Editorial Note

Non-communicable diseases (NCDs) clearly demonstrate that health is a political issue. Or, as Rudolf Virchow, the nineteenth-century German pathologist stated: ‘Medicine is a social science, and politics is nothing more than medicine on a grand scale’. According to Virchow, medicine and public health practice could transform society. He believed that all epidemics were social in origin – thus public health action had to be political. In the case of NCDs, clearly medicine and health systems will not be able to deal with problems on their own. A more effective approach will include all segments of society; this means a political approach. Also, the complexity of causes, prevention, and treatment of NCDs showcases the importance of taking a public health approach. The strengthening of national public health functions lies at the core of what must be done to tackle most NCDs effectively. Dr Bloomfield will introduce the topic of NCDs in the following pages.

Bettina Borisch, MPH, FRCPathInstitute of Social and Preventive Medicine, University of GenevaE-mail: bettina.borisch@unige.ch

Commentary

The global burden of NCDs continues to grow, and tackling it constitutes a major challenge. NCDs, primarily heart disease and stroke, cancers, chronic obstructive pulmonary disease, and diabetes, caused 60 per cent of global deaths in 2005 – an estimated 35 million deaths – with mortality projected to increase by 17 per cent by 2015.1 Importantly, an estimated 15 million of these deaths occur before age 70 and are potentially preventable.

Too few understand that fully 80 per cent of these deaths occurred in low- and middle-income countries (LMIC).2 NCDs disproportionately afflict and kill the poor in both developed and developing countries. By 2030, 8 of the 10 leading causes of death will be linked to these conditions.2, 3

The burden of NCDs poses serious implications for social and economic development worldwide but particularly for LMICs. At a personal level, high health care costs associated with treating such diseases lead to ‘catastrophic expenditures’ for many poor households, resulting in diversion of the bulk of any family's income away from other basic needs to treatment, medicines, and associated medical costs. Simultaneously, the illnesses rob these families of able-bodied breadwinners, and require other family members to dedicate time and energy to caring for their ailing loved ones. Developed countries are not immune to the economic impact of NCDs. Health care spending in many of these with developed economies today represents a huge financial burden; most of struggle with health care cost growth.

Although the size of the problem has been well described for the last decade, as has the evidence for highly cost-effective interventions to both prevent and treat NCDs, the global response has been muted. Notably, international resources for preventing and treating NCDs in low-income countries are negligible.4

There are a number of reasons for this lack of concerted global action to address the growing burden of NCDs, particularly, in developing countries. First, since 2000, the global development agenda has been driven in large part by the anti-poverty millennium development goals (MDGs).5 There are three health-related goals: two relate to child and maternity health (goals four and five), and one to HIV/AIDS, malaria and tuberculosis (goal six). But NCDs are absent. Thus, they are not identified as a priority for donors.6 Although an increasing number of developing countries are requesting support to address the growing impact of NCDs, donors are reluctant to divert resources from the extant MDGs, which remain a high priority.

A second reason for the apparent inertia is the very nature of NCDs. The major common risk factors are tobacco use, unhealthy diet, harmful use of alcohol, and physical inactivity. Strong commercial interests drive the first three of these to a greater or lesser degree. Thus, tackling them involves complex political, economic, trade, and legal issues. The tobacco, food, and alcohol industries each require a tailored, industry-specific, public health response – there is no way to combine them for a single approach.

Finally, a wide range of public and private sector players need to be engaged to effectively prevent NCDs – making progress is not straightforward. So-called ‘intersectoral action for health’ is required; often the reality amounts to ‘intersectoral action against health’. Even getting to the ‘startline’ requires sustained advocacy and strong political commitment.

Recent developments give cause for hope and 2011 may be a watershed for NCDs globally. Momentum has been building over the past few years, most obviously at the annual World Health Organization (WHO) World Health Assemblies. In 2008, the Sixty-first World Health Assembly endorsed the Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases.7 The Action Plan supports coordinated implementation of strategies and evidence-based interventions across individual NCDs, their risk factors and determinants, both at the global and national levels. The Plan is framed around six broad objectives and outlines a series of activities for members states, the WHO secretariat, and international partners.

In response to goal five of the NCD Action Plan, the WHO has established the global non-communicable disease network (NCDnet). NCDnet is a voluntary collaborative arrangement comprised of United Nations agencies, intergovernmental organizations, academia, research centers, non-governmental organizations, and the business community.8 NCDnet exists to support the implementation of the NCD Action Plan, and it provides a platform for collaboration among the range of stakeholders to that end.

Over the last 5 years, the Lancet has published three series of articles on chronic diseases. The most recent, published in November 2010, specifically addresses chronic disease and development. The publication of these articles in a high profile journal has contributed significantly to raising awareness of the global impact of NCDs in both scientific and political spheres.

Through 2009, an increasing number of countries and other stakeholders joined the call for a greater focus on NCDs globally, including their placement on the development agenda. A recent statistical analysis supported this, concluding that NCDs are a key driver of inequalities in progress towards achieving the MDGs.9

The Caribbean community (CARICOM) countries led in placing NCDs on the agenda of the UN General Assembly in New York leading to a resolution in May 2010 on the prevention and control of NCDs.10 The resolution, inter alia, includes a decision to convene a high-level meeting (HLM) of the General Assembly in September 2011, with the participation of Heads of State and Government, on the prevention and control of NCDs.

The importance of such a meeting cannot be underestimated: it was a similar meeting a decade ago that elevated HIV/AIDS to its now prominent place on the global health agenda. Just before Christmas 2010, the General Assembly agreed the dates and format for the HLM – to take place in New York on 19–20 September 2011. The meeting will address prevention and control of NCDs worldwide. Participants will focus on the impact of NCDs in developing countries – particularly on the social and economic aspects of development. The anticipated key output will be a concise, action-oriented outcome document.

Another crucial event this year is the First Global Ministerial Conference on Healthy Lifestyles and NCD Control – hosted by the Russian Federation in Moscow in April. As it will be an important standalone event, this conference provides a timely opportunity to fully engage health ministers on the issues before the HLM in September 2011.

A wide range of stakeholders are scaling up their activities in anticipation of the Moscow Ministerial Summit and the September UN General Assembly HLM. Four major non-government organizations have formed the NCD Alliance and have dedicated resources to build-up activities in preparation for the HLM.11 Many private sector and industry organizations are also focused on the HLM, no doubt with a range of motives, at least some of which are aligned with achieving improved public health. The World Economic Forum has become increasingly engaged, not least because their flagship ‘global risks’ report identified chronic diseases as one of the top global risks for the last few years; the recently released 2011 report is no exception.12

The UN High Level Meeting presents an historic opportunity to rethink the global response to NCDs and to substantially step up support for developing countries to address their disproportionate share of the NCD burden. Public health professionals worldwide can play key roles, individually and collectively, in ensuring that the opportunity is not lost. This will require sustained advocacy and mobilizing the full range of ‘tools’ proven to support effective public health action. The stakes are high and the potential benefits are large, especially for the world's poorest people.

The author alone is responsible for the views expressed in this publication; they do not necessarily represent the decisions or policies of the WHO.

Ashley Bloomfield, MBChB, MPH, FNZCPHMContact:Partnerships Adviser, Non-communicable Diseases and Mental Health Cluster, WHO, 20 Ave Appia,1211 Geneva 27, Switzerland,E-mail: bloomfielda@who.int