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The Challenge of Noncommunicable Disease in Emerging Powers

Speakers: Rachel Nugent, Deputy Director, Global Health, Center For Global Development, Derek Yach, Senior Vice President, Global Health Policy, Pepsico, Inc., and Jean-Paul Chretien, Jean-Paul Chretien, Public Health Adviser to The Commanding General, 2nd Marine Expeditionary Force
Presider: Yanzhong Huang, Senior Fellow for Global Health, Council on Foreign Relations
October 26, 2010
Council on Foreign Relations

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YANZHONG HUANG: Welcome to the Council on Foreign Relations. I'm Yanzhong Huang, senior fellow for Global Health at the council. And this is the first time in the global health -- actually first meeting in the global health governance roundtable series that will examine the challenges of noncommunicable, chronic diseases in emerging powers, especially India and China. Last month New York Times published an article by Tom Friedman entitled, "Too Many Hamburgers." In that article he described a skit showing four children -- one wearing the Chinese flag, another the American, another the Indian and another the Brazilian -- getting ready to run a race. Before they take off, the American child, Anthony, boasts that he will win "because I always win, and he jumps out to a big lead. But soon Anthony doubles over with cramps.

"Now is our chance to overtake him for the first time," shouts the Chinese child. "What's wrong with Anthony?" asks another. "He is overweight and flabby," says another child. "He ate too many hamburgers."

I like this satirical piece, not because it is true -- in fact, the same kind of problem, I believe, is bedeviling China and India -- but because it raises some very interesting questions that will be addressed today in our discussion. What are the major risks associated with the rise in noncommunicable diseases in emerging powers -- like China, India, Brazil?

Do we expect the growing burden of non-chronic (sic) diseases to have a substantial effect on the growth of emerging powers? To what extent are non-chronic (sic) diseases said to be a factor in the very balance of power between U.S. and other emerging powers over the decades ahead? And if we agree that non-communicable diseases are among the most severe development threats, how should international society tackle that problem?

So we are thrilled to have such a diverse, dynamic and high-level group for our first session today. Thanks for coming.

I'd also like to thank Laurie, who unfortunately cannot attend today's meeting because of an important meeting in San Francisco. I'd like to thank her for her unfailing support to this roundtable series. I'd also like to thank Zoe and Mary for their assistance. In particular I'd like to thank Dan, Dan Barker, for his hard work and significant contribution in making all this possible.

And this meeting will be on the record. So please also turn off -- I have to do that myself -- switch off your cell phones, BlackBerrys and other wireless devices, as they may interfere into the mikes.

We'll begin with remarks from Dr. Rachel Nugent and Dr. Derek Yach. We won't take time away from our speakers with their impressive biographies, which you may already have, I think you already have. We'll then open up the floor to questions. And in the last 10 minutes, Dr. Jean-Paul Chretien will give closing remarks.

So we're going to start with Rachel. You have 20 minutes exactly. (Laughter.) The 21st minute, I'm going to stop you. So Rachel.

RACHEL NUGENT: Okay. I'm looking at Maria, so she'll have to hold up the signs -- (laughter) -- with how many minutes I have left.

So good evening. It's really a delight to be here and to see a lot of friends. I don't frequent CFR in New York as much as I frequent CFR in D.C. and other places in D.C., so it's great to be up here and see some people that I don't see on a regular basis. So thank you for the invitation.

And I'm delighted to be on the agenda with Derek, because I always learn things listening to Derek. And as many of you probably know, he's a real doctor. So when it comes to the key questions about these conditions that we're talking about here tonight and how to deal with them, I will defer to him, who has actually treated them and knows how to deal with them.

So I tend to look at the economic aspects. I'm an economist by training, so that's my interest in it, and I think quite relevant for our topic tonight, which is the NCDs as a development issue. And it's something that has interested me as a development economist because I see that health has been understood as a development issue for some time now.

It first sort of came on to the agenda as a development issue, with the WHO's Commission on Macroeconomics and Health. I think that was probably the first major milestone that helped us to understand the relationship between health and development, let by Jeff Sachs (sp), who was at Harvard at the time, and a very large and stellar group of economists and others. And I was at NIH at the time and we were involved in contributing to that major sort of milestone in understanding development. And we continue as economists to struggle with understanding the relationship and, I think, making, you know, baby steps as we go along.

But I think we've understood, both the economics community and the larger development community, a couple of important things. We now understand that the links between health and development are a two-way street. They go in both directions. And so that tells us, those who are concerned about development, that we also need to be concerned about people's health and the contributions that it can make to development, or the undermining of development that can happen if health -- if poor health reaches certain levels and affects certain people. So I'll touch on that tonight. That's going to be sort of point number one, health as a development issue.

Point number two, I'll make a few comments about China and India and emerging economies. I'm not an expert on either of those countries. But I think that certainly it doesn't take expertise to see what the implications are of the increasing noncommunicable disease epidemic, if you will, or increasing prevalence of noncommunicable diseases in those countries. And I'll touch on a few aspects of that. And I'm sure in the discussion, that we'll get into further thinking about that. And then finally, I'll point towards the, I think also major milestone that -- what could be a major milestone, next year the U.N. high-level meeting on noncommunicable diseases that has been called and is now being prepared for. So I'll touch on that a little bit, too, in terms of what we might expect. But again, I am sure in the discussion that we'll get into more details and different viewpoints, because there's a lot that is yet to be determined. And I think informed, thinking people can have an influence on this discussion as we move forward.

So a little background on health as a development issue. And I don't think I have to belabor it too much, but it's worth reminding ourselves.

After the Commission on Macroeconomics and Health, very shortly after that, there was an UNGASS, a U.N. General Assembly Special Session, in 2001 on AIDS. I don't think that would have happened had we not already been coming to the realization that there is this close relationship between health and development. And the possible implications of the AIDS epidemic for development, particularly in some of the poorest countries of the world, were really devastating, of course. And so heads of state there at the UNGASS declared the commitment to address AIDS.

It was perceived as an urgent need. And subsequently there was good research done to try to measure the possible effects on economies, on macroeconomics of the countries most affected by AIDS, and to keep health sort of central to our discussions about development. And as people know, subsequently there was a very significant and continues to be a significant increase in the amount of donor involvement in health.

So the whole global health community as we know it now is still quite young, but has emerged as a dominant -- very dominant force in the whole development agenda. And I think the discourse that we have in the global health field is quite influential in the broader development field as we wrestle with issues of governance and institutions, public and private, and so on. A lot of the things that we are tackling in health are things that perhaps presage issues in the broader development community that haven't been fully tackled.

So this -- health as part of the development agenda has been brought into the discussion about health: ministries of finance, ministries of planning, civil society, in a big way, of course -- and the AIDS community is the best example of that -- philanthropy, academia and so on.

It really is a very broad-based discussion. And that's a good thing, because our sort of -- I guess you could call it our sort of newest topic on the agenda of global health -- noncommunicable diseases, if you will -- is something that requires that very broad-based involvement for, you know, a number of clear reasons, and we can talk about those.

So I wanted -- I have a little handout here -- very little -- and I've got two pages. I want to point to page number 1, that you probably have in front of you, which is a little bit of a -- well, it's more than a little bit; it's a very busy graph. And I'll very briefly -- some of you may have seen it before. But the point I want to make with it is how the community that doesn't normally think about health or isn't directly involved in health has come to recognize NCDs as a major risk, as something that they really need to be aware of and understanding and perhaps responding to.

So this graph, entitled "Global Risk Report," came out of the World Economic Forum. They do this every year. And it's a poll that some of you probably are yourselves respondents to. So it's -- let me say I don't find it exactly very scientific. (Laughter.) If you're responding to it, you probably don't, either. But nonetheless, it is indicative of some sentiments or understanding from a pretty important community: people who are thought leaders, particularly in the financial industry, investment industry.

