The slow-motion disaster that is breaking the bank

On 19–20 September 2011, the United Nations (UN) General Assembly convened a High-Level Meeting on Prevention and Control of Non-communicable Diseases (NCDs) in New York. This is only the second time in its 66-year history that the UN General Assembly has gathered to consider a health issue, the previous occasion being for HIV in 2001.

NCDs principally comprise cancer, diabetes, cardiovascular disease and chronic respiratory disease, and share four main risk factors — unhealthy diet, physical inactivity, tobacco smoking and harmful consumption of alcohol. The rationale behind the UN high-level meeting is that NCDs currently account for more than all other causes of death combined, and are estimated to have been responsible for 36 million deaths, or 63% of all deaths globally, in 2008.1

NCDs are no longer just problems of old people in wealthy countries. They now disproportionately affect the poor in low- and middle-income countries, where they also kill at a younger age — 29% of NCD deaths in these countries occur among people under the age of 60 years, compared with 13% in high-income countries.1

Two of the most telling statistics highlighted at the UN high-level meeting are the estimate that 366 million people are living with diabetes in 2011,2 and the prediction that an estimated 1 billion people could die from tobacco use this century unless urgent action is taken.3

Estimates from the World Economic Forum are that NCDs will cost more than US$30 trillion (representing 48% of global gross domestic product in 2010) over the next two decades and push millions below the poverty line.4 As Margaret Chan, Director-General of the World Health Organization, pointed out in her address to the General Assembly, NCDs are “a slow-motion disaster” that will “break the bank” unless we act.

In an environment where governments and scientists alike call for an evidence base for global investments, these ballooning data are decidedly at odds with the fact that only 3% of development assistance in health is invested in NCDs — the least amount of funding compared with other health focus areas.5

It was largely the Caribbean nations agitating for global action on NCDs that resulted in the convening of the UN high-level meeting. Many lead-up meetings were held in 2011, such as the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control in Moscow,6 in an attempt to move NCDs up the political priority list and to establish global consensus for action.

The original UN resolution to convene the high-level meeting, in 2010, called for the adoption of “a concise and action-oriented outcome document”. In the run-up to the meeting, this changed into a “political declaration”. Those charged with writing the declaration had to grapple with contemporary issues that included: reduced donor funding due to the global financial downturn; donor countries wanting to remain focused on AIDS, tuberculosis, malaria, and maternal and child health; the potential for huge spending on new treatments that would be pushed on by “Big Pharma”; corporate harassment by “Big Tobacco”; and pressures from the lobbying of the food and beverage and alcohol industries.

The UN is often derided for its slow and ponderous processes, but this criticism fails to appreciate that the UN is a world parliament with 193 highly self-interested and politically diverse members, with an absence of any cohesive political parties familiar to Western democracies. Despite these systemic limitations, a political declaration on NCDs was made,7 and 30 presidents and prime ministers and 100 ministers spoke at the meeting, many probably for the first time, about NCDs.

A major positive outcome of the UN high-level meeting process has been the formation of the NCD Alliance, a network of more than 2000 non-governmental organisations in 170 countries, which has been formed by the Union for International Cancer Control, the World Heart Federation, the International Diabetes Federation and the International Union Against Tuberculosis and Lung Disease.

Another positive was Australia’s announcement of funding towards implementation of WHO’s 2008–2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases.8 Australia was well represented by Minister for Health and Ageing Nicola Roxon, whose presentation in a number of forums about legislation for plain packaging of tobacco products aroused great interest. Another pleasing feature was the presence of Peter Dutton, Shadow Minister for Health and Ageing, and the support of AusAID and the Department of Foreign Affairs and Trade, emphasising that Australia does have much to contribute in this burgeoning area of health and development.

The downsides are, as Her Royal Highness Princess Dina Mired of Jordan pointed out in the opening plenary session, that the political declaration fails to name NCDs as an epidemic, that it lacks clear and measurable targets, and that it is infused with vague language. She, like many others, stressed that what gets measured gets done, and that the declaration should have sent a message to the world to reduce deaths from NCDs by 25% by 2025. It was time to stop numbering deaths and start counting survivors, she said.

Another problem was that, apart from Australia and Russia, there were no pledges of funds. In all the discussions leading up to the meeting, there had been a distinct lack of interest in setting up a new agency or fund to drive and underwrite new work in preventing and controlling NCDs. Given the explosion of new health agencies and initiatives in the past decade (UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, the International Health Partnership and related initiatives, and UNITAID, just to mention a few), this lack of interest is understandable — but it throws the weight of expectation back onto WHO, which has few staff working on NCDs in Geneva.

Many countries endorsed the role of WHO as the key agency to progress action, but there is little doubt it will need a lot of support. Despite the backing of its Director-General Margaret Chan, it appears that WHO has less than adequate capacity for the tasks it has been given (such as setting global frameworks and indicators, and developing targets). To date, the global effort has been led from WHO’s second level of influence (the Assistant Director-General level), which means it has less than optimal internal and external support, given the many other competing issues for the organisation. WHO will need to leverage expertise and skills from bilateral, philanthropic, multilateral and academic organisations from across the globe. As we learned from HIV, it is vital that action coalesces around an agreed set of data and time-bound goals.

The World Bank is starting to seriously engage in NCD prevention and treatment,9 but it will also require the active participation of other multilateral agencies, such as the Food and Agriculture Organization of the UN, the UN Development Programme, UNICEF and the International Labour Organization.

Two other groups of major players are yet to get seriously involved. The first is made up of the major donor countries, such as the United States, United Kingdom, European Union and Japan, whose policy capacity, research support and funding will be vital for progress. The second consists of the major international development non-governmental organisations interested in health, such as Médecins sans Frontières, World Vision, Oxfam and CARE International, who will have to engage in NCD prevention and control. After all, evidence now suggests that development is being hampered by the impact of NCDs in low- and middle-income countries in particular.1 These countries must also invest their own resources in NCD prevention and treatment.

The role of the multiple and highly diverse industries that have a stake in NCDs is unclear. Tobacco companies are so discredited internationally that they have become corporate pariahs. However, working with food and beverage, alcohol and energy companies, for example, is much more complex. On one hand, we in global health must identify the common ground where we can work together, such as workplace health promotion, food and beverage reformulation, alcohol licensing, and making drinking cultures safer. On the other hand, it is highly unlikely that there will be any accord between these industries and those interested in health over issues such as banning and limiting promotions to children, sponsorships, product warning labelling, and pricing and taxation. These issues will become the battlegrounds for the first half of this century.

There are real positives to be drawn from the UN high-level meeting. The fact that NCDs have become an issue of the UN General Assembly and not just the WHO World Health Assembly in Geneva is a major plus. NCDs are now on the political agenda and in the media, and, compared with as recently as 12 months ago, an increase in interest is clearly visible. Whether, and how, this interest will be transformed into preventing premature death and disability, only time will tell.