NY Event: Addressing the Chronic Disease Crisis in Developing Countries

NY Event: Addressing the Chronic Disease Crisis in Developing Countries

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Noncommunicable Diseases

from Global Health Program


Event Description

Task Force Co-Chair Thomas E. Donilon, Task Force Project Director Thomas J. Bollyky, and Task Force Member Barbara Byrne, join Juju Chang, coanchor of ABC News’ Nightline, to discuss the CFR-sponsored Independent Task Force Report on Noncommunicable Diseases (NCDs), which assesses the NCD crisis in developing countries and recommends practical, scalable strategies for intervention. Poverty and urbanization are contributing to the rise of NCDs like cancer and diabetes, and although NCDs are judged by the World Economic Forum to be the main threat to economic development after climate change and pose risks to global security, the United States spends 0.1 percent of its health budget on the issue. The panel discusses findings from its data-driven report and offers answers ranging from low-cost drug interventions that can be implemented now, to creating a U.S. strategy on NCDs, increasing funding, and including NCDs in strategic dialogue with other countries.  

Event Highlights

Tom Bollyky on the destabilizing effects of NCDs in low- and middle- income countries:
 "…you've seen unprecedented rates of urbanization and a global integration of consumer markets driving an increase of risk. So with people living longer but without access to preventative care, you are more likely to get an NCD. Without access to chronic care and without the wealth to pay out of pocket, you're more likely to die and become disabled as a result. …these are having huge economic effects in these countries. In some cases some destabilizing effects as well, and this is the reason why it's in the U.S.'s interests."

Tom Donilon on how NCDs undermine existing U.S. health programs in other countries:
"We have had tremendous global health successes in the AIDS area, for example, but the very same populations that we've had tremendous success in saving are populations who are subject to these noncommunicable diseases. So we have one platform of successful operations on programs that are underway, being directly undercut by the NCD problem."

Barbara Byrne on corporate involvement in fighting NCDs:
“…most major corporations actually are—especially in the last two to three years—very focused on wanting to work with NGOs specifically on these types of issues in developing countries. …There a lot of good intentions, and there is funding. Those organizations will fund and will work.”

CHANG: Hello. I want to welcome you to this panel today on the emerging global health crisis of noncommunicable diseases. And we have a very distinguished panel as always here at the council to discuss the matter, and they're going to talk about a task force, which—I didn't know this.

The Council does a bunch of reports all the time issuing all sorts of relevant and important information, but this is—of the seventy-two task force reports that the Council has published, this is the first one on global health. So it gives you an indication of just how important the issue that we're discussing today is.

To my immediate left is Tom Donilon. He is vice chair at O'Melveny in Washington. He's returned to the firm for the fourth time after serving in the Obama administration most notably as national security advisor responsible, as you can imagine, for steering the administration's foreign policy, intelligence and military efforts.

President Obama was quoted as saying that he was the most effective national security advisor our country has ever had. Not a bad endorsement from your boss, the commander in chief.

(APPLAUSE)

A leading national security expert with deep experience of course in global strategy, cybersecurity, financial services, Mr. Donilon has a golden Rolodex, perhaps even a platinum one in fact, he's—because he has served as the president's personal emissary on a number of missions to different world leaders from China, to Russia, Saudi Arabia and Israel.

Tom has advised three presidents, beginning with President Carter. He was assistant secretary of state as well in the Clinton administration, and he is also back at O'Melveny working on the firm's public interest and pro bono initiatives So he's here obviously doing the work of the angels.

Barbara Byrne is to his left. She is vice chair in investment banking at Barclays, responsible for leading the firm's relationships with a diverse group of blue chip Fortune 100 corporate clients including GE, IBM, U.S. Steel, Microsoft and others of course.

Byrne joined Barclays from Lehman Brothers, where during her very distinguished twenty-eight-year career she became the first and only woman to achieve a vice chair position in Lehman's 158-year history.

She—just a couple of career highlights relevant to today's discussion. In 2007, she led teams advising the $62 billion spin-off of Kraft and later Philip Morris International, as well as GE on her—on their $11 billion sale of its plastics division.

To her left is Tom Bollyky. Tom is the senior fellow for global health, economics and eevelopment here at the council. He's also an adjunct professor of law at Georgetown, as well as a consultant to the Bill and Melinda Gates Foundation.

Prior to coming to the council, he was at the Office of the U.S. Trade Representative where he held negotiations for pharmaceuticals, biotechnology and medical technologies to the U.S. Republic of Korea free trade agreement. We were talking about Seoul a lot earlier (inaudible) in the back. And he represented USTR in the negotiations with China on the safety of food and drug imports.

He was also, again relevant to today's discussion, a Fulbright Scholar to South Africa where he worked as the staff attorney to the AIDS Law Project on treatment access issues related to HIV and AIDS. Obviously health policy is an important part of his portfolio and why he's here today.

Because we're going to talk, despite the fact that my business gives so much breathless attention to tropical diseases like Ebola and super viruses and et cetera, it is not the exotic parasites or the tropical viruses that are of pressing concern in today's global health perspective.

Really we're talking about the threat and the crisis of noncommunicable diseases, from the increase in the risk of premature death, premature death being death before the age of sixty. We're talking about problems that have been intransigent in our culture: obesity, cardiovascular disease, preventable cancers, adult-onset diabetes.