And what they have identified for us here are a whole variety of events or conditions that pose risks in the world. And they've measured in terms of severity of the risk and probability of the risk, in current and future -- sort of what's happened in the past and what's projected in the immediate term. And of course, the point that I'm pointing you towards here is that the risk of chronic diseases -- number 31 on a long, long list that you don't have in front of you; all these 36 risks that were identified by the WEF -- of all of those, the risk of chronic diseases is almost the highest, both in terms of severity and probability.

And again, not terribly scientific, but the point here being that with chronic diseases recognized as so important, we have to ask ourselves: All right, what's the response? If it's recognized in the nonhealth community as very important, how do those communities respond to it, and what are the avenues that we in the health community might offer them to respond to it? and then, secondly, of course, it implies that it is very much a major global issue. So that sort of, I think, cements its place to some extent in terms of development, policy and even foreign policy.

So turning from that, what are the linkages between health and development? Just a couple of points for what we have traditionally thought of as the major global health issues. And then, how do NCDs fit into that, into those couple of points?

Important linkages: Higher income generally leads to improved health. That's the "development leads to better health" direction of the linkage. We have improved life expectancy almost everywhere. Life expectancy is one of the main ways in which we measure well-being and development. And so almost everywhere, except AIDS-stricken countries and among Russian men, we see improved life expectancy.

Health disparities similarly, because of that in part, around the world are shrinking. So we're seeing a convergence between rich and poor in terms of life expectancy. The poor countries, as infectious diseases decline, in terms of the burden, we see poor countries getting closer to rich countries in life expectancy and in other measures -- some of them with a long way to go still, but we see those disparities shrinking.

We also -- in terms of the donor involvement and foreign assistance, we've had, as I mentioned already, huge increases in donor funding for health, and that's what's helping create this convergence, or shrinking disparities. And the other graph that I brought to share with you has two pieces to it. The first, those bars that go from 2001 to 2007, the higher bars show official development assistance for health. So, you know, how much are donors giving to health issues year by year? And it continues to increase. The last year that we have numbers for, which is not on this graph, it's gone up again to about 26 billion (dollars). So continuing very substantial increases in donor assistance for health.

The arguments in support, of course, have been of many types: Moral, and this is where I think the UNGASS for AIDS really was a watershed event, the moral argument about people's lives in poor countries; arguments economic, which I will turn to here momentarily; and then, in terms of public health and prevention of epidemics and pandemics and so on. So we have a number of reasons to care about health. And those traditionally have been centered, of course, on the infectious diseases and maternal and child conditions and so on, the nutrition -- those traditional ones.

So why should we care about NCDs? Do any of those reasons for caring about health that have really come to the fore in the last decade or a little more, do they -- do they fit? Well, NCDs are really an exception to some of these trends that I've just pointed towards. Higher income in this -- in this instance, leads to increased risk of most major NCDs, through increased exposures -- for instance, environmental harms -- and lifestyle changes. Rather than higher income improving health and reducing risks, we see that increases in income tend to increase risks. That's up to a certain point, and I'll talk about that in a moment.

Now, I want to make the -- I want to sort of make the parenthetical point here that we shouldn't interpret when I talk -- when I say lifestyle changes, I really have to add that I don't mean lifestyle choices in every case. And that is one of those sort of issues that arises very quickly, I think, in terms of people's sort of interest or response to this: You know, should we really be caring much, and should donors contribute towards ameliorating the effects of people's own poor decisions? So we will, I'm sure, come back to that. But I will just state that I don't consider it to be lifestyle choices in many cases, because these are not a matter of choice. They're changes in work demands and workplaces and the kinds of things people do in their employment, changes in transportation, food and alcohol and tobacco, a whole range of things.

And the pattern that we see in macroeconomic terms, I alluded to a second ago, that links income to noncommunicable diseases is pretty much the same pattern across countries as within countries. So we're looking at from lower income to upper income, whether it's people within a country or comparing countries themselves. What we see is the prevalence of NCDs increases when you move from low to low and middle income, and then begins to decrease at some point when you reach upper income. So we in the wealthy countries of the world are beginning to see quite significant improvements in some of these disease conditions -- notably, cardiovascular disease.

And Derek can talk much more eloquently about the epidemiology. But in terms of the economics of it, it's important to understand that there is this progression across the SES ladder, if you will -- the socioeconomic ladder, if you will. And again, I think it's important that we don't accept that these are conditions of rich people, because in fact they're less and less conditions of rich people. They're not the conditions of the poorest people, it's true. But what we see is a very quick transition that has happened -- much quicker in the poor countries than what we ourselves have experienced. And that's important, too, in understanding what's the right response and should we care.

A note on that. Even in poor rural areas of the world -- for instance, the Matlab region in rural Bangladesh, where we have very good longitudinal data -- a recent study tells us that in the 20 years from 1986 to 2006, diarrheal deaths decreased by 86 percent, respiratory deaths increased by -- respiratory mortality -- infection mortality dropped 79 percent, and cardiovascular deaths increased by 3,500 -- over 3,500 percent, and cancer by 495 percent, in 20 years -- admittedly, from a low base, but I think that, again, it's very important for us to recognize this is happening fast. And it's happening fast into environments that are ill prepared. So I think that's, again, something that we're probably all somewhat aware of, but the question is what to do about it. So finally, on the development issue: Perhaps a bigger development impact from NCDs than from any of the other global health diseases that we've been spending a lot of attention on and money on over the last decade and more, because these diseases do hit people most severely in adulthood.

There is certainly -- and we can discuss the biological basis and the life-cycle basis for early-life risks increasing later risks, but they really hit people when they're adults in the working-age ages of their lives and when they're expected to be most productively contributing to their economies.

And so for countries that are perhaps especially poor, haven't yet gone through the demographic transition but are already going through this epidemiological transition, there's a very serious concern that the benefits of increased labor force that happens as countries get a little older and, you know, from lower -- lowering fertility, countries get a little older, they have more people in the labor force, that's when their economies can really surge forward -- that the effects of mortality and illness from these diseases will significantly slow down that economic growth path that they could realize.

So Gary Becker, a Nobel Price winner in economics, pointed out in an article recently that cardiovascular disease is the only health area causing countries to diverge, that is, increasing the disparities between the rich and the poor countries because of our improvements in cardiovascular disease and the huge upsurge in cardiovascular disease in the poorer countries. That's, I think, a pretty significant issue when the rest of the health path is towards more equity.

Finally, on the -- on the development issue, I've mentioned the donor -- the donor issue a number of times. We've just completed a study that we will be releasing next Monday at an event in D.C. -- and it will be on our website, and I welcome you to look -- that tracks donor funding for NCDs in relation to donor funding in other health areas. And we find that less than 3 percent of donor funds in health are going to NCDs.

So recall -- I didn't mention it, but probably you've come here and you're all somewhat aware that more than (60 ?) percent of the burden of disease overall comes from these noncommunicable diseases. So more than (60 ?) percent of the burden overall, almost 50 percent in developing countries, less than 3 percent of the donor funds. And that's a pretty staggering sort of misalignment, if you ask me. So that leads us to the questions about: So what should be done about it, which we'll talk about.

A few points on China and India, and the -- some -- I have -- HUANG: Two minutes.

NUGENT: Two minutes left. Okay, then -- well, that's fine, because I don't know China and India well enough to take more.

I think I'm --

HUANG: We can leave that to the Q&A.

NUGENT: -- for the Q&A. I think I probably will.

