reported in the research “Chronic Disease Burden” in China, you immediately notice how the causes of death have changed over time with the changes of our society, therefore they can be associated to cultural, economic, urban, food changes, industrial development, and other factors that over the centuries have brought contemporary global society to be what it is today. Particularly significant were the numbers collected about the change of trend in deaths due to flu, heart problems and cancer. It is enough to say that at the beginning of the last century, 17% of the causes of death in the United States were attributable to flu and to the various symptoms related to it; at the end of the last century the percentage concerning this type of illness has instead become a cause of death

for only 2% of Americans who die in a year in the USA.This is a clear symptom of how well-developed countries, infectious diseases and problems concerning cases of bad health or hygiene have been effectively solved. This is undoubtedly a positive starting point for the fight against global health problems, but on the other hand, there is an increase in the number of deaths due to illnesses linked to chronic health situations. As mentioned, undoubtedly are the percentages related to deaths due to heart problems and cancer that stand out. In fact, in these two cases, percentages are passed from lower than 10%, to a current situation in which the deaths due to heart problems reach about 35% of the annual total, while for cancer it is reached 22%. The data reported by these two diseases are undoubtedly the most dramatic, but there are also other diseases that concern such as diabetes, chronic problems to lung and liver. Indeed, it was noted that at the beginning of the 20th century there were no cases of death caused by these causes, or at least not recognized as such. Today, however, together they represent the 10% of causes of death among the US population.8

7 Jing He, Joseph S. Copes, Chronic Disease Burden in China, 2007 8 Strong K at all, Lancet, p.366, 2005

02.3—Chinese situation

Fight against big numbers

Once to have seen and understood what the situation at a global level with respect to this problem is, I have analyzed in more detail what is the current status in China, as the development phase of my thesis will take place right here in China during my graduation year at Tsinghua University. The search for the data about China was not very simple, as most researches on chronic diseases are done in America, or in any case in Western countries. Secondly, Chinese sources were difficult for me to use, due to my lack of knowledge in Chinese language. Therefore, I had to use my Chinese university colleagues to do some translations, which took a long time, and in some cases forced me to refer to data collected by American or international researchers about public and private health in China. Despite this, I managed to find an interesting

Wang Longde, released for a WHO report.

Minister Wang Longde report

From his statements and the data I gathered, I understood how China currently is, and will be more and more in the years to come: a country in great difficulty in the fight against the reduction of the deaths and the sick with chronic health situations. Deputy Minister Longde began his report by giving some explanatory examples of the bad trend that is taking shape in the great Asian country. 300 million of Chinese men between the ages of 18 and 45 are smokers, and 160 million adults have hypertension problems. The rate of underweight or even obese children under the age of 18 is also worrying, and it is now considered a true epidemic, reaching the 20% in urban areas.

These risk factors will cause an unacceptable number of

people to die prematurely and often after years of needless

suffering and disability, and tragically, so many who have

recently escaped poverty will be plunged back, due to the

burden of health care costs. This situation is especially

tragic considering that at least 80% of all heart disease,

stroke and diabetes are preventable.

9

Some numbers

Other data, far from reassuring about the Chinese situation, were communicated by the WHO on January 19th, 2015; in the announcement the epidemic that is rapidly spreading throughout the country is even referred to as the „tsunami“, a term that is correclty used, as today the figures show that every year about 3 million people die prematurely due to causes attributable to chronic clinical situations.10 _{In 2012 the}

total number of deaths for these cases amounted to 8.6 million. The most worrying fact, however, is undoubtedly the number of patients currently residing in China, which in recent years has reached the impressive figure of 300 million people. Furthermore, in 2016, the number of deaths due to slow-development pathologies increased from 80% to 86.6% of the total.11 _China,

obviously, can not try to solve the problem by simply thinking about what is the current situation: for a country of this size and with a population that amounts to more than a fifth of the global one, it becomes essential to know how to plan and evaluate the way in which chronic diseases can spread and what extent it can reach from here to the next 10 years or more. In this regard, there are many

studies carried out to try to understand how much relevant will be the average increase in the age of the population. At the moment the problems related to the management of this type of patients are already worrying for the country, despite the population has a really low age; when, inevitably, the number of over 65s, that are people considered elderly and therefore potentially more vulnerable, will reach a significant number, the economic situation for the state and for individual families will become unsustainable. It is estimated that in 2030 the number of elderly people present in China will exceed 20 million; at the moment they are only 8 million.12 _{As previously done to evaluate}

more closely the increase in deaths due to causes associated with corneal diseases at the global level, I decided to compare the causes of death in China in the mid-1900s with the current ones, with the aim of obtaining an accurate and objective interpretation of them, useful for the development of a service specifically designed for this country. Even in this case I think it is immediately evident how the new trends (causes of death) are symptomatic of the changes occurred in modern society at several levels.