What we have found in this task force is that there are cheap, affordable, and very effective preventions. And that's part of why we're here to talk today, but I want to start off with Tom. You know, we discussed how this is the first task force report on health. Why is the Council, when it should be counting missiles and dealing with terrorist threats, talking about obesity and cardiovascular disease?

DONILON: Thanks Juju, and nice to be here with everybody. And as you said, it was an unusual task force for the Council in that it was—I think there's been seventy-two reports since 1995 and this was the first one on global health. It was an extraordinary group of people as well from a multidisciplinary group of—group of fields.

That was the question we asked ourselves at the beginning. Mitch Daniels and I co-chaired this task force, and the first meetings were on the topic that you asked about, which is why is the Council on Foreign Relations doing this? What are the U.S. interests involved? If we identify U.S. interests, what can the United States do about this? What can the United States do about this in terms of its resources available? How effective can be it be and in what sort of timeframe? Those are the very questions, and we didn't presuppose any answers.

CHANG: And Mitch Daniels, you were saying, was quite skeptical.

DONILON: Yeah. I think there were a number of people who were skeptical. And so we decided as a group that this would be a data-driven exercise, that we would go where the evidence led us and come to the conclusions that the evidence—the evidence took us to.

You know, a lot of—I've been on a number of task forces. In many cases, they don't abide by the old Daniel Patrick Moynihan maxim that you're entitled to your opinions but not your own facts. There's a lot of opinion in foreign policy and national security. Here it really was quite unusual that we really did really go with the data—where the data took us.

And indeed, if you look at the report, it is really full of data. And—and—and in addition to the printed report, there's an online annex with analysis, methodological explanations and country-by-country reviews of what the data told us about various threats in those countries.

Now on the U.S.—on the U.S. interests, one is that, as you said correctly, noncommunicable diseases are the biggest threat to the health of populations in low and moderate-income countries by far.

Indeed, the World Economic Forum and, as indicated, it concluded in a report that it did that this was the biggest threat to global development of any threat other than climate change. So it's a major threat to global—to global populations and global development and global economics going forward.

The World Economic Forum had published a figure on this indicating that they—they concluded that the cost in low and moderate-income or developing countries, was their—was their grouping, the cost would be $23.1 trillion between now and 2030 of noncommunicable diseases, an extraordinary amount of money equal to the entire GDP of these countries last—last year.

So an enormously important issues with respect to these countries' economic futures. And from the U.S. interests of course, that—that—that is a U.S. interest. It's a U.S. interest in terms of economic growth and stability around the world, stability of countries that we care deeply about, and the problem is only going to increase because, as you indicated, this is a problem really of younger populations in the low and moderate-income countries.

Additionally, we determined that this undermines existing U.S. programs. We have had tremendous global health successes in the AIDS area, for example, but the very same populations that we've had tremendous success in saving are populations who are subject to these noncommunicable diseases.

So we have one platform of successful operations on programs that are underway being directly undercut by—by the NCD—by the NCD problem.

Additionally, more broadly, this really is about U.S. leadership in health. U.S.—U.S. leadership in health is essential. It has been and is an area in the world that we're looked to. It's—U.S. leadership is essential, and it's very important reputationally for the United States.

And last I would say that we also saw that there were real opportunities here for us to work bilaterally with important countries around the world on this, including countries like China and India.

So we determined, again, across a whole range of interests that the U.S. had—had significant interest here. And most importantly, and we'll talk about this as we go through this, that there were things that we could do at—in an affordable way that could show really pretty extraordinary results.

CHANG: So Tom, let me skip over Barbara for a second and get you to come in on this discussion about sort of how we got to this place. Why is it that it's trending in this direction and—and what did the task force recommend in terms of what the U.S. could do to act in a leadership role, much like it did in the AIDS crisis?

BOLLYKY: Great. Well let me start by thanking Tom and Mitch, who unfortunately couldn't be here today, for great leadership of this task force. And we have a number of task force members here, Barbara being one of them, Nancy Brinker being another. And I want to thank them all for this—for their great service on this task force.

So—what's new about heart disease, cancer, diabetes being a problem? They've existed in high-income countries for decades now. Why are we concerned about what's happening in low and middle-income countries?

And we're concerned because these diseases are increasing in prevalence much faster in much younger populations and having much worse outcomes than ever happened in developed countries. What are some of the stats behind that?

Well, deaths from noncommunicable disease, again, cancer, cardiovascular disease, diabetes, chronic respiratory illnesses, increased 53 percent since 1990 in low and middle-income countries. There are more than 8 million deaths that occur in populations fifty-nine and younger from these—these diseases in low and middle-income countries.

And the rates are growing worse in the very same countries that we've invested in to address other global health issues. Why is this happening? Well, it starts actually with a bit of good news, which is life expectancies are increasing in low and middle-income countries, but most of that increase is driven by improvements in child mortality.

So populations are living longer, but you've not seen the same increases in wealth or improvements in health systems that you saw in higher-income settings. For instance, when OECD countries hit a median age—life expectancy age of fifty-nine, the GDP per capita in those countries was $4,400.

Low-income countries just hit that threshold, and the GDP per capita is $1,000. So significantly lower. You've seen health spending in low and middle-income countries triple over the last twenty years, but it is really low in comparison to high-income settings.

All the governments of Sub-Saharan Africa spend as much as Poland on health care. If you combined all governments of all low and middle-income countries, representing 5.7 billion people, their governments spend less on health care than the United Kingdom, France, Germany and Canada combined, representing about 260 million people.

