The Challenge of Non-Communicable Diseases

Monday, July 25, 2011

Experts discuss the importance of prevention and control of non-communicable diseases, as well as the need for the United States and the United Nations to play a larger role.

SHERI FINK: Good afternoon, everybody. Thank you so much for joining us, and welcome to today's Council on Foreign Relations meeting on the challenge of noncommunicable diseases.

I'd like to remind you to please completely turn off all devices, not just set them on vibrate, so that they don't interfere with the sound system here. And I'd also to like to remind the members that today's meeting is on the record. And there are CFR members from around the national and around the world, in fact, who are listening in -- hello to all of you -- along with our audience here of members in New York -- and they are joining us on password-protected teleconference. So we're looking forward to also getting their questions, which will be coming on this handy iPad. If you see me playing with it, it's not to -- reading The New York Times or whatnot; it's getting the questions from the larger audience.

So I would like to start by welcoming our distinguished panelists. You have their full biographies in your handouts, and briefly they are in order to my right here Dr. Neals (ph) Daulaire, Nils Daulaire, the director of the Office of Global Affairs at the U.S. Department of Health and Human Services, and our country's representative to the WHO's Executive Board. And Dr. Daulaire, as many of you know, previously served for more than a decade as the president and CEO of the Global Health Council and also worked on global health issues in the Clinton administration.

Next to him is Dr. Babatunde Osotimehin. He's the executive director and undersecretary general of the United Nations Population Fund and previously served as the health minister of Nigeria.

And finally, we have Dr. Derek Yach. Dr. Yach is senior vice president of Global Health and Agriculture Policy at PepsiCo, and he is also the former executive director of the WHO, and previously headed global health efforts a the Rockefeller Foundation, and was a professor of global health at Yale University.

And just to start out by giving everybody a very brief overview of this issue that we're discussing today, it's part of a new CFR initiative on the challenge of noncommunicable disease. And also, as you no doubt no, it's very timely, because in a little over a month the United Nations General Assembly will hold a special high-level meeting on the prevention and control of noncommunicable diseases.

There have been several recent international meetings on the subject, and the focus has tended to be on four chronic disease entities -- diseases of the heart and blood vessels, chronic diseases of the lungs, cancers and diabetes. And these of course share common risk factors, which suggests in some way that these noncommunicable diseases are, in fact, in some sense, communicable illnesses, because underlying them are risk behaviors including overeating, unhealthy foods, physical inactivity, smoking, alcohol use that are in fact communicable in the sense that they spread through families and communities.

So there has been talk of a branding problem. It's hard to get traction around an issue that's framed in terms of a negative, noncommunicable disease. And there are a large number of important health issues, of course, that are not infectious diseases but that aren't typically included in the definitions that have been offered by people who've been working on these type of initiatives, such as psychiatric illnesses, kidney disease, malnutrition.

So if the definition ends up excluding some important noncommunicable diseases, then perhaps do we need a new name? How do we define this entity? On what do we base the definition? Are there metrics that tell us which diseases are the most important?

What is the goal? Is it to target the most deadly diseases, or the most economically devastating, the most preventable, the most cost-effective to prevent? These are of course partly value judgments. Some have argued, for example, anecdotally, that in low-income countries, some of these illnesses are those of the rising middle class, the somewhat wealthier people among some of these countries. And they are certainly of course -- or they tend to be -- diseases of the older.

So hopefully, we will discuss many of these questions and others today in our discussion, and we'll start by a few questions amongst us and then open it up to the larger audience here.

And I'd like to start with Dr. Yach, as somebody who's worked on this issue and your current position, as well as with the WHO and your recent work with the IOM on this issue, the Institute of Medicine. Why is this issue coming to prominence now? And maybe perhaps you could address that and any of the other questions that have just been raised.

DEREK YACH: Well, I think it's really coming to the fore because the data is so compelling. We've seen a decade of build-up showing that the overwhelming evidence suggests that particularly cardiovascular disease, heart disease and stroke, with many cancers, diabetes, chronic respiratory diseases are by far the major killers and causes of disability everywhere in the world, with the exception of parts of sub-Saharan Africa. And the trends for most developing countries are steadily rising.

The economic impact has also made it clear that these are issues, from an economic perspective, that we can no longer afford to ignore. They are starting to impact on people in the productive years of life, particularly in economies where we're hoping we're going to see the engine of growth being able to power the economies worldwide.

I think also there's been a buildup of a number of people and organizations in the NGO world, in the private sector, in governments and the U.N. agency who've actually recognized that they need to start taking action, particularly on some of the preventive focus.

You could say, well, why these four risk factors, which are tobacco, diet, physical inactivity and excess alcohol? They do underpin many of the four major diseases I mentioned. We also know that we've got success stories in dealing with many aspects of those risk factors that have also started increasingly getting focus over the last few years, particularly powered by tobacco. And we continue to see tobacco as exceptional because of the death killing impact it has, causing 6 million deaths worldwide now, with figures rising over the next few years.

So I think this coalition of people, the strength of the numbers on both the economic and the health impact and the fact that we know we can actually take action is finally leading to the U.N. to raise this to the highest level of policy discussion.