10 Sui-Lee Wee, WHO says chronic diseases kill 3 million annually in China, WHO statement 2015

11 Linkang report, An integrated service for people (slow disease patient). A brief introduction of third party slow disease innovation service system and platform function, 2017

Heart Diseases

Stroke

8 Leading Causes of Death in China: 1957, 1991-2001

0-5% 6-10% 11-15% 16-20% 21-30% 31-40%

Respiratory Diseases

Infectious diseases

Tubercolosis

Cancer

Chronic Lver Diseases

Comparison between periods

Following the evaluation line used for the comparison between periods at global level, I paid particular attention to assessing changes in the number of deaths due to flu or infectious diseases, heart problems and cancer. The result is a country that perfectly follows the values globally reported; indeed, it could be said that in some cases the numerical data reported are even more worrying than the global average, especially considering that for the overall situation at global level they were specifically analyzed the years at the beginning of the 20th century and those at the end of the same century, while for China the period is about a half (1957-2001). Moving on to talk about the problem in numerical terms, we can see how the problem of infectious diseases, even if still present, is close to being almost completely eradicated: there were about 8% of the deaths due to infections or fever in the middle of this century, while today they are only a bit over 2%. If you think back to what the percentages in number of deaths due to these causes are, you understand how is true what the WHO said in 2005, saying it was a commonplace for decades to consider infectious diseases more impactful and more dangerous than chronic ones.

Obviously with this statement I do not mean that we should have done less to eradicate infectious diseases, which in any case still remain the main cause of death in some countries, but that we should probably have done more to prevent the spread of diseases that now have become the leading cause of death on the entire planet. To confirm what has just been said, also for China, are the percentages concerning deaths due to cardiac disorders and cancer. In the Asian country, in the mid-century, these two disorders barely reached 10% of total deaths, while today they are the cause of death for almost 50% of the deaths occurring in China in a year. The analysis of numbers is a raw and sometimes inaccurate way to carry out a research, but the data, even if they do not say everything, are almost always reliable to understand the general situation.13 _{In the}

case of health care they must be taken very seriously, precisely because the number of patients is such that it is not possible to can carry out a large-scale research taking into account the specifics and the particularities of each individual case (think about China where there are currently 300 millions of patients with chronic situations).

Mortality proportion for the 5 leading causes of Cancer

deaths

Given the worrying information collected so far, I decided that it would be essential to investigate in more detail what is the Chinese case, in order to have more specific and indicative data, able, perhaps, to highlight some peculiarities more relevant than others to intervene about, and to which direct my project. I then explored in the most thorough way as possible internationally renowned websites, magazines and medical journals that deal with the spread and problems related to chronic diseases in China. The amount of obtained information simply underlined what I already expected after taking note of more general data: nowadays China has a non-homogeneous and poorly organized health system, which does not allow doctors and professionals to carefully follow the care of patients with the need for prolonged treatment. Major investments have been made and will become even bigger in the future, but at present the State does not provide a real public medical service; most of the health costs fall on the patients and their families, who in many cases are unable to meet the costs of maintaining a person who will remain ill for the rest of his life.14

Chinese DATA on main chronic diseases

To demonstrate what I have just said, I will go on showing data on the main chronic

diseases spread in the great Asian country. As previously announced, today vascular problems and cancer are two of the main factors of death. The main vascular problems causing death in China can be divided into five pathologies: infarction, chronic pulmonary heart disease, coronary problems, heart failure, rheumatic heart disease. The collected data compare the extent of each of these diseases between men and women. The shown list is arranged in descending order from the most incisive in terms of death to the mildest one. Without reporting every single issue, it is enough to say that more men than women are affected by these health problems, despite a change in trend regarding heart failure and rheumatic heart disease, where there are more deaths among women. However, the numbers relating to deaths due to heart attack are not negligible, as the sum of deaths for men and women reaches about 550 thousand people a year. The five most common types of cancer are lung, liver, stomach, esophagus and colon. Even in this case the comparison between men and women is made, and the order is always decreasing from the most impacting to the slightest. 15 _{As far as cancer deaths are}

concerned, numbers are undoubtedly to the detriment of men, but this is not surprising if we think about the number of male people in China recognized as regular smokers,

14 Linkang report, An integrated service for people (slow disease patient). A brief introduction of third party slow disease innovation service system and platform function, 2017

