UN high level meeting on non-communicable diseases: an opportunity for whom?

In September, world leaders will meet at the United Nations in New York to discuss non-communicable diseases. A decade ago, at a similar meeting on HIV/AIDS, they created the Global Fund for HIV/AIDS, Tuberculosis and Malaria—a revolutionary new global health funding mechanism.

The September meeting will focus on four leading conditions—heart disease, cancer, diabetes, and respiratory disease—that together cause more than half of all deaths in low and middle income countries. Without action, the number of premature deaths (age < 60) caused by non-communicable diseases is expected to rise from 3.8 million each year to 5.1 million in poor countries by 2030, trapping a generation of families in cycles of poverty and disease. As Thomas Frieden, director of the US Centers for Disease Control and Prevention, recently stated, developing countries must immediately tackle the rapid rise of non-communicable diseases because they will “kill four times as many people by 2020 as infectious diseases.”

Hopes are high that the UN meeting will mark a turning point and avoid the belated response that hampered HIV strategies. Progress on HIV required not only technical discussions about which drugs work and how to make them cost effective; it also needed to tackle the broader ethical, social, and political dimensions of the HIV pandemic.

Throughout the process, the imperative to act was presented as one of social justice. It emphasised that HIV was a manifestation of inequalities in power and resources. Efforts by drug companies to protect long term patents on antiretroviral drugs were met by activists fighting for access to treatment and declaring that human lives in poor countries were just as valuable as those in rich ones.

Misconception and neglect

Non-communicable diseases, by contrast, remain neglected despite their social parallels to HIV. As with HIV, discussions are plagued by misconceptions. Although they have been thought of as diseases of the wealthy, this is simply incorrect. The common non-communicable diseases increasingly affect the poorest in low and middle income countries, just as in high income nations. Women aged 15-49 in sub-Saharan Africa are four times more likely to die or experience disability from a non-communicable disease than women in high income countries. High blood pressure is the second leading risk factor for death in low income countries (behind child underweight), and high blood glucose is the fifth.

Another common fallacy is that non-communicable diseases stem from a moral failure—that weakness of will leads to obesity or sedentary lifestyles. But people in many parts of the world face major barriers to making healthy choices and face powerful pressures to adopt unhealthy ones.

Pervasive fallacies have led to serious under-budgeting for non-communicable diseases. As the health minister of Uganda put it, “We know what to do [but] we have no budget.” One survey of health ministers worldwide found that only about a third had even a single budget line for non-communicable diseases. Overall, less than 3% of global health aid has been designated for non-communicable diseases. WHO—which has provided the strongest support to NCDs among global institutions—allocates less than 10% of its budget to these diseases.

The paradoxes are obvious to observers in developing countries. Guyana’s health minister, Leslie Ramsammy, pointed to the fact that the millennium development goals did not include non-communicable diseases even though they account for 60% of global deaths. “Most of the morbidity and mortality caused by the chronic diseases are preventable. [This is] a serious omission,” he said.

Because non-communicable diseases are not part of the goals, development agencies fail to prioritise them; health ministers in turn do not seek support for prevention and control because of the lack of available funding. Little research can be done on how to prevent and treat these conditions, and this allows cynics to argue there is weak evidence for intervention—a Catch 22 situation is created.

Yet proved and cost effective interventions do exist. For example, the World Bank says tobacco and alcohol taxes, smoking bans to reduce deaths, and treatment of acute myocardial infarction with aspirin and β blockers are among the most cost effective measures for disease control available in low income countries. Tobacco and alcohol tax increases have been shown to reduce consumption as well as raise revenue for governments. A meta-analysis of alcohol tax studies estimated that a doubling of the price of alcohol beverages would reduce alcohol related mortality by 35%, traffic crash deaths by 11%, sexually transmitted diseases by 6%, violence by 2%, and crime by 1.4%. Salt reduction reduces blood pressure and risks of cardiovascular disease. Regulating salt intake could save billions in healthcare costs annually.

