Non-communicable diseases (NCDs) were once considered to be primarily epidemics of the developed world. But data shows that out of the thirty-six million deaths in 2008 related to chronic ailments like cancer and cardiovascular disease, 80 percent occurred in the developing world. Caribbean countries such as Trinidad and Tobago, which are reeling from the economic burden of NCDs, moved to get action started at the UN level. In April 2011, UN health ministers agreed to the Moscow Declaration (PDF), which calls for globally coordinated action on NCDs, with a focus on the developing world. At a high-level September meeting, governments agreed to a political declation (PDF) to work with the UN on voluntary policies to lower disease rates. Efforts will largely be on preventing four risk factors (poor diet, inactivity, alcohol abuse, and tobacco use) considered major contributors to NCDs. Attempts to combat non-communicable diseases still face a number of challenges, especially a lack of funding. While some experts say there is plenty that can be done on prevention, others are skeptical that global health policy should move in this direction.
The Rise in Chronic Disease
The success of global health programs has led to a drop in annual infectious disease deaths from a little over 18 million in 2011 to 15.6 million in 2008, according to the most recent World Health Organization (WHO) data. AIDS showed the single biggest drop in deaths, declining by more than 1.1 million annually between 2001 and 2008--with 80 percent of the decline in African countries. Deaths from childhood diseases, particularly measles, in that time have dropped by two-thirds. As infectious diseases have declined in the developing world, death rates from non-communicable diseases rose from 59 percent globally in 2001 to 67 percent in 2010. Much of that increase is from developing countries. According to a May 2011 UN report, over 80 percent of cardiovascular deaths, 90 percent of deaths from respiratory disease, and 67 percent of all cancers occur in developing countries. Rates of childhood obesity, diabetes, and high blood pressure in the developing world are also skyrocketing.
By 2008, 29 percent of deaths under the age of 60 in low- and middle-income countries were caused by non-communicable diseases, compared to13 percent in the developed world. The UN estimates that instances of these diseases overall will rise as much as 82 percent by 2030 in developing countries. The countries experiencing the greatest NCDs burden are those in the World Bank's lower-middle income category, where per capita incomes range between $1,000 and $4,000.
"Classically, as countries develop, infectious deaths fall and NCD deaths rise," writes Sudeep Chand, a research fellow with London-based Chatham House. "[R]ich countries have managed to get infectious diseases largely under control, with slow declines in disability from NCDs. In contrast, today's low- and middle-income countries will face stubbornly high burdens from NCDs due to the pace of this transition."
According to a 2010 report from the World Health Organization, early deaths coupled with the cost of chronic-illness care are "a two-punch blow for development" (PDF). NCDs cause billions in lost national productivity as well as pushing an estimated 100 million people below the poverty line every year. The WHO report shows that a 10 percent rise in NCDs could cause a 0.5 percent loss in a country's GDP, and a study from the U.S. Institute of Medicine in 2010 found that chronic illness cost developing countries up to 7 percent in GDP losses annually.
"The ability already exists to counteract the non-communicable disease epidemic, thus saving millions of lives, preventing untold suffering, and reducing enormous costs," says the UN's May 2011 report. "Knowing how to reduce such diseases is not the problem; the problem is lack of action."
A Focus on Risk Factors and Prevention
Some experts argue the focus should be on four major NCDs--cancer, cardiovascular disease, respiratory illness, and diabetes. The NCD effort is expected to target the following four major risk factors that contribute to these diseases:
- Unhealthy diets. Many experts say increased consumption of fast food, processed foods, and soft drinks contributes to excessive intake of salt, saturated fats, and sugar, which are significant risk factors for diabetes, obesity, cardiovascular disease, and some cancers. Overall, globalization has contributed to a growth in diets heavy in meat products, vegetable oils, and sugar. Annual sales for soft drinks (PDF) in countries such as China and Indonesia grew between 5 percent and 19 percent between 2003 and 2008, according the U.S. Agriculture Service. Packaged food sales in these countries grew anywhere from 4 percent to 40 percent (PDF) annually in that time period. Sugar alone is the world's single largest food crop. India, the world's largest consumer of sugar, has the world's largest population of diabetics.
According to the World Diabetes Foundation, 70 percent of the current cases of diabetes occur in low- and middle-income countries. Meanwhile, the WHO estimates that more than 2.3 billion people will be overweight by 2015. Though the highest levels of obesity currently exist in high-income countries, rapid growth is being reported in lower-middle income countries.
"It is not uncommon to find under-nutrition and obesity existing side by side within the same country, the same community, and even within the same household," writes OxFam's Duncan Green. "This double burden is caused by inadequate pre-natal, infant, and young child nutrition followed by exposure to high-fat, energy-dense, micronutrient-poor foods, and lack of physical activity." Poor childhood nutrition is a risk factor for NCDs as well. Under-nutrition in utero and low birth weight increases the subsequent risk of cardiovascular disease and diabetes.
Some experts say NCD risks could be significantly reduced through nutritional labeling, regulations limiting certain fats, regulations for marketing products to children, and reformulation of processed food. Though some large food companies have signed onto efforts to reduce salt, fat, and sugar, some health activists worry that this is more a marketing measure (NewYorker) than a commitment to good health. However, consumers are already trending toward health-conscious packaged foods (PDF), currently "the biggest innovation driver" for the industry, according to market analyst Euromonitor International.
- Physical inactivity. The WHO estimates that approximately 3.2 million people die annually from illnesses related to physical inactivity. It is estimated that insufficient physical active leads to a 20 to 30 percent increased risk from all chronic diseases. In the WHO's European, Eastern Mediterranean, and Americas regions, over 50 percent of women are overweight because of poor diet and lack of exercise. Some health experts point out that impoverished people--many of whom work long hours and have families--have few opportunities to exercise. Experts say more should be done to promote and improve conditions for daily exercise such as providing sidewalks, parks, and community recreational facilities; improving indoor and outdoor air quality; and improving traffic congestion.