At the same time, you've seen unprecedented rates of urbanization and a global integration of consumer markets driving an increase of risk. So with people living longer but without access to preventative care, you are more likely to get an NCD.

Without access to chronic care and without the wealth to pay out of pocket, you're more likely to die and become disabled as a result. As Tom mentioned before, these are having huge economic effects in these countries. In some cases some destabilizing effects as well, and this is the reason why it's in the U.S.'s interests.

In terms of just briefly—and I want to make sure we leave time for Barbara because she has a lot of interesting things to say on this topic. But in terms of why we think we can make progress on this, most people don't realize how much progress we have made in high-income countries like the U.S., despite much higher rates of obesity, much higher rates of unhealthy habits, how we've dramatically cut mortality in under-sixty populations.

A lot of the interventions around that? Really cheap drugs for hypertension, tobacco control, vaccinations around hepatitis B and C, and for HPV, for cervical cancer, things that can be done relatively cheaply but are not broadly available in low and middle-income countries. And that's really where we focused.

CHANG: Well Barbara, we want to bring you in at this point because not only is the private sector involved as large-scale employers, but also, you know, as actors and partners in the fight against noncommunicable diseases. What impact might this have on businesses and what is possible?

BYRNE: Well I'm sure you're wondering what is an investment banker doing focused on this issue. First, I'm sitting here in Mitch's seat. So—but I tell you that it is critically important to—I—I deal with very large multinational corporations who are incredibly focused. Right now, most of these guys get 60 percent of their business from outside the United States. They're U.S. companies, but they're very focused on developing countries, and they're actually very focused.

There's an alignment between what we're talking about here on the health issues and what the IBMs and the GEs, and I can go through a large range of companies that are focused—focused on—in developing.

In particular, if I focus on the Sub-Saharan where we—and I am familiar with Sub-Saharan because we're one of the largest banks, Barclays, in Africa. Sort of where—you know, think about where the sun shined on the British Empire. That's where we are.

And—but in any event, this issue is critical for that particular population. And when Tom talks about the lack of funding that is available in these countries, the opportunity that I think we have as a nation that—that the U.S. has, is to be a convener on this topic.

And everybody thinks about, well where's the funding going to come from, but major corporations will work with you on this to actually create what I would call the new type of NGO/government/corporate experience, the shared value type of initiative.

And the data in this report—and there was a lot of discussion. That was one of the more interesting—nobody—this was not a group that agreed on everything, but there was—which made it fun. And—but the data's fabulous, and the ability to be able to look at what is actually occurring.

Especially for me looking at the Sub-Sahara and where could you, especially with technology—for example, HP is very active right now in Africa, very focused on what they can do on health care side. So there's a tremendous opportunity to act, and the world needs this type of leadership now because we're economically, as we all know, extremely fragile.

And with the kind of number we have at a $21.3 trillion—OK, maybe it's off by 10 percent. Who cares? It's—whatever that number is, it's huge. And it's lost opportunity, and it's lost human capital, and that human capital for what is a very minor cost can be added in. And quite frankly I think it's critical.

CHANG: You've heard all three task members talk about the data. And Chris wanted to nudge me and tell everyone that not only are we livestreaming today on CFR.org, but we're also providing a tremendous amount of interactive data on this task force result. So you know, I would encourage you all to look.

One of the things that struck me that you said earlier, Tom, was that, you know, the U.S. really doesn't have a strategy. There is no plan, and yet the task force really found that there are effective low-cost measures that can go into effect.

DONILON: Yeah. That's I think exactly right. You know, the—the United States as we sit here today does not have in its assistance program or in its global health program a specific effort aimed at addressing the NCD problem.

And that's a principal recommendation of the group, obviously, is that the United States should put in place a determined and specific effort and program with respect to NCDs. And it can be done across a range of—a range of—range of ways.

So one, an overall program. Two, that would inform our interaction with international institutions and organizations in terms of making it a priority, as Barbara says, putting the United States in a leadership role.

Third, we'd recommend that it become also a priority in our bilateral—our bilateral relationships with countries around the world, especially these major countries like the Brazil and India and Chinas of the world.

So yes, there is not a focused strategy. There should be a focused strategy. And that conclusion is driven not just by the general observation we made about interest but about, as you said, the fact that it's a—it's a big problem and we can have fairly significant impact for not that much money I think.

CHANG: Tom, do you want to delve into some of the policy aspects of the solutions?

BOLLYKY: Sure. No, I'm happy to. First, I should say on the data side, I want to make sure that I note the contributions of Chris Murray and his team at the Institute of Health Metrics and Evaluation.

It's really their Global Burden of Disease project that provided some of the data for this report and was very generous of them to share it. They shared it pre-publication. It will be coming out in out The Lancet later this year. It's a type of collaboration you don't often see in global health and is worth acknowledging.

In terms of the recommendations, what we looked at is we looked at where are we making progress, but you haven't seen that type of progress happening in low and middle-income countries. And we put them in three categories.

There are the shovel-ready projects. Very similar to our interventions around HIV, the types of things that can be—aren't accessible now in low and middle-income countries but could be for cheap.

In many ways, particularly in the current environment of budgetary and fiscal austerity, NCDs are—are the perfect agenda for austere times, and that many of the interventions exist and could—could be introduced.