Age-specific mortality for the five leading causes of death

by age groups, China

0-200 201-400 401-600 601-800 801-1000 1001-1200

Age>65 years

Age<65 years

1201-1400

Stroke

Cancer

Pneumonia & influenza

Infectious diseases Cancer Stroke Heart diseases Accidents Infectious diseases Heart diseases

the presence of cancer lungs on top of this sad ranking underlies all of this. In the research phase for the development of my graduation project, I attended several seminars and conferences focused on the importance of take care of elderly people and on the fact that they are a category particularly at risk, especially at the clinical and health level. However, the information I have collected shows a quite different trend compared to the one I was expecting: the over 65s, age from which we are conventionally recognized as elderly, are not the most affected by chronic health problems, even though their immune defenses do not allow them to be as strong as younger people. The three main causes of death taken into consideration in comparing over and under 65 were: heart problems, stroke and cancer. Before mentioning the magnitude of the number of deaths for the two different categories, we have to open a short parenthesis, recalling that the total number of elderly people in China is currently very low and that the population has a relatively young age. Therefore, despite the numbers report a state of health apparently better for the elderly than for others, it is necessary to know how to read this data in the right way. In fact, the data report specific numbers, while it would be more effective to have estimates in percentage to be compared. That said: the figures show that every eight people died for heart problems, only one is over 65, a similar relationship is also found for stroke, about

1 death every 7 affects a senior, in the case of cancer instead, the difference between the two categories is lower: one third of the deaths affects people over the age of 65. 16 _The

developed analysis has led to investigate the differences between the number of deaths in rural and urban areas, and between north and south China. These two researches, however, have not led to unexpected or particularly significant results. The numbers are in fact very close. The unique element that a reader not sufficiently 23 informed about the situation of Chinese public health may consider significant, is a slightly higher share of deaths in rural areas than in urban areas. In fact, if great Chinese metropolises are undoubtedly more polluted and responsible of a more frenetic life style compared to the country areas, it is also true that here medical facilities are in a number undoubtedly more considerable, and in case of need a person in danger of life can be more easily rescued. Another factor that could affect this result is the availability of better education in urban areas than in rural ones.17 _Another

serious problem in China are undoubtedly people who are affected by hypertension; It is shown that today a Chinese male aged between 35 and 74 years is 50% more likely to suffer from hypertension than in 1991.18

16 He J., Gu D., Duan X, N Engl, J Med, 353: 1124-1134, 2005

17 Franck Le Deu, Rajesh Parekh, Fangning Zhang, Gaobo Zhou, JHealth care in China: Entering “unchar-tedvwaters”, November 2012

Prevalence of hypertension among Chinese men, ages 35- 74

years, in 1991 and 2000-2001

per

cent

ag

e, %

The hypertension problem

The hypertension problem perfectly introduces what in China is the main cause of death spread among the population, that is the irregularity of blood pressure, abbreviated as BP. Abnormal values of blood pressure can cause cardiovascular problems, cerebrovascular problems and coronary insufficiency. In 2005 the number of deaths due to this kind of problems reported really disturbing statistics: about cardiovascular problems, there are 1,395,400 men and 935,300 women who dead due to this cause, while in the case of cerebrovascular problems men are 1,076,400 and women are 786,100. 19 _{A summary that quickly defines}

the current situation in China can be defined by following information: the mortality rate caused by slow-developing diseases has increased in recent years from 80% to 86.6%; the main causes of death related to chronic diseases are: cardiovascular problems, lung cancer, chronic respiratory problems and diabetes (although the deaths caused by

diabetes are not a large number if compared to the other diseases we have mentioned, the increase in percentage terms, which they have year by year is particularly relevant); of the 300 million Chinese with chronic clinical situations, 50% are under 65.

02.4—Economic impact

An unsustainable expense

So far we have talked about chronic diseases explaining the impact they have on the population only in terms of deaths. Undoubtedly, death is the main reason why we try to fight and eliminate any agent that can lead to it prematurely then the normal cycle of life. However, these diseases also affect many other factors. One of the most significant of these factors, that also arises the greatest interest in the entities that deal with the public health administration, is undoubtedly the economic impact that this calamity can have. It is for this reason that it is in the interest of many governments, where public health

for countries where health is predominantly private, to understand what are the costs for maintaining critically ill patients with chronic health situations. It is well known that for many countries in the world the maintenance of an efficient health service has a drastic impact on their annual public expenditure. It seems obvious to say that at global level taking care of patients with hypertension, diabetes, asthma, chronic kidney disease and arthritis costs billions of dollars to any healthcare system. Precisely for this reason, there are many online platforms born with the aim of collecting data on costs and other factors relevant to the maintenance of patients with

