In New York this week a very eminent group of clinicians, scientists, epidemiologists and politicians have been sitting down at a major UN conference on non-communicable diseases (NCDs). They are rightly concerned about the rapidly burden of cardiovascular disease, chronic obstructive pulmonary disorder (COPD), cancer, obesity, diabetes etc which affect more of us each year. And although the main focus is on the wider public health priorities, with people having to work longer and the workforce around the world getting older it is no longer enough to think of these, and other, conditions being confined to those who have already retired.
The key message of this blog post is that the burden of chronic disease in the world’s workforce is bad now and set to get much worse over the next 20-30 years. Prepare yourself for a blitz of data to support my argument. If you feel dazed and slightly gloomy by the end, then you’ll have grasped something of the scale of the problem we face. Here we go. Let’s take a quick look at the UK and then the USA, India and China.
In research that The Work Foundation conducted with Bupa, RAND Europe and the Oxford Health Alliance we forecast that up to 21m UK workers would have at least 1 long-term health condition which affects their ability to work by 2030. There are currently around 15 million people living with a long-term condition in England. These people are the main driver of cost and activity in the NHS as they account for around 70% of overall health and social care spending. People with long-term conditions are disproportionately higher users of health services – representing 50% of GP appointments, 60 per cent of outpatient and A&E attendances and 70 per cent of inpatient bed days. Today 77% of bed days are due to exacerbations of long-term conditions. Sir John Oldham, National Director for Quality, Innovation, Productivity and Prevention (QIPP), then suggests that we factor in an increase in the number of people with long-term conditions by 252%. That is the rise in over-65s that will occur by 2050. In the case of just one long-term condition, diabetes, there will be a 188% rise in prevalence over this period. By only 2013, there will be a 60% increase in the number of existing patients with long-term conditions who will have two or more – including mental health problems.
This is not just about ageing. In the UK, 42% of men who have hip replacement operations are of working age. We will need to adjust our expectations about staying in work despite our health as the retirement age rises towards 70.
Over 18 million working age Americans are not working due to ill health or chronic disease. Obese workers are costing the US $73.1 billion. One in four employees in the USA still smokes. Nearly two out of three employed Americans (62%) are overweight or obese. More than 20% of American workers is currently receiving treatment for high blood pressure. Almost one-third of Americans entering the workforce today will become disabled before they retire.
So how about the big developing economies? What do we know about the health of their workforces?
Almost 47 per cent of the Indian workforce, especially in urban areas, are overweight or obese. By 2015 India will incur an accumulated loss of $236.6 billion due to lifestyle-related chronic diseases. India has largest number of diabetics in the world — 25 to 30 million. India is projected to have more than 57 million diabetics in 2025. Indians in their productive years succumb to cardiovascular disease (CVD) 5-10 years earlier than their Western counterparts. By 2020, cases of cardiovascular disease are expected to rise in India by 120% in women and 137% in men. In the 20-29 years age group, 12% of the Indian workforce suffers from hypertension and 30% are overweight. By 2030 India will lose 17.9 million years of ‘productive’ capacity as a result of ill-health in its workforce, compared to 10.4 million for China and 1.9 million for the US.
In 2008 China suffered a consolidated loss of $558 billion due to lifestyle disease, an eight-fold increase since 2005. Up to 38% of all deaths in China are caused by CVD and 33% of all Chinese adults are overweight. Type II diabetes prevalence in China has increased 300 percent since 1980. More than 60% of men and 7 per cent of women smoke (rising rates). Tobacco use alone claims about one million lives in China every year. Over 15% of all deaths among Chinese males aged 15 to 44 can be attributed to alcohol and China has the second highest TB burden globally, accounting for almost 14% of the global disease burden. Over 700 million Chinese (62 percent of the population) are infected with at least one kind of parasite.
There are 35 million to 40 million diabetics in China, 20% of the world’s total. By 2030 the numbers are projected to reach 70 million. One out of every 20 diabetes sufferers in Beijing is 13 or younger. Around 700 million Chinese, more than half the population, have had hepatitis B. Of these 120 million are long term carriers (ie asymptomatic & infectious).
Prevention is better than cure
So, the burden of chronic disease in the working age population is growing and global phenomenon. In developing economies there is also a clear urban-rural divide as population and labour migration – together with a growing middle class – swell the cities. Similarly, growing prosperity is all too often accompanied by adoption of Western diets and lifestyle behaviours.
All too often the response of governments to these kinds of data is a shrug of the shoulders as they recoil at risk of a political backlash against ‘nannyism’ and infringements of personal liberty. Where action is taken it is currently focused on a largely inadequate and ideologically-driven reliance on ‘nudge’ theory. Regulation and financial incentives (where there is an evidence-base of effectiveness) are too often rejected as too interventionist.
I was struck by the news today of a coordinated cyber-attack on Japan’s defence systems. Around the world, huge resources and considerable political energy are being directed at preventing such attacks undermining the integrity of similarly critical systems and resources. Yet the very same governments seem content to sit back and watch the physical and psychological integrity of their ‘human capital’ assets erode before their eyes as their populations and their productive capacity get progressively and chronically unfit.
The really bad news is that the situation doesn’t look like it will improve anytime soon. Total spending on preventative healthcare in the whole of the EU represents only 3% of all healthcare expenditure. This is, frankly, a scandal. Until policy-makers, clinicians and employers – supported by the scientific community – join together to take decisive and coordinated steps to make step-change improvements in public health, both their healthcare bills and the proportion of their workforces who consume rather than pay tax dollars will be at unsustainable levels for decades to come.
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