To give you those on the shovel-ready projects, we're talking again about cardiovascular disease, which causes one-fourth of all deaths in low and middle-income countries but we've cut dramatically in the U.S. and other—and in other high-income countries despite much higher rates, four times the rates of obesity that exist in these countries.

Tobacco control. Again, working with interested countries on having—having strong tobacco controls in place. And given a task force that was both bipartisan and had trade officials, development officials, private sector representation, we have very strong recommendations on tobacco control and they're worth noting.

We also look at vaccinations around liver cancer, preventing liver cancer and cervical cancer. That's the first category. Then we looked at the range of activities where we've actually made a lot of progress in high-income countries, but you need more investment to adapt those solutions for low-resource environments.

And that's many of the cancers. We've seen a lot of progress in cutting premature mortality rates from breast cancer, from leukemia, from stomach cancer, areas like that. But most of the—many of the diagnostic tools involved in treatment aren't necessarily currently adaptable to low resource settings. And that was really the second category.

We also look at diabetes, which the treatment is actually quite cheap but is—we need to see more progress on the prevention side. And that's true here and that's true in low and middle-income countries as well.

The last category are—we should acknowledge there's a lot we don't know in—around how to prevent noncommunicable diseases. This is particularly true on nutrition, salt reduction, a lot of the behavioral changes that you need to see.

We don't have an answer to that. Nobody has an answer really to childhood obesity yet. The rates are much lower in these countries, but they are becoming a problem everywhere. And these areas provide an opportunity for collaboration with developing countries who are having some success, particularly about—around lower-cost models of chronic care, and also the private sector.

And I want to acknowledge Barbara's input in this sector. It's really working with her that we had a lot of good material come out in this task force report about what would be the role of the private sector.

CHANG: Barbara, I'm curious if you look at it more through the lens of a workforce issue or is it a, you know, economic impact on trading partners issue, or—or is it both?

BYRNE: It's actually building—building from the bottom of the economic pyramid. So yes, that includes workforce, but any time you have illness, even in a family where there is workforce, it's a dramatic economic impact.

So—you know, I can give you an example of Zambia where—which is a project I know fairly well. So one of the things that appeals to me about this study and the thought of the U.S. being a leader is having the convener.

We're working in Zambia to help provide access through a particular project. We're working with GSK. We're working with NGOs on the ground, et cetera. And we—do we have a legitimate—we being Barclays—do we have a legitimate business interest? Yes, but what would that be?

Well, ultimately if you are alive, you could potentially be a customer of ours, right? So there's a view—when you—it goes that basic. And when you look at the world from—and I'm trained as an economist in economics—you must have this part of the world contributing and healthy.

And the cost, the intervention cost, what we're doing in Zambia, is quite simple. We're actually funding nurse practitioners as an alternative way of providing very basic health care out in the bush. We're doing that together with GSK. I'm sure their motivation is ultimately they can sell pharmaceuticals there, but right now there's just a government—a government. So it's creating an alternative track.

They—there are a lot of these what I would call sub-scale projects occurring all around the world with people with all—who need to have the government impact and need to be able to focus on how to scale and how to deal with those particular issues.

This—and they are mostly NCD type issues. We're not talking about the, you know, communicable diseases. Those are clearly a major issue, but setting aside, these are lifestyle issues. So we view it as economic bottom of the pyramid growth and growing from our perspective in business.

I know major international corporations view these markets—developing markets as where global growth will come from over the next twenty years.

CHANG: Tom, you talked a lot about the bilateral considerations and—and working with other governments. That's part of the task force recommendation, and building those partnerships. You spent a lot of time meeting with heads of governments of the countries that I mentioned in your profile.

How much of an appetite do you think there will be among other nations to help support and build a coalition to help?

DONILON: I think—I think—you know, we hope that the task force report and the data and the conclusions we reach will be an impetus towards raising interest in—in this issue, number one.

Number two, in these—in these strategic dialogues we have with major partners around the world, you know, I always find myself looking for really high-impact win/win projects, you know? You know, I—so I have had as much interaction probably with the Chinese leadership as anybody in the last five or six years.

And you find on the natural that a lot of those interactions are about problems. You know, we have this problem with you. You have this problem with us. And it's really important to have robust and effective win/win kind of positive agenda projects.

And this seems to me to be a perfect—a perfect example of that, where they have issues in their own populations and issues in populations in countries that they care about around the world. So I do think it's a real opportunity for increased bilateral—increased bilateral cooperation.

These are also very important countries in—in international organizations that deal with these—that deal with these issues.

CHANG: Tom, can you pick up on the NGOs, the nongovernmental organizations that might have an impact?

BOLLYKY: Absolutely. So this is a underfunded area. To give you a sense of how underfunded it is, if you look at the U.S. government, Tom mentioned before there is no established program. And you look at health spending by year of disability loss.

For HIV, that is about $44 per disability-adjusted life year. For malaria, that's around $5. Tuberculosis, it's $1.80. And for NCDs its two cents. Very low. If you—most of the funding that has come in this area is really from two sources.

The first is the World Health Organization, which has been trying to generate interest in this area for some time. And the second is the Bloomberg Foundation, which has contributed significantly to this area. It is also a funder of this task force.

You've seen increased interest in some areas. The Bill and Melinda Gates Foundation has recently announced more money to do tobacco control in Africa. And there are some interests from the other public/private partnerships that have been working on global health for some time. Steve Davis was another task force member and runs PATH, which is the largest PDP in this area.