I -- one thing to say about India and one thing to say about China, then. On India, I think what's particularly critical there is the dual burden of disease is really, really at play. And by that, of course, we mean the continued high prevalence of childhood diseases, of maternal mortality, of undernutrition most particularly. You know, I don't have to tell you about the disparities in India and what a complicated place it is.

So we have the dual burden of disease. But we (have ?) very clearly relatively significant obesity and overweight among children and among adults. So that calls for, I think, policies that can address both of those, not one or the other. That's my view on it.

On China, what is China's number-one future challenge? It's labor force. Because of the changes in the demographics going on there, already they're more than aware; they're, I think, quite alarmed about the demographic conditions that they face, and the question: "Where is labor force going to come from?" And so as I already mentioned, where we have, you know, very serious impacts on adult -- on working-age population and reduced productivity because of NCDs, we have very serious issues for labor force.

So finally, on my third point, what's to be done, this high-level meeting next year, pushed by the developing countries initially, the CARICOM countries were really the instigators and leaders. And they, mind you, were an area of the world with a very severe AIDS burden as well. You know, this was -- this was not a bunch of rich countries that, you know, had already kind of taken care of all the infectious diseases. And then the commonwealth countries, a broader group of countries, came on board. And between them, they got the approval for this high-level summit, with very strong U.S. support as well.

And the last thing I would say on the U.S. -- and it's a bit of a mystery I think, to me, anyway, where our support came from -- we supported the resolution for the high-level meeting, but we don't yet have a plan in the U.S. on what we want from it or how we're going to -- I'm saying we as an American, but how the U.S. is going to engage in it. So I think that's, again, something that we can have some influence on, and I hope we do.

So thank you.

HUANG: Thank you, Rachel, for keeping the time limit.

And Derek -- (inaudible).

DEREK YACH: Thanks. Do you -- do you need this thing on? No -- or is it on?

HUANG: I think this is on.

YACH: Well, thanks. And it's a real privilege to be in the council and to talk about noncommunicable diseases in Laurie's home. So I'm really thrilled to have that opportunity to do that.

First point, just to dispel any myth, I am a doctor. (Soft laughter.) My mother, though, will say, "Yes, my son is a doctor, but if you're sick, don't go to him." (Laughter.) "You -- he's actually not going to be any good. You've got to go and gather a thousand people, some who are sick and some who are not sick -- (laughter) -- and then he starts getting interested." (Laughter.) (Who said ?) I'm an epidemiologist.

The other myth I need to dispel is this is not a new topic. The first time it was raised in WHO was in 1956 when the Indian government brought a resolution calling for urgent action on noncommunicable diseases.

We certainly have seen over the last two decades quite dramatic declines in infant, child and maternal deaths, and we've seen investments in AIDS, malaria, TB. We've also seen rapid aging and increases in life expectancy in all emerging economies -- all of them, with a few exceptions.

Some of those changes are now showing sharp declines in the MDGs. So, you know, when we think about if the glass is half full or half empty, actually world health is slowly and steadily improving. At the same time, and partly as a consequence of children surviving the diseases of poverty and people living longer, there has been a rapid increase in NCDs. Of course, it's being driven by greater exposure to risks and (all come after it ?).

And just for those who don't understand the language -- which none of us really do -- this heterogeneous, very poorly (set ?) named group of conditions called "noncommunicable diseases", when we talk about it, Rachel and I generally would include heart disease, which is the world's leading cause of death everywhere expect Sub-Saharan African, cancers, diabetes and chronic lung diseases.

And we do not talk about mental health, muscular-skeletal diseases. There are a whole lot of other things which could be in the list, but that is not what the focus of the U.N. high-level meeting is or our discussion. That group share some common risk factors, particularly unhealthy diets, tobacco, physical inactivity and excess alcohol. And they also share the need to be clinically managed within health services that are able to provide long-term, often life-long care.

Importantly, in most OECD countries, trends in incidents in mortality for heart disease, for example, and many cancers have been in decline for 15 years or more, particularly due to reductions in risk and better treatment. And we don't spend enough time thinking about what can we learn from that extraordinary experience of pretty dramatic declines in, for example, cardiovascular disease death rates.

I'm not going to go through the data here, and we -- between us we can certainly provide you with recent WHO, Institute of Medicine and Lancet reports, but let me just give you a few pointers.

Heart disease death rates in India and China today are two to three times higher than those in the USA, and heart disease and deaths tend to occur about a decade younger than in the U.S. For example, 35 percent of heart disease cases occur in 35- to 64-year-olds during productive years in India, compared to about 10 percent here; so 35 percent during productive years, 10 percent here, meaning 90 percent occur over 65. This plays into exactly the point Rachel mentioned about productivity.

Trends with regard to the risks are negative in most development countries. Tobacco currently kills about 5-1/2 million people a year, of which over a million deaths occur in China alone and near to 800,000 in India alone. The Chinese data, we need to remember, reflect mainly deaths in men. We know from most developed countries that unless action's taken, women will show increased smoking (anytime ?) death rates. That is inevitable unless we act.

China's state tobacco corporation, by far the largest source of tobacco use in the world, produces most of the 2.1 trillion cigarettes smoked in China. In contrast, most tobacco is consumed in India in the form of bidis, often from informal markets and not from commercial cigarettes.

This is important because bidi control is beyond the reach of current regulatory approaches to tobacco encompassed in the WHO framework convention.

Profound changes in nutrition are under way globally. The major dietary components of importance to NCDs include changes in the use of fats and oils, sodium consumption and shifts to energy-dense nutrient core foods often at the costs of consuming fruits and vegetables. And I'm sure we'll have a debate about sodium later, Michael.

Some examples. Over the last two decades in China, there's been a 240 percent increase in per capita meat consumption and a 640 percent increase in palm oil consumption. In India, palm oil has increased over that period 730 percent. A major difference in consumption trends between India and China has been the sharp increase in fruits and vegetables in China of about 400 percent over the 20 years compared to a small 40 percent increase in India.

Further, while we still have one billion people who are hungry in the world, we now have an equal and growing number who are overweight or obese. And obesity rates in China are increasing most rapidly in the larger cities, but they're increasing in every jurisdiction -- maybe not as fast, but increasing.

These dramatic shifts in basic dietary patterns generally favor increases in heart disease and certain diet-related cancers. Globally, it's important to note that the top 10 food companies account for about an eighth of the global volume and value of packaged foods and a much smaller fraction of total sodium, saturated fat or trans-fats. This reality has profound implications for how we think how best to improve global diets. It remains an issue that is really being discussed in WHO.

Solutions developed on the dietary side to address in OECD countries where regulatory capacity is strong and formal markets dominate requires significant adaptation when thinking about what's going to work in developing countries.

Dietary change combined with profound reductions in physical activity is placing populations at increased risk for diabetes. Few high-quality long-term projects have looked at the size and causes of decreased physical activity. One that really has done very well is one based in China that looked over the last 15 years and showed that adult physical activity levels in China have declined by a third, driven by many factors related to urbanization that engineer daily movement out of peoples' lives. And anybody who visits China on a regular basis can't but note the decreased bicycles, the decreased walkability of cities and then possibly simply to do basic movement.

So let me ask another question related to the (trades ?). What distinguishes NCD control and challenges in OECD countries from emerging economies? And I think there are three additional issues in addition to those that we think about in OECD countries to think about. The first are a set of factors related to maternal and early childhood nutrition. It might seem paradoxical that evidence is strengthening to show that populations who experience high levels of maternal and infant under-nutrition are at increased risk in adulthood for diabetes and cardiovascular disease compared to those of optimal nutrition.