FINK: Dr. Daulaire, what is our current U.S. policy with respect to global noncommunicable diseases and this initiative in particular? How is the U.S. supporting the effort to fight noncommunicable diseases globally? At what level will our country, in terms of representatives, be participating in this high-level meeting? With U.S. global health funding already under attack from some in Congress, is there any chance that the U.S. would be contributing new money to this effort? And if not, will the efforts on noncommunicable diseases from our country take money away from other efforts, for example HIV/AIDS or prevention of maternal mortality?

DAULAIRE: Well, the reason for our very active engagement in the high-level meeting on noncommunicable diseases is very simple. The United States spends more than $2 trillion a year on health care, and of that, more than 70 percent -- over $1 1/2 trillion -- is spent on the treatment and control of noncommunicable diseases.

This is central to the U.S. economy. It's central to the issues that have been behind the drive for the Affordable Care Act and health care reform within the United States. And as the country that has the unfortunate history of being the world's leader in noncommunicable diseases and the costs thereof, we think that we have a responsibility to work with the rest of the world to help them to avoid, as best possible, some of the dire consequences that the United States has faced.

As a result of that, the U.S. delegation to the high-level meeting in -- here in New York in September will be led by my boss, Secretary Kathleen Sebelius of the Department of Health and Human Services. And we view this as an opportunity to put on the world stage both the challenges and the strategies that can be used moving forward in terms of addressing and hopefully cutting short this trend towards a vast explosion of noncommunicable diseases.

The United States has actually been remarkably successful, in spite of being at the head of the pack in terms of obesity and chronic diseases, in starting to address those. We've had a dramatic reduction in smoking rates over the past 20 years. There is much less hypertension, fewer heart attacks, fewer strokes than there were 15 to 20 years ago, and this isn't just because we happened to get lucky or guess the right way. It's because there has been a strategy applied domestically to reduce tobacco consumption, to look at the major risk factors for cerebrovascular and coronary heart disease, to look at chronic lung disease. I'd say diabetes -- we're still not where we need to be because that is so tied to diet and physical activity, and certainly our first lady has put that on the radar screen as a top priority for young people in this country, which has, hopefully, a payoff curve over 20 to 30 years.

But now that we look at what's happening around the world, we're seeing the very rapid emergence of noncommunicable diseases not as problems of the elite or even the middle class in some of the low, middle-income countries, some of the rapidly emerging economies, but even within the very poorest segments of those populations; particularly in urban settings, it's rapidly becoming a very serious problem. So no longer is this what could be called problems of the rich. It is the problems that all of us have.

In terms of the funding issue, that's a big challenge in today's environment. I haven't checked my BlackBerry in the last 20 minutes, but I don't think we have a resolution of our budget crisis yet. And it does not look like the Congress of the United States is likely to enthusiastically endorse an increase in U.S. international development assistance spending in the next year.

We recognize that when the U.N. undertook its commitment to the Millennium Development Goals in the year 2000, and focused particularly in MDGs 4, 5 and 6, on children's health, on maternal and reproductive health, and on major infectious diseases, that that is a serious commitment that the world community has taken on leading up to 2015. And we're going to stick to that. So we're not looking to replace one set of commitments with a new one and sort of change the goal line.

I don't think that there's going to be a major increase in the near future from the U.S. in terms of international assistance in noncommunicable diseases, but that is a very different thing from saying that we can't work jointly with the global community to do something about it. And working in the policy arena, working in prevention, working on transferring some of the strategies that have worked here, and looking at what the global frameworks are for addressing noncommunicable diseases is something we're already doing, and does not require additional resources; it just requires them to be spent more strategically and thoughtfully.

FINK: Thank you.

Dr. Osotimehin, I guess I would be interested in two things. One, as the head of UNFPA, here does UNFPA come into this whole discussion of noncommunicable diseases? Because you focus on something that would seem on the surface to be very different. And another is just in your role as former health minister and somebody who had to set health priorities, can you give us a sense, you know, for a country, how big of a burden are noncommunicable diseases there? You know, what are the costs of those illnesses, if you know?

And again, you know, in terms of priority setting, how easy would it be to add this in a -- in a more robust way, or in a way that will likely be demanded of countries coming out of this U.N. session -- you know, additional focus, additional resources on these issues? How easy would it be for countries to do that, since they're already focusing on so many health priorities?

BABATUNDE OSOTIMEHIN: Thank you very much. Let me start by saying that I agree with Nils that the issue of noncommunicable diseases is not an issue of the West or the developed world; it's an issue of the global world. And as a physician in Nigeria, before even I became health minister, it was evident to us that what was -- what we were doing -- which I didn't think was right -- was to put the communicable disease in a silo as if that's all we had to deal with, and not invest in the noncommunicable diseases. In an average clinic, you will see a lot of blood pressure, you will see diabetes of various types, and you will see these in various ages.

