I write often about communicable diseases, such as HIV/AIDS, which get a lot of international attention and popular support, spurred on by celebrities, government leaders, and the media. What is ignored, however, is the growing epidemic of non-communicable diseases (NCDs), also known as chronic or “lifestyle” diseases. With the upcoming United Nations High Level Meeting (HLM) on NCDs next week, a discussion has been building about NCDs and how to address their expanding prevalence. The World Health Organization (WHO) has classified (PDF report) four main NCDs: cancer, diabetes, cardiovascular disease, and chronic respiratory disease. Although NCDs are viewed frequently as an epidemic of the wealthy, this is demonstrably not so. Almost two-thirds of all global deaths in 2008 were due to NCDs, with 80% of NCD-related deaths occurring in low- and middle-income countries. NCDs are the leading cause of death in every region besides Africa. It is projected that by 2030, annual deaths related to NCDs will reach 52 million (all WHO report, linked above). This is no longer a problem that the global community can ignore.
The UN High-Level Meeting is being called a “once-in-a-generation” opportunity, and many public health professionals and others argue that the HLM should result in a concrete plan and a goal to cut preventable deaths from NCDs by 25% by 2025. Although the draft resolution is not available to the public, reports are coming in that the plan is watered-down and lacking any hard commitments. The Chair of the NCD Alliance, Ann Keeling, said: “There is very strong language…about recognition of the problem and the need to act. But there are no strong, time-bound commitments in there, so it’s a great disappointment from that point-of-view.” Sara Reardon of Science Insider, citing a source who has seen the HLM document, reports that it includes a pledge to institute a UN-led global monitoring framework for trends in NCDs and country efforts, as well as a recommendation that the WHO and UN give recommendations for government action on NCDs at the end of 2012. Which sounds like the sort of vague, wishy-washy language for which the UN is notorious. Reardon also reported that there was no clear plan for acquiring new funding for any NCD-related programs or actions. Deborah Cohen, for The British Journal of Medicine, suggests that lobbying and pressure from the food, drug, and tobacco industries weakened the HLM resolutions, as did reluctance from donor countries, who are facing NCD epidemics in their own backyards and the global economic crisis, to fund NCD prevention efforts in low- and middle-income countries. Cohen writes that the US, Canada, and the European Union have been aggressive in blocking proposals for the 25% death reduction goal and pushing voluntary, as opposed to mandatory, targets for progress. With no robust plans or commitments, hesitation from the get-go from three powerful presences in the UN, and corporate undermining, any UN resolution from the HLM will be short-lived at best. Given the magnitude of the NCD epidemic and its implications for global health, human rights, and economic success, stronger action must be taken now.
Commonly viewed as a consequence of voluntary lifestyle choices of the wealthy, NCDs are often stigmatized and overlooked. It is true that lack of exercise, a diet high in processed foods, fats, and sugars, as well as tobacco and alcohol use and other social factors greatly increase the risk for NCDs. What is also true is that NCDs are diseases of poverty, as the UN Secretary-General discusses in a 2011 report (PDF): “Strong evidence links poverty, lack of education and other social determinants to [NCDs] and their risk factors.” These risk factors–tobacco and alcohol use, physical inactivity, and unhealthy diet–are “pervasive aspects of economic transition, rapid urbanization and 21st-century lifestyles,” and the developing world and low-income countries are hit the hardest. Insufficient nutrition during pregnancy and low-birth weight, both more common in the developing world and low-income populations, increase the risk of diabetes and cardiovascular disease for the baby down the road. The WHO also points out that a “vicious cycle is created by the epidemic,” where NCDs and their risk factors increase poverty and then poverty increases the risk of NCDs. In another report, the WHO writes that many developing nations are now experiencing a “double burden,” due to the prevalence of infectious diseases, under-nutrition, and NCDs: “It is not uncommon to find under-nutrition and obesity existing side-by-side within the same country, the same community and the same household.”
With globalization and a lack of legal social protections and health awareness programs in many lower-income countries, cheap, processed foods and tobacco products are widely available. However, NCDs are out-of-fashion for global and public health programs, and there is often little funding for health care for these chronic illnesses. While a wealthy person in the US may be able to afford insurance that will cover his or her diabetes treatment, a person in a lower-income country may not. Communicable diseases, especially HIV/AIDS, are sometimes covered under national health programs or by global health organizations working in-country because a strong public outcry forced a widespread, funded global commitment. This lack of support for NCDs, which are often chronic, prompted a Cambodian man to tell UN Representative Princess Dina Mired of Jordan: “I wish I had AIDS and not diabetes.” While a communicable disease may be covered (universal access for HIV/AIDS, TB, etc. are still huge issues, but we won’t go there today), NCDs are generally out-of-pocket expenses that can bankrupt already-struggling families in the developing world. The expanding incidence of NCDs will have an effect on national economic productivity, as a 2007 study by Abegunde et al in The Lancet found. Abegunde et al calculated that in 23 countries studied, an estimated $84 billion in economic productivity would be lost due to NCDs between 2006 and 2015.
All this points to the need for more equitable access to health care for NCDs and more prevention and awareness programs (while still working on infectious diseases). That’s a tall order to fill, especially in the midst of an economic recession and in the context of the widespread nature of the epidemic. Celebrity chef Jamie Oliver, who is an advocate for better childhood nutrition and obesity prevention through healthier diets, has taken up the cause of NCD awareness and prevention as well, calling for a “global movement to make obesity a human rights issue.” Oliver echoes Keeling, who in an interview with PBS likened the NCD epidemic to the early days of HIV/AIDS before activists campaigned for access to treatment. Keeling said: “I think that what will really turn this epidemic around…is when people with these diseases stand up and demand the right to health and the right to universal access to medicines.” There is no denying that the burden of NCDs falls unequally on the developing world and lower-income populations (like most other morbidities) and that treatment options in high-income countries are more accessible. Health infrastructure in the developing world cannot handle most NCD treatment. For example, there are few cancer treatment options in West Africa outside of Ghana or Nigeria, or going all the way down to South Africa. Beyond that, however, the solutions, such as better urban planning, restrictions on tobacco and alcohol advertising, better nutrition in schools, and general public awareness campaigns add another dimension of complexity and cost. Although at least one study has calculated that the funding spent on prevention and risk reduction are cheaper, and may even result in a return-on-investment of $3 for every $1 spent on such programs, the political will does not exist to make it a reality. This is a human rights issue, but it will take time, and more awareness, before prevention and treatment of NCDs is an accepted development issue.
What this all comes back to is that no one health, human rights, or development issue can stand in a vacuum. Food availability, education, poverty levels, and a host of factors can contribute to NCDs, and NCDs contribute to poverty, poor national economic development, overburdened health systems, and another host of results. Although there has been some success with vertical, or single-issue, interventions, integrated programs are key to overall public health. Of course, with so many factors at play, it is hard to know when to stop integrating. All the same, the global community must first try. The UN’s (reported) inability to create a stronger resolution and to put itself at the head of efforts to prevent and treat NCDs and their risk factors is disappointing but in keeping with the way in which most global health epidemics are handled: inaction and hand-wringing until the crisis reaches a breaking point, which usually means that many people have died. As with so many health (and other) interventions, an unwillingness to make a high up-front investment results in more costly fixes. When these up-front preventative measures are funded, they often mean more money and more lives saved. Although this may be a well-established truth, it won’t change the fact that little will be done at present to stem the non-communicable disease epidemic.
The header photo is a 12th-Century Japanese depiction of obesity. Available here, via WikiMedia Commons, PD-US.
