INTERVIEW

Dr. Ryozo Nagai

President of the Japanese Circulation Society

The major four NCDs share many common risk factors, where cross-cutting measurements are needed to combat the chronic diseases. Research evidence is essential to build wisdom before we can tailor the right strategies for the society in large.
The important of evidence based NCD-control


In general, people think that with advanced medical progress, disease can be formulated as an equation. However, NCD cannot be explained by simple formulas, such as Y = aX + b. NCD intervention is about probability. For example, it is known that high cholesterol may cause heart attack. However, among people with no previous history of heart attack, whom cholesterol level is slightly higher than the usual, the probability of having a heart attack is at most 10 people in 1000. With cholesterol treatment, the probability of having a heart attack comes down to 7 people in 1000. In view of this, only 3 people out of 1000 are expected to be benefited from the cholesterol treatment, which the probability of not having a heart attack is low. And I have no idea who will be one of the 7 or who will be one of the 3. As a doctor, I cannot help but guess with the statistical probability while giving treatment.

The prevalence of NCD in the country is a crucial factor for making decisions on appropriate national policy measures. Japanese are especially sensitive to numbers when it comes to policy making. When 3 out of 10 in 1000 whom have a disease would be saved with treatment, in a long run of 20 years, 60 in 1000 people can be saved. With that estimation, 600 thousand in 10 million people can be saved, and with 1 billion people, 6 million are saved. The society needs to reason if treatment is necessary and accepted. This is the major theme in NCD, however we have not discuss this in Japan, and there is no large data sets that allows us for discussions in the first place.

NCD studies have not always been appreciated in Japan academic society. A study that is not able to show a causal relationship is considered of low science value. However, theory advancement without seeing the reality is often the cause of failure. What we think in our head about causal relationship of the disease may consist of biases, and that tells us how important it is to have a long-termed large scale data base in assisting treatment decisions. However, as the scholars and government officials are bound to the desire to see a causal relationship in the result, it is quite hard to get studies done in this area.
The care for chronic diseases progression
As chronic disease pathology is formed over a long period of time, the progression of disease and causal relationship of symptoms onset differ from one to another. When the set point of equilibrium changes, then more factors emerged. While it is important to target the primary causal factors to the diseases, we need to understand that if that is the only thing we do, it just does not work. For example, the factors to type-2 diabetes are diet and lack of exercise, the strategy of calling out for "Let's take care of your diet and exercise" will not work for people who have already advanced into co-morbidities and complications. Of course it is important to take care of your diet and exercise in term of the case of type-2 diabetes, there are a lot more that we need to consider if we like to prevent disease complications, progression into dialysis, stroke or cardiovascular disease. The strategy alone just does not work for primary prevention. It is the same for the people with chronic obstructive pulmonary disease (COPD), it is not just about trying to give up smoking, it will be important to incorporate strategies to care for patients whom COPD have progressed to some extent already, and how we could enhance QOL of the patients. Health care of chronic disease will leave a significant impact on QOL and extending life.

Besides of health care, the health care expenses are also an issue, where total expenditure of NCD definitely consumes a large medical budget.
Seeking cooperation with various organizations
In view of the individual attempt in seeking corporations of relevant ministries and organizations, I feel that the academic society should have put more effort into this area. The focus of academic society should not be limited to the development of innovative therapies, but it is important to consider strategies in combating NCD which including chronic heart failure. I am also interested to learn from what have been implemented in overseas, of how they had communicated the risk of heart disease to the public, and the efficacy of implementations. At present, The Japanese College of Cardiology and The Japanese

Circulation Society are working individually for policy recommendations, which in future we should seek to work together to address the public health needs.

Circulatory diseases are nevertheless of important aspect with regards to the NCD issue. Heart failure can be acute or chronic. In the case of chronic heart failure, the medical cost is expensive as it develops over a long period of time which required various treatments. We would also need to understand that this phenomenon is not uncommon in the elderly.

The action of the promotion of general national health "Healthy Japan 21" based on the Health Promotion Law, had only focused on hypertension and ischemic heart disease. Chronic heart failure is included in reference, but has not been considered as a target for the movement. It is necessary to position chronic heart failure as the behavioural goal of the action, therefore clarifying the actual situation is important. To achieve that, the Japanese Circulation Society will need to work in conjunction with the other related parties.
Expectations towards NCD Alliance and cross-disease measures
The need for cross-chronic disease is tremendous. Although there are some differences in the individual diseases, diabetes, chronic respiratory diseases and cardiovascular disease do share many common risk factors. Cancer cases have also seen to derived from metabolic syndrome; cross-cutting measurements are definitely essential.

If NCD Alliance is formed, there are three main areas that I hope to see out of the network alliance:
  1. How we could advance our medical knowledge on evidence based in Japan
  2. How we could integrate the health care information for societal use
  3. How we could incorporate health care information into IT system and its development

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