And it is important for us to also understand that globally people are aging, and the demands of age also brings with it all these noncommunicable diseases. And so in the context of a national system, every country must now begin to understand that you cannot actually separate one from the other, and you have to look at this in a broad sense. And I think one of the -- one of the very important initiatives that we had -- we put together, as minister of health, was to try to integrate these issues in a -- in a manner in which we can actually begin to address them, so that when you go to a primary health care center, you can have health education about simple things like salt (ingestion ?); simple things like being able to take a blood pressure so that somebody can tell you that you run a risk of developing a stroke, maybe not a heart attack; simple things like testing your urine to be able to tell you that you have diabetes, or if, in point of fact, there is somebody in your community or your family that has diabetes, to tell you that there is some genetics to it.

So I think that we lost those opportunities because we were investing so heavily in doing things which you thought were the (heavy-body ?) issues, but in point of fact, those other things are there. And I have always said that once we got rid of the malarias and tuberculosis and the HIV -- which, incidentally, has now become a very chronic disease and it -- it's ceased to be an acute disease -- we were going to be overwhelmed by, you know, these noncommunicable diseases.

Add too the fact that lifestyles are also changing in other parts of the world. The rate of smoking out there is (obviously going up ?). Actually, I have a story which -- it's about a tobacco company just taking its establishment from Southampton in England and just putting it in Nigeria. And we had to resist it, because, you know, it was trying to get people to smoke, and we understood what that meant.

So I think that what I would hope that heads of state and member missions would take out of this meeting is that it is not either/or, it is everything together. It is that we must invest in health system that can look after everything and invest -- at this point in time in, you know, some parts of the world, invest in prevention, prevention, prevention, prevention, because we cannot get to the point where we spend trillions of dollars, because we can't afford it. And there are many, many simple things which you can do in terms of prevention, because they relate to lifestyle. And I will go and develop that further a little.

Now with regards to UNPF and how we take it, I think that again, maternal health and child health also has implications there. You know, the -- if the mother has diabetes, her chances of having a surviving child or a delivery which is not complicated, you know, is increased, you know, that -- or is decreased. If she has blood pressure, which are the things that we look out for in terms of a mother's health -- those are the things we deal with.

And there is something else which, you know, 10 years ago, maybe 15 years ago, we didn't even think about, I mean -- cervical cancer. Cervical cancer is now -- even though we now know it's infectious, but at that time we didn't know it was infectious. Now those are some of the things we have to, you know, take into consideration in terms of the range of issues we deal with maternal and child health.

FINK: Thank you.

I want to get into just some of the financial interests at play here, and I'll start with Dr. Yach. Many large multinational companies obviously earn their profits by making products that are implicated in the causation of these diseases. So companies that are produce sugary soft drinks -- (laughter) -- or snack foods, alcoholic beverages, tobacco products, many companies -- and we love these products, obviously.

DR. : (Chuckles.)

FINK: (Chuckles.) Have any of them or -- of these companies or their trade organizations actively tried to oppose initiatives on noncommunicable diseases, particularly if this comes into questions of international taxation or regulations or just efforts that would reduce the use of their products?

And on the commerce side, on the other side, what are the ways or are there ways that these companies -- that we can engage with them that they are involved in this? You know, where does it meet their interests, perhaps, to be involved and to be brought into the umbrella?

YACH: Yeah. What a surprising question -- (laughter) -- but, I think, a very important question.

What struck me over the last year and a half was to see how deeply engaged the private sector has become, whether it's the food industry and everything that it stands for and particularly the large multinationals, the medical devices and the pharmaceutical industry and a few others, but mainly those groupings. And I think between us, many of the leading companies now accept that there is no question that these are long-term threats to health and the economy that we need to address together.

When I was at WHO, I was privileged to be involved in writing the Global Strategy on Diet and Physical Activity, and list what we thought the private sector should do. And we had a list without really talking to the companies what should be -- what will be the best things to do -- low salt, low saturated fat, all of these things -- very easy to write.

Fast forward to where we are now. Many of our companies not only have taken every single one of those but they're doing things which are much harder than and -- I ever anticipated in the public sector to do. We've already heard here that there are a few simple things you've got to do: Change behavior, change lifestyles, lower salt. Those are unbelievably tough things to do. They will not happen without money, additional money. And the private sector has been leading the way, investing in trying to lower salt through its product lines, reduce fat.

And just let's stop on reducing fat. We all know that that underpins the cardiovascular epidemics of the world. What does it really take to reduce saturated fat?

Certainly, on the one hand, people must just watch their diets, and that's very nice. But if you want to engineer it out so that people don't even have to worry about that, we have to have healthy oils.

Well, to change the oil supply of the world from palm to anything else that's healthier requires deep engagement in agriculture, something that we as a company have actually been doing and being bold about trying to accelerate our work, as have other companies.

These are not easy things to do, and we're doing them not because there are going to be short-term returns to the bottom line, because there aren't, but because we know first of all they're right the right things to do, and over the longer term we're hoping that consumers will respond to the healthier products.

So I would say if I was to have been asked, when I was at WHO, whether I could anticipate six, seven years from now seeing the kind of transformative work going on across the food and beverage sector, I would never have anticipated it. I would have thought it would have had to come through much more top-down approaches.