This is profoundly important in countries like India and throughout much of sub-Saharan Africa where high levels of under- nutrition coexist with rapid changes in nutrition in early childhood, and suggests that UNICEF and those involved in advocating for child health need to broaden their perspectives.

The second set of risk factors relates to the impact of NCD risks for HIV/AIDS and tuberculosis. WHO now recognizes particularly the importance of diabetes and tobacco as an independent and important risk factor for tuberculosis incidents and severity. In countries like India and South Africa with ongoing epidemics of TB and AIDS, the need to address major NCD risks within settings where TB and AIDS treatment happens becomes all the more urgent, yet rarely happens.

Only a couple of weeks ago, I saw one of the first studies, I think it was from Uganda, by colleagues at Duke starting to ask the question, what is the blood pressure of people in one of their PEPFAR projects -- the first such study. The results weren't surprising. They were similar or slightly higher than the expected levels, which are very high.

The third set of issues that I think are important when thinking about a difference relate to aging. OECD countries achieved high levels of GDP growth and had conquered diseases of poverty before they aged. Emerging economies are aging without wealth and while they still have to address the health agendas associated with poverty.

A few brief comments on policies and actions to address NCDs. We know that the policy options used to address communicable diseases are simpler, cheaper and less multi-sectoral than those needed to address NCD risks and disease impact. Innovation in developing health-care solutions to NCD is accelerating and includes progress in developing personalized medicine that focuses on better genetic, imaging and early diagnostics, interventions focused on preventing disease with those with early markers and personalizing therapies in ways previously not possible. We know that billions are being invested in this approach. It may well yield population benefits over the very long-term, but these will come at extremely high cost and with inevitable negative consequences for inequalities in health outcomes. Globalizing the $2.3 billion U.S. health care model that continues to favor personalized approaches over public health measures is neither affordable nor effective.

There are large treatment gaps that do need to be closed using currently available and relatively cheap medicines, but to do so will require significant investments in health services and related diagnostic, IT and human resources.

One measure of the size of the gap is available from large surveys of the percentage of patients with heart disease who require statins to receive them. Across Europe, the figure is 85 percent. In contrast, it's about 12 percent for large developing countries in Asia and the Middle East for statins. Dietary change may be a more sustainable and equitable way of achieving the same outcomes statins do, but are rarely discussed.

Sir Andrew Dillon, the chief executive of NICE, the United Kingdom's National Institute for Clinical Excellence, recently commented on this saying that, "To make the really big gains in health, we must make investments in public health interventions, improved diets, stimulate exercise and stop smoking." In 20 years, the benefits of these changes would far outweigh any new technology coming into the system. The problem, however, is that one could be addressed -- and one that could be addressed in the upcoming U.N. meeting is that to implement any one of the priorities Sir Andrew highlights is not simple as we're often told, and cannot be done by the health sector alone or by traditional public health approaches. It requires the type of multi-sectoral planning and agreement rarely seen in government or between government and civil society. I'll end with this point in a second.

So since we're at the Council on Foreign Relations, let me -- hesitate to ask the question -- what are the foreign policy imperatives for action in addressing NCDs? Rachel hinted that, clearly, we understand what they've been in infectious diseases. But I think they're different and I would be keen to help you -- have you help us frame the argument better. But let me try and give you four arguments for why OECD countries need to invest more in addressing NCDs for their long-term benefit.

First, we heard from Rachel about worker productivity in many of the developing countries playing an important role in their own productivity, but what we need to be aware of is that they -- the worker productivity of emerging markets plays an increasing role in OECD pensions and social security investments.

Gordon Clark from Oxford warned seven years ago that reduced workforce productivity in emerging economies due to NCDs would harden such investments and about the same time, Peter Heller, then at the IMF, wrote extensively about the long-term fiscal challenges posed by aging, NCDs and climate change. All are upon us today at a magnitude we never suspected would happen then, and the dependence on social security systems and pensions for investments happening in developing markets is even greater than it was some years ago.

Second, on the positive side, opportunities exist for reverse innovation in R&D to address the looming OECD health-care costs. Today, General Electric India is making significant progress in developing cheap and effective diagnostic devices for heart disease that can and already starting to be imported back into the U.S. Academic groups in India are leading efforts to develop a polypill, a mixture of drugs that would cost-effectively and safely address large populations' needs to lower cholesterol and blood pressure.

And I was just with one of the researchers today from India, who confirmed that he's now moving into the next phase of his work.

Many IT companies have developed sophisticated ways of supporting better patient adherence to chronic care for AIDS and TB patients in South Africa and many African countries, with real implications for improving diabetes and heart disease care. And Discovery South Africa, a large insurance and health-risk management company, is pioneering the use of economic incentives to promote positive behavior change, and the results of their studies in over a million people show positive outcomes.

All of these cutting-edge research examples from emerging markets have implications for OECD countries. Joint investment between OECD and emerging country research teams could be mutually beneficial.

Some solutions -- the third point -- required to advance NCD prevention need cross-border action. These include continued elaboration of the protocols for the Framework Convention on Tobacco Control; a treaty that required ratification by heads of state and not just a minister of health; greater focus on many aspects of the codex process for improving labeling; and I could go into many others related to climate change.

And the fourth area relates to something that Rachel was hinting at, and that is that we have -- we have shown, in a report we both worked on for the Institute of Medicine, that long-term global changes in trends in unhealthy consumption accelerate unsustainable development. For example, in addition to health impacts, there are significant environmental consequences for all countries of increased livestock consumption in Asia and of rapid expansion of palm oil production in the heavily forested areas of the world.

Growth of cities in developing countries that emulate the worst characteristics of U.S. cities, with urban sprawl and dependence on public transport, threaten health and the environment.

Spelling out the links and embedding the goals of sustainable development into NCD control seems to be long overdue.

Before ending, just a few comments on the U.N. high-level meeting to complement those Rachel made. Clearly it's an opportunity to move towards more types of multi-stakeholder engagement. And remembering that this is a U.N. high-level meeting that should bring together the development sectors, it's an opportunity to think about the role of other sectors particularly.

In my view, WHO has little direct capability to implement the changes in agriculture required to shift food production to be more supportive of people eating optimal diets, or to ensure that city planners include mobility as a core requirement of city design, or that customs officers more effectively reduce cross-border illicit trade as tobacco excise taxes increases. Yet these are the very actions that we depend upon if we're going to start making a difference to some of the preventive needs around dietary and tobacco changes.

Within the U.N., a stronger call for support of NCDs that pulls together all U.N. agencies is essential and is still not happening. This approach was done early on in the development of the framework convention through ECOSOC's Ad Hoc Committee on Tobacco Control. It was through that process that we got agreement between WHO, FAO and the World Bank re: the critical importance of promoting demand reduction, which led to FAO and the World Bank no longer supporting tobacco farming.

It was WHO and UNICEF working together on recognizing the power of the Convention on the Rights of the Child as a tool to promote child -- smoke-free environments for children. And it was UNCTAD and ILO, working with WHO, that got them to find common ground between many aspects of tobacco control, particularly related to workers, and the agendas. And even the IMF at the time issued strong statements of support and provided country guidance to address the economic issues of tobacco control.

That kind of cohesion has yet to emerge, and there's very little time to do it. We believe an equivalent effort is critically needed.

The last point to make is that we know that the NCD summit comes at a time of lingering global financial crisis. The impact is starting to be seen in terms of declining private support for major global NGOs. We saw that from a report released just two weeks ago. And it's likely to translate over the next few years into declining public support for development aid and health. Already this is apparent in some of the problems faced in trying to achieve the full replenishment of the global fund on AIDS, malaria and TB.

