The United Nation’s High-Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (NCDs), convened at UN Headquarters September 19-20, brought with it high expectations. The only previous UN General Assembly Special Sessions on a health issue had been on HIV/AIDS, with the first, in 2001, credited with helping spur the global AIDS response. NCDs – the four categories that the summit addressed being heart disease, cancer, diabetes, and chronic respiratory illnesses – already are responsible for more than 60% deaths globally [Political Declaration, para. 14], and are the leading cause of death even in many developing countries. They are on track to be responsible for 70% of deaths in developing countries by 2020 [Abdesslam Boutayeb and Saber Boutayeb, “The Burden of Non Communicable Diseases in Developing Countries,” International Journal for Equity in Health 4(1) (2005): 2].
Until now low on the global health agenda – consider that a mere 3% of WHO’s 2010-2011 budget was programmed to address NCDs – NCDs are certainly worthy of a special session at the United Nations. The question is, will the summit mobilize a global response against NCDs?
The honest answer may be the least satisfying: time will tell.
The good news is that there is much the world can do. To name but a few – all of which the Political Declaration that emerged from the summit encourages:
- a whole-of-government approach, recognizing that all sectors, must be involved in the response, as well as all elements of society, not only government – a whole-of-society approach;
- implementing relevant tax measures (though an aside: this significant possibility – for example, taxing sugary drinks – which has been very effective in the realm of tobacco control, receives short shrift in the Declaration);
- health literacy campaigns;
- accelerating implementation of the Framework Convention on Tobacco Control and WHO strategies and recommendations addressing diet and physical activity, alcohol, and food and beverage marketing to children. Collectively, these frameworks include such measures as banning indoor smoking in public places and taxing tobacco products, promoting physical education and urban planning to encourage physical activity, and reducing marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt to children.
- promoting the use of cost-effective vaccines for cancer, as well as cancer screening;
- reformulating foods to be healthier, ensuing that they are affordable and accessible, and meeting standards on nutrition labeling;
- reducing salt, sugar, and saturated fat in foods, and eliminating industrially produced trans fats;
- increasing the accessibility and affordability of medicines to address NCDs;
- promoting workplace wellness programs;
- specifically addressing high levels of NCDs in indigenous populations;
- strengthening health systems, including the health workforce;
- involving people living with NCDs in designing national responses;
- integrating NCDs programs into primary care services, such as maternal and child health.
The Declaration also has various, generally non-specific, calls for increased international financing, international cooperation, capacity building, technical assistance, and partnerships.
With all of these steps (and others – see below) that can dramatically reduce risk factors for NCDs – and with taxation on unhealthy foods is one strategy that could help pay for other measures – it seems as though the world should make considerable progress. And with the UN meeting sounding a call to action, working synergistically with civil society advocacy to put NCDs on the world stage, it is hard to see the light now shining on NCDs being shut – even if it might dim a bit now that the summit is over.
At the same time, the Political Declaration – and in particular, what is missing from the Declaration – provides cause for concern about what lies ahead.
Most worrying, perhaps, is the lack of clear targets and benchmarks that could help force action, bolster advocacy, and hold states clearly accountable. The specific targets include little more than encouraging states to develop or strengthen national strategies by 2013. The Declaration also calls for the WHO to lead efforts to develop, also by the end of 2012, a comprehensive global monitoring framework, including indicators, and to prepare recommendations for voluntary global targets. So we will have to wait more than a year to see just how ambitious the NCD summit proves to be. Or perhaps longer. The Declaration asks countries to “[c]onsider” developing national targets, though proposes no timeline.
Also missing from the Declaration was any mention of stress as a risk factor for heart disease (and other diseases), though it is one – in particular the accumulated, chronic stress that people whose daily existence is a struggle experience.
