Bone and Joint Decade 2010 - 2020 The Global Alliance for Musculoskeletal Health

1. Bone and Joint Decade 2010 - 2020The Global Alliance for Musculoskeletal Health How do we get policy makers to take musculoskeletal health and conditions seriously? Professor Anthony D Woolf Chair, Bone and Joint Decade 2010-20 Royal Cornwall Hospital, Truro & Peninsula College of Medicine and Dentistry

2. Musculoskeletal conditions - the unmet need • Musculoskeletal disorders are common in all countries and cultures • include joint diseases, spinal disorders, back and regional pain problems, osteoporosis and fragility fractures, and consequences of injuries and trauma • hundreds of millions of people are affected around the world • They are a major burden on health and social care • worst impact on quality of life of many chronic diseases • most common cause of severe long-term pain and physical disability • They are one of the greatest threats to healthy active aging • There are effective ways of preventing and controlling musculoskeletal conditions but these are not being implemented with equity • There is a lack of policies and priorities for musculoskeletal conditions • There is enormous unmet need and avoidable disability

3. Musculoskeletal conditions - some reasons for lack of priorities and policies • Lack of awareness by policy makers, non-expert health workers and public about • the impact of musculoskeletal conditions (epidemiology, costs etc.) • what can be achieved by prevention and treatment

4. Musculoskeletal conditions - gaining priority How do we ensure that musculoskeletal conditions are among the leading major health concerns in the minds and actions of opinion formers and policy makers throughout the world ?

5. Contextual factors Competing priorities Opportunities NGOs Needs Evidence Lobbying HEALTH POLICY Commercial interests What is achievable Expert opinion Economic climate Cost effectiveness Public opinion Factors that influence health policy

6. Evidence to support advocacy • Identifying and communicating the evidence that policy makers need and understand “making the case” • How many people are affected (voters!) • What is the cost to us • What can you do about it • What savings can be made with what investment (tax payers!) • Guiding principles • Demonstrate value for money • Appeal to the public

7. Bone and Joint Monitor Project Health Needs Assessment of Musculoskeletal Conditions IMPACT OF DISEASE UNAVOIDABLEBURDEN “STATE OF THE ART” EFFECTS OF INTERVENTION EFFECTS IN CLINICALPRACTICE AVOIDABLE BURDENOF DISEASE Co-ordinators:Anthony Woolf, Kristina Åkesson, Mieke Hazes

8. Bone and Joint Monitor Project Health Needs Assessment of Musculoskeletal Conditions IMPACT OF DISEASE UNAVOIDABLEBURDEN “STATE OF THE ART” EFFECTS OF INTERVENTION EFFECTS IN CLINICALPRACTICE AVOIDABLE BURDENOF DISEASE Co-ordinators:Anthony Woolf, Kristina Åkesson, Mieke Hazes

9. The Burden of Musculoskeletal Conditions “Musculoskeletal diseases are the major cause of morbidity throughout the world. These diseases have a substantial influence on health and quality of life and they inflict an enormous cost on health systems” Dr Gro Harlem Brundtland Past Director General, WHO, January 2000 Scientific Group Meeting organised by WHO and Bone and Joint Decade, Geneva

10. The Burden of Musculoskeletal Conditions “Musculoskeletal diseases are the major cause of morbidity throughout the world. These diseases have a substantial influence on health and quality of life and they inflict an enormous cost on health systems” Dr Gro Harlem Brundtland Past Director General, WHO, January 2000 ”…. With the increasing number of older people and changes in lifestyle occuring throughout the world, this trend will increase dramatically over the next decade and beyond. …we must act on them now” Kofi Annan, 1999 Secretary General, UN

11. “The Burden of Musculoskeletal Conditions at the Start of the New Millennium”Geneva, January 2000 • Scientific Group Meeting organised by WHO and Bone and Joint Decade and opened by Dr Gro Harlem Brundtland, (then Director General WHO) • Experts from all continents and in all conditions • What is the global burden? • How should we monitor the burden? • WHO Technical Report October 2003

12. Musculoskeletal Conditions • Joint diseases • Osteoarthritis • Rheumatoid arthritis • Gout • Infections • Systemic connective tissue disorders • Back pain • Musculoskeletal pain • Osteoporosis and low trauma fractures • Bone infections • Trauma • Injuries and more………

13. 22% of the population in Europe currently had, or had experienced “long-term muscle, bone and joint problems such as rheumatism and arthritis” Health in the European Union Eurobarometer Special Report 272, September 2007

14. 1 in 3 experience musculoskeletal pain restricting activities of daily living 32% experienced activity-limiting musculoskeletal pain in the preceding week Health in the European Union Eurobarometer Special Report 272, September 2007