Taken together, this suggests that significant additional finance for NCDs, with the sole exception of increased tobacco excise tax, is unlikely, and a different route to addressing NCD prevention financing is going to be needed from the approach we follow to infectious diseases.

Our view is that a newly invigorated approach to private-public partnerships that goes beyond infectious diseases' approach of humanitarian and corporate responsibility is needed that actually asks the question, "How can we get markets aligned to be better aligned to make them work for NCD prevention and control?" And I believe that there are ways of doing that, but it's going to take a lot of deep thinking to make it happen.

I will -- hopefully we can go into some details in question time, but let me end with that point. Thanks.

HUANG: Thank you, Derek.

Well, I'm going to use my privilege to ask the first question. Actually, just as a follow-up of the -- this declining donor support for development aid, and also Rachel just mentioned there's like less than 3 percent donor bonds going to NCDs, but the problem is that even though NCDs kill more people -- HIV/AIDS, malaria, and TB have remained -- this is called "sexy" issues in global health -- why is this and how can we bring more focus on this issue? If we agree that framing the issue like AIDS pandemic and other infectious diseases as a security threat, like the U.N. Security Council did in 2000, or if that helped bolster international initiatives by raising awareness resources, should NCDs be securitized, or can it be securitized?

YACH: Can it be --

HUANG: Actually, this question is to both of you.

YACH: Well, I would -- I would avoid that -- and I think I would also try and distinguish -- whenever people give the arguments for why one needs to invest in NCDs, I think we need to each to have a different and legitimate set of arguments that don't play to the fear of massive insecurity and -- I think that the reality is that it's a long, slow burn, the impact of NCDs, and it's particularly, as said, going to be on the economic, on the pension systems that will come back to haunt us, and on the environment. And I think we haven't played up the environmental consequences enough, partly because there hasn't been a greater amount of linkage between the two.

But certainly the immediate productivity impacts are perhaps the first that are very well documented by Rachel.

HUANG: Rachel.

NUGENT: I'll add a little bit and say we certainly need a lot more work to document on a country-by-country basis what the economic implications are, both in terms of the macroeconomic impacts -- and there's been some work done on that, depending on how you measure it. And this is the problem with economists, is that they all have different ways of measuring things. So there are different numbers out there, but for countries such as India, we could be talking about anywhere from a lost billion dollars a year to many multiples of that, depending on how expansive our measurement of the costs are. So there is significant macroeconomic impact, and we need to do more work on that side, because that speaks to the kinds of issues that you're talking about, Yanzhong, I think, in terms of the impacts on all of us.

Secondly, aside from the productivity and then related macroeconomic, there's the health system effects. And that's one of the things that concerns me the most, is we have health systems in poor countries that have for many years of course been aligned to deliver services to deal with the conditions we've talked about, the traditional conditions of infectious diseases and maternal mortality, et cetera. And that's as it should have been, but that's not as it should be in the future. We have to have health systems that can deliver care for all of the people in the population. And I believe that there are ways to do it without completely transforming them away from what they're doing.

And this gets to this issue of, you know, the funding, and do we need to somehow divert funding from where it is now. I think we can go a long way without diversion, but towards more efficient and comprehensive care where, for instance, we're doing good blood pressure screening and monitoring of women at prenatal clinics, where we're having our nutrition programs be -- providing education about both under- and overnutrition, and more than education, but the means to help people figure out how to deal with different kinds of nutritional deficiencies and problems.

So I'm suggesting, I think, that it's really not just a question of money, though there will be some money needed, but it isn't the big new fund that we saw 10 years ago for the infectious diseases. I don't believe that's the way to go right now.

HUANG: Thank you, Rachel.

I have a laundry list of other questions, but I think -- (chuckling) -- I think I would open the floor up to questions. Please flip your (placards ?) if you want to ask a question, and please also identify yourself and your affiliation before asking the question. If you have any urgent comments to make, we allow the one-finger rule -- (chuckles) -- but please keep your comments as short as possible.

Okay. We have Professors Hemps --

QUESTIONER: Hemphill.

HUANG: Hemphill.

QUESTIONER: Yeah. Scott Hemphill, from Columbia Law School. So the discussion of tobacco taxes, excise taxes being successful, desirable, you know, naturally raises the question of, you know, would it be feasible to tax other products? We have a debate here over -- I mean, I can't help it, right, since you're -- since you're at Pepsi --

YACH: (Chuckles.)

QUESTIONER: -- over, you know, a sugar tax or somehow taxing certain -- either calories or derivatives or what have you. Is there a similar debate going on in developing countries? Is that more feasible than it seems like it's been here? Would that be desirable, as one way of combatting some of the underlying issues?

YACH: The first question -- I think, on tobacco taxes, I would really want to stress that the full benefit of tobacco taxes have yet to be seen. And we are seeing dramatic, steady increases in illicit trade in counterfeit medicine -- counterfeit -- not medicines -- counterfeit tobacco being confiscated in a number of the major markets.

I mention that because what seems such a logical, easy thing to do for tobacco -- simply raise the taxes and consumption will drop -- is not proving to be as simple. And very few countries have put the money into border and customs control -- the U.K. probably is one of the few -- required to really ensure no leakage. And I suspect that we're going to see more of that over time. WHO has still got a year or two before it even gets its protocol done on illicit trade.

When you come to that areas, I think it's a perfectly fair and critical question to ask the question broadly: What is the potential role of pricing in addressing food? And I would argue that the core concern is if you look at the base commodities that drive many of the aspects of overnutrition -- really have been structural changes that have brought down the price of corn, soy -- (inaudible) -- a very heavily subsidized set of conditions both in the U.S. and Europe, and in some other countries.

Compare that to what has happened over the last two decades as we've a seen a parting of the ways in the base price of those three commodities relative to fruits, vegetables and almost everything else, and almost everything else is what we want to see more of in the diets.

So as a company you of course are going to choose where the pricing is going to be the lowest, and you're going to offer it to consumers, and they're going to buy for value.

Coming at it then with an effort to choose one particular part, whether it's soda, we generally do not believe is going to have the desired impact in -- certainly in places where it may constitute .1 percent of the calorie intake, which it does, say, in India. So while there may be a lot of popular spiel, from a policy point of view, the bigger issue is around changing the pricing structure to ensure that we could have fruits, vegetables, nuts, whole grains, all of these things, more available.

Any change in closing that gap would create incentives for small, medium and -- enterprises to actually get into a market for healthier products. That debate is starting to move very slowly but steadily inside many of the leading agricultural fora where I also have an opportunity to meet with colleagues, and it's really being driven by the fact that they see enormous opportunities for smallholder farmers, for countries -- developing countries to expand fruit and vegetable production or for nuts and whole grains.

HUANG: Doctor?

MR. : Well -- Rachel, you want to respond?

NUGENT: I promise it'll be short, but just to touch on some things that Derek mentioned in terms of agricultural policy, I think in the U.S. and in Western Europe and in some other countries that have long had agricultural subsidies that don't make sense from a whole variety of points of view, it's all the more clear that it doesn't make sense from a health point of view. Now your question really is, what about developing countries? There's bee relatively little research about the potential effect of agricultural policy changes in those countries on the health of their food supply systems and therefore improving nutrition that way. But there's every reason to believe that it would be more feasible and fundamentally more -- probably efficient, from an economic point of view, to address distortionary policies in the ag system before trying to add on taxes at the consumer level, because there are all kinds of issues with consumer taxes that -- Derek has hinted some of them.

So we have some -- we've done a little bit of research, myself and others, looking at ag policies in developing countries, and certainly there's potential. Won't take us all the way, probably, but it's a place where we need some more work.

HUANG: Dr. Sturchio.

QUESTIONER: Thanks. I'm Jeff Sturchio with the Global Health Council.