So I think there is some real space, particularly around the adaptation of technologies that could be used in these environments. That would be a big help. In terms of the—the behavior change or social issues that will happen for a long time, this is an area in which a lot of the global health NGOs have really excelled for some time.

Most people don't realize that the vast majority of what we do in global health is already around behavioral change. Our biggest source of funding—biggest target of funding is HIV. The dominant modes of transmission around HIV are behavioral. They're sex and IV drug use.

We've been at the behavior change game for a long time, but we haven't necessarily addressed some of these areas. And I think the NGOs can really help.

CHANG: With that, about half of the discussion is over and I wanted to open it up to the audience so you can get your thoughts and your questions. I would encourage you to raise your hand. Yes? We'll get a microphone to you.

QUESTION: Hi. Jeff Laurenti. On page thirty-seven of the report, and Barbara's already alluded to it, the report makes the case that the U.S. has its own economic interests in trying to deal with this problem. One could argue, however, that there are within that larger private sector interest specific private sector interests that in fact may be partially or substantially contributing.

One thinks first of tobacco. The Reagan administration made breaking open markets for tobacco exports one of its top trade priorities despite predictions that within thirty years you would have lung cancer and heart disease pandemics, which have happened just as had been predicted.

You have the food processing industry, which has been subject to criticism at home to some degree. And here it's the Europeans as much as us, whether— they have their equivalent to Coca-Cola and KFC. And arguably pharma, the pharmaceuticals companies, all of which have used international trade law and investment law as a battering ram for being able to diffuse their products in poorer countries.

To what extent do you all see that piece of the wealthier world's very narrow, specific industries selling goods with good advertising budgets as part of the problem? To what extent do you think the World Health Organization should be given the authority to override general trade liberalization provisions in existing law?

Because page fifty-four refers to Obama's pushing some exemption in the Trans-Pacific Partnership, but it's WTO and TRIPS that are the big guarantors.

BYRNE: You know, it's interesting. Jeff—I know Jeff. The—the problem on tobacco is that tobacco in most of these countries is actually owned by their own government. These are not the BATs or the—the Philip Morrises, et cetera. They're actually owned.

You probably even saw yesterday in the New York Times talking about the e-cigarettes in China and the safety issues there. In particular, it's one of the largest single sources of government funding in—in China, is tobacco.

That's true actually in most parts of Africa as well. It's true in India. It's true everywhere. And that actually—you know, you don't want to sit there and feel superior—but true everywhere as—and countries have sold them off.

It's—within the realm of food, there is not a huge amount in most of these countries of food going in. People are targeting, but most of it—maybe Coca-Cola, certainly the distribution, but most of those guys have been very good about sustainability and sourcing locally.

So I think it's important to remember that of course people do want to sell their products. But most of the products that you're talking about are actually being controlled by self-same governments, and that raises issues of its own in terms of how you can actually make progress on them when it is indeed a source of funding for those—for those governments.

CHANG: Is there a hypocrisy sort of question when, you know, we're unleashing weapons of mass obesity? Just made that up. Either Tom?

BOLLYKY: So I'll just take the trade question on because it's the one I know best. In terms of the task force report, we have a fairly strong recommendation on tobacco and trade, and it was unanimous.

This was remarkable in that there were three former trade officials in these task force. It was bipartisan, and it makes a recommendation that the announcement that the administration has currently made that they are looking for a potential exception in our trade negotiations on tobacco should be—should encompass the measures provided under U.S. law and provided under international law, specifically the Framework Convention on Tobacco Control.

Nice strong recommendation. We do not make as strong—we don't make any recommendation on food or beverages in this area. I think there are good legal and policy reasons why. Tobacco is unusual in that it has an international treaty. It's one of the most widely subscribed treaties in the world.

Compelling states that have signed on to this treaty to take on these activities. President Clinton issued a executive order compelling U.S. agencies to take a certain approach on tobacco and not to promote tobacco.

Tobacco is the only consumer product that when used as directed, kills you. It is not—it's different from food. It's different from the pharmaceuticals issues. And both from a policy perspective and from a legal perspective, I think there are very strong grounds for treating it differently under a trade agreement.

On the pharmaceutical side, the one thing I would mention in this area, one of the great potential advantages for intervention around NCDs is a lot of these treatments already exist for addressing noncommunicable disease, particularly cardiovascular diseases.

Treatments for diabetes have existed since the 1920s. These are not—it's by and large, at a population level, these aren't issues of patents. These are—the vast majority of what needs to be distributed and adapted in these countries is off-patent.

There's a lot of progress that can be made in this area. And particularly given limited resources, we've talked about how—another way of putting the resource disparities in this area, of the U.S.'s $8 billion global health budget, we spend $10 million on noncommunicable diseases.

The disparity is similar internationally. Given that kind of disparity, we should focus on where we can make progress soonest.

CHANG: Do you want to...

DONILON: Just—just for thirty seconds. Jeff, the—you know, we really—we really didn't try to—where we focused on an issue, we wanted to get to an issue where we could do something about it.

And with—and with respect to—and didn't engage every potential issue. With respect to tobacco, there are tobacco control regimes which are proven and are effective and are exportable and can make a big difference. And that was the conclusion of the task force with respect to tobacco and endorsed, as you pointed out, the president, Mike Froman's exemption in the TTP negotiations.