This points to a broader concern with the Declaration – and indeed, the summit itself – that an astute colleague observed. NCDs go beyond the risk factors highlighted in the summit – tobacco use, unhealthy diets, lack of physical activity, and the harmful use of alcohol, significant though these are. And NCDs go beyond the four types of disease that the summit focused on. While there is certainly merit in focusing on particular diseases – they need attention, and specific strategies to address them are required – this type of fragmentation of global health by disease runs against trends in human rights, primary health care, and universal coverage of integrated, patient-centered care to treat the health needs of the person.
Missing, too, from the Declaration was any acknowledgement of conflicts of interests between efforts to control NCDs and the food, beverage, and alcohol industries – whose products contribute to obesity and other NCD risk factors – and strategies to managing these conflicts. (The Declaration does “Recognize the fundamental conflict of interest between the tobacco industry and public health.”) The above-mentioned actions, and many others, stand to limit the spread of NCDs, but will industries that profit from unhealthy foods using the economic and political sway to sap decision-makers of the political will to take some of these actions?
For all the important, if only broadly described, measures in the Political Declaration, there is much that the document does not include, as the UN Special Rapporteur on the Right to Food, Olivier De Schutter, has observed. He called for “ambitious, binding commitments,” as voluntary measures – all that the Political Declaration includes, or that an inherently non-binding document could include – “are not enough.” He called it “unacceptable that when lives are at stake, we go no further than soft, promotional measures that ultimately rely on consumer choice” – which is the approach of the Political Declaration – and that it was also necessary to address “the supply side of the food chain.” Except in the softest of language (“discouraging the production and marketing of foods that contribute to unhealthy diet”; “Encourage policies that support the production and manufacture of, and facilitate access to, foods that contribute to healthy diet”), the Declaration again falls short.
The Special Rapporteur highlighted another gap: “A comprehensive strategy on combating bad diets should also address the farm policies which make some types of food more available than others….Currently, agricultural policies encourage the production of grains, rich in carbohydrates but relatively poor in micronutrients, at the expense of the production of fruits and vegetables. We need to question how subsidies are targeted and improve access to markets for the most nutritious foods.” Look for terms like “subsidies” or “fruits and vegetables” in the Political Declaration, and you will come up empty.
Concerning to me, too, is WHO’s announcement the day before the summit of a new report summarizing how low- and middle-income countries can take highly cost effective measures to control NCDs for only $1.20 per capita (and even less in the poorest countries). These measures are:
• Tax increases
• Smoke-free indoor workplaces and public places
• Health information and warnings
• Bans on tobacco advertising, promotion and sponsorship
Harmful alcohol use
• Tax increases
• Restricted access to retailed alcohol
• Bans on alcohol advertising
Unhealthy diet and physical inactivity
• Reduced salt intake in food
• Replacement of trans fat with polyunsaturated fat
• Public awareness through mass media on diet and physical activity
Cardiovascular disease and diabetes
• Counselling and multi-drug therapy for people with a high risk of developing heart attacks and strokes
• Treatment of heart attacks with aspirin
• Hepatitis B immunization to prevent liver cancer
• Screening and treatment of pre-cancerous lesions to prevent cervical cancer
On the one hand, this is certainly cause for cheer. Even in our tight global economy, even allowing for political realities and the often inadequate priority given to health, surely there can be no excuse for failing to undertake these interventions. And they could save many millions of lives – about 3 million per year, or 10-15% of premature deaths from heart disease, diabetes, cancer, and chronic respiratory illnesses in low and middle income countries.
On the other hand, these control measures are focused almost entirely on prevention, and even then, not the full range of important prevention measures. Yes, surgeries, medicines, medical devices, chemotherapy, radiation – the types of interventions to treat NCDs and mitigate their consequences – are more expensive. But does a focus on only the most cost-effective interventions risk solidifying global health inequities between poorer and richer nations and people? The Political Declaration’s failure to address financing for NCDs in any meaningful way – along with the global financial crunch – heightens this fear.