The last point I'd say is, when we talk about the private food and beverage sector, we're talking here about a very small part of the total supply of the food in the world coming through the hands of multnationals. Most of the countries that you'd know well -- Nigeria, my own country, South Africa -- probably 12, 13 percent of all packaged food is produced by known multinationals. The rest, 80 percent plus, is produced by small or medium enterprises or the vast informal sector. And how we're going to engage them remains a real deep challenge that I haven't seen the governments rise to the bait of thinking about in new and innovative policy terms.

DAULAIRE: Could I just weigh in on that for a second?

FINK: Please. Yes.

DAULAIRE: From the U.S. government standpoint, I think there is a risk in viewing this as all of business, all of the commercial sector. There are really two parts to it. There's one part of the commercial sector that produces a product which, when used as directed, kills a third of its users, and that's tobacco. And then there's the rest of them. And there is a risk of sort of lumping them all together. There are good foods and bad foods. There are good beverages and bad beverages.

There is no effective way in modern science to make tobacco into a safe and useful product. There are many ways to improve the way in which foods and beverages are used and commercially marketed. So there's a very strong role for government intervention in this, in terms of regulation, in terms of a playing field; on the one side, to do everything possible to diminish the use and access to tobacco products, particularly for young people, who are the ones who become first addicted, but on the other side, to create a set of incentives and disincentives for the food and beverage industry, that levels the playing field so that PepsiCo, shall we say, doesn't have to compete against another industry that has a different product mix which might be less healthful but for some reason is more attractive to consumers, at least to make this an area where the incentives are towards healthier and more beneficial food products.

FINK: Thanks.

I'm going to go to questions now, and we'll just start with one from a D.C. listener, Welby Leaman, who's with the trade counsel on the House Ways and Means Committee.

And it has to do with a question that I think I'll put to you, Dr. Daulaire, which is how we characterize noncommunicable diseases and do we characterize them as a global academic, and what the implications of that are. And you'll enlighten us about that.

And his question is: Many pharma companies are struggling financially right now as blockbuster patents are moving toward expiration. And as HIV and other medicines are offered at significantly reduced prices in many markets around the world, medicines for chronic noncommunicable diseases are often companies' principal source of profit.

If compulsory licensing is imposed or if companies are pressed to lower prices on these drugs, what will be the impacts on these companies' business viability and ability to sustain extensive R&D? And also, just to add on the other side of that, is there a way that this could perhaps be -- whether pharmaceutical companies could be brought into this and see it in some ways as a positive for them moving into other countries.

DAULAIRE: Well, to avoid getting into the arcane details of international trade negotiations, I'll oversimplify.

But the issue of whether noncommunicable diseases are called an epidemic or not is a sensitive one, in that the trade agreements negotiated at Doha, the so-called TRIPS agreements, had an exclusion for issues that were public health emergencies, under which HIV/AIDS has fallen, and that has led to the widespread availability of generic antiretrovirals, which has cut the cost by a factor of a hundred. This has been a very good and a very important part of the global response to HIV/AIDS and a number of other severe communicable diseases.

If -- there's a concern that by tagging noncommunicable diseases as an epidemic, that it would fall under the same category and therefore that it would open the door to eliminating a wide range of patent protections for a lot of pharmaceutical products used widely in the United States and elsewhere around the world.

So we're approaching this with a great deal of sensitivity in the international negotiations leading up to the high-level meeting. And one of the things that we're focusing on is the importance, particularly in low-income countries, of recognizing that they're at the point in this curve where early prevention, and particularly prevention in the area of tobacco control, is the most critical thing that they can do.

This is not about treating our way out of the problem. This is about preventing the explosion of the problem. And when we look at issues of what countries can do, raising taxes and reducing advertising on tobacco products, making them less accessible to young people are some of the most important things that can be done, certainly far better than whether we can reduce the price of a theoretical lung cancer drug by the same factor that we have for antiretrovirals.

So we're trying to focus on that as a key issue. We also have to recognize that pharmaceutical companies make the lion's share of their global profits right here in the United States. This is where most of their R&D investments are returned. They make the next large segment of their returns in the other industrially developed countries, Europe and the Pacific and Far East. And then the next sector is the emerging economies, and that's where the battleground right now over drug pricing is being -- is being waged.

And this is an issue that will occupy us for the next 20 years, I'm sure. And there's no single answer, but we recognize that innovation and the development of new products is going to be critical at the tail end of the spectrum of dealing with noncommunicable diseases, and we certainly don't want to inhibit that while at the same time trying to maintain a reasonable balance in terms of access for people in low-income countries.

FINK: All right, let's take some questions from the audience.

(Chuckles.) Laurie Garrett is trying to signal something. Why don't you ask our first question?

QUESTIONER: Sorry, I just was noting that Babatunde wanted to say something.

QUESTIONER: No, just -- I just wanted to underscore what you said and to tell a little story. As minister of health, the day I started work, which was actually the 8th of December, 2008, I got a visitor in my house at 7:30 in the morning. It was the manager of British American Tobacco. He came to see me at home. He was the first visitor that came to see me as minister. And I didn't know him. And somebody opened the door, and I came and said, can I help you. So -- (I'm so, so sorry?) -- and he sat down asking, can we work together. I say it's not possible. It's like night and day. You and I, you know, cannot work together.