So we didn't engage every potential element here. We tried to focus in on those that were the most important and where, most importantly, we could make a difference. And tobacco, the task force strongly believed, was one of those areas.

CHANG: I see a hand here.

QUESTION: Elizabeth Cafferty, Women's Refugee Commission. Thank you very much for this report. I haven't read the whole thing, but one thing that I didn't see in terms of how this could be used as an advocacy tool really very immediately is the post-2015 sustainable development goal process.

And obviously the negotiations are beginning in about a month's time and the indicators could still be fleshed out, so it would be interesting to hear your thoughts about that. I found it very sort of bilateral-focused rather than sort of thinking about international, you know, U.N. mechanisms, certainly being here in New York.

The other thing which I would have hoped to see more of is the data disaggregated by gender because I think that things would look really different if we had that picture in front of us. And certainly gender norms—there are global gender norms which are shared, but then again they're different by country and region.

And that's going to determine what we talk about for prevention and response when we're designing interventions. And that is certainly a place where both in the post-2015 but then again bilaterally the U.S. could have—I mean, we don't have—I agree we don't have a sort of coherent global strategy.

But certainly the CDC is doing really interesting things on women's health and some reproductive health. And State and AID are obviously involved as well. So perhaps you could speak to that point as well. Thank you.

BOLLYKY: I have good news for you. And when you get to about two-thirds through the report, we do talk about the SDGs, which is—for those of you who don't know, these are the successor goals that will be put in place after the Millennium Development Goals.

There are sadly going to be far too many of them. I think by last count, something in the area of 150 or 160. Yes. And one of them will be on noncommunicable diseases. One of them is expected to also be on tobacco control. We do talk about the opportunities that provides.

We also talk a bit but probably not enough about the gender issues around noncommunicable diseases. You do see a disproportionate impact, particularly for certain noncommunicable diseases on women and girls, and that's an issue that's talked about in the report but probably could be talked about more.

DONILON: And a—one of the specific recommendations is cervical cancer, where there's a—obviously a—just a tremendous opportunity there for—for a big impact.

CHANG: Right, with the HPV vaccine, which is part of the recommendation. Yes?

QUESTION: I'm Charlie McCormick, president emeritus of Save the Children. The—the big numbers amongst the 8 million are in the Philippines, Indonesia, China, India, et cetera. Middle level, middle-income countries. And number one, AID doesn't have a whole lot of expertise in sort of policy change and social change in these middle-income countries.

They have very small missions in these particular countries. So drilling down on your recommendations on strategy, given this—this context in which this problem is lodged, as it were, what—what additional modifications would you have to recognize that these are countries that have resources and capabilities and research and so on and so forth of their own? Thank you.

BOLLYKY: So just quickly, you'd be surprised. If—we did forty-nine country case studies of the burden of these diseases and we focused on U.S. countries that received $5 million or more annually. We didn't want to do the more—the bigger population countries that received less. So for instance, China is not in that grouping.

And what we found is that in populations fifty-nine or younger, NCDs cost—cause nearly 30 percent of the deaths in the countries that the U.S. currently targets with its global health programs, and more than a third of the disability in the countries that we currently target in global health programs.

For those of you who haven't seen the interactive online, we have those country case studies available. And you'll see low-income countries that it causes more than 40 percent of the deaths and disability.

These are the very same countries that we currently invest in in global health. Another way of looking at this is non-communicable diseases causes 3.5 times as much—as many premature deaths in those forty-nine countries than HIV.

If you add HIV, malaria and TB combined, it causes nearly two times more premature deaths than those diseases. So these are countries we've been invested in a long time, we have platforms in. We just haven't been invested in these issues.

And we're seeing this epidemiological shift in those countries, and the question is is how are we going to respond that?

I mean ultimately—I was at a global health conference, gosh, maybe a few months ago on the best buys in global health. And there was a U.S. agency representative there. I won't say the person's name or the agency, but somebody asked about, well what about cardiovascular diseases is really cheap, or what about tobacco control? It's revenue generating in most instances. Why aren't we focusing on that?

And the agency representative said, well I'm interested in the best buys for malaria and HIV. And ultimately I think this becomes a question of why do we invest in global health? And the justification in most of these issues are not—these diseases aren't direct threats.

People are not going to get malaria in the United States because people have malaria in low-income countries. We invest in these diseases because they affect poor people and because we can do something about it, and it improves the welfare of those countries.

That's true for noncommunicable diseases as well. We just haven't responded to that. So I—I would just encourage people who haven't looked at the—the data. You might be surprised.

CHANG: Yes?

QUESTION: Thank you very much for bringing this report to our attention. I'm Laurie Phipps from the U.S. Mission to the United Nations.

And in 2011, the General Assembly held a high-level meeting on the prevention and control of NCDs and all the countries of the world at a high-level ministerial level or above signed on to that. And a lot of what you've already discussed is included in the political declaration that was adopted by the G.A. several years ago.

The U.S. approach to that document was to try to keep the emphasis on prevention rather than treatment, not because we don't want to do treatment but because it's such an enormous and growing issue to try to treat all the cardiovascular disease or diabetes in the world, whereas if we can focus on prevention, the burden will be less burdensome.