I have a question for both -- for both Derek and Rachel which may seem quixotic, but it has to do with behavior change. And I'm thinking of three different areas of behavior change, because I was struck by things that each of you said.

One is, you know, unlike HIV and AIDS, for instance, where for many years we actually didn't know how to treat it and weren't -- you know, it wasn't until we had antiretroviral drugs and a lot of other work that had been done that we found ways to intervene effectively. But we're finding out now that some of the biggest challenges with continuing the progress in HIV and AIDS has to do with behaviors; that, you know, people have multiple concurrent sexual partnerships, and that helps fuel the continued spread of the epidemic.

So a lot -- you know, just if we switch then to NCDs, you know, in many of the cases that you've talked about, if people simply exercised more, ate better, you know, did things that in some cases they have control over -- I realize that Derek just talked about pricing of foodstuffs, and that has an impact -- but behavior change could probably solve a lot of these problems. But how are we going to find ways to get people to change those behaviors?

If you then look quickly at two other areas, one of them is, we'll need behavior change among the actors who need to engage in the multi-sectoral partnerships that Derek talked about. And I just -- you know, just thinking about what I know about the WHO, for instance, where many of these discussions will take place or, for that matter, the U.N., you wonder how we're going to find a way to actually enable those kinds of multi-sectoral collaborations.

And then finally -- I'm looking at Rachel's chart on ODA for health -- how are we going to get OECD countries to change their behavior -- (laughter) -- in investing so much in other areas of health and virtually nothing in non-communicable disease, which is already three-fifths of the disease burden? YACH: Thanks, Jeff. (Laughter.)

NUGENT: You want to take three and I'll -- (laughs) --

YACH: Yeah. Well, let -- I mean, just to say, I mean, I think that we know -- any Canadians in the room? (Scattered laughter.)

Well, I mean, way back in 1985 there was the Ottawa Charter on Health Promotion, and really it provided the key framework for how I think we need to think about behavior change. And it was really about making healthy choices the easy choices and not requiring -- ideally, requiring minimal individual behavior change, because that usually fails.

So I think there is a lot we could be doing. So if we -- you know, we had this discussion inside our company, and that's why our pledges are very clear. What can we do to make it easier? We can restrict marketing to kids under 12 or whatever it is, and that's what is in place.

We can take all full-calorie beverages out of all schools worldwide, which hopefully will be in place by the end of next year.

We can change the default option on the products that they eat by lowering the sodium, saturated fat and sugar, which again is something that we're starting to do.

We can go further and get partners to actually make it easy for physical activity to happen in the school environment and change some of the urban design.

So I think there are a range of practical things on the food/physical activity side which either engineer out the need for individuals' human frailty to come into it or, if that fails, are involved in regulating it out, as particularly in tobacco did it.

But to actually expect any education program alone, without an environmental impact to do it, doesn't work.

And the best review I ever saw of this was by colleagues at McKinsey, who did a fantastic macroreview, asking -- you know how McKinsey like to do these very big macro things -- asking the big question: What is the independent role of education and educational behavior change versus education plus environmental or regulatory change? And the answer was, across all of public health, everything from AIDS to motor vehicle injuries to eating healthily, education alone had zero -- zero -- effect. And we all think: Oh, well, the problem is, you've just got to increase the dose. You know, scream louder, tell them more, give them bigger posters.

Well, if you don't do that without some environmental signals or support, and sometimes some regulatory environment, it doesn't work. So I think getting that balance right is really critical. But I think there are really powerful levers we could pull. And we're starting to see them happen, partly in tobacco. And smoke-free public places is a good example.

NUGENT: Okay, I'll speak to your other two questions briefly. On how to engage or enable multisectoral involvement, it's something that both Derek and I are very interested in and have explored a lot with the agricultural community. I think the simple answer -- much easier to say than to do -- is to think about what are the common goals that you can set forth for these different sectors. You know, what is it that -- if we're going to live in this sort of results-oriented environment that we live in in global health, you know, what are the results that you can get buy-in across several sectors for? And I think that it's possible to identify those. And that's very consistent with the way donors are thinking, as well. So I think that that's a -- you know, it's some metrics, it's some targets, it's some measurement, those kinds of things; but thinking, you know, not in such a sort of distinct, separate -- if you will, siloed -- way.

You know, it comes down a lot to incentives, and saying how are you going to incentivize the people that develop these programs and the people that operate in these different sectors. It's not that hard to figure out how to incentivize people. I think there's just an awful lot of gain to be made in some of these areas that we have -- just haven't really tried yet, but that can be tried.

So for instance, within the U.S. government, there's a lot of interest in -- from the built-environment people in HUD, to the physical-activity people, the agriculture people, the trade people. I mean, it's really -- if they're asked how can they do things differently to achieve a certain goal, they really respond to it. So I don't mean to make it sound too easy. It's not an overnight thing. But I think we haven't really asked them the kinds of questions that will get the responses that we're looking for.

Finally, on the donors, there again, as I already suggested, it's -- I don't think it's about asking for a big pile of money. I think it's about figuring out, you know, how do we come to where the donors are? Right now, a lot of the donors are thinking a lot about country ownership, they're thinking about integration, they're thinking about health-system strengthening. Those are all the buzzwords that we all are all too familiar with now. And the NCD agenda is very well suited for all of those goals. And again, I think with a little bit of creative thinking, we can get a lot of return, without having to spend a whole lot of money. So I think the dialogue must begin.

And donors -- as you know, we're in an environment where they're not looking for new ways to spend money. But they are very aware of this issue, and I think if we can offer some good evidence-based activities for them to begin engaging in this, it's just -- it's the beginning of a long process for them that I think they're willing to start taking those steps.

HUANG: Ms. Miles.

QUESTIONER: Thank you. I'm Carolyn Miles. I'm the COO for Save the Children. And I spend most of my time in developing countries, visiting the programs on the ground. And I guess the thing I'm struggling with a little bit is, you know, I have seen some great successes -- you talked a little bit about them -- in terms of these issues around child survival and other issues. We certainly can't give up on those, so this argument of taking funding out of those programs and putting it into, you know, NCDs doesn't make any sense to me.

But I do wonder if there is a way we can use some of those lessons. I mean, a lot of the things that we have learned there is about the ability to give responsibility to community health workers, to push that responsibility down the chain closer to where poor people live. So, you know, a community health worker can diagnose pneumonia, and they can now give doses of antibiotics to a child who normally probably would have died for lack of those antibiotics.

So are there -- now, obviously, NCDs, this is a lot more complicated, but are there lessons that we can learn from those kinds of activities? Because there is a long way in most developing countries in connection between those poor people and the health system, quote-unquote. It just is a very long distance, both geographically a long distance, and a very long distance till people will be able to access health systems for these kinds of diseases. So is there the ability to learn lessons there and push that responsibility and the ability for community health workers to be involved in these? And maybe it's not behavior change and maybe it's not education; maybe it's basic diagnosis or something. But I do think we need to look at things that have actually worked and be realistic about how far away the health systems are in developing countries -- certainly in India, certainly in China, certainly in Brazil, in poor communities.

NUGENT: I'll go ahead first. I just want to say -- and I hope this doesn't sound too reactive -- that I really don't hear people in the NCD community talking about diverting attention away from childhood illnesses and so on. The only people I hear saying that are people in the infectious disease communities. They -- you know, it's always stand up and say, "But you really don't mean to take money away from AIDS, do you?" I don't hear people saying that; I hear it as a response. And I don't find that that's very conducive.