But that's how pushy the tobacco industry is. And I know that, you know, in Nigeria they actually insist that -- they will throw parties, and all you have to have is a pack -- an open pack of cigarettes. That's your entry. So you must buy a pack of cigarettes to enter into the party. That's your entry fee. So it is important that the message must go out loud and clear that if we are not going to get that kind of explosion and epidemic of tobacco-related disease out there, it -- you know, we have to stop the tobacco industry. I just thought I should -- I should say it.

Q: So -- and I -- I do have -- Laurie Garrett from the council. Quick question. Nils, we're -- I would imagine that you're having long conversations about this at HHS, the uncomfortable position you will be in at the NCD UNGASS in September. You just finished telling us that controlling tobacco use is the number one way to get to the bottom of this problem. We have never signed the Tobacco Convention, and the United States is the world's greatest exporter of cancer. We export more tobacco than everybody else. So aren't we in the position of having to walk into this meeting as total hypocrites?

DAULAIRE: Well, I always try not to walk into a meeting as a hypocrite. (Laughter.) If I have to, I'll walk out as one. (Laughter.) But the Framework Convention on Tobacco Control is a very important topic, and the challenge here -- as you may have noticed, there is sometimes a little difficulty getting certain things through the United States Congress. And there is no question -- the president has spoken of his support for the Framework Convention. The question is entirely one of whether we can get this through the United States Senate with a two-thirds majority, and if not, whether we want to spend the time spinning our wheels on something that isn't going to move forward. It is being very, very seriously looked at, and if we think we can do it, we will do it.

YACH: I just wanted to say, Laurie, that, you know, for the last decade, people have often forgotten that the largest government support for the work on the Framework Convention has come from the U.S. government. Without the U.S. government, you wouldn't have the Global Youth Tobacco Survey, which is now being executed in 150-plus countries -- maybe two or three times in some countries -- which provides the essential data for moving the epidemic -- for controlling it. Without the National Institutes of Health, you wouldn't have what was the largest investment in building capacity and research in the developing world. And without the EPA, you wouldn't have had a lot of focus on issues related to indoor air and smoking control.

So I think we've got to draw the distinction between moving from adoption, which is what the government has done, to full ratification, having to go through a complex Senate process, to being deeply engaged both from a leadership position in government -- and even, I might say, from the NGO world in tobacco control.

DAULAIRE: And let me just add that the secretary of the Department of Health and Human Services, the deputy secretary, the commissioner of the Food and Drug Administration, the director of the Centers for Disease Control and Prevention, the director of the National Institute of Health -- all of which are part of the HHS family -- all are profoundly committed to tobacco control, scientifically, operationally and socially.

FINK: I'd like to open this and invite other members to join our conversation as well with their questions. And please wait for the microphone, speak directly into it, stand, state your name and affiliation. And please limit yourself to one question, and keep it concise so as many people as possible can join in the conversation.

Over here, please.

QUESTIONER: Thanks so much. I'm Robert Marten, with the Rockefeller Foundation here in New York, and just a quick question for the panel. Given the financial situation that the world is facing now, and also given the fact that the -- in global health, it seems that the vertical approach is going out of fashion, so to speak, what is the best chance for success for the NCD summit? In five years, if we look back, what would be the best-case scenario, given those two quite limiting caveats?

OSOTIMEHIN: I think that, going forward, integration is the answer. And the fact of the matter is that there are some things which developing country situations -- which is what is challenged at this point in time -- need to do which they have not done in the past.

When I said that I spent two years of my life looking after HIV in Africa, then I want to say that, you know, with some degree of responsibility, the amount of resource that passed through my hands, if we had -- if I was going to start -- do it again, I'd probably spend it differently. Because what we did was to set up a system to deliver HIV messages and drugs and treatment to a group of people. These same people have blood pressure, these same people have diabetes, these same people have malaria. Some of them actually don't have access to clean water. So -- and if you look at the investments we made, and do it in a little different way, we could actually have provided all of those things for the same amount of money. It's just a question of planning and thinking about it.

Most African countries and South Asian countries just don't have a health system that works. And so you need to invest in a health system, a health system that can deliver properly. If you go across, there aren't even people to deliver care. So you need to invest in those things. And I think that that's what, you know, going forward, we have to do. So take it all together, integrate it, and make sure that you can deliver the minimum package to look after some of these things.

Now, one thing that I wanted to say in regards to what Nils said in terms of providing treatment, and the issue of the big pharma in terms of their fears of losing market and not being able to meet the bottom line, I think that -- and as, you know, my colleague here would certify -- that some of the treatments for these diseases actually do require too complicated medication. And I think that, you know, we just need to work at the global level to identify those very simple techniques that work. You know, a thiazide diuretic, you know, works beautifully for blood pressure, and those sorts of things.

So you don't have to elevate it to the kind of level that you would have to get in a -- in a medical clinic in New York. I mean, you can do it with simpler combination of drugs, just as effective. But it is important that we have to work on that, and make sure that governments understand that with those investments we can make a difference.

DAULAIRE: And those drugs are already on the generic market?

