On September 19, 2011, the UN held a high-level meeting to elevate noncommunicable diseases (NCDs) as a priority for the international community--only the second UN meeting of its kind devoted to global health. So far, the movement has failed to generate the sustained popular attention and donor resources that the UN General Assembly meeting on HIV/AIDS program mobilized in 2000, says CFR Senior Fellow Thomas Bollyky, in part because NCDs have been presented as an "impossibly large and complex" problem. Bollyky hopes that more progress can be made once concensus NCD indictators are identified and the global monitoring system is established. He offers a number of targeted strategies, like concentrating on low- and middle-income countries and tobacco control, which Bollyky believes would help marshal support and resources for NCDs.
Last September, there was a high-level UN meeting on noncommunicable diseases. Can you give us a sense of what happened?
The intention behind the UN meeting was to elevate the attention and resources given to noncommunicable diseases, a category which includes conditions like diabetes, cardiovascular diseases, cancer, and chronic respiratory illnesses.
The international community has long known that NCDs were a growing epidemic in the developing world. The World Health Organization (WHO) had published a report way back in 1996, which indicated that these diseases would soon dwarf infectious diseases like HIV/AIDS and malaria and pose significant challenges to developing countries’ health systems. But WHO was not able to get any traction on this issue. NCDs continued to represent less than 3 percent of the official development aid (ODA) for health, and the NCD problem in low- and middle-income countries kept getting worse.
So a group of Caribbean governments and NGOs joined together to try to take a page from the playbook on HIV/AIDS by proposing a UN high-level meeting dedicated to NCDs at the General Assembly. The HIV/AIDS version had elevated that issue on the international agenda, mobilized billions in donor resources, help build a popular movement to address the disease, and spurred action on a country level. The community that works on noncommunicable diseases hoped to replicate this strategy. And remarkably, they succeeded in elevating the issue to the General Assembly. The high-level-meeting on NCDs was the first UN General Assembly meeting on a health issue other than HIV/AIDS.
In looking at it a year later, what played out as expected and what’s taken you by surprise?
It was expected that placing NCDs on the UN agenda would help elevate the attention given to the issue and it did. One hundred countries including thirty heads of state, attended the meeting. There was—and continues to be – media interest. The meeting initiated a WHO process to develop consensus indicators for monitoring NCDs and their risk factors worldwide, and to convince national goverments to develop plans for addressing that problem. At the recent World Health Assembly, countries have committed to their first NCD target as part of this process: to reduce premature deaths from NCDs by 25 percent by 2025.
What the UN high-level meeting has yet to do is generate more popular attention and resources for addressing NCDs internationally. ODA for NCDs remains 3 percent. Less than 3 percent of the 2012 WHO budget is devoted to NCDs and their risk factors. The UN meeting has not yet spurred sizable popular movement that many hoped for. The barricades outside last year’s UN meeting were largely empty of patient groups. And, as of yet, there is a fairly limited number of country measures that one can point to as being a result of the UN NCD high-level meeting.
So on one hand, the UN NCD meeting hasn’t yet managed to follow the HIV/AIDS blueprint in producing a groundswell of popular support, new donor resources, and concrete country action. On the other hand, optimists on this issue believe the UN meeting elevated a long-neglected cause to the heads-of-state level and firmly established it as an ongoing concern for the UN. Their hope is that over time is that international dialog will filter down and translate into national government programs and tangible action to meet patients’ needs.
One of the things that arose from last year’s discussion was some pushback from the infectious disease community on whether this initiative might be a distraction. What are your thoughts about why this issue hasn’t taken hold the way HIV has?
NCDs have been billed as a worldwide problem, which they are, but discussions have tended to treat these diseases as involving the same issues in both developed and developing countries. For that reason, I belive, NCDs come across as a natural byproduct of economic development and inevitable. Policymakers most likely look at the obesity problem, rising levels of diabetes, and the difficulty in monitoring hypertension in the U.S., and justifiably ask how should they be expected to solve the same challenges in Rwanda or India. As the NCD problem has been framed, it just seems impossibly large and complex.
More broadly, on the topic of HIV, I think the conversation around redistribution of resources is wrongheaded. I agree with many HIV advocates who say that the resources that have been devoted to HIV are the product of the unique dynamics around HIV/AIDS, which may not be available for other global health issues. So I don’t think the HIV/AIDS initiatives are consuming the resources that would be otherwise available for NCDs. The NCD movement will have to carve its own path and generate its own resources, most likely at the host country-level. I think there is a path for progress on those issues if we can pursue a more targeted strategy.