So -- but to your question, I think that's a great question, to talk about how community-based work, which is where a lot of the, I think, increasing attention is going towards, sort of covering that last mile, or last 10 miles or whatever it is, with some of the hard- to-reach communities and some of the most severe, persistent issues -- I think those community-health workers have a huge role to play, because communities are where a lot of this change will happen. And some of the most successful programs that we do know about are the ones that are in a number of sites within a community -- so where you're getting consistent messages and consistent sort of incentives in the workplace, in the schools and in the home. And the community workers are the ones who can help bring those messages, as well as deliver some services. So if they're delivering antibiotics, they can bring insulin, for instance, which is not often available. They can -- they can help advise on overnutrition or other kinds of nutrition risks, just as much as they are already doing on undernutrition risks.

So again, to sort of, I guess, beat a drum I've already beat a little bit, I think that there's a lot of commonality in the way services can be delivered -- integrated, at least -- if there are some goals set, some results that'll be measured, that can achieve outcomes on both the noncommunicable disease side and as well as some of the other areas that we're concerned about. So I think there's great potential for organizations like Save to creatively think about modifying programming, and helping the donors realize that this can be done and they can achieve more that way.

YACH: Just a very brief add-on. I think if you actually take some of the core programs you're doing in relation to the "1000 Critical Days" efforts under way -- breastfeeding, micronutrients for mothers and children, and stressing optimal growth are all interventions for chronic-disease prevention as well. And we need to frame them as such. In the report, the Institute of Medicine report, which we can let you have as well, there's a whole section on recognizing that chronic diseases are really childhood diseases with adult manifestations, and getting that early start right is something that you focus on very heavily.

I think the other thing we would love to see Save do is to bring together its expertise in the U.S. around obesity that's starting to unfold with the work that you're doing in developing countries around undernutrition, and look at where some of the commonalities might be in programming.

HUANG: Here, well, we have only 10 minutes, but we have, like, six or seven questions -- people to ask questions. So Dr. Alderman, could you -- everybody, if you want to ask questions, keep your questions short? QUESTIONER: Michael Alderman, with Albert Einstein College of Medicine.

A brief point. One is that I think we've heard a lot -- and I appreciate the presentation, or the presenters -- about the difficulties of altering the environment, the behavioral kind of modifications that would make a difference in cardiovascular disease, which I know a whole lot about. But we do know a lot about secondary prevention. I mean, the treatment of preventing -- preventing disease. And an interesting project that's going on in Jamaica is an attempt to focus on industries that have an insurance commitment to their -- a health-insurance commitment to their workers; getting them to recognize the component of health-care dollars that go to cardiovascular disease, and get them engaged.

I think that has -- going to have a snowballing effect.

The second point I'd like to make is, not mine, Paul Farmer and others have suggested that there should be an international service course for health organized by the U.N. to become both a source of development in the developing world, but also a means for exchanging and developing new knowledge and new information about how to deal with the health problems in the developing world.

I wonder if you'd want to comment on the second, particularly?

YACH: Well, the first, I agree 100 percent and I think our company and many companies are part of a consortium with the World Economic Forum to really -- as a collaboration actually with WHO to try and strengthen workplace wellness.

On the second, it sounds like a good idea. Who is going to pay?

MR. : It sounds like a doable thing and not an enormous expenditure

YACH: Someone's got to pay.

MR. : And engage the academic communities as well, I think.

HUANG: I'd like to -- okay. Ms. Gade (sp).

QUESTIONER: I'm Rika Gade (sp) from -- (inaudible). (Inaudible) -- the linkages of diabetes and TB. Can you -- and HIV. Can you expand a bit more on the clinical science there? Because I've heard in some conferences that prolonged ARV treatment guarantees the condition of diabetes. I've heard that people with diabetes have three times more risk of -- (inaudible). What is the correct clinical connection or linkages between these conditions?.

YACH: We had a go at trying to review the evidence also in our own report. I think the first point is that prolonged therapy for HIV/AIDS prolongs and improves the quality of life, with, if anything, at this stage unmeasurable increase in the expected increase in cardiovascular disease.

So the benefits are just, you know, way above. The fear, though, is that, over time, you're going to start seeing the lipidemias growing and clearly you've got to deal -- that can be dealt with. And I think the plea would be that a patient who has been on 10 years of therapy for HIV/AIDS needs to make sure that their blood pressure is taken care of and their blood glucose is taken care of, not because they're going to alarmingly jump up, because they will be going into the age group where they would be at risk anyway.

The relationship between TB and AIDS is -- TB and diabetes and TB and tobacco is more direct. There appear to be a two to three-fold increase risk of tuberculosis incidents and severity in those who smoke versus don't. Clearly, the implications are obvious, and their concern is that TB incidents will rise with increasing levels of diabetes, suggesting again that you've got to act on both those diseases, but it's just a double reason why we've got to focus on diabetes and TB. And unfortunately, India happens to actually have the concentration of both happening together.

HUANG: Dr. Zlovnick (sp).

QUESTIONER: Thank you very much. I didn't hear in all your fabulous presentations anything about what government can do without external funding to use the funding that exists in the country, especially that most countries have two-tier health systems where a lot of the people are paying from out of their pocket for health care that is not very good. And how could governments use that money that is being used in any case to be more effective in providing health care for their own people?

NUGENT: I'll start with two ways in which I don't think that they're able to be very helpful. And I heard about this from a colleague recently who works in Latin America, and what's happening there, as you I'm sure know, is that health insurance schemes, publicly funded health insurance schemes have become quite widespread in Latin America and there -- some of them are partially targeted towards the poorest that provide broader coverage and some of them are a little more limited, but very broadly, the populations are being covered by public health-care programs with various designs.

And increasingly large proportions of the monies spent through those programs are covering sophisticated care for non-communicable diseases, tertiary care and very -- same kind of care that we would get here, publicly funded regardless of income level. So what's happening in that region of the world -- and I think in some other regions I'm told, but I haven't seen the data myself -- is huge expenditures, I think addressing perhaps the lowest public return, the lowest return on public investment, I believe. So I don't think that that's a very good way to go.

The other part that you point out rightly, of course, is the large proportion of out of pocket expenditures in the poor world that go towards health care, often towards ineffective health care. You know, some kind of traditional medicines, some of which might be useful for some things, but not where the money should go. And we're seeing fairly well documented the impacts of increased poverty of families trying to take care of these conditions and they're really unable to do it. It has just a whole cascade of catastrophic implications, if you will, in the household.

So I think, you know, when we are looking at reforms, we're looking at a lot of primary health care, sort of universal health coverage for primary health care is being discussed a lot in countries in Africa and elsewhere, and I think we need to think about what those programs need to include as coverage for early detection, screening, monitoring, as well as care and management of these conditions using low-cost technologies -- which is available for many of the manifestations of these conditions.

HUANG: Probably the last question -- (Harry ?), keep it short, and then answer -- (inaudible) --

MR. : One of the things that we have not talked about is that the public health educational infrastructure in this country turns out no one capable of dealing with non-communicable diseases. Most of the MPH students are not M.D.'s; they have no capacity mid- career to develop an expertise in dealing with these conditions. And my prediction, as a physician who was in an ICU when the AIDS epidemic hit in New York, is that in 20 years, HIV will be about like pneumonia. It will be a disease that's manageable, serious, expensive, but not a primary economic driver of development. And the diseases that are will not be at all approachable by the entire public health infrastructure because we're not educating anybody to do it. And there is not a single concentration in chronic disease in any school of public health in the United States. And that is going to be a major problem.

Someone is going to write a brilliant Ph.D. thesis in 20 years on why public health failed to deal with this issue, and it's the public health education environment in this country that is just paralyzed.

(Cross talk.)

HUANG: One minute.