OSOTIMEHIN: That's right.

YACH: Yeah, they cost pennies. Let me just try and answer -- because I think that's a very powerful question -- five years from now what we expect. I think there's a mixture of immediate, medium-term and some longer-term shifts that we have -- (we'll/will ?) start by September.

So let's first ask the question, where in the world have we seen success on NCDs? And the answer is, the entire OECD group of countries. We have seen the most profound decline in death rates over the last two to three decades of any major public health problem. And we often forget that. The dramatic decline that Nils mentioned in the U.S. has been a huge shift in mortality from cancers, from diabetes, from cardiovascular disease. We are now seeing a little bit of a risk on the diabetes side, driven probably by obesity, but on all the other major causes of death, we've seen unparalleled declines.

And if you go to some countries where they ask the question "why" -- Finland perhaps is the best example -- where they documented over the last three, four decades that it was clever policies taken very early, in the '70s, that first of all shifted agricultural production and the incentives for agriculture to move towards healthier foods and making the healthier foods those which farmers would want to grow and consumers would want to eat. We've been inspired by that kind of work at PepsiCo to support the Chicago Council to actually look into this in depth and say, globally, what shifts do we need to make in agriculture long term to recognize that that will have a huge impact across the entire food supply and affect not just chronic diseases, but also hunger?

Second, in the sort of (closer-in ?) period, I think that you highlighted the fact that the future generation, the children born today, are already being influenced -- right -- both in utero and in the early periods of life. How can we introduce simple measures into the early period of childhood?

And these could be as simple as smoking cessation in pregnancy, ensuring that we actually monitor and treat gestational diabetes more rigorously and far more early, and ensuring that kids grow up in smoke-free -- cooking stove smoke-free environments. Those three simple measures, taken early in life, will over the course of those children's lives have huge impacts, and they don't cost huge amounts of money.

The third is, what do you do today? Because you have got a huge burden of disease. What we often forget is that all governments, particularly all middle-income and low-middle-income countries, are spending a lot of money on chronic diseases, but they're spending it on the complications. So it would be towards the end stage of heart disease. It would be towards the end state of diabetes when the drug treatments and the other treatments are not that cost-effective. Persuading and working with them to shift those earlier into the early phase of primary health care could make a huge difference, even within the existing budget. Ensuring, for example, that no adult left their primary health care clinic without having their blood pressure recorded -- that alone could have a huge impact, particularly across many of the Asian and African countries where hypertension alone is a major cause of death, disease and ill health.

So I think there's some practical things. But obviously I (would say ?) five years from now these will be commonplace. And for me, one of the tests on the early childhood one would -- (inaudible) -- that UNICEF stood up to the plate and said, we recognize that chronic diseases are diseases of childhood that manifest in adulthood and act accordingly. We have seen dramatic declines in some of the MDG goals, but yet we have so remained fixed within the UNICEF and the child health realm at only focusing on how do we reduce the mortality rates at age five without forgetting that the majority of kids are going on to survive into adulthood, what are the conditions we now need to give them to lead long and productive adult lives.

QUESTIONER: Thanks. Danielle (sp) -- (inaudible) -- from Dalberg. We've talked now quite a bit about how systems need to evolve in order to better address chronic diseases. Isn't, in the short term, there an opportunity to shift away some of the big pots of Global Fund money are being spent, particularly the Global Fund in PEPFAR? Because we know there's not going to be new money, but if we need to shift treatment, those two entities are inching towards flexibility. But if you increase their flexibility a lot faster, couldn't you start allowing health systems to make the changes that they need much more quickly?

DAULAIRE: Well, as the alternate board member from the United States for the Global Fund, I guess I should take that one on. There's a challenge here. I think you're right on the principle. And the challenge is maintaining true to the mission and purpose of the Global Fund -- I'll come to PEPFAR in a second -- and making sure that the Global Fund carries out its mandate, the reason for which it is being given money by the United States Congress, by other countries around the world.

So what we're trying to do with the Global Fund is to make sure that the focus continues to be on the three disease that are the basis for its creation. And the board has had meetings and discussions about whether the scope of the Global Fund should be expanded to become the Global Fund for health, and has decided that this is not the right thing to do at this point in time. It might be at a later point. So that policy decision, for the time being, is very clear.

On the other hand, there is a strong health-systems window within the Global Fund that could be used more productively, and there are certainly ways -- and we've been strongly encouraging the Fund to do this, and others in this audience have been actively involved with that -- to use the focus on HIV/AIDS, TB and malaria to also do more for mothers and children; that this is -- these are not either/or kinds of propositions.

Within the context of PEPFAR, again, this is a law that was passed and then reauthorized by the United States Congress. It's very clear about its aims. But within the context of the Obama administration's Global Health Initiative, we are looking for ways to make the focus on AIDS and malaria under the President's Malaria Initiative something that helps to build a stronger infrastructure. And as you may well be aware, some of the basic principles of the Global Health Initiative under which PEPFAR falls calls for integrated services, calls for decisions driven by data -- so it's not just focused on doing one thing no matter what -- and focuses on country ownership.