And I'm wondering if you factored into your study the—the pronouncements of the General Assembly and the World Health Organization on that and whether—when you say that there's no U.S. policy, whether you're looking at a more multisectoral approach and looking beyond just the health sector and looking into the sort of sectors that the first questioner mentioned with the—the food industry and the prevention that can come by better—better policies in that realm, and tobacco control, which you've already talked about quite a bit, alcohol control and other efforts to address the risk factors, as the U.N. calls them. Thank you.

BOLLYKY: So I would say on—we do, and we—all our shovel-ready interventions are prevention. The cardiovascular disease, whether it's around hypertension or primary or secondary prevention of cardiovascular disease prevention, tobacco control obviously is prevention, the vaccinations and screening programs around cervical cancer and—and hepatitis B are all prevention.

So that—you're completely right that this needs to be a focus moving forward. There is no treatment solution to—to noncommunicable diseases. In terms of how it relates to the U.N. declaration, one of the things we tried to do differently in this report than what was done at the U.N., and I think it's—was an enormously useful exercise. It raised the profile of these issues.

And as I mentioned before, WHO has been really trying to mobilize attention around noncommunicable diseases since the late '80s, and they deserve a lot of credit for that. One of the things we wanted to do a bit different though in this taskforce is we focused on low and middle-income countries.

And the reason why we did that is because the drivers are different than high-income countries. Again, to give you some evidence of this, obesity rates in the United States are more than four times higher than they are in low-income countries.

They're more than—almost three times higher than they are in lower middle-income countries. If you had to focus somewhere in a low-income country on noncommunicable diseases, focusing on obesity probably shouldn't be your first stop, given what the data is.

That doesn't mean it's not important. It just—again, the drivers are a little bit different. So that's one of the things that we tried to do to build on the great efforts that have happened at the U.N. and other settings.

In terms of the U.S. policy, it is true we're talking about programs and budgets through global health, but I'm not sure you see a lot in the development area either in this space. There certainly is a fair amount happening domestically looking at issues of tobacco and nutrition.

And part of what that does is provide an opportunity to expand that internationally, but so far that hasn't—hasn't happened yet. We're hoping to see more.

DONILON: Yeah. I agree with that. You know, in terms of U.S. policy, so I was the national security advisor in 2011, and we certainly had to have a physician with respect to that meeting, and did, but the United States doesn't have this as a priority right now and it's reflected in the budget.

You can't—you cannot say that the United States has as a high priority NCDs and have it be a $10 million project. That's just—I—you know, I think back on the scale. You know, we—we—we are trying to change our focus in Afghanistan, move to a different phase on Afghanistan.

You know, during 2011 for example, the year you mentioned, we were spending $10 billion a month in Afghanistan. So the scale here in terms of the real priority and potential impact is really what we wanted to underscore here.

So in terms of—yes, we'll have a physician at any given meeting, but we don't have a real national—we don't have a national strategy, and it's not at the core of our development and global health effort, I think is—is the issue.

And it's certainly not there in terms of resources. And that's—those—that's what we're trying to underscore here in the...

CHANG: And what are you...

DONILON: ... task force report. And it's not—for example, I don't know—and I oversaw for five years every one of these meetings. I don't know that we ever had an interagency meeting on NCDs. And one of the—and one of the—one of the things you hope to come forward from a report like this is to have the government begin to look at it on an interagency basis as a priority.

CHANG: And were you to acquire resources for it, would it be you think best distributed in the form of foreign aid or in—what kind of leverage would you bring to that?

DONILON: Tom can give some details on this, but the—but there are a variety of ways in which it can be—which it can be done.

But the scale we're talking about here is I think the figure we use—Tom, remind me—is $236 million is kind of a figure for—that was spent on tuberculosis last year. That's kind of a figure we think would be a figure here that could make progress across the range of the recommendations that we've put forward here.

So this is really not a lot—this is—this is not—this is not a lot of money. $236 million would not really be a discussion point in the defense budget.

BOLLYKY: I mean, to give a sense, so that's still twenty-three times more than what we spend currently noncommunicable diseases in the United States. So it is—it's not—it's not a lot, but it's significantly more than we spend in that area.

And we use the tuberculosis threshold to say, here's a global health priority. It's not HIV, which takes up the bulk of the U.S. global health budget, but it's something that we take seriously. How much do we spend in that area?

And what the task force said is if we just spent that much in this area, you could—you could start to really make some progress. It certainly isn't a number—it's a number intended to indicate what the U.S. could do, not what needs to be spent globally and primarily by the governments themselves to address their noncommunicable disease problems. So I want to recognize that.

And then we have—we had that as a specific threshold, but we also looked at the possibility of working with partners. And maybe Barbara wants to say something on the private sector end of what we recommend.

BYRNE: I—I—the—I—I'll just go back to, I've said it before, which is most major corporations actually are—especially in the last two to three years, are very focused on wanting to work with NGOs specifically on these types of issues in developing countries.

And every—and we're beginning to see elements of that. I know we are. I know the major—several of the major companies I've mentioned, but more than that. And there is a lack of convening on that topic. There—there's a lot of good intentions, and there is funding. Those organizations will fund and will work.

There's also, you know, many mistakes to be made as you go in a learning process. But I—I—I know that to be true. That's the entire shared value initiative and discussions on that basis. And there's—and I actually for—even just to set aside for my own firm, chair something called the Social Innovation Facility, which is a facility that is set side to specifically work on issues like that.