MS. : As a professor at a school of public health, I teach a course on managing chronic diseases in developing countries. As a point of honor, I wanted to point that out.

YACH: I think also just to correct that a little bit, Henry, we've got to give some credit where it's due. And the National Institutes of Health, particularly the National Heart, Lung and Blood Institute and some aspects of Fogarty over the last five, six years have really started increasing their investment in research support for aspects of chronic diseases in developing countries. And that has an knock-on effect on starting to build the faculty interests and so on. And the more you start seeing that, the more the money actually gets invested in that and I suspect it will happen. HUANG: I think we can stop for the Q&A, but we have a last item. That is, Jean-Paul is going to make closing remarks. Also, Jean-Paul, that's just the one who pitched the idea to me for the non- communicable diseases.

Jean-Paul?

JEAN-PAUL CHRETIEN: Thank you, Yanzhong. This has been a fantastic discussion, and what a honor to be on a panel on non-communicable diseases with Rachel and Derek who have been at the leading edge in this -- to address this problem. And I know I speak for a number of colleagues in my organization in the Department of Defense who are very interested in the views of you, of this diverse and distinguished group on this issue and I know they won't be disappointed.

What I'd like to do in our last couple of minutes is draw on the discussion and the presentations that we just had and highlight three key ways that emerged in the conversation that non-communicable diseases may be different, may be especially challenging and may require approaches that are -- that are different from the ones that have worked for other global health priorities.

And in doing that, I'd like to expand our scope a bit to talk about some other conditions that are not always included in discussions of noncommunicable diseases as -- and Derek delineated the -- how the concept is often treated -- but bring those in, too, because they're important sources of morbidity and mortality in rapidly developing countries. And then I'd like to leave you with a question to think about after we leave here tonight.

So one way in which noncommunicable diseases seem to be different is that the problem is often less visible or less salient. Derek called it a long, slow burn. Every minute a woman dies from complications of childbirth or pregnancy; every year, 2 million people die from AIDS. When we think about the importance of a health issue, we often naturally and justifiably think in terms of number of deaths. And as we've heard tonight, noncommunicable diseases are overtaking infectious diseases as the most important cause of death in many countries.

But even that only gets at part of the picture. They can be terribly and chronically disabling, even when they're not fatal, or for many years until they are fatal. And as both Derek and Rachel pointed out, this tends to happen to people in their -- in their most productive years. So they not only reduce quality of life. They make people less productive. And that works against economic growth.

To take one example of a condition where it's very important to look at this ability and not just deaths, think about something that we haven't talked about: mental illness. Now, mental illness contributes to suicide. But suicide is not an important cause of death in most populations. It's not high on the list in most populations.

But if you look not at deaths but at disability, at healthy life years lost or disability-adjusted life years, as some people look at it, then you get a completely different picture. In China and in India, healthy life years lost to psychiatric and neurological conditions is on the rise. In China, it's now the number-one cause of healthy life years lost -- depression, alcohol use and other related conditions. And in India it's on track to be the top cause in the next couple of years. So disability may be less salient a concept than death and it may be harder to build donor support and political support around it, but I think based on our discussion tonight, this is a perspective that we need to have and need to be able to sell to address these diseases. A second way that noncommunicable diseases seem to be especially challenging that both Derek and Rachel and a couple of you pointed out, is the need for action well beyond the health sector. Now, of course, we know it's important for infectious diseases too, but it's absolutely essential for noncommunicable diseases. We're not going to prevent a person's obesity or cancer by distributing drugs.

Now, medication may be an important part of helping people live the best lives they can, but from a public-health standpoint and from an economic standpoint too, I think, the most important thing is to prevent these diseases from occurring in the first place. And as we've heard, in theory that's possible. If you look at the top risk factors for death worldwide, they're tied to behavior: high blood pressure, tobacco use, high blood sugar, physical inactivity.

But as Dr. Sturchio pointed out, it's, of course, very difficult to change behavior. And after all, as -- you know, as Rachel, I think, made the great point, these are not lifestyle decisions. These are not completely free and -- decisions that are -- that are not determined by the environment, by the context.

We did hear about some models for driving a change towards positive behavior tonight, and I think it's worth exploring those a bit more. We heard about the Framework Convention for (sic; on) Tobacco Control, which Derek was instrumental in bringing about; it works across sectors, involves international collaboration. And the idea of making the right decision easier, providing that nudge, as Derek mentioned, is also something that probably deserves a lot more -- a lot more research in addressing noncommunicable diseases.

And lastly, one other way that these conditions may be especially challenging is actually that some of the more important ones are tied not so much to individual behavior but to the way in which rising powers are rising -- more of a direct connection that bypasses individual decision-making. And I'll give you a couple of examples that we didn't talk about tonight.

One, again, is mental illness. Why is it increasing in rapidly developing countries? I don't think we know the full picture, but it's been -- there's been a lot of suggestion that the contributing factors, the rapid social and economic upheaval that these -- that people in these countries are experiencing. So people move from rural areas to cities and that disrupts family-support networks. Some people become wealthier, some people are worse off, and some people find their job skills are no longer relevant in the new economy. So on average, incomes rise and the middle class grows, but it's possible that mental illness is maybe increasing along with that as part of that transition.

Another example, illness from environmental pollution. China, to take one case, gets about two-thirds of its energy from coal, and of course, when you burn coal, you put pollutants in the atmosphere and that causes respiratory and cardiovascular disease, apart from the climate change effects that we hear more about; cars, another important source of outdoor air pollution in rapidly developing countries.

China actually did a great job in reducing outdoor air pollution in the '80s and early '90s, but in the last years there's been a really concerning increase in some of the most dangerous outdoor air pollutants in China's cities. And the World Bank estimated a couple of years ago that about 300,000 people die prematurely each year in China because of --

HUANG: (750,000 ?).

CHRETIEN: Seven -- at a high end; I was being conservative. But it's a lot. And the GDP impact on China was estimated at the time at about 3 percent of its GDP projected to go up to 13 percent by the year 2020, if the current pollution trends continue, just from health- care costs of outdoor air pollution just from burning coals.

So for these types of conditions, for environmental health especially, maybe for mental illness, prevention may be especially tricky, because, you know, they're not tied so much to individual behavior -- as difficult a problem as that is -- but to the way in which countries are developing.

So those are three ways in which noncommunicable diseases may be different, may be challenging that we -- that we heard about tonight. And in closing, I'd like to leave you with a question to think about from a different perspective, from the opposite perspective, and that is: What are the -- what are the commonalities? And several of your questions made me think about this. Rachel showed us that funding for noncommunicable diseases globally is low, and Derek forecast that it's probably not going to get significantly greater.

So how do we build on the investment that we've already made in global health to address noncommunicable diseases without derailing the other global health efforts that are already under way? There are efforts under way around the world to help countries meet basic public-health capacities required by the international health regulations which recently went into effect. We talked about well- funded financing mechanisms like the Global Fund, programs delivering assistance and building capacity like PEPFAR.

What is the overlap between what those programs are doing and what we need to do for noncommunicable disease control and prevention, and how can we exploit that moving forward?

So I'll end there. Thank you, Yanzhong, for letting me participate. Thank you all for a great discussion.

HUANG: Thank you, Jean-Paul. Let's also thank our other two speakers for their very -- giving us a(n) intellectually stimulating session. And we are -- I believe we all benefited from that lively discussion. Thank you all. (Applause.) And thank you for attending.

And just a reminder, our next session will be on November 16th, and we'll focus on the role of the WHO in the new government landscape. Our speakers will be Jack Cho (sp) and Jennifer Lugar (sp). And we look forward to seeing you all at the next session of the Global Health Governance Roundtable Series. Thank you, and have a good night.

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