And without exception -- I've been to 26 countries in the past year in this position, and without exception, the ministries of health I've talked to have talked about their challenge of addressing this broad spectrum of health problems among their populations. So I think we're inching in the right direction, but we have to remain true to the purpose under which these programs were started and under which the money is set aside each year.

OSOTIMEHIN: Just -- thank you very much.

I think I'll speak from two sides of the divide. I think one very critical factor which is missing in most of the program recipient countries is strong country ownership. And I think that with PEPFAR and the Global Fund, if we can engender strong country ownership and a system where countries have a plan of what they want to do to the health of their population -- (inaudible) -- plan, that enables the Global Fund to actually -- and now I know for sure that the Global Fund actually takes country plans to provide resources. That's the first.

The second is that on a very practical thing with the head of the Global Fund, he and I agreed that we could and should try and get some (high-volume ?) countries to apply for monies for HIV, TB, malaria and health systems in such a way that they can strengthen their health systems. For an example, if they want to train health workers that would enable them to deliver better, that they would provide that resource, and we can then come in with commodities and other things that assist them to ensure that they can actually get those things to (the last mile ?). And I think that kind of cooperativity, even without a change of policy, would do well. And we're working on those things.

FINK: (Off mic.)

QUESTIONER: Thank you. Mike Hodin from the council. I firstly just congratulate all of you. It's been a great discussion, and the fact that we're here talking about NCDs itself is wonderful. The fact that we'll be meeting in a couple months is really great news.

But what puzzles me is that there are three components that seem not to be -- or have been sufficiently part of the discussion. I'd like to ask your opinion on, A, if you think that's right, and B, how that might be so. One is -- notwithstanding Babatunde's comments on aging, aging as a major driver, a strategic component of this NCD explosion both cost and prevalence, seems to be very clear and will be more so during the course of the 21st century. It's not really recognized as fully.

Secondly, and connected to that, we're missing Alzheimer's. We're missing a lot of components. But Alzheimer's stands to be the 21st century fiscal and health nightmare, and if we get through this NCD approach and don't have that as part of the discussion, I think, you know, we'll look back and say, what happened?

And the third one is the component that you alluded to on the role and strategies of biomedical research and technology innovation, not as the only one, but as part of the strategies. So those are three things that it seems to me have not been sufficiently part of the conversation today.

Thank you.

FINK: The question is, what do you think of those?

YACH: Well, let me -- let me have a shot at some of them. First, I mean, I see that NCD prevention is about healthy aging. That's the whole purpose of it. So this is very much about aging. And I think we understand that -- the work by Friese and many others around the world showing that it is possible to have the compression of morbidity with increased age, and that's the entire vision of trying to put so much emphasis on early origins and the prevention work across the life span. So this is a healthy-aging agenda.

On the question of biomedical sciences, I mentioned the role of the U.S. government in tobacco control. What I should have also mentioned is that over the last year, two years, the National Heart, Lung and Blood Institute, with United Health Care, has -- have put significant funding on the table to support 11 centers of excellence in the developing world, including the work of the Fogarty Center helping to coordinate some of this.

And those collaborating centers are focusing on building the science base in the countries where the epidemic is growing the fastest, whether it's China, India, South Africa, Tunisia, Mexico, Argentina and so on, a very impressive set of investments that are already starting to yield actual data, results. And we hope that not only will you see the emergence of new scientists and new researchers and new ideas, but you're also going to see policymakers basing their policies on science and facts rather than ideology.

The issue of Alzheimer's is a complex one. When I was at WHO, the whole question of how do you align mental health with the four diseases which we mention, and it was never seen as either/or. It was always seen that there's a parallel track. For the purposes of this meeting there's been a decision to try and -- to circumscribe where the focus is, particularly given the link to a number of common risk factors.

And that in no way suggests that Alzheimer's is less important. Obviously, it's hugely important, as is depression and the major causes of mental health. And as you know, WHO gave special separate focus to mental health both through its world health reports, through its global advocacy. And I would hope that we will see in time a separate high-level focus on the entire entity of mental health alongside the emphasis on NCDs as it's been described in a more circumscribed manner.

DAULAIRE: Let me just add very briefly. When you look back at what's happened in the world in terms of issues of child health, back to the early 1980s, when Jim Grant at UNICEF launched what he called the Child Survival Revolution, he did not undertake to deal with all of the array of issues in child health. In fact, at the time, I was a researcher working on childhood pneumonia, and it was not in Jim Grant's "big two," which were diarrhea and immunizations. But there was a very good strategic reason for that, which was to focus on the low-hanging fruit and the big issues that could be addressed early and show some success so that you could build this larger context.

I think we're at a very similar point early in the development of a global approach to noncommunicable diseases. We do have a set of well-articulated strategies that have worked in some places, as Derek has mentioned, here in the United States, against the "big four" that are pare of the discussion coming up at the high-level meeting.

There's obviously a much broader range of issues that will need to be addressed over time, but there's a real risk, if we start talking about going from four to six to eight to 12 to 18, that we lose the focus of an effort to actually do something about these issues.