Vested interests

So why has there been no clear response to non-communicable diseases? One crucial difference from HIV is that there has been no strong base of advocates to tackle the root social causes of illness. Advocacy on non-communicable diseases has been described by young people as “dull” and “uninspiring,” lacking an emphasis on social justice or inequality and missing a sense of outrage and urgency against continued inaction.

As a result, much of the agenda is being written by powerful vested interests. Margaret Chan, director general of WHO, stated that “Today, many of the threats to health that contribute to NCDs come from corporations that are big, rich and powerful, driven by commercial interests, and far less friendly to health. Today, more than half of the world’s population lives in an urban setting. Slums need corner food stores that sell fresh produce, not just packaged junk with a cheap price and a long shelf-life.”

At a preparatory meeting in New York representatives of the United States, Europe, and key Western allies, blocked consensus on action on non-communicable diseases after lobbying from the alcohol, food, tobacco, and drug industries. Negotiations have now stalled. When asked why Michelle Obama’s successful childhood obesity programmes in the US should not be modelled in developing countries, a US official responded that they might harm American exports.

The current draft of the declaration on non-communicable diseases has no time bound commitments; does not allocate resources to prevent and control these diseases; and does not include language focusing on the most cost effective fiscal and regulatory interventions.

The NCD Alliance, a leading non-governmental advocacy group, highlights the “unwillingness” of donor countries to call for increased resources for non-communicable diseases and for “the need for evidence-based fiscal policies such as increased taxation on tobacco.”

Food companies have hired US President Obama’s former communications director, Anita Dunn, to lead lobbying efforts on food regulations; these industries look to low and middle income countries as their greatest growth markets.

There is also evidence that food companies have worked through US diplomats to secure a more favourable economic and legal environment in developing countries. McDonald’s sought to delay the implementation of new US free trade legislation until El Salvador appointed new judges to resolve an ongoing court dispute.

Should the industries that profit from unhealthy products be viewed as trusted partners and have a seat at the table during public health negotiations? At recent UN civil society hearings—the main opportunity for advocates to shape the final UN political declaration—representatives from food (including the International Food and Beverage Alliance) and alcohol industries (including Anheuser-Busch, SABMiller, and the Global Alcohol Producers group) were among the main representatives of civil society. Alcohol industry representatives said at a preparatory meeting: “We will do anything as long as it is voluntary.”

Corporate influence takes many, often subtle and indirect forms. Philip Morris’s latest campaign, “Project Sunrise,” explicitly aims to “weaken tobacco control by working with it,” funding front groups and exploiting differences of opinion within the tobacco control movement to “create schisms—force them to fight among themselves.”

Where collaboration does not work, direct threats may be used. After WHO released its report on diet, physical activity, and health in 2003, which recommended reduced sugar intake, the sugar industry threatened that it would lobby the US to cut off its financial support to WHO. Three of Washington’s largest lobbying firms now work for the food industry. Vested interests also pose a problem for the non-governmental organisations that are most actively engaged in the UN civil society hearings. Many receive a considerable proportion of their funding from drug companies or food companies, potentially compromising their ability to argue for greater use of generic drugs or taxation and regulatory interventions.

Policy debates may also be shaped by decisions on what is prioritised and what is not in global health. For example, the Bill and Melinda Gates Foundation, which funds more than $3.5bn of global health research each year, offers less than 3% of its funding for research into non-communicable diseases, while holding large stocks in food and drink companies (owning 10% of global Coca-Cola stock, for example).

Like the HIV meeting, the UN high level meeting on non-communicable diseases is a battleground, pitting public interests against powerful private ones. But unlike the HIV activism of the past, the voices of people affected by non-communicable diseases are mostly quiet. Whether the meeting encourages the emergence of a global social movement for change will shape the future of our health for years to come.

This post first appeared in the BMJ, co-authored by David Stuckler and Martin McKee.

4 responses to “UN high level meeting on non-communicable diseases: an opportunity for whom?