15. Worker Health Chartbook 2004, USAInjuries and illnesses in private industry, 2001 The majority of occupational health problems are acute musculoskeletal injuries or associated with repetitive musculoskeletal trauma

16. Distribution of occupational injury and illness cases with days away from work in private industry, USA 2001Worker Health Chartbook 2004, USA

17. What effect do musculoskeletal conditions have? • Pain • Deformity • Physical disability • Quality of life • Mortality

18. The impact – the human and financial consequences Lower quality of life (pain, restriction of activities) National economy Caregiver time Health care system Caregivers Person

19. Health conditions associated with disability Limited data but national surveys in some countries Australia:arthritis, backpain, hearing disorders, hypertension, heart disease, asthma and vision disorders were most common disability-related health conditions in1998 population survey Canada:arthritis, backpain and hearing disorders were most common in adults over 15 years in 2006 study USA: rheumatism leading cause among adults >65 years, accounting for 30% who reported limitations in their “activities of daily living” Road traffic injuries: between 1.2 and 1.4 million deaths pa but further 20 – 50 million injured; post-crash disability 2 – 87% in systematic review

20. Impact on quality of life of chronic disease Musculoskeletal conditions are associated with the poorest quality of life Sprangers et al J Clin Epidemiol 2000; 53(9):895-907

21. The impact – the human and financial consequences National economy Health care system Caregivers Person Work disability Health care costs Social support

22. The burden of MSC on primary care UK consultation rates

23. Percent respondents visited health provider in past 12 months Source: EHIS; Wales National Health Survey; Austria National Health Survey

24. 1 in 4 on longterm treatment because of “longstanding troubles with muscles, bones and joints (arthritis, rheumatism)” Health in the European Union Eurobarometer Special Report 272, September 2007

25. Duration of incapacity benefit claim by condition England, Scotland & Wales 2010 Source: Department of Work & Pensions 2010

26. Disability pension by main diagnosis Finland Source: Finnish Centre for Pensions and The Social Insurance Institution of Finland. Statistical Yearbook of Pensioners in Finland

27. From the individual to health of the population

28. Measuring population healthSummary measures of population health combine information on mortality and non-fatal health outcomes to represent the health of a particular population as a single numberDisability Adjusted Life Year (DALY) 100 90 C B 80 70 60 % surviving (thousands) 50 A 40 30 20 10 0 0 20 40 60 80 100 Age • C = Years of Life Lost (YLLs) • B = Years of Life lived with Disability (YLDs) • DALY = YLL + YLD • DALY is one lost year of healthy life

29. The 20 Leading Causes of Global Burden of Disease (DALYs), 2001 Global Burden of Disease and Risk Factors Lopez et al DCPP World Bank 2006

30. High-income countries Low- and middle-income countries  Cause YLD (millions of years) % of total YLD Cause YLD (millions of years) % of total YLD 1 Unipolar depressive disorders 43.22 9.1 Unipolar depressive disorders 8.39 11.8 2 Cataracts 28.15 5.9 Alzheimer’s and other dementias 6.33 8.9 3 Hearing loss, adult onset 24.61 5.2 Hearing loss, adult onset 5.39 7.6 4 Vision disorders, age-related 15.36 3.2 Alcohol use disorders 3.77 5.3 5 Osteoarthritis 13.65 2.9 Osteoarthritis 3.77 5.3 6 Perinatal conditions 13.52 2.8 Cerebrovascular disease 3.46 4.9 7 Cerebrovascular disease 11.10 2.3 Chronic obstructive pulmonary disease 2.86 4.0 8 Schizophrenia 10.15 2.1 Diabetes mellitus 2.25 3.2 9 Alcohol use disorders 9.81 2.1 Endocrine disorders 1.68 2.4 10 Protein-energy malnutrition 9.34 2.0 Vision disorders, age-related 1.53 2.1 Global Burden of Disease: the 10 Leading Causes of YLD, 2001 Global Burden of Disease and Risk Factors Lopez et al DCPP World Bank 2006

31. YLDs due to musculoskeletalconditions vary by European region WHO 2004 Source: WHO Global Burden of Disease 2004 http://www.who.int/healthinfo/global_burden_disease/YLD14_30_2004.xls

32. The problem • Musculoskeletal conditions are • the single biggest cause of physical disability in developed countries and rapidly increasing in developing countries • major cause of healthcare and social support costs • a major cause of lost productivity • The burden will increase unless actions are taken

33. The future The burden of musculoskeletal conditions is increasing Why? • Growing and ageing population • Changes in lifestyle