The data collected by the Medicare Chronic Conditions Dashboard in 2014 show the average expenditure per patient with chronic diseases in the world. 20 _{This table}

distinguishes patients based on the number of chronic illnesses from which they are disturbed, showing that for patients with only 1 chronic disease the cost of overall care is around a value of $ 4,000 annually, while for those considered critical cases, and therefore affected by 6 different diseases or more, the cost of treatment reaches as much as $ 30,000 per patient.21 _{As a result, it is not}

surprising that patients with the highest number of complaints are responsible for most of the costs involved in the care of patients with chronic conditions. Of the total

amount of patients with chronic diseases, only 17% report disorders associated with at least 6 different diseases, but health costs for this 17% correspond to almost 50% of total expenditure. Continuing to dig into these numbers we find that 5% of these patients with more than 6 diseases represent about 30% of the total costs addressed to the treatment of chronic diseases with an annual average of $ 78,198 per patient. The 1% of this 5% even goes beyond the cost of $ 100,000 a year for each case. In contrast, although people with only one chronic disease represent the 35% of the total chronically ill patients, they are responsible for less than 10% of the total expense, which means a cost of around $ 2,000 per person. 22

20 Jennifer Bresnick, AnalyzingMedicare Chronic Disease Prevalence, Spending Rates, HealthIT Analystics, 2016 21 Center for Medicare &Medicaid Services (CMS), Medicare Chronic Condition Dashboard, 2014

22 Agency for Healthcare Research and Quality (AHRQ), Steven B. Cohen, Differentials in the Concentration of Health Expenditures across Population Subgroups, 2012

Per capita Madicare spending on C.C

$0

$4.000

$8.000

$12.000

$16.000

$20.000

$24.000

$28.000

Number of chronic condition

$0

$5.000

$10.000

$15.000

$20.000

$25.000

$30.000

$35.000

Per capita Madicare spending on chronic

diseases by age group

Researches of this type always tend to use procedures that require to create categories and more specific sub-categories of patients with increasingly precise characteristics. Thanks to this accuracy I

could see that unexpected data concern again the group of people over 65. We could expect for this group higher maintenance costs than for younger patients, but surprisingly it does not seem to be like this:

Number of chronic condition

0 to 1

2 to 3

4 to 5

6+

all national

>65 national

<65 national

It would seem reasonable to assume that the growing

age produces more chronic diseases and therefore

more expenditure, the data do not show such a direct

correlation. Beneficiaries of public health care under

the age of 65 are actually more likely to incur in higher

costs than older patients.

23

Black

Percentage of Medicare enrolles aged 18 to 75 with diabetes

whose blood pressure was less than 140/90, by race/ethnicity

Asian or Pacific Islander

20.0 40.0 60.0 80.0 100.0

percentage

White

Hispanic

Other interesting information about cost analysis for patients with chronic diseases is shown by making a gender distinction, in which there are slightly higher costs for male patients than for women, or even better by dividing the population of patients

particularly relevant for the purposes of my research; in fact, the analyzed situation shows the percentage of people of different ethnic groups who respect the controls of blood pressure. This figure is closely related to health costs for individual patients, as

with lower percentages the costs can increase up to $ 5,000 more than individuals of ethnic groups with higher percentages. In this specific case the people of Asian origin (included in the same group of people coming from the Pacific Islands) turn out to be a virtuous example, since the percentage of patients who regularly carry out blood pressure checks is almost 80%.24

Economic impact for China

As mentioned, the data collected so far,

even if extremely specific and significant, have a global connotation, therefore lacking punctuality with regard to Chinese context. Unfortunately, I was not able to collect such precise data regarding the costs of every single patient suffering from slow-developing diseases in China. Despite this, however, forecasts on the economic impact, which China will have to face from now to a few years to resolve, or at least be able to stem, such an epidemic, exist. As already mentioned, non-transmittable diseases (NCD: set of chronic diseases, including cardiovascular diseases, tumors, chronic respiratory diseases and diabetes,

characterized by a long latency period, a prolonged clinical course and debilitating manifestations) represent the main health threat in China, accounting for more than 80% of annual deaths and contributing to 68.6% of the total cost of treating diseases in the country.25 _{The number of cases of}

cardiovascular disease, chronic obstructive pulmonary disease, diabetes and lung cancer among Chinese people over the age of 40 will double or even triple in the next two decades if effective prevention and control strategies are not implemented. This trend is a consequence of the social, economic and environmental changes that the country has experienced in recent decades, in particular of the rapid aging of the population and the increasing exposure to health risk factors.26