  1. Pingback: Non-communicable Diseases « The Pulse

  2. 3 comments

    1) The relative increases and relative disparities are quite misleading. The absolute numbers are still low and the same woman also has 50X the risk of dying of in childbirth. While NCDs may be a substantial burden in poor countries, if you disaggregate country data by income you’ll see a very different story – it’s still concentrated in the wealthier quintiles. There are a lot of good reasons to support more focus on NCDs but these arguments are not some of them.

    2) Are the forces that drive incidence across regions and social class? Some may be, tobacco for instance. But many are not. I heard MSF and PIH at some meeting brought up other risks, indoor air pollution and rheumatic fever, that are risks for NCDs actually concentrated among the poor and relatively unmentioned. What do you think this means for a global effort – it certainly does not bar a coordinated effort at funding (like GFATM) but does make global policy more complicated especially if we mean it to be pro-poor.

    3) When I read “an opportunity for whom”, I was expecting to see some mention of the pharmaceutical industry who have been enthusiastic promoters of the NCD Alliance presumably to shift the emphasis from risk factor regulation towards secondary and tertiary prevention and great uptake of their products (not on essential medicine lists).

    • thank you for your comments, Naman. a few quick thoughts:

      1) If we were to use the WHO Global Burden of Disease study, whose data go up to about 2003 and then use projections of questionable integrity, this would no doubt be considered true. In light of newer data from the WHO SAGE dataset and related work, it appears that NCDs do have an increasing and substantial concentration among the very poor non-elderly; they may not be the dominant affected class in many countries, but we’re seeing the burden increase among them even when they do not acquire new income, as key risk factors (tobacco and unhealthy foods in particular) increasingly enter their markets. The broader point we wish to make is that conceptualizing these as diseases of “lifestyle” may be a misnomer when so much of the burden is related to social determinants of consumption and risk. It is worth also looking at Salim Yusuf’s PURE study in this regard. Along these lines, Partners in Health has offered some notable comments on the NCD burden they recognize among Rwanda’s poor: http://www.pih.org/news/entry/demanding-attention-for-the-non-communicable-diseases-of-the-poor/

      I think Paul Farmer’s speech about avoiding infighting about what diseases to prioritize is worth listening to:

      2) Indeed, some NCD risk factors concentrate disproportionately among the poor; you mention indoor air pollution from cooking stoves and rheumatic fever, but also malnutrition is a NCD, and cardiac disease among pregnant women and related young people is increasingly identified. There are several risks across region and class beyond tobacco, most prominently those of dietary risks: salt and high-energy-density foods. Data from India suggest marked salt consumption and associated heart disease mortality among non-elderly very poor, particularly urban groups. Data from southeast Asia and Latin America suggest similar concerns for diabetes emergence, and the renewal of the concept of “malnutrition-associated diabetes”. It is also important to recognize the marked impact of alcohol on global morbidity and mortality between regions and classes. I totally agree with your broader point that there are some clear choices to make about making the NCD campaigns “pro-poor”, and PIH has also started a petition in this regard: http://act.pih.org/page/s/non-communicable-disease-petition?source=ncdpage

      3) In our experience, particularly following the Doha WTO trade negotiations, the pharmaceutical industry is very concerned about generic product entry for the NCD market, e.g., extensions of parallel importation or compulsory licensing provisions to allow generic production and distribution of heart disease and cancer meds; their limited show of support for some NCD advocates appears connected to efforts to strong-arm several provisions of patent licensing towards extending protections for trademarked goods. Oxfam commented on this a few years ago: http://policy-practice.oxfam.org.uk/publications/patents-versus-patients-five-years-after-the-doha-declaration-114562

  3. Thanks for all the great links. Dr Farmer’s comments are well worth heeding, which is exactly why I’m skeptical of advocacy that relies on focuses on increased or absolute NCD burden relative to other causes instead of the opportunity to address preventable, systemic risks, which you note, or the ideology that health systems should prevent and treat all forms of disease to provide dignity to those who would use it.

    On number three, I guess the broader concern I am voicing is the hope that the movement maintains a primary focus on structural determinants supplemented with the provision of healthcare rather than just the latter which some groups seem inclined towards.

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