And you mentioned Alzheimer's as one in particular. We need to figure out what we can do before we try to put this on a global agenda to try to get everyone else to figure out what they ought to do with this. We need to work with some of the few countries that have the resources that we do in NIH and other places to put into this. And then that will be ready for this kind of discussion.

FINK: Do you want to --

OSOTIMEHIN: Yes. I just wanted to speak to the issue of biomedical research and to say that biomedical research actually should be universal, should be democratized. I think that there are -- there is a need for investment both in the global north and the global south, because the issues, for an example, of blood pressure and the -- (inaudible) -- of blood pressure in the global north is very different from the global south.

And maybe the opportunity of these NCD high-level meetings is to press that each member state should actually invest in biomedical research. And that is, not to wait for the United States to begin to invest in their countries, but they should actually set aside resources for research. Research doesn't have to be complicated. Research actually assists us in providing better quality, in understanding what's going on. And I think that it should be a portion of the resolution that comes out of this. I just thought I should say that.

FINK: The question was about Alzheimer's. I'm curious about kidney disease. Is that another example of one where just such a huge financial burden in terms of treatments and dialysis, that it's being avoided in this discussion, this elephant in the room about the treatment side of all of them.

OSOTIMEHIN: Kidney diseases would also fall into blood pressure, would also fall into diabetes. It also has implications in all of those. So if you actually deal with those "big four," you will reduce a lot of kidney diseases.

FINK: Are we going to provide dialysis for everybody in the world?

YACH: When I was at WHO, I was approached by the minister of health of an African country with a large amount of kidney disease, and his question was could we give technical support for a law to implement a transplant program. And we had a long discussion and explained that end-stage renal disease is just that; it's the end stage of a cascade of failures, which includes failure to deal with diabetes early enough, failure to deal with infections early enough, and that the better investment would be earlier in the cycle than jumping to the end and building a transplant program.

And I think that's something that, again, I would hope this meeting would highlight, that the end-stage diseases are not the place to start the investment in trying to change the course of population health. We need to move further back. That doesn't mean that you have to (sic) provide adequate care and (palliation often ?), but that's where almost all the investment is currently going because there hasn't been the strategic question asked, where's the best placement of our investment for these conditions?

FINK: Yes. And I asked that as a serious question about the dialysis, because these are really tough issues.

I think we're out of time, unfortunately. Do we have time for one more? Anita? OK, Anita -- (inaudible).

QUESTIONER: I'll be fast, and I'll close out the program with asking you to -- sorry, Anita Sharma with the the U.N. Foundation -- asking you a question about previewing what we might see in September. You know, David, as you mentioned, there is a great deal of engagement from the NGO sector. At the high-level meeting in June, the consultation, some of the NGOs expressed disappointment at the draft outcome document, saying that there wasn't a lot of depth or new money associated with it.

So do you think that that outcome document is being discussed, reviewed? Will we see an enhanced document in September?

And then a question in terms of representation. Should we expect it to be mostly like the United States, at ministry-of-health level?

DAULAIRE: The document is being actively worked on. There is a new draft that is supposed to be out by the end of this week. It may be behind, but there's been active discussions and negotiations. Those discussions and negotiations will continue through until, as these things often are, until the eve of the high-level meeting itself. So this is -- what was seen in June, which I also agree was disappointing at that point, was early, and it takes time to develop these things. We certainly hope it will be stronger, that it will have some clearer targets, things that the world can aim for.

As far as the resources, as I said early on, it's not a great time in the global economy to be looking at major new resources. And so what we're trying to focus on is ways in which we can use the resources that are on the table currently to much better effect and to work at global policy shifts using what's being done within countries themselves.

There is a vast amount of resources that could be raised in many countries around the world if they increased their tobacco taxes. A

And those could be put to very good use.

FINK: And a last?

YACH: I would just say that -- in the lead-up as you said, we have seen the unprecedented coming together of NGOs, particularly led by World Heart, International Diabetes, cancer, lung and patient support groups, and a consortium of the private sector in civil society. I would hope that that civil society grouping gets a permanent place in the ongoing discussions of how their resources, their capabilities can be released and put us alongside the work of government as we move ahead. If we achieve that, it's going to be less important to focus on dollar increases than to put in place a governance system that really draws upon the best capabilities of those who are really wanting to make a difference.

FINK: And last?

OSOTIMEHIN: Yeah. And just to say that the middle-income countries and the emerging economies are actually very, very interested in this, and so their representation is going to be at a very high level, because they are kind of moving away from the infectious diseases arena to these noncommunicable diseases. And as I said earlier on, the issue of aging and all of that are the things that concern them right now, and they want answers to them. So they're going to get some fairly senior representation at the meetings.

FINK: I'd just like to sum by saying, as somebody who has reported in low- and middle-income country -- countries and come face to face with people who have cancer, who have chronic lung diseases and heart disease, because there is so little treatment in these areas, I think that it is really exciting, even though we've talked a lot about the challenges today, very exciting that there is attention to these issues. We are at the beginning of the process, and hopefully, with future engagement here at the council and in all of the various ways that all of you on the panel are engaging, that we will see some improvements.

And so I want to thank everybody for their participation and interest today, and especially our panelists. Thank you. (Applause.)







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