This kind of health care implications, could cause huge losses of money to the country, which could negatively affect the state but mainly households and citizens, as China does not have a public health plan extended to the whole population. Estimates say that in the next 10 years a propagation of large scale of these diseases could cost to the Asian country about $ 558 billion. 27

24 Medicare Chronic Conditions Dashboard, Clinical Care: Diabetes Care-Blood Pressure Controlled, HealthIT Analystics, 2014

25 The World Bank, Growing “Epidemic” of Heart Attacks, Stroke, Cancer, Diabetes Threatens China’s Eco-nomic and Social, Well-Being, July 26, 2011

26 WHO and Chinese Ministry of Health, Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases, 2011

27 Catherine Le Galès-Camus, Robert Beaglehole, JoAnne Epping-Jordan, Preventing Chronic Diseases, a vital investment. Projected foregone national income due to heart disease, stroke and diabetes in selected countries 2005–2015, WHO 2005

THE PROBLEM HAS SERIOUS IMPACT

The burden of chronic diseases:

has major adverse effects on the quality of life of affected

individuals

cause premature deaths

creates large adverse and underappreciate economic effects on

families, communities and societies in general

An economic weight of this type will certainly have devastating repercussions on the Chinese population, moreover it could generate a spiral that leads to an increase in poverty and consequently to worse and worse health conditions. In fact, it is shown that precarious or totally unstable economic conditions, which lead people to poverty, are among the main reasons for poor clinical conditions, as they highly expose people to factors deemed to be risky and reduce their chances of access to health services. Therefore, increasing costs for the treatment of chronic diseases will lead to a marked increase in the poverty rate of the population, which will result in ever more chronic patients. The conclusions that could be drawn from the emergence of the situation described, are dramatic. It is therefore inevitable that developing and not yet developed countries start planning a health service supported by state aid, which does not fall exclusively on shoulders of individual citizens; in this way it will be possible to fight at the same time slow-developing diseases. and poverty. Various studies on the analysis of behaviors of people from different social classes show how poor people are more vulnerable to chronic diseases due to psychosocial stress, high-risk lifestyle, unhealthy living conditions and limited access to good quality care. Once the disease is contracted, poor people are more likely to suffer negative consequences than people with a greater well-being. To demonstrate this trend are all rich states, such as: Denmark, England, Wales, Finland,

Italy, Norway and Sweden, where the inequalities between well-to-do people and poor ones in terms of number of deaths, have increased in the period between the 80s and‚ 90s. This change is mainly due to two factors. First of all, mortality rates among well-to-do people due to cardiovascular problems have fallen dramatically within these western societies. This could be a symptom of a greater attention to one‘s own health by the more well-off social strata, or simply a greater ease in accessing efficient care services. On the other hand, the numbers of deaths due to lung cancer, breast cancer, respiratory diseases and gastrointestinal diseases among the poorest are constantly increasing.

Some of the causes

The considerations made by researchers regarding these data lead us to believe that the increase in deaths for such causes among people in economic difficulty are attributable to a growing consumption of tobacco among these social groups. 28 _This

social and economic difference regarding the prevalence of risk factors is particularly evident in high-income countries but is also rapidly becoming a major problem in low-income countries.29 _{Poor people and}

those with less education are more likely to maintain risky behavior for several reasons. These include inequality of opportunities, such as general education, psychosocial stress, limited choice of consumption models, inadequate access to health care

inequali-and health education, inequali-and vulnerability to negative effects of globalization. 30 _Despite

all the causes and considerations that can be made about the reasons that allow poor people to enjoy good health, it is clear that the most important factor is the possibility of access to a good quality health service. Indeed, the administration of efficient medical care has a primary effect in limiting and controlling the spread of chronic diseases.

The challenges for poor people

The challenges faced by the poor person to be able to enjoy good health has numerous obstacles: financial constraints, lack of proximity and/or availability of transport to health care centers, and lack of responsiveness from the health system.31 _The

financial considerations made by individual patients can become real „walls“, able to prevent these people from accessing health care. Some people are unable to afford large health care costs and the absence from work, even if for health reasons, could make them lose their salary. 32 _{Transport costs can also}

become a source of impediment in seeking health care by people, especially for those who live far away from valid and competent medical centers. This kind of problem finds a particular response in a country like China, where the difference in health services offered between rural and urban areas is particularly accentuated (in some cases even abysmal, as in many rural areas there is not any medical assistance), and the distances to be covered are very relevant. As already mentioned for the possibility of reaching or having available good medical facilities, poor people are also having more difficulty in obtaining drugs prescription. If this is taken for granted in those countries that do not provide public care services or state subsidies for chronic patients, the same data are also reported in countries where insurance and subsidies are able to help people suffering from chronic situations; this is particularly true in countries recognized as poor or developing, where it has been noted that the wealthiest people still manage to get more from this type of service. 33

