The Path Forward on NCDs

This week, the United Nations hosted a two-day meeting on non-communicable diseases (NCDs), only the second high-level meeting that the UN General Assembly has ever devoted to a health topic. Initial hopes that the outcomes of the meeting would match those of its predecessor, the 2001 UN General Assembly meeting on HIV/AIDS, faded after months of disagreements (ForeignAffairs) among countries over whether to mandate disease-reduction targets and the taxation, regulation, and other means needed to achieve those targets. In the end, this week’s UN meeting helped mobilize civil society and improve public recognition of the alarming human and economic toll of cardiovascular diseases, cancers, diabetes, and other NCDs worldwide, but produced, at least so far, limited resources and accountability for governments addressing that challenge.

Some have argued that the modest result (WSJ) of the meeting reflects its unfortunate timing, coming amid a global economic crisis and before the World Health Organization (WHO) produces the data needed to finalize voluntary risk and disease-reduction targets. While that argument makes sense, the outcome also suggests a more likely conclusion: The global fight against NCDs, if it is to progress, will need to be led by different actors, incorporate different approaches, and advance in different venues than international efforts on HIV/AIDS.

The Emerging Challenges of NCDs

NCDs are the leading causes of disease, disability, and death worldwide, accounting for 63 percent of all deaths. Four out of five of these deaths occurred in low- and middle-income countries in 2008, up from just under 40 percent in 1990. Many NCDs are preventable, like cervical cancer, or treatable, like juvenile diabetes, in developed countries but are death sentences in low- and middle-income countries, which often have limited primary healthcare systems and resources. Accordingly, 90 percent of the premature deaths from NCDs, which the WHO defines as before age sixty, occur in low- and middle-income countries. The toll of NCDs on the young and middle-aged consumes household budgets, robs families of their primary wage earners, and hinders economic development. With tobacco use rising and the increasing availability of unhealthy processed foods in the developing world, the prevalence of NCDs is expected to expand in the coming years. A joint report by Harvard and the World Economic Forum this week predicts staggering economic consequences.

International attention and donor support has not been keeping pace with the growth of NCDs. To remedy that situation, Caribbean countries and a group of NGOs led a successful effort to hold a UN special session. Expectations for this meeting were high. The first UN special session to discuss health in 2001 on HIV/AIDS led to the creation of the Global Fund to Fight AIDS, Malaria, and Tuberculosis, and mobilized billions of donor dollars to put patients in the developing world on lifesaving drugs. Hopes for the UN NCD meeting included agreement on firm deadlines for reducing preventable deaths, risk-reduction targets like lowering salt intake, and increased development assistance for resource-poor countries to start tackling chronic diseases.

The Outcome of the High Level UN meeting on NCDs

The UN declaration that emerged this week fell short of expectations, but has positive elements. It recognizes the epidemic proportions of NCDs worldwide and their social and economic impact. The declaration notes that "the rising prevalence, morbidity, and mortality" of NCDs can be largely prevented with cost-efficient public health measures such as improved tobacco control, although it does not mandate specific approaches or their adoption. It mobilized no new resources for global NCD prevention and control efforts, but calls for private-sector partnerships and information-sharing to provide the technical assistance and capacity-building needed in developing countries. The declaration tasks the WHO with developing a comprehensive global monitoring program and voluntary targets to prevent and control NCDs by 2012, which countries should "consider" in developing their national plans. It requires the UN secretary-general to prepare a report on options for facilitating multi-sectorial action on NCDs by 2012 and to assess its implementation by 2014.

The high-level meeting had other benefits as well, increasing media attention on NCDs and improving cooperation among international NGOs and advocacy groups. There also was modest progress at the national level with Hungary and South Africa announcing new regulations on trans-fat and dietary salt and Australia committing $25 million in aid to help Pacific island countries tackle non-communicable diseases. Numerous corporations likewise announced voluntary initiatives to improve the health of their foods and new NCD philanthropic initiatives in low- and middle-income countries.

Moving Forward

Making international progress on NCDs is hardly hopeless, but this week’s UN meetings inspire three observations regarding the path forward.

First, the future progress on international NCD control and prevention is unlikely to occur in the UN General Assembly or be led by traditional global health donors. Even when limited to their four major risk factors--tobacco, alcohol, unhealthy diet, and inactivity--NCDs implicate such a wide array of industries and vested interests that achieving consensus among the more than 190 countries of the UN General Assembly is difficult, except in broad and voluntary terms. Tobacco is a possible exception, with 165 countries having already ratified the Framework Convention on Tobacco Control, but more work is needed to convince the few remaining outlier countries. The donor countries and organizations that dominated efforts to address HIV/AIDS and other global health challenges over the last decade have shown little appetite to tackle NCDs.

Second, progress on NCDs is more likely to occur at the national level, especially in the middle-income countries where these diseases will soon be most prevalent. According to the WHO, the most effective interventions for preventing and controlling NCDs are relatively low-cost and can be implemented at the national and local level. These include: tobacco and alcohol taxation and marketing restrictions; regulation of dietary intake of salts and trans-fats; and low-cost interventions to control hypertension. The World Bank estimates that more than half of the NCD burden in developing countries could be averted with these interventions. These interventions require political will, however, and will only occur when governments become accountable to their citizens for their control, prevention, and treatment costs. International efforts can help foster that accountability by supporting local civil society groups and media, educating government officials, and building the evidence on the local applicability of interventions. The efforts of the Bloomberg Foundation and its partners in this regard on international tobacco control provide a potential model for other NCD campaigns.

Third, there remain important roles for international cooperation, donors, and trading partners on NCDs. International consensus on risk-reduction measures and the challenges presented by NCDs provide important cover for countries seeking to implement public health interventions in the face of industry lobbying. The UN declaration tasks WHO, which is reeling from a 20 percent budget cut (Reuters) and the loss of hundreds of jobs, with developing these consensus targets, but donors must first provide the resources for that expanded new role.

Likewise, while population-based initiatives are relatively low-cost, they are not free. The WHO estimates (PDF) that implementation of its "best buy" strategies on NCDs in low-income countries will require millions of dollars annually that these countries do not have. However, the money needed to provide the necessary support for NCD initiatives at WHO and in low-income countries would represent a small part of current global health funding and could be incorporated into existing aid programs. Finally, it is important that developing countries be given the support of their trading partners to implement the same tobacco-control programs and labeling restrictions that exist in many developed countries.