So—and that—multiply that by multiple corporations around the world. So there's funding available outside of government. And even more importantly, many of those organizations have access into government for advocacy and access into those markets in a way that can be particularly helpful.

CHANG: I saw your hand up over there.

QUESTION: Thank you. I'm Jeff Sturchio with Rabin Martin. I wanted to come back to the question that Laurie Phipps raised about the 2011 high-level meeting. And then particularly, Mr. Donilon, on the point you made about how it's clear just from the evidence, and this report is full of terrific evidence, that NCDs are not a U.S. priority.

Now we've talked a lot about the policy recommendations from the report. Those are all—they all make perfect sense to those of us who've been involved in this for the last few years, but I want to come to another aspect of this and ask you to just talk a bit if you would about the political side of changing those priorities and the allocation of resources.

You know, in 2011 the entire world agreed at the U.N. that NCDs should be a priority, all countries would have NCD plans, there would be an NCD global coordination mechanism, you know, on and on and on. There were all these commitments.

Well it's now more than three years later. The global coordination mechanism, which was supposed to help ensure that this work went forward, is only now being organized. It has not yet met. It's not actually doing anything yet.

And the political—despite the political declaration, that being followed with real resources that would change the situation and make it possible to implement many of the recommendations you've made, just hasn't appeared.

So the question really is if we're going to be serious about this and to find a way to put the—the recommendations that you've made into practice, what is the political road map both in the U.S. Congress for instance and also in the U.N. bodies, and more importantly in the national governments and the parliaments that are going to have to really make in lower and middle-income countries the tough decisions about where to allocate scarce resources?

DONILON: Well again, I—that's—that's one of the impacts you hope a report like this has. And it's interesting. You know, the—the makeup of a task force I think is—is—is important here. You had, as Tom said, you know, we had a number of trade officials, and we came around a—a unanimous view with respect to tobacco control regime and trade issues.

You had on this task force not just health—health experts, but you had two former national security advisors, myself and Sandy Berger, trying to look at the national security side to this. You had people from the private sector and the financial sector.

So the—the goal here, having identified it as an important issue, having dug into the research and the data and come to the conclusion that it is the most important health issue facing low and moderate-income countries, that it can have the kinds of effects that we talked about, including undermining our really successful contagious disease efforts.

We would hope to raise this up in the—in terms of the priorities of—of the U.S. government. That's what these task forces are about, by the way. They're about U.S. policy. And that's—that would be—that would be the goal here. And we'll—and Tom can talk about some of the interactions that we'll—that the task force and he will be having with the government to brief on the—to brief on the findings.

BOLLYKY: Yeah, and we will be doing the range of White House executive branch briefings, congressional briefings and foreign diplomatic corps that we do really for all task force reports.

One thing I want to say in this case, I think the framing is important. And I think one of the challenges in 2011 is we looked at this issue globally across all age ranges. The solutions that came out of that, uniformly you would hear about whole of societies approaches being necessary to make progress, a whole-of-governments approaches being necessary to make progress on these issues.

I mean, at the WHO we're talking about twenty-five—I get them confused. There are nine goals and twenty-five indicators. This has been presented as a global problem across all age ranges and something that we need to change agriculture, trade, cities, health systems before you can make progress.

And one of the things we've tried to do in this report is actually this looks a lot like a lot of global health issues. It's a problem for the poor. It's a problem for the young working-age populations, and it's a problem in the same countries we've invested in in other areas.

There are really specific, targeted things you could do to help slow down the increase of these diseases and help provide those governments times to tackle them themselves.

And I think the framing of the—the issue the way we've done it with the data we've done with it, we're hopeful—in conjunction with having wonderful people like Tom and Barbara say this is important, we're hoping that this looks different than what's been done on NCDs before.

CHANG: One of the many traditions of the Council is to finish on time. So we are almost out of time, and I wanted to give you both an opportunity to do a summation. And—and then we'll call it a day.

BOLLYKY: All I would say in conclusion on this is, again, this is not an issue that's going away. It's a issue that will continue to increase. We're going to continue to work on it. I want to thank Richard Haass, who has had real interest in this personally, and Chris Tuttle, who led the task force report around this, and the committee, for a great effort.

BYRNE: I just appreciate the opportunity to have been part of it and to bring a voice to some of the major corporates who want to be part of it as well and be on the team.

DONILON: You know, I want to—and let me mention kind of the impact of these kinds of things. So there's many people here I know—when you're in the government, you know, the coin of the realm and what you're really sometimes desperate for is good intellectual capital.

You know, you have so many things you're dealing with every day, right? You know, and you have this huge inbox and it's easy to be in government and see the same people all the time who have kind of come up with the same ideas.

And—and you get through your inbox and you get through the problems on your—on your—on your desk that say and you think you've done a good job, but you haven't, because you're just responding. And the impact of things like CFR task forces and really powerful intellectual capital that's backed up with data like this I think is significant.

Because again, you're just—you're in the—you're just in the vortex constantly, and fresh intellectual capital coming into the government, challenging ideas, reinforcing new priorities, showing with specificity the ways in which government can act I think is a real—hopefully is a real contribution, I think can—can change a number of—it certainly did in my time in government.

Where you would have something that was—that was specific and compelling, implementable, can have a real—can have real impact.

CHANG: That's where thought leadership is invaluable. Thank you so much for contributing to the task force, Chris, everyone else here who took part, and thanks for being with us today. Have a great day.

END

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