30 Bovet P, Ross AG, Gervasoni JP, Mkamba M, Mtasiwa DM, Lengeler C et al, Distribution of blood pres-sure, body mass index and smoking habits in the urban population of Dares Salaam, Tanzania, and associa-tions with socioeconomic status, International Journal of Epidemiology, 2002

31 Goddard M, Smith P, Equity of access to health care, York, University of York, 1998

32 Lorant V, Boland B, Humblet P, Deliege D, Equity in prevention and health care, Journal of Epidemiolo-gy and Community Health, 2002

32 Heisler M, Langa KM, Eby EL, Fendrick AM, Kabeto MU, Piette JD, The health effects of restricting pre-scription medication use because of cost, Medical Care, 2004

Rural area people: no acess to health care system

What if...

An analysis by the World Bank draws attention to the following potential gains from effective NCD policies in China: at the microeconomic level, an improvement in health status among adults may result in an increase of 16% of the worked hours per year, translating into a 20% increase in individual income, in tackling non-communicable diseases, as well as being a valuable investment in health, is at the same time an investment in people‘s productivity. At the macroeconomic level, the reduction in cardiovascular disease mortality of 1% per year over a period of 30 years (2010-2040) could generate an economic value equivalent to 68% of China‘s real GDP in 2010, more than 10, $ 7 trillion. In addition, the returns related to NCD are even greater if we consider the economic value that can be generated by the people made active, then able to produce revenue, by a correct system of care and prevention. Reducing CVD mortality by 1 percent a year could have an annual benefit of about 15% of the current Chinese GDP (PPP US $ 2.34 trillion), while a reduction of 3% would be equivalent to a benefit annual rate of 34% (PPP US $ 5.40 trillion).34

02.5—Possible causes and prevention

Researches that aimed at explaining the reasons for an epidemic of such magnitude and characterized by such a rapid diffusion, are very numerous. It is undoubtedly curious to note how these researches are carried out by working groups that come from extremely different sectors, and which do not seem to have any kind of connection. Logically, a considerable number of these researches is carried out for scientific purposes by doctors, or at least by people working in the health sector: in this case the purpose is easy to understand, research is done to define how to prevent, or to treat this type of disease more effectively. However, there are also other sectors involved in the analysis, such as the world of finance and global economic trends. The reason for such an interest explains the extent that this element is having and will have for the society as we currently know it, which could experience a drastic change and turn into something that has never been considered. For the purposes of my research I had to study some of these scientific papers to get a clearer picture of what are the causes of this diffusion, that

even if it is not already called in this way, it must actually be recognized as an epidemic, and without any doubt can be considered the worst epidemic the world has ever suffered. A disease, in order to be recognized as epidemic, has to be caused by well-defined causes and considered to be actually harmful to a large number of people, plus the effects, or better, the symptoms and the consequences must have common or similar implications. A definition of this type, even if extremely simple and generalized, would be sufficient to classify chronic diseases as an extremely broad epidemic group. One of the problems associated with these diseases is perhaps the fact that they are not seen as a unique group, but rather as single diseases that do not have true relationships with other diseases known as “slow development” ones, but which in some cases may have a common origin. These are some considerations that I made as I explored the large world surrounding the chronic disease, with reference to what can be recognized as the „average patient“ of these diseases.

I will now proceed with make a list and then investigate some of the main causes of the spread of chronic disease, starting from broader concepts up to actions and daily habits that are extremely risky to health. We must therefore consider first those elements assumed to be of greatest impact for very different realities, on a global level. These are the great causes of transformation of the world we are living today.

Demographic increase

One of those that are attracting more the interest of scientists and the media is undoubtedly the demographic increase. On Earth there have never been many people like those there are today. The increase of human beings on Earth is classified by researchers of various sectors as one of the major causes of lifestyle and environmental changes. The problems linked to the demographic increase are many, and perhaps a whole book would not be sufficient to make a detailed and correct analysis, nevertheless I will present the situation that is emerging, underlining the main dangers. The world population has grown continuously starting from the sore of the black plague of the fourteenth century and it is estimated a progressive increase, at least until 2100. Many people believe that the progressive growth of the population is due to an increase in birth rates but in reality, this is not exactly the case: even before births, this phenomenon depends on an improvement in living conditions and the introduction of drugs that can reduce mortality rates and make us live longer.