One of the debates surrounding HIV, prior to the discussion of NCDs, was: Do you allocate your resources to direct treatment, or do you build up health systems and strengthen them across the board (as part of a way to treat HIV and tuberculosis)? Any chance of a meeting of the minds on that issue?
These same debates are happening on noncommunicable diseases. Some question whether the movement is too focused on NCD prevention, reducing tobacco use, alcohol consumption, inactivity, salt consumption. For those people, such a strategy ignores the plight of people currently suffering from NCDs without the hope of treatment.
I think the HIV model has shown it’s certainly possible to provide treatment and build sustainable systems. The early focus in HIV was the delivery of antiretroviral therapies, but systems were built to deliver treatments and are now being used to address other health problems, potentially even NCDs. You can build health systems in support of delivering specific interventions. Those health systems that are being used for HIV may be the best platform for expanded NCD treatment.
When we spoke last year, we talked about going after low-hanging fruit. Everybody agrees that curbing tobacco use is a good idea. Has there been any progress on that front?
Not as much as I would like. UN NCD declaration had strong language on tobacco, but there has not been a focused push in the international community for more resources for international tobacco control initiatives or integrating them more into current global health programs.
The push on international tobacco control may just be held up by the effort to develop indicators across all NCDs that would be applied worldwide. The frustration on tobacco is that those indicators are already exist and are already monitoring in the global tobacco surveillance system.
More broadly, I think frustration around regarding the slow progress on NCDs has led people to broaden the discussion. There are new international initiatives on promoting universal health care, addressing social determinants of health, and advocating for changes in the way that cities are designed and agriculture is produced globally. These all may be very good policies, but I worry that they are too big and complex to be achieved by an international initiative. I worry that we’re getting broader in our prescriptions instead of more specific.
As I recall, the potential for mission creep was a concern some critics identified early on in the process. So what needs to happen next so that the initiative is more narrowly defined?
We are wedded to the process of developing consensus indictators and a global monitoring system. More evidence would be welcome and, once that system is in place, I’m hoping we can start getting more specific on our priorities. Once we do, the problem will become a lot less complex and it may be easier to mobilize support.
I would focus, as I explain in my recent Foreign Affairs article, on low- and middle-income countries and the diseases and risk factors that are most common in these settings. In short, noncommunicable diseases are too big of a problem to be addressed worldwide and all at once. The drivers of the NCD epidemic are different in low-income settings than in high-income settings. China and India, for instance, have a fast growing NCD epidemic, affecting young working age people, and causing terrible health outcomes, but they have relatively low rates of obesity and alcohol, particularly in comparison to the U.S. The problem in many low- and middle-income countries is persistent poverty, unprecedented rates of urbanization, and limited health systems. You need different strategies to address those problems than in developed countries. So I would focus international NCD efforts on the poor in low- and middle-income countries who need the assistance most.
Second,I would build, wherever possible, on existing platforms and existing consensus. Tobacco, again, is an obvious place to start. It is a huge problem -- tobacco use is projected to kill one billion people in this century. There is an international treaty on tobacco control and evidence-based strategies to curb tobacco use that have worked in high- and low-income settings, but these strategies are woefully underfunded. Tom Frieden spoke at the Council last week and one of his things that he said was: If you want to save trillions of dollars and millions of lives in global health, ensure that all children reach adulthood without being nicotine-addicted and underweight.
Third, I would build in surveillance on other risk factors like salt consumption, obesity, and inactivity into the already existing global tobacco surveillance system that already exists. Better monitoring can help build the consensus we need for more effective action in these areas. I would also look to establish a fund that finances and monitor small-scale programs to help identify the strategies that work on these risk factors in developing countries.
Since prevention alone cannot solve the problem, I would, last, focus on adapting and scaling access to the many effective treatments for NCDs that already exist and are off-patent. They merely need to be adapted and scaled for use in low-income settings. For example, PATH, a global health NGO, is working to adapt diagnostics for diabetes for use in low-income settings and having good success integrating them into sustainable, scalable treatment programs. We have platforms for regionally pooling the procurement and delivery of drugs in low- and middle-income countries. It is a matter of adding treatments that are relevant for NCDs to those platforms to ensure a more predictable and affordable supply.
All of these four strategies are evidence-based, cost-effective, and supported by good precedent. The global health community has been able to make good use of these strategies in other areas. They may provide the simplified path forward that we need so next year we will have more successes to report on the global fight against NCDs.