34. Bone and Joint Monitor Project Health Needs Assessment of Musculoskeletal Conditions IMPACT OF DISEASE UNAVOIDABLEBURDEN “STATE OF THE ART” EFFECTS OF INTERVENTION EFFECTS IN CLINICALPRACTICE AVOIDABLE BURDENOF DISEASE Co-ordinators:Anthony Woolf, Kristina Åkesson, Mieke Hazes

35. Interventions for musculoskeletal conditions are effective Osteoarthritis exercise. pain control and self management joint prostheses Rheumatoid arthritis effective disease modifying therapy eg methotrexate, biologics Osteoporosis and Fractures fracture prevention strategies using anti-resorptive agents for those at highest risk Back Pain early rehabilitation

36. The Evolving Management of Rheumatoid Arthritis (RA) Early aggressive treatment Biologics Methotrexate (MTX) Steroids Gold Injections Manufactured Aspirin Quinine Willow Bark 1680s 1860sa 1890sa 1920s 1940s 1980s 1990s 2000s 1591 1859a “Rheumatism”(Guillaume de Baillou) “Rheumatoid Arthritis”(Sir Alfred Garrod) aAppelboom T. Rheumatology (Oxford). 2002;41(suppl 1):28-34.

37. RA can now be effectively treated Best StudyPercentage in remission 100 80 60 % with DAS44 <1.6 40 20 0 0 3 6 9 12 15 18 21 24 Time (months) sequential mono step-up combination combi with prednisone combi with infliximab Goekoop - Ruiterman: A&R 2005

38. Bone and Joint Monitor Project Health Needs Assessment of Musculoskeletal Conditions IMPACT OF DISEASE UNAVOIDABLEBURDEN “STATE OF THE ART” EFFECTS OF INTERVENTION EFFECTS IN CLINICALPRACTICE AVOIDABLE BURDENOF DISEASE Co-ordinators:Anthony Woolf, Kristina Åkesson, Mieke Hazes

39. Identifying gaps in the provision and outcome of care Secondary prevention of fractures Multinational Survey of Osteoporotic Fracture Management Dreinhöfer et al. Osteoporos Int 2005; 16:S44-S54 Management of musculoskeletal pain Major inequities in care: use of resources unequally distributed to people with equal needs

40. Differences in RA across countries

41. In spite of this enormous and increasing burden and the major advances in what can be achieved by prevention and treatment, this is not reflected in: • Public awareness • Political priorities • Health care provision • Medical education for undergraduates and primary care • Research expenditure

42. Contextual factors Competing priorities Opportunities NGOs Needs Evidence Lobbying HEALTH POLICY Commercial interests What is achievable Expert opinion Economic climate Cost effectiveness Public opinion Factors that influence health policy

43. Recognition of the need for concerted action in late 1990’s • In Europe a recognition of need to gain priority for prevention and management of arthritis and other musculoskeletal conditions in mid 1990s – modelled on St Vincent’s Declaration for diabetes • In Sweden a recognition of the need to gain priority and resources for research into musculoskeletal disorders – modelled on Decade of the Brain

44. Influencing the decision makers – changing public and political opinion • Clear objectives • A strong case supported by data and examples • Suggest solutions • Activities to achieve objectives • Work with all stakeholders

45. What do we want? • To reduce the burden and cost of musculoskeletal conditions to individuals, carers and society in all countries • Promotion of a lifestyle that will optimise musculoskeletal health at all ages • Identify and treat those who are at highest risk • Accessible, timely, safe, appropriate treatment to control symptoms and prevent unnecessary disability due to musculoskeletal conditions and injuries • Accessible and appropriate rehabilitation to reduce any disability due musculoskeletal conditions and injuries • Advance knowledge and care through research

46. Physicians, health professionals, patients organisations Orthopaedics Scientists

47. Recognition of the need for concerted action Professional, scientific and patient organisations brought together in 1998 in Lund and agreed to launch the Bone and Joint Decade 2000 - 2010 Remandated in 2010

48. United Nations Official Support by Kofi Annan UN Secretary General 30 November 1999

49. Bone and Joint Decade – The Next Ten Years 2010 – 2020“Keep people moving” The Bone and Joint Decade is a global alliance of professional, scientific and patient organisations working together to make musculoskeletal health a public health priority • Promoting musculoskeletal health and musculoskeletal science worldwide • To reduce the burden and cost of musculoskeletal conditions to individuals, carers and society “Keep people moving”

50. Bone and Joint Decade – The Next Ten Years 2010 – 2020“Keep people moving” • Endorsed by the UN, the WHO, the World Bank, the Vatican and health ministries in over 60 countries • Steered by an International Co-ordinating Council and delivered by National Action Networks in over 60 countries