But what will be the future of the world‘s population? According to the most recent UN estimates, updated in July 2015, in 2030 there will be about 8.5 billion people on Earth and these will continue to grow: in 2050 our planet will reach a total of 9.7 billion inhabitants and 11 , 2 billion in 2100. According to most demographers, birth rates should decrease

by 2100. The progressive and constant growth of the world population must make us worry in many ways: the overpopulation of our planet in fact represents, according to researchers, a real global crisis to which we must find a solution.35 _{If we do not act}

now, billions of people around the world will face thirst, hunger, marginalizationt

Global population growth with forecast up

to 2100

and conflict as a result of drought, food shortages, urban degradation, migration and increasingly scarce natural resources, while production is trying to meet the demand. Imagine another two billion people on the planet in 40 years, all in need of food, water and a roof, while climate change accentuates these fundamental human needs.

Consequences of population increase

The first consequence of the increase in the global population is an ever-increasing demand for basic necessities, raw materials or services indispensable for the survival of a human being. This could be expressed in: a doubling of agricultural production in four decades; an increase in water consumption of 30% by 2030; and by the middle of the century urban accommodation will be needed for another three billion people.36

As a consequence, urbanization plans will increase the number of cities classified as megacities, where the number of inhabitants exceeds 10 million. By 2025 the number of these cities is expected to rise to 29, with a global population concentrated in urban

areas that will achieve the number of 3.3 billion, almost doubled in 2050, with a forecast of 6.4 billion inhabitants in areas considered urban. These are simply some examples of what the consequences of a constant increase in population could be, without appropriate security measures being taken. Going into the specifics we will see how food, energy, water, urbanization and finance will be the areas that will be affected more significantly by the uncontrolled demographic increase. Such areas, do not seem to have all a direct connection with the causes that lead to chronic diseases, but some of them have an indissoluble link with these diseases.37

36 NATO REVIEW, La crescita demografica: la grande sfida del XXI secolo, 2011

37 Dr. Tim Fox, POPULATION: One planet, too many people? (REPORT), the press release, Institution of Mechanical Engineers 2011

as already mentioned, it is expected that by 2030 the consumption of water, or rather the demand for water consumption will increase by 30%. This increase will be due to multiple causes: first of all it is the ever increasing need for water for agricultural production, or related to the food sector, which today already employ 70% of all water resources exploited on Earth.

However, the increase will also be due to the ever increasing demand for people who will need this raw material for personal purpose, especially due to hygienic factors. In fact, to maintain the production rhythms to which we have arrived today, they will have to use increasingly large quantities of water, this is because the number of consumers will be higher.

the number of people who will live in urban centers is constantly increasing from the first industrial revolution. The cohabitation of large numbers of people involves many logistical problems; with the overcrowding that will occur in the coming decades there will be great cases of disservice related to sanitation, waste management and urban transport. Moreover,

gatherings of people living in disadvantaged conditions are the perfect habitat for the proliferation of infectious and bacteriological diseases, but also a cause for concern for safety factors. It is indeed extremely difficult to provide effective security services where the number of people involved in events, demonstrations, or simply everyday life is difficult to control. 38

38 Dr. Tim Fox, POPULATION: One planet, too many people? (REPORT), executive summary-Increasing pressure, Institution of

Food

Water

Urbanization

currently 1.2 billion people live in rich countries, representing less than 18% of the world‘s population, but consume 44% of the total energy available and produced on the planet.

This means that an inhabitant, recognized as „western“, consumes 2.5 times more than the average of the world inhabitants. 39

Energy

an increase in the number of mouths to feed and changes in eating habits, including increased meat consumption, will double the demand for agricultural production by 2050. This will

lead to further pressure on already strained resources that face the uncertain impacts of climate change on global food production.

Top 10 world countries for energy consumption

If we think about these numbers, we realize how dramatic the prospect is. It is in fact consolidated that population growth will mainly affect underdeveloped countries, which currently use scarce quantities of energy resources, but in the future these countries will need to require a growing energy contribution to respond to the needs that their inhabitants will show. Briefly, the inhabitants of poor countries, which are the great majority of the whole Earth inhabitants,

will require more suitable and well-adapted lifestyles, but given the amount of energy used by rich countries, the supply will not be able to meet the demand. This could be the prelude of great political tensions. In fact, it is necessary to remember that practically all the wars fought internationally in this new millennium, even if in a more or less veiled way, have been fought for reasons linked to the possibility of seizing energy sources.