- Tobacco use. The WHO estimates about one billion people in the world smoke, consuming roughly six trillion cigarettes annually. China alone has an estimated 350 million smokers and is the world's largest tobacco grower, according to the UN Food and Agriculture Organization. Also prevalently used are pipe tobacco and bidis--hand-rolled tobacco leaf of which 700 billion are smoked (PDF) annually in India alone. An estimated 700 million children are exposed to tobacco smoke. An estimated 6 million people die from tobacco use each year, causing nearly 10 percent of all deaths worldwide, two million more than AIDS, malaria, and tuberculosis combined. Tobacco is considered responsible for more than two-thirds of lung cancers, 40 percent of chronic respiratory disease, and 10 percent of cardiovascular disease.
The Framework Convention on Tobacco Control, which went into effect in 2005, is expected to be the basis for further action on reducing tobacco use, which most global experts agree would help reduce NCDs. The treaty, already in effect in 165 countries**, focuses on marketing bans, public awareness, raising taxes, preventing sales to minors, and control the illicit trade of tobacco products. However, only 10 percent of signatory countries are in compliance. The United States has not ratified the treaty but is considered mostly in compliance, though some experts, such as CFR Thomas Bollyky, hope to see more action from the country on tobacco trade policy.
- Alcohol abuse. According to the WHO, alcohol is the third-highest risk factor for disease burden after underweight childhoods and unsafe sex. "Harmful drinking" (primarily binge drinking and heavy daily drinking) can be a major determinant for neuropsychiatric disorders, cardiovascular diseases, cirrhosis of the liver, and various cancers. The WHO estimates that approximately 2.5 million deaths each year are caused by alcohol; some of these deaths are due to injury rather than disease. In May 2010, the WHO put forward a global strategy for reducing alcohol consumption (PDF), which will likely be the framework for action. The policies recommended include national plans to reduce consumption, protect children and young adults from marketing, limit access to alcohol, and improve access to substance abuse treatment services.
The Global Health Challenge
In a 2011 report on "getting the politics right" (PDF), researchers at the Center for Strategic and International Studies call for the development of specific, measurable goals on reduction of mortality rates; for governments to commit to national plans to flesh out targets and develop regulations; and for innovative financing such as public-private partnerships. They also call for a specific person within the UN or WHO to head the effort at the international level.
"The way to limit the burden of non-communicable disease is implement tobacco-control convention, put real restrictions on sugar and salt, and limit marketing [of unhealthy foods, tobacco, and alcohol] to children and young adults," says CFR Senior Fellow Laurie Garrett, who notes that doing so will require taking on powerful multinational interests, such as the food, tobacco, and alcoholic beverage industries.
In the days leading to the September meeting, some advocates said Japan, the European Union, Canada, and the United States were blocking language in the outcomes document (Medscape) that called for specific national action plans, targets, and accountability, all of which would require funding. Some experts, such as the NCD Alliance (PDF), worry that a document without these commitments will mean little action. One expert said without such action it will be difficult to tie NCDs to a new set of Millennium Development Goals when they come up for review in 2015. Another contentious element has been language on promoting access to "essential drugs and technologies" (PDF), which also would likely require increases in funding, and use of the word "epidemic," which raised concerns about triggering the use of compulsory licenses for patented drugs.
At the opening session of the September meeting, the UN adopted a political declaration (PDF) that calls for "a multi-pronged campaign by governments, industry, and civil society to set up by 2013 the plans needed to curb the risk factors behind the four groups of NCDs--cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes." The new government policies would be voluntary, taking into account national circumstances, such as political and funding climates. However, the World Health Organization is directed to come up with a "global monitoring framework" by the end of 2012 to help measure progress. UN leaders also called on more responsible action from industries, especially on issues such as advertising to children.
Some health experts believe the NCDs effort should be even broader. CFR Adjunct Senior Fellow Michael Hodin argues two things should be driving the NCD strategy: prevalence (the number of people affected) and cost, and without taking those things into consideration, the result will be a "profoundly flawed [UN] document." Hodin is among those arguing for a greater focus on issues of aging, particularly Alzheimer's disease and dementia, calling them problems that will "cripple the twenty-first century." More than thirty-five million people suffer from dementia, which is expected to rise to 115 million by 2050 (PDF). The UN declaration does recognize that mental health, including Alzheimer's, adds to the global disease burden, but the focus remains on the four risk factors outlined.
The push on NCDs comes at a time when the WHO, which is likely to spearhead action, has cut its budget by 20 percent (Reuters) in 2011 and is expected to eliminate three hundred jobs. Though some advocates believe NCD measures will largely pay for themselves (PDF) through reduced healthcare expenditures, questions remain about whether tackling NCDs is an effective use of global health resources.
"When you look at how our donor dollars are spent, we have the view that infectious disease is a better investment of aid dollars," says Gabrielle Fitzgerald, deputy director for global health policy at the Bill and Melinda Gates Foundation. "When you see the overall foreign aid budgets [of donor countries], they are fairly small in contrast to the need, and they are under extreme pressure right now." She argues that while there is nothing wrong with calling attention to NCDs, the first priority should be making progress on existing infectious disease and maternal and child health development goals, as well as ensuring current aid commitments for those are met before adding other diseases to the mix.
**Editor's Note: The backgrounder originally stated the tobacco control treaty was in effect in 163 countries.
Adine Mitrani contributed to this report.