The WHO report itself notes that the four types of NCDs that were the focus of UN summit were costing low-and middle-income countries $500 billion annually by 2010. At country level, these losses generally exceed the entire health budget. The cost of the WHO‘s NCD control “best buys” will reach $12-13 billion per year. Even from a purely economic perspective – much less under human rights obligations guaranteeing “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” – the “best buys” alone would surely be an underinvestment in public health.
Also of great concern is the NCD summit’s neglect of mental health, which received only a vacuous acknowledgement in the Political Declaration. Yet mental illnesses are a form of NCDs, with enormous individual and population-level consequence. Indeed, depression is expected to become the second greatest contributor to the total global burden of disease by 2020. When will the marginalization of mental illnesses end?
One final issue to note, one that drew particular attention from civil society organizations in the run-up to the summit: intellectual property. The international legal trade regime, through the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), recognizes the importance of protecting public health and provides governments avenues for producing patented products without authorization (breaking patents) when faced with national emergencies or needed for non-commercial public uses. The Doha Declaration on the TRIPS Agreement and Public Health further clarifies these “flexibilities,” and affirms that TRIPS “can and should be interpreted and implemented in a manner supportive of WTO Members’ right to protect public health and, in particular, to promote access to medicines for all.”
Civil society advocates had been deeply concerned about how the Political Declaration would affect access to medicines. As Shiba Phurailatpam, Director of the Asia-Pacific Network of People Living with HIV/AIDS, put it: “People died during long and hard-won battles for access to HIV/AIDS medicines; we will not stand by and allow this to happen again for people suffering from cancer, diabetes and heart disease.”
Many drugs to address NCDs are already off patent, but many newer and more expensive ones are not. As a BMJ blog reported, several governments, including the United States, opposed mention of TRIPS flexibilities or the Doha Declaration. In end, the Political Declaration incorporates a European Union-proposed compromise, promoting “the full use of trade-related aspects of intellectual property rights (TRIPS) flexibilities.” So while there is no mention of the Doha Declaration, this language does make clear that these flexibilities can – and should – be used in the NCD context.
Where does all this leave us? With questions.
Will the momentum on NCDs that the summit generated be sustained? Will NCDs prove a “flavor of the day,” or will the summit expand global health actions and contribute towards whole-of-government and all-of-society efforts towards health that includes, but are not limited to, NCDs?
How will states respond to the challenge of taking significant actions when up against powerful economic interests? How ambitious will the proposed global targets be, and how ambitious will national targets be? What impact will industry pressure have on both sets of targets, and ensuing action? Who will ensure that policymakers receive sufficient high-quality – and public health and human rights-based – guidance and capacity-building to deal with these complex issues? Where will the funding come from?
Will advocates be able to build on the Political Declaration to address missing issues – such as subsidy policies – or will the Political Declaration set the full framework of action? That is, will it be a springboard or a wall? Will there be future prominent efforts to address mental health, or will it remain marginalized? How will TRIPS flexibilities be extended to this realm? Will the Political Declaration’s failure to mention the Doha Declaration lead countries to hesitate in using TRIPS flexibilities, or will the Political Declaration’s promotion of these flexibilities suffice?
Will the process going forward of developing national targets, and even the global targets, be up to addressing the deeply global nature of the increase in NCDs? Or will these targets fail to address how globalization – such as the spread of Western diets through culture and (in the words of the UN Special Rapporteur on the Right to Food) “the globalization of food supply chains,” and other cross-border trade and marketing strategies – contributes to NCD risk factors?
In the final analysis, it is not quite true that, as I asserted, that time will tell. Time won’t tell. The answers to these questions, at the end of the day, are political. How governments and other societal actors advance efforts to control NCDs – or fail to do so – and whether they can integrate these efforts into broader struggles for the right to health and universal health coverage will have much to do with their will to do so. And ultimately, whether or not they have that will depends on whether their constituents (and consumers) demand it.
Time won’t tell. We will.