Life style

The macro areas that have been presented so far lead us towards a more precise identification of the causes that are recognized in the medical field as a reason for grafting of chronic diseases. We will therefore proceed with presenting more specific and

concrete cases, analyzing them and proposing also preventive aspects, where possible. Earlier we talked about the macro-area called „food“, now entering into a more specific and meticulous explanation we will talk instead of

40 World Health Organization, definition of “health

„lifestyle“ in relation to health. The World Health

Organization (WHO) defines

health as „a state of

complete

physical, mental and social well-being

and not just an absence of disease or infirmity“.

40

As will be discussed in the following para-graphs, nutrition is a very important compo-nent in the definition of a healthy lifestyle, and incorrect eating habits may represent the first risk factor for the onset of major non-trans-missible diseases, and therefore may harm in some way to person’s health. The WHO report realized in 2002 shows that in developing and rich countries one of the major risk factors for incurring chronic situations is excessive food consumption and an irregular and improper lifestyle. Tobacco, alcohol, hypertension, high levels of cholesterol and obesity, or the

combi-nation of these factors, are the main causes of diseases in the most industrialized countries. In developed countries it is estimated that about a billion people are overweight; this fig-ure is also worrying for developing countries, especially for the situation conceivable for the next few years deriving from the continuous increase in percentages of cases of hospital-izations a year for reasons related to obesi-ty. The WHO projections for 2020 concern-ing deaths due to obesity speak of 5 million deaths per year with continuous increment. 41

Alimentation impact

Remaining on the issue of obesity we have to introduce the topic of nutrition: in fact, it is very important what we feed and the way we do it. It is now proven that an improper diet can lead to many diseases. An estimated 2.7 million deaths are attributable annually to a reduction in fruit and vegetables consump-tion. 42 _{At the same time, it has been shown}

that there are some components of the diet that have a harmful effect on the physical state, such as salt excess, sugar and fat. In addition, excessive energy intake favors the development of overweight and obesity that affect the onset of metabolic abnormalities predisposing to diabetes, cardiovascular

dis-eases and cancer. Researches carried out in the health-food sector have shown that 30-35% of responsibility in cancer pathologies is due to dietary factors, whereas, unlike what could have imagined, only 2-4% is a consequence of what we breathe.43 _{An alarming fact,}

espe-cially for Western countries, that demonstrate clearly the relationship between diet and the possibility of being able to contract non-com-municable diseases, is the fact that in North America or Europe, a person has the proba-bility to be affected from colon cancer twenty times higher than an Asian or African person.

42 World Health Organization, The Tobacco Atlas, 2002

Consumption of red meat

The difference is so marked to lead to hypoth-esize that the typical diet of the West, which is characterized by a higher intake of fat and a high consumption of red meat, can promote the onset of this disease. There are also many studies that show how people emigrated from poor to rich countries, after many years start-ed to suffer for tumor diseases that have lit-tle diffusion in their native country, but that instead are frequent in the new host one. It is therefore demonstrated, from data about deaths and cases of tumors associable to bad food habits, that in the richer countries the adopted diet is one of the main causes of

cancer. This diet is characterized by an unbal-anced composition that consists in an exces-sive consumption of animal fats and meat, without any valid nutritional reason. About fats and animal meats, it seems necessary to open a short parenthesis on the production of such food-related goods: an unbalanced diet towards excessive consumption of meat implies not only a potential increase in the risk of contracting tumor diseases, but also a strong negative impact on the environment. In fact, if we consider that on the Earth live about six billion people and four billion of from slaughter animals, we understand the

<11,1

<21,1

<31,2

<41,3

<51,3

Incidence of colon tumor

44 Water Footprint Network

45 World Health Organization, “North Karelia Project”

reasons why the majority of the production of cereals is used in breeding, with consequent impacts on climate change ( breeding is one of the main causes of the greenhouse effect) and on the consumption of water (it is estimated that one kilogram of beef requires as many as 15,500 liters of water).44 _{The incidence of}

nu-trition also depends on the precise pathology or chronic situation from which a person is affected. The impact that the feeding has to-wards cardiovascular pathologies is different from the one it has on diabetic pathologies. In the case of cardiovascular diseases, for ex-ample, it has been noted that the introduction

into the diet of animal fats and salt is partic-ularly significant. A specific case study devel-oped by Finnish researchers for the project “North Karelia Project”, has investigated the habits of the local population for 25 years, starting from 1972.45 _{Such a prolonged}

exper-iment has made possible the application of targeted interventions to improve the health of population used as reference. The results showed a clear change in the eating habits of the inhabitants of this region of Finland. In 1972 about 90% of people spread butter on bread for breakfast, in 1992 only 15% did it.

<5,0

<9,4

<13,